Ethics Curriculum for Emergency Medicine Residencies 1994 SAEM Ethics Committee James G Adams Terri A Schmidt (Ch airArthur R !erse Glenn C "reas #e$is R Goldfran% &enneth ' serson )orm ! &al*fleisch Samuel M &eim Ro*ert & &no++ Gregory # #ar%in Marc # ,ollac% !a-id , S%lar
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1. #ist s+ecial +ro*lems associated $ith ethical decisionma%ing in emergency
medicine.
. !escri*e t$o models for ethical decisionma%ing in emergency medicine.
@. #ist ad-antages and disad-antages of the t$o models in emergency medicine.A 9 year old man in acute res+iratory distress is *rought into the emergencyde+artment from a nursing home. 2e had *een at the nursing home for ; monthsand is descri*ed as normally alert and oriented3 *ut *edridden due to his end stagecongesti-e heart failure. 2e has no family in the area. 2e a++ears frail andde*ilitated3 and cannot ans$er any 5uestions. 2is *lood +ressure is 9= systolic3heart rate is 1= and res+iratory rate is 4=. 2e has rales in all lung fields. Records
from the nursing home do not +ro-ide any information a*out +atient +referencesregarding resuscitation or code status. Shortly after arri-al3 his daughter from outof state calls and states her father $ould not $ant aggressi-e treatment.
The E! is not only a com+le6 medical en-ironment3 *ut +resents com+le6
ethical challenges as $ell. ur unfamiliarity $ith our +atients and their $ishes3 the
minimal time to esta*lish a relationshi+3 and the com+le6 situations3 all contri*ute
to ethical conflict. n addition3 decisions must often *e made 5uic%ly3 sometimes
*efore sufficient information is a-aila*le.
t is useful to ha-e a model for ma%ing ethical decisions3 ust as $e use
models to ma%e other clinical decisions. ne such model $as de-elo+ed *y Jonsen3
Siegler and 7inslade. They +ro+ose that any ethical decision can *e made *y
considering four factors/ medical indications3 +atient +references3 5uality of life and
conte6tual features. The conce+t of medical indications includes the diagnosis and
treatment of the +atient?s condition and a consideration of $hat is needed to
e-aluate and treat the +ro*lem. The conce+t of +atient +references is *ased on
the *elief that health care +ro-iders should res+ect the $ishes of +atients3 and
$hene-er +ossi*le +ro-ide treatment $hich meets the +atient?s goals. Fuality of
life considerations assume the goal of medical inter-ention is to im+ro-e the 5uality
III. Issues #elated to $atient AutonoyA. Infored Consent
Objectives
1. E6+lain $hy informed consent is o*tained for treatment.
. #ist the critical elements in the consent +rocess.
@. !efine the emergency rule.
4. !efine e6+ress consent.
. !efine im+lied consent.
;. !escri*e the circumstances under $hich a +hysician may treat a +atient against
his or her $ill.
A @9 year old +atient +resents $ith a se-ere headache. The +atient has a history ofheadaches3 *ut this e+isode is $orse than usual. There is no fe-er3 and the +atienthas a nonfocal neurological e6amination: the +atient?s sensorium is clear. 2ead CTscan is normal. The +hysician feels that a lum*ar +uncture is indicated.
Res+ect for autonomy re5uires us to recogniBe a +erson?s right to ma%e
inde+endent choices3 and ta%e actions *ased on +ersonal -alues and *eliefs. A
+erson cannot ma%e inde+endent choices $ithout the necessary information to
ma%e those decisions. Thus3 informed consent in-ol-es t$o duties/ the duty to
disclose information to +atients3 and the duty to o*tain +atients? consent.
8nderstanding the *asis u+on $hich the +atient grants +ermission for medical
treatment is fundamental to effecti-e3 rational and medicolegally acce+ta*le care.
n the emergency care setting issues of consent fre5uently arise in the form of
informed consent for +rocedures3 informed refusal of care3 treatment of minors3 and
consent for research +rotocols.
nformed consent is intended to +romote +atient selfdetermination and $ell
*eing. Although +atient selfdetermination im+lies a unilateral decision3 the
+rocess of decision ma%ing is *y necessity a shared one/ the +hysician offers
information and e6+ert ad-ice for the +atient to consider. t is the health care
+ro-ider?s res+onsi*ility to assure that the +atient can meaningfully +artici+ate in
the decisions. Shared decision ma%ing re5uires that the +atient +ossess correct
and com+lete information3 and that the decision +romote the +atient?s goals and
life -alues. n the consent +rocess the three elements that must *e met are
information3 com+rehension and -oluntariness.
%egal support for infored consent
7hile informed consent is fundamentally an ethical im+erati-e3 8nited States la$
re5uires that a +atient +ro-ide informed consent for medical treatment3 e6ce+t
under unusual circumstances. This legal +rinci+le $as recogniBed in 1914 $hen the
)e$ Dor% State Su+reme Court held thatE-ery +erson of adult years and sound mind has
the right to determine $hat shall *e done $ith his o$n*ody and a surgeon $ho +erforms an o+eration $ithouthis +atient?s consent commits an assault for $hich he islia*le in damages.
This landmar% case cites the fundamental +remise u+on $hich our understanding is
*ased. Any time a health care +ro-ider touches a +atient3 such action must *e
authoriBed *y the +atient. n the a*sence of such authoriBation3 the inter-ention
could *e actiona*le in tort as a *attery. The imminent threat of such a -iolation
constitutes assault. This +rinci+le gi-es the +atient $ith decision ma%ing ca+acity
the legal right to refuse medical care.
n addition3 lac% of informed consent may result in an action for negligence
against the health care +ro-ider. A failure to disclose +otential com+lications or
alternati-e treatments may constitute negligence if such information $ould
influence the +atient to alter his or her decision. This distinction $as made clear in
19<3 $hen the court affirmed that +erforming an unauthoriBed +rocedure is
must *e careful *ecause *oth consent and refusal must *e made $ithout coercion
or duress.
,hysicians should +ro-ide treatment des+ite a -er*al refusal in +atients $ho do not
ha-e decision ma%ing ca+acity3 or $hen the life threat is so acute that the +hysician
does not ha-e time to assess their refusal. 7hen +atients do not ha-e decision
ma%ing ca+acity3 the e6+ected *enefit of the inter-ention must out$eigh the
+otential ris% of harm to the +atient.
!tudy "uestions
1. n this case3 $hat must *e discussed $ith the +atient in order to o*tain her
consent
. !o you need to o*tain $ritten consent from this +atient
@. 7hy does a +hysician o*tain informed consent for treatment
4. 2o$ do the +rinci+les of *eneficence and autonomy relate to consent issues
BibliographyA++lelaum ,S3 #idB C73 Meisel J!/ nformed Consent/ #egal Theory and Clinical,ractice 6ford 8ni-ersity ,ress3 )e$ Dor%3 19><.
0oisau*in E'3 !resser R/ nformed consent in emergency care/ llusion and reform.Ann Emerg Med 19><: 1;/;;<.
0roc% !7/ nformed +artici+ation and decisions in serson &'3 Sanders A03 Mathieu!R3 0uchanan AE (eds/ Ethics in Emergency Medicine. 0altimore3 7illiams and7il%ins3 19>;.
S+rung C#3 7inic% 0J/ nformed consent in theory and +ractice/ legal and medical+ers+ecti-es on the informed consent doctrine and a +ro+osed reconce+tualiBationCrit Care Med 19>9: 1</1@4;1@4.
III. Issues #elated to $atient AutonoyB. $atient &ecision Ma'ing Capacity
Objectives
1. !efine decision ma%ing ca+acity
. Contrast medical inter+retations of decision ma%ing ca+acity $ith the legal
definition of com+etence.
@. !efine surrogate decision ma%er and health care +ro6y
4. #ist the $ays decisions can *e made $hen a +atient lac%s decision
ma%ing ca+acity.
A year old male +atient came to an E! com+laining of nausea and chest +aino-er the +ast t$o hours. An E&G immediately u+on arri-al re-ealed significant (@mm ST de+ression in an anteriose+tal distri*ution (' 4. The +atient?s chest+ain $as relie-ed after a third su*lingual nitroglycerin ta*let $as administered.Su*se5uent E&G re-ealed 1mm ST de+ression. 2e has not seen a +hysician inthe +ast years. 2e ta%es no medications and smo%es 1 +ac% of cigarettes a day.2e refuses to *e admitted to the hos+ital and demands that he immediately *ereleased. !es+ite all efforts *y the +hysician to con-ince him to stay3 he demandsthat he *e allo$ed to go home.
7hen a +atient arri-es in an emergency de+artment and an e-aluation *y a
+hysician is *egun3 a +hysician+atient relationshi+ is esta*lished. This relationshi+
carries certain legal and ethical o*ligations for *oth +arties. The +hysician assesses
the +atient and +ro+oses a +lan of e-aluation or a course of care. ,atients ha-e the
ultimate authority to acce+t or refuse this +ro+osal.
The +atient?s authority is founded on 1 the ethical +rinci+le of res+ect for
autonomy3 the legal right of selfdetermination3 and is *ased on the +i-otal
assum+tion that the +atient is acting in his or her o$n *est interests. The
o*ligation of +hysicians to +rotect +atients from harm can conflict $ith the
o*ligation to res+ect +atient autonomy $hen the +atient ma%es decisions that
seem un$ise or harmful. 7hen this conflict occurs3 +hysicians must assess the
III. Issues #elated to $atient AutonoyC. Treatent of inors
Objectives*
1. E6+lain ho$ consent for minors is o*tained.
. E6+lain ho$ the emergency rule a++lies to minors.
@. E6+lain ho$ state la$s regarding minors and +regnancy3 se6ually
transmitted diseases3 su*stance a*use3 and child a*use relate to
consent and confidentiality.
4. E6+lain the conce+ts of emanci+ated minors and mature minors.
. !escri*e situations $hen a minor can refuse care.
A si6teen year old is *rought to the emergency de+artment *y his +arents$ho insist on a drug screen to confirm their sus+icions that the teenager isusing mariuana. The +atient refuses to su*mit to any e6am or +roduce aurine sam+le.
Res+ect for autonomy +resumes that a +erson $ith decision ma%ing
ca+acity has a right to ma%e choices a*out health care. 2o$e-er3 minors are
generally +resumed not to ha-e decision ma%ing ca+acity. n general3
consent for treatment of minors is o*tained from the +arent or legal
guardian. 7e assume that +arents $ill ma%e decisions *ased on the *est
interests of their child. Thus3 $ith minors $e are more li%ely to *ase our
actions on the +rinci+le of *eneficence than on the +rinci+le of res+ect for
autonomy. 2o$e-er3 as children *ecome old enough to e6+ress their $ishes
and reason for themsel-es3 they are entitled to res+ect for their +references.
The ethical tas% is to $eigh the +references of +arents and children and sol-e
1. !efine ad-ance directi-es/ dura*le +o$er of attorney for health care and
li-ing $ills
. State the +ur+ose of an ad-ance directi-e and descri*e the re5uirements
for a -alid ad-ance directi-e.
@. E6+lain your state la$s regarding ad-ance directi-es.
4. E6+lain the conditions $hich ma%e an ad-ance directi-e a++lica*le.
A 4 year old male is *rought into the emergency de+artment $ith altered
le-el of consciousness. According to his com+anion3 he has A!S3 *ut untilyesterday $as alert and interacti-e3 although confused at times. 2e has*een diagnosed $ith A!S dementia. 2is com+anion *rings along the+atient?s dura*le +o$er of attorney for health care that names thecom+anion as the surrogate decision ma%er.
An ad-ance directi-e is a $ritten document $hich e6+resses the future
$ishes of a +atient. t is designed to gi-e +atients control o-er the treatment
decisions $hich $ill *e made $hen they are una*le to +artici+ate directly.
The t$o main ty+es of ad-ance directi-e are li-ing $ills and dura*le +o$ers
of attorney for health care.
t is li%ely that the use of ad-ance directi-es $ill increase $ith
im+lementation of the +atient self determination act3 $hich *ecame effecti-e
!ecem*er 13 1991. This federal act re5uires that all hos+itals $hich acce+t
Medicare and Medicaid funds +ro-ide information a*out ad-ance directi-es
and de-elo+ +olicies for im+lementation of ad-ance directi-es. nformation
a*out ad-ance directi-es has also *een mailed to all social security
regarding health care +ro6ies and li-ing $ills. Emergency de+artments
should ha-e guidelines regarding ad-ance directi-es.
!tudy +uestions
1. 7hat are your state la$s as they relate to ad-ance directi-es 7hich
forms of ad-ance directi-es are allo$ed
. n this case3 $ho has decision ma%ing +o$er for this +erson
@. 7ho $ould you consult for decisions if the +arents also came to the
emergency de+artment and re5uested to ma%e decisions for their sonBibliography
Annas GJ/ The health care +ro6y and the li-ing $ill. ) Engl J Med1991:@4/[email protected] EJ3 Emanuel ##/ ,ro6y decision ma%ing for incom+etent +atients.
. E6+lain the conditions $hich must *e +resent to $ithhold resuscitation
in the emergency de+artment and in the out of hos+ital en-ironment.
@. E6+lain the role of family and significant others in decisions a*out
resuscitation.
An >@ year old $oman $as found asystolic. The family +resented the+aramedics $ith a +a+er3 signed *y a +hysician3 noting that the +atient $asnot to *e resuscitated in the e-ent of cardiac arrest. State EMS +olicy3ho$e-er3 does not recogniBe +rehos+ital do not resuscitate orders. n this+atient3 no resuscitation $as underta%en. The +olice $ere notified that the+atient $as dead on arri-al.
t is legally and ethically acce+ta*le to $ithhold resuscitation attem+ts
on +atients $ho ha-e e6+ressed clear $ishes not to undergo resuscitation.
The challenge arises in the communication of such desires. The means of
communication must *e legally3 ethically3 and medically sound. The
emergency setting +resents difficulties since the +atient?s $ishes3 medical
condition3 and +rognosis are usually un%no$n. Effecti-e means of
communication must *e +resent to relay the +atient?s desire that
resuscitation *e $ithheld. This can *e through standardiBed mechanisms
that many regions ha-e de-elo+ed. Some states utiliBe a form $ith +atient
and +hysician signature and a +atient arm*and.
f there is dou*t regarding the +atient?s $ishes or the -alidity of a
document3 resuscitati-e efforts should *e initiated. The decision to
. !escri*e situations in $hich futility may *e used to $ithhold treatment in
the emergency de+artment and out of hos+ital setting.
A year old male is *rought to the emergency de+artment *y +aramedicsafter sustaining a gunshot $ound to his head. 2e arri-es $ith agonalres+irations3 and a *lood +ressure of ;= systolic. The *ullet entered at theleft tem+le and there is a large e6it $ould $ith e6truding *rain from the righttem+le. 2e has a GCS of @.
Although not e6+licitly stated3 $e generally assume that health care
+ro-iders are not e6+ected to offer treatments to their +atients $hich are not
medically indicated. "or many clinical conditions3 the medical indications
and +rognosis for resuscitati-e measures still need to *e defined. ,hysicians
and ethicists continue to discuss ho$ to +roceed $hen it is *elie-ed that
attem+ts at resuscitation $ould *e futile. f a medical inter-ention is of no
*enefit3 then it should not *e a++lied. Det relying on +oorly defined notions of
futility may diminish +atient autonomy. The American 2eart Association
suggests the follo$ing criteria for medical futility in AC#S/1. A++ro+riate 0#S and A#S ha-e already *een attem+ted $ithout
restoration of circulation.
. )o +hysiologic *enefit can *e e6+ected from A#S and 0#S*ecause the +atient?s +hysiologic functions are deteriorating
,. The $hysician)$atient #elationshipA. Confidentiality
Objectives
1. !efine confidentiality.
. !iscuss your duty of confidentiality to E! +atients
@. !escri*e threats to +atient confidentiality in the E! including hos+ital
em+loyees3 +er+etrators and -ictims of -iolent crime3 minors and cele*rities.
4. !iscuss the duty to *reach confidentiality including duty to $arn3 +u*lic
health and contagious diseases and legal re+orting re5uirements.
A @ yearold +aramedic comes to the emergency de+artment in a +ostictalstate. 2e $as $itnessed to ha-e a grand mal seiBure. After a*out an hour3he *ecomes more res+onsi-e and relates that he had a similar e+isode in the+ast. 2e *egs you not to tell the !e+artment of Motor 'ehicles (!M'*ecause if he does not ha-e a dri-er?s license he cannot $or% as a+aramedic. Dour state la$ re5uires you to re+ort e+isodes of loss ofconsciousness.
Confidentiality and confide are deri-ed from the #atin confidere, to
trust. ,atients confide in their +hysicians $ith the understanding that $hat
they re+ort $ill not *e disclosed $ithout e6+licit +ermission. Since
res+ecting confidentiality has long *een ac%no$ledged as a *asic
res+onsi*ility of +hysicians3 it is understood as an im+licit +romise to
+atients. Confidentiality +romotes full disclosure of detailed and accurate
+atient information $hich is essential to +ro+er diagnosis and treatment.
Confidentiality +romotes societal trust3 +ersonal autonomy3 and thera+eutic
candor.
'arious codes of 7estern medical ethics echo the sentiment that
confidentiality is an im+ortant +rinci+le in the healing arts. "or e6am+le3 the
7hatsoe-er in my +ractice or not in my +ractice shallsee or hear amid the li-es of men3 $hich ought not to *enoised a*road3 as to this $ill %ee+ silence3 holding suchthings unfitting to *e s+o%en.
More recently3 the AMA Council on Ethical and Judicial Affairs acce+ted the
statement/ The +atient has a right to confidentiality. The +hysicianshould not re-eal confidential information $ithout theconsent of the +atient3 unless +ro-ided *y la$ or *y theneed to +rotect the $elfare of the indi-idual or the +u*licinterest.
Thus3 *oth ancient and modern +hysicians ha-e recogniBed the im+ortance of
confidentiality and ha-e included it in -arious oaths3 +rinci+les3 and rules of
+rofessional conduct.
American common la$ has found +hysicians lia*le for *reach of
confidentiality on grounds of defamation3 in-asion of +ri-acy3 and *reach of
an im+lied contract. n the other hand3 +hysicians ha-e *een indicted for
failing to *rea% confidentiality $hen it $as deemed o*ligatory for them to do
so in order to $arn or +rotect others. "or e6am+le3 the courts ha-e found
against +hysicians for failing to $arn a third +arty a*out a +atient?s seiBures3
failing to $arn a third +arty of the danger of infection from a +atient?s $ound3
failing to $arn neigh*ors and others li-ing in +ro6imity to +atients $ith
contagious diseases3 and failing to $arn a $oman that a +atient $as
contem+lating her murder.
n s+ite of its -ital im+ortance3 the duty to maintain confidentiality is
*est -ie$ed as a prima facie (not a*solute o*ligation that may *e
o-erridden $hen it conflicts $ith stronger moral duties. "or e6am+le3 $hen a
+atient threatens to harm others3 emergency +hysicians may need to *reach
confidentiality in order to +rotect the needs of identifia*le -ictims. The
decision to re-eal information to +re-ent harm should *e *ased on the
certainty3 duration and magnitude of the harm and the +ossi*ility of
alternati-e methods for a-oiding harm $hich do not re5uire infringement of
confidentiality.
!tudy "uestions
1. Should you re+ort the +atient in this case to the !M' 7hat are theconflicting ethical +rinci+les
. f the +atient $as a highly -isi*le +u*lic figure $hat3 if anything3 $ouldyou re+ort to either the media or !M'
@. f the +atient -oluntarily agreed not to dri-e $ould this affect yourdecision to re+ort
BibliographyAmerican Medical Association/ Council on Ethical and Judicial Affairs/ Currento+inions of the Council on Ethical and Judicial Affairs3 Chicago3 19>;3 I.=9.
Annas GJ/The rights of +atients/ The *asic AC#8 guide to +atients rights nded3 #i*rary of Congress catalogingin,u*lication !ata3 19>93 ++.1<19.
Mc!onald 0A/ Ethical +ro*lems for +hysicians raised *y A!S and 2'infection/ Conflicting legal o*ligations of confidentiality and disclosureS+ecialty #a$ !igest 2ealth Care 199=: 1@4/<4.
Siegel !M/ Confidentiality in Emergency Ris% Management ACE,3 !allas3 ++.1>11>4.
,. The $hysician)$atient #elationshipB. Truth telling and Counication
Objectives
1. E6+lain $hy truth telling is im+ortant.
. !iscuss circumstances $hen one might not tell a +atient the truth.
@. E6+lain the ethical foundations mandating honest +atient+hysician
communication.
4. !iscuss *arriers to effecti-e communication in the E!.
A ; yearold man $ith a ;= +ac% year history of smo%ing comes to the
emergency de+artment $ith shortness of *reath. 2is chest 6ray sho$s alarge mass. n +re+aring to admit the +atient3 he as%s $hat his 6ray sho$s.7hen told of the mass3 $hich you thin% is +ro*a*ly cancer3 the +atient as%s3t?s not li%ely to *e cancer3 is it3 doctor Dou say3 7e can?t *e sure at thistime. The +atient +ersists in %no$ing $hat you thin% it is. 7hat do you tellhim
Telling the truth may seem to *e a straight for$ard and ancient ethical
+rinci+le in health care. Certainly3 religious and moral codes ha-e +roscri*ed
lying3 from the Ten Commandments of Mosaic la$ to the $ritings of St.
Augustine. 2o$e-er3 the duty of truth telling in medicine has actually only
recently *ecome an ethical issue and in certain cultures such as Ja+an and
taly3 truthtelling is not the current norm. The 2i++ocratic oath does not
ma%e any mention of truth telling to +atients3 nor is telling the truth +art of
the 2i++ocratic tradition. The +re-ailing ethic su++orted *y Thomas ,erci-al
in his 1>=@ ,rinci+les of Ethics $as one of *ene-olent dece+tion: he
recommended that *ad ne$s *e %e+t from +atients to a-oid se-ere
reactions. The AMA?s first Code of Ethics in 1>4< +er+etuated this attitude.
This *ene-olent dece+tion $as ustified *y the +rinci+le of nonmaleficence
and continued into this century. n 19;13 9= of +hysicians still $ould not
com+assionately inform the +atient of *ad ne$s so that she or he is a*le to
control the medical decision ma%ing +rocess. This route may *e
uncomforta*le for the +atient and the +hysicians3 *ut the *enefits are greater
for +atients $hen +hysician and +atient engage in $hat has *een
a++ro+riately called braving the truth.
!tudy "uestions1. 7hat ans$er should *e gi-en to the +atient in this situation
. Dou diagnose a +atient $ith gonorrhea and *elie-e his $ife needstreatment. 2e as%s you to treat her3 *ut not tell her no$ she ac5uiredthe infection. 7hat should you say to the man?s $ife
@. A +atient comes to the emergency de+artment re5uesting o+iate +ainmedication for his *ac% +ain. 2e is %no$n to ha-e a history of druga*use. Dou +rescri*e an inecta*le antiinflammatory medication. The+atient as%s $hat he is getting. s it ethically ustified to lie or stretchthe truth !oes it ma%e a difference if the +atient has engaged indece+tion
Bibliography
)o-ac% !23 !etering 0J3 Arnold R et al/ ,hysicians attitudes to$ard usingdece+tion to resol-e difficult ethical +ro*lems JAMA 19>9: ;1/9>=9>.
,ellegrino E!/ s truth telling to the +atient a cultural artifact JAMA 199:;>/1<@41<@.
Schmidt TA3 )orton R#3 Tolle S7/ Sudden death in the E!/ Educatingresidents to com+assionately inform families J Emerg Med 199: 1=/;4@;4<.
,. The $hysician)$atient #elationshipC. Copassion and Epathy
Objectives
1. !escri*e the im+ortance of com+assion and em+athy in the E!.
. !escri*e ho$ com+assion and em+athy im+ro-e +atient care3
+hysician satisfaction3 and +atient satisfaction.
A +atient $ith metastatic terminal +rostate cancer comes to the E! for a+ain shot. 2e is on !ilaudid3 *ut lately the *one +ain is se-ere. 2e isuna*le to ta%e oral medications *ecause of se-ere nausea and -omiting. 2eis an6ious and frightened a*out dying. The de+artment is *usy3 *ut he $antsto tal% to you a*out his fears. 7hat ethical +rinci+les a++ly to this situation
Although em+athy is a desira*le attri*ute of health care +ro-iders3 it is
not contained $ithin the ethical +rinci+les3 *ut rather +ro-ides de+th and
human feeling to them. Em+athy is a central tenant of all as+ects of medical
ethics3 $ithout $hich the +rinci+les are *arren3 lifeless and lac%ing in color.
t is this a*ility to trade +laces emotionally $ith the sic% +erson that allo$s
health care +ro-iders to feel the anguish of illness and struggle to treat the
anguish e-en if the illness cannot *e cured. Em+athy is the feeling am
you or could *e you3 $hile sym+athy creates the message3 $ant to
hel+ you. Throughout history +hysicians did little *ut +ro-ide a caring3
em+athetic ear to +atients for $hom they had no treatment.
t is easy to *e nice to +atients $hom $e li%e and $ho ha-e illnesses
$hich im+ress us. Com+assion and em+athy are harder to feel $hen the
+atients are distasteful and noncom+liant. Maor tragedy may rarely mo-e
us3 $e may scoff at the minor com+laints $hich generate so much concern.
f $e neither understand nor connect $ith the grief3 fear and concern of our
+atients3 ho$e-er3 $e cannot address the feelings. gnoring the emotional
com+onent of +atients and families lea-es them unsatisfied and lea-es the
,I. Issues #elated to -usticeA. ealth Care #ationing
Objectives
1. !efine rationing.
. !efine allocation.
@. E6+lain ho$ rationing and allocation im+act emergency care.
A 4 year old man cuts his finger and then goes to the emergencyde+artment for treatment. n the E! he is noted to ha-e hy+ertension. The+atient states that he $as on medication for hy+ertension. 2o$e-er3*ecause he lost his health care co-erage he has not seen a +hysician and no
longer ta%es his medication. 2e is gi-en a +rescri+tion for a once a day ACEinhi*itor3 and the +hone num*ers of se-eral +hysicians. 7hen he goes to the+harmacy3 he learns that the medication is -ery e6+ensi-e. 2e contactseach of the +hysicians to $hom he $as referred and none of them $ill acce+tne$ uninsured +atients. 2e is referred to a local clinic3 $hich has a @ month$aiting list. 0ecause he $as +rescri*ed only enough medications for t$o$ee%s3 he returns to the E! for follo$u+.
!istri*uti-e ustice3 a *asic +rinci+le of medical ethics3 demands that $e
see% a morally correct distri*ution of *enefits and *urdens in society.
!istri*uti-e ustice re5uires an e5uita*le3 *ut not necessarily3 an e5ual
allocation of health care resources. )orman !aniels has descri*ed e5uita*le
distri*ution as re5uiring that there *e no information *arriers3 financial
*arriers or su++ly anomalies $hich +re-ent access to a decent *asic
minimum of health care.
!istri*uti-e ustice affects allocation of health care resources at three
se+arate le-els. "irst3 health care is *ut one of many societal interests.
7hen society allocates its resources3 health care com+etes $ith other
interests including housing3 education3 defense and the en-ironment.
Currently health care accounts for 14 of the gross national +roduct (G),3
and has *een gro$ing more ra+idly than any other go-ernment +rogram.
Callahan !/ Rationing medical +rogress/ the $ay to afforda*le health care. )Engl J Med 199=:@/1>1=1>1@.
!aniels )/ Just 2ealth Care Cam*ridge 8ni-ersity ,ress3 Cam*ridge3 19>.Eddy !M/ Rationing *y +atient choice. JAMA 1991:;/1=1=>.
serson &'/ Assessing -alues/ Rationing emergency de+artment care. Am JEmerg Med 199:1=/;@;4.
Society for Academic Emergency Medicine Ethics Committee/ An ethicalfoundation for health care/ An emergency medicine +ers+ecti-e Ann ofEmerg Med 199: 1/1@>11@><.
1. !efine the Good Samaritan statute in your state.
. E6+lain the a++lica*ility of the Good Samaritan statute to emergency
+hysicians in the +rehos+ital setting and in the Emergency !e+artment.
@. !efine your ethical and legal duty to +atients $ho +resent to the E!.
A +atient +resents to the emergency de+artment $ith nausea3 -omiting3 andmild diarrhea. The +atient *elongs to an 2M $hich re5uires +rea++ro-alfor emergency care. The 2M denies a++ro-al for the +atient to *e seen in
the E!3 since the +atient has no fe-er3 no significant a*dominal +ain3 and isnot dehydrated.
Emergency +hysicians ha-e *oth an ethical and legal duty to e-aluate
and treat any +atient $ho re5uests treatment. These +atients must at least
*e screened to ensure that no illness e6ists that $ill cause harm to the
+atient if untreated. This duty is *ased on the +rinci+les of *eneficence and
nonmaleficence as $ell as ustice. This o*ligation also has *een codified into
federal la$ *y the C0RA legislation. Reim*ursement issues do not affect
this duty: all +atients must *e e-aluated regardless of a*ility to +ay. f
+otentially significant illness or inury is +resent3 the +atient must *e
sta*iliBed or treated.
2ealth care reform and managed care are going to add ne$ strains to
emergency +hysicians? traditional role of +ro-iding uni-ersal access. n an
effort to control costs3 more third +arty +ayors are going to e6+ect
gate%ee+ers to limit access to s+ecialists and other ser-ices. )onetheless3
emergency de+artments must maintain their a-aila*ility to all +atients $ho
see% ser-ices3 and at a minimum screen +atients to determine the e6tent of
their urgent medical need.
2o$e-er3 other circumstances do e6ist $hich may limit the o*ligation
to treat +atients. Although all health care +ro-iders assume some +ersonal
ris% in choosing to treat +atients3 emergency +hysicians do not ha-e to +lace
themsel-es in e6cessi-e +hysical danger. ,atients $ho are threatening
+hysical harm to staff or other +atients do not ha-e a right to treatment.
7ea+ons may also *e remo-ed from +atients as a condition of treatment.
7e do ha-e an ethical o*ligation to treat +atients des+ite the ris% of
e6+osure to contagious diseases.
n addition to defining res+onsi*ility of health care $or%ers on the o*3
society has an interest in +romoting the $illingness of +eo+le $ith health
care e6+ertise to assist others in need e-en $hen the +erson $ith e6+ertise
is not on the o*. Good Samaritan statutes ha-e *een instituted to ser-e
this end. These la$s generally state that a +erson $ho has no duty to
another and e6+ects no +ayment for ser-ices is +rotected *y la$ as long as
no gross and $illful negligence is committed. The Good Samaritan rule
does not generally a++ly to +hysicians in the emergency de+artment since a
duty is generally recogniBed to all +atients +resent3 *ut $ould a++ly to an
emergency +hysician $ho comes u+on an automo*ile accident or $itnesses a
cardiac arrest.
!tudy "uestions
1. 7hat is the duty of the emergency +hysician to the +atient in this case
. 8nder $hat circumstances might you refuse treatment to a +atient
@. s it acce+ta*le for the emergency +hysician to loo% at the +atient3 *rieflye6amine the a*domen3 and +ro-ide detailed3 $ritten instructions of signs andsym+toms that signify an emergency
American College of Emergency ,hysicians/ Emergency care/ res+onsi*ilitiesand +rinci+les. +olicy statement3 June 1991.
American College of Emergency ,hysicians/ Guidelines concerning $or%sto++ages and slo$do$ns. Ann Emerg Med 19>:14/<<.
Curran 7J/ Economic and legal considerations in emergency care. ) Engl JMed 19>:@1/@<4@<.
!erlet R73 )ishio !A/ Refusing care to +atients $ho +resent to anemergency de+artment/ Ann Emerg Med 199=/19/;;<. serson &'/ Refusal of care/ the ethical dilemma. (letter Ann Emerg Med199=:19/119<.
Miles S2/ 7hat are $e teaching a*out indigent +atients JAMA199:;>/;1;.
Sha$ &)3 Sel*st SM3 Gill "M/ ndigent children $ho are denied care in theemergency de+artment. Ann Emerg Med 199=:19/9;.
Kuger A/ +rofessional res+onsi*ilities in the A!S generation. 2astings CentRe+ June 19><:1</1;=.
1. !escri*e the ethical issues surrounding the use of animals for teaching
and research.
. !escri*e the ethical issues surrounding the use of the ne$ly dead for
education.
Emergency medicine +hysicians attem+ted cardiac resuscitation of an >>year old +atient. Efforts $ere discontinued after @ minutes. ne of theresidents as%ed if anyone $ould mind if he e6tu*ated and reintu*ated the+atient to +ractice.
Clinical Teaching
A maor o*ligation of academic +hysicians is to ensure that future
generations of +hysicians +ossess the re5uisite s%ills to effecti-ely and
e6+ertly +ro-ide medical care. Emergency medicine +hysicians and allied
+rofessionals3 themsel-es3 share an o*ligation to *e s%illed and com+etent
$hen they hold themsel-es out as medical +rofessionals. The uns%illed
+rofessionalintraining must ac5uire the +rofessional attri*utes +rior to
assuming full res+onsi*ility for +atient care. These +rofessional attri*utes
include the re5uisite %no$ledge3 a++ro+riate *eha-ior3 and technical a*ilities.
Educational +rograms must struggle $ith the *alance *et$een the
resident?s need for graded res+onsi*ility3 and the +atient?s right to *e treated
*y a fully 5ualified +hysician. n the +ast3 an im+licit assum+tion $as made
that indigent +atients +aid for their health care *y allo$ing learners to treat
them. 7ith health care reform and uni-ersal insurance this assum+tion may
need to change. "aculty +hysicians $ill *e e6+ected to *e more directly
in-ol-ed in the care of all +atients treated in the emergency de+artment. At
1. !iscuss +romotional offerings that are clearly not to *e acce+ted *y+hysicians.
. E6+lain circumstances $hen gifts of nominal -alue can *e acce+ted.
@. E6+lain $hy the relationshi+ $ith industry must remain ethicallya++ro+riate.
A drug com+any re+resentati-e in the emergency de+artment as%s to s+ea%$ith the senior resident for a moment. The senior resident sits $ith there+resentati-e in the charting area3 and they discuss the -alue of hiscom+any?s ne$ anti*iotic for an emergency de+artment use3 -ersus other+roducts on the mar%et. The re+resentati-e distri*utes +romotional materialon the anti*iotic to the resident and other residents in the area. There+resentati-e then reaches into his shoulder *ag and +asses out com+any+ens3 note +ads3 and +enlights to the residents3 and +resents a te6t*oo% oninfectious diseases for the resident?s E! li*rary. The resident than%s there+resentati-e for his gratuities. The re+resentati-e +asses out his card andoffers to *ring food to one of the future resident conferences3 or +ay for anoted emergency medicine s+ea%er to come and +resent a grand rounds oninfectious diseases in the emergency de+artment.
The interaction *et$een emergency medicine residents and the
*iomedical industry has recently *ecome a matter of concern *y
organiBations $ithin emergency medicine. As the *iomedical industry must
com+ete in a free enter+rise mar%et system3 they must ad-ertise +roducts to
+hysician consumers. )e-ertheless3 +hysicians must *ase their
+harmacothera+y on the scientific literature. ,romotional materials
de-elo+ed *y the *iomedical industry may not *e designed to gi-e +hysicians
o*ecti-e scientific data regarding a +roduct. ,hysicians may not *e
a$are of ho$ undue influence3 +romotional materials and gift gi-ing im+acts
their clinical decisions. Additionally3 *iomedical industry re+resentati-es are