Originally published December 2012
International adoption can be a significant undertaking for prospective parents wanting to welcome a child from abroad into their family. The CMPA recognizes the importance of international adoption and the potential benefits to the children and families involved. Parents and physicians should also be aware of the medical care issues that sometimes accompany adoption.
Physicians may be asked for a medical assessment or to write prescriptions for a child being considered for adoption. Understanding the possible risks allows physicians to discuss these with the prospective parents and better assist them during the adoption process.
Citizenship and Immigration Canada reports that in 2010 there were 1,946 international adoptions, compared to 2,122 in 2009 and 2,180 in 2003.1
The health of adoptees
Parents are often rightly concerned about their adoptive child's possible health issues, many of which are unknown. Some children will have been well cared for, while others may have had little medical care. For instance, some children who come from orphanages may have suffered neglect and may have developmental delays or behavioural problems.2 According to a December 2010 report by the Public Health Agency of Canada3 adoptive children "...can have unique medical issues related to growth and developmental delay, attachment disorders, long-term institutionalization, prenatal and postnatal exposure to toxins and drugs, variable immunity to vaccine preventable disease, and exposure to infectious diseases."
Physicians may be approached for assistance at any point during the course of the adoption. Adoption and government agencies often recommend that prospective parents consult with a physician throughout the process. However, it is the consultations before the adoption that pose the greatest medico-legal risks for doctors since they often will not have the opportunity to personally examine the child.
In preparing for adoption, parents may seek a physician's counsel for various reasons — for medical advice on country-specific medical issues such as tuberculosis or on a condition such as fetal alcohol syndrome, for help deciphering foreign medical assessments, or for advice on health issues adopted children may experience during air travel or integration within their new home. An adopted child's health may also affect the health of other family members, leading some prospective parents to request updates to immunizations for other members of their household.
Most often during a pre-adoption consultation, however, physicians are asked to assess a specific child's health while the child is overseas, or to write a prescription for a child overseas in anticipation of health problems, or both.
Prospective parents seeking a health assessment usually ask physicians for advice about the possible medical difficulties that might be expected in a child who has not had a physical examination or whose medical history may not be known or reliable. A doctor may be presented with medical records from the child's country of origin, and occasionally photographs or a video. The records can be sparse, inadequate, or inaccurate. For instance, birthdates have been known to be incorrect, yet even a few months make an important difference in the developmental milestones of a toddler. The content of records may also have been poorly translated. Videos and photographs can provide some useful information, but represent a limited view of the child, often in artificial or stressful conditions.4 Even after the child's arrival in Canada, a physician cannot guarantee the child's ongoing health, as many medical conditions take time to manifest.
Physicians may find it difficult to provide parents with a thorough assessment of a child's health status given limited or unreliable information and without the benefit of a physical examination. They can take several steps, however, to reduce their exposure to medico-legal risk. Physicians should ensure they are qualified to provide the requested assessment. They should be fully transparent with parents, explaining that their assessment is based on limited information that may be incomplete or inaccurate. Physicians should also explain that they cannot counsel adoptive parents on whether or not to proceed with the adoption, nor can they fully advise on the potential health issues their child may face as he or she grows up. Finally, physicians should carefully document in the medical record the details of their discussions with parents.
Parents may also want to take medication with them on a trip to meet or pick up the child, allowing them to begin treating the child immediately for health problems. For example, they may ask physicians to prescribe medications such as antibiotics for infections.
Colleges generally require physicians to have a full understanding of a patient's health status before writing a prescription. This is often accomplished following a thorough medical assessment including an appropriate history and physical examination, a diagnosis, and a plan for treatment including follow-up investigations, if required.
Physicians may consider advising adoptive parents who wish to have medication for a child who is not yet in Canada to contact the adoption agency or the Canadian embassy or consulate for advice about local medical resources and to secure the necessary medication for travel.
Other areas of risk
In addition to the pre-adoption consultation, there are other services provided during the adoption process that could pose medico-legal risks for physicians. For example, adoptive parents may ask a physician to be available to provide telephone advice while the parents are in the foreign country. In other cases, doctors may be asked by adoption agencies to visit the foreign country to assess the medical condition of children being considered for adoption. While unlikely, in both these situations physicians may be exposed to legal action in a foreign jurisdiction. Physicians should first obtain advice from the CMPA when considering providing these types of services.
Some adoptive parents may visit a doctor for a determination of their own health status, to fulfill an adoption requirement. During this process, physicians may be asked for a copy of their medical licence so parents can provide proof of the doctor's professional credentials. Given the rise in identity theft, physicians should consider alternative methods of proving their credentials, such as providing their medical licence number only.
Physicians asked to provide consultation services to potential adoptive parents can mitigate risks by considering the following:
be appropriately qualified to provide medical advice on the health of a child
understand the limitations of the medical information on which any assessment or advice is based
clarify to adoptive parents the medical advice that can be reasonably provided to them
work with the adoptive parents to help secure any needed medications locally
decline to guarantee the health of a child, or to advise on whether or not the adoption should proceed
document in the medical record all discussions with parents, any assessments of the child's health status, and any advice provided to the adopting parents
More information is available by contacting the Association and speaking with one of the CMPA's medical officers, physicians with experience in medico-legal matters of this type.
Citizenship and Immigration Canada, Research Data Mart (RDM). retrieved on October 5, 2012 via Adoption Council of Canada http://www.adoption.ca/adoption-news?news_id=56
Canadian Paediatric Society, A note from the doctor: Advice for parents and caregivers, "International adoption: Health issues for families," Paediatrics and Child Health (2005) Vol. 10, no.5 p.293–294
Public Health Agency of Canada, "Canada Communicable Disease Report, Committee to Advise on Tropical Medicine and Travel, Statement on International Adoption," (December 2010) Vol. 36, ACS-15, introduction.