ETHICAL ISSUES IN EMERGENCY MEDICINE
From Emergency Medicine 2008—Moving Forward, sponsored by Mayo Clinic Scottsdale College of Medicine, Mayo
School of Continuing Medical Education, in cooperation with Maricopa Integrated Health Systems, and endorsed by the
Arizona College of Emergency Physicians
Peter Rosen, MD, Senior Lecturer, Harvard Medical School, Boston, MA
Educational Objectives
| The goal of this program is to provide guidance about ethical issues that may occur in emergency medicine. After
hearing and assimilating this program, the clinician will be better able to:
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 | 1. Explain the importance of having a well worked-out system of ethics in place before practicing in the
emergency department (ED).
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| 2. Define ethics and law, and describe the difference in these principles of conduct.
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| 3. Explore the current concept of an ethical relationship between the physician and the patient.
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| 4. List some of the general ethical problems that may be encountered in the ED.
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| 5. Describe the recommended approach to resolving ethical dilemmas presented in case examples.
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Faculty Disclosure
In adherence To ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the
planning committee to disclose relevant financial relationships within the past 12 months that might create any personal
conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes
quality in health care and not a proprietary business or commercial interest. For this program, Dr. Rosen and the planning
committee reported nothing to disclose.
Acknowledgements
Dr. Rosen spoke at Emergency Medicine 2008—Moving Forward, held March 31 to April 2, 2008, in Scottsdale, AZ,
and sponsored by the Mayo Clinic Scottsdale College of Medicine, Mayo School of Continuing Medical Education,
in cooperation with Maricopa Integrated Health Systems, and endorsed by the Arizona College of Emergency Physicians.
The Audio-Digest Foundation thanks Dr. Rosen and the sponsors for their cooperation in the production of this
program.
| Introductory remarks: regardless of training or knowledge, lack of established ethics system in practice prevents
clinician from acting when problem arises; not every scenario that appears to present ethical problem actually requires
ethical decision (sometimes problem requires factual decision; sometimes physician’s problem is lack of
knowledge or poor judgment); without having well worked-out ethics system in place, emergency department (ED)
physician likely to commit preventable error (ie, something that was physician’s responsibility, that he or she could
have done but chose not to do for wrong reasons)
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| Definitions: ethics—principles of conduct; defined by group that governs individual (can be small group [eg, family];
religious group, or employing organization); in reality, no definable universal ethic (ie, no moral precept to
which exception cannot be found); thus, in considering ethical dilemma, one must apply judgment; law—
essentially same as ethics, except that group that dictates law has right to punish individual for not following it; in
general, external authority required to write law
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| Ethical attitudes: attitudes towards trauma different from attitudes towards disease; physician’s attitude towards
disease makes difference in his or her willingness to handle it (eg, speaker compares response of hospitals and
health care workers to patients with poliomyelitis vs response to those with AIDS); suggests that physicians’ attitudes
towards disease reflect their own ethics and morals rather than medical reality
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| Medical ethics of Greeks: Hippocrates (first to suggest that disease not punishment of gods for sin; that it happens
to normal people, and thus, physicians can intervene and attempt to treat disease without risking overturning gods’
judgment); cultural dependence (Greeks had no hesitation about using slaves as research subjects); Greeks did not
believe in abortion but practiced infanticide
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| Middle Ages: ethics defined by Catholic church (involved in every phase of life, including health and welfare;
when excommunicated, people not entitled to food, shelter, or medical care, which was largely administered in
monasteries); trauma care delivered on site, usually by nonclergy
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| Legacy of Reformation: science progressed because people began to question authority and practice scientific experimentation
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| Hebraic medical ethics: Jewish culture respectful of life and health; however, also respectful of body, which
makes caring for orthodox Jews somewhat difficult (eg, they do not want to have amputations, as they believe body
must be whole on Judgment Day)
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| Modern medical ethics: deontology—traditional position; argues by precepts; utilitarianism—cannot be avoided
in modern clinical ethics; flaws in utilitarianism well known (what is good for majority not necessarily good for
minority; just because more people vote for something does not make it right thing to do); thus, speaker suggests
utilitarianism must be tempered with judgment
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| Physician roles: today, physicians told that worst form of relationship with patient is paternalism; yet in some situations,
patient cannot understand what he or she needs and cannot make informed decision; speaker believes that
physicians have degree of knowledge and sophistication that cannot be obtained by nonphysicians; physician must
be trustable expert (ie, person who can be trusted to make judgments in best interests of patient’s health, as opposed
to physician’s financial interest); “and if that isn’t paternalism, I don’t know what is”; modern concept of ethical
relationship— physician should form contract with patient; however, speaker does not see contract as defining anything
but trust, since no way to legally bind person to do right thing; clearly, physicians more than technicians, and
speaker does not think they have done their job by just offering series of choices and trying to “sell” patient on best
option; speaker thinks physician should be adviser, since he or she knows more about problem than patient does
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| General ethical problems: futility of treatment—no easy definitions of futile treatment, but many situations in
which it occurs; patient’s family often has wish for magical outcome that cannot be delivered; 3 missions of
medicine—1) to cure disease; 2) to alleviate ravages of disease, even when cure not possible; 3) to give comfort,
even when cure or alleviation of ravages of disease cannot be accomplished; in this scenario, question becomes
how to give comfort without subjecting patient to futile treatment; paradigm conflicts—increasing number of patients
convinced they can influence outcome just by thinking correctly; many have paradigm that physicians do not
have (ie, they believe that right outcome can be achieved if physician would just recommend right health food or
organic compound); religious conflicts—another frequent source of ethical problems, especially when dealing with
religious groups such as Jehovah’s Witnesses; economic conflicts— in current economic model for medical care,
people convinced they have right to any kind of care they want; however, we have not figured out how to pay for it
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| Case 1: 34-yr-old man in high-speed crash; right leg mangled, and after all attempts to salvage it, clear that leg had
no blood supply; orthopedic surgeon recommended amputation; patient refused
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| Comments: not unethical for patient to decide that he or she does not want recommended treatment; this does not
mean physician can abandon patient; speaker has seen patients sent out of ED and told to come back when they
are ready to accept recommended treatment; much better to try to determine why patient cannot accept recommended
therapy, and if possible, to involve family in decision-making process; in this case, young man’s father
had died after having his leg amputated, and patient thought he would also die if leg amputated; correct approach
to managing these patients not always comfortable and does not always have positive outcome
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| Case 2: patient stabbed in abdomen; refused operation, and anesthesiologist refused to continue unless psychiatrist
certified patient incompetent; speaker criticizes protocol that requires certification by psychiatrist or judge; speaker
believes ED physician much better qualified to determine whether patient competent, because he or she knows
more about circumstances of case (speaker suggests that the more people involved in critical decisions, the more
likely they will be made in wrong direction)
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| Case 3: 39-yr-old man; crashed in ultralight aircraft; came into ED with multisystem trauma; patient stated he was
Jehovah’s Witness, and would accept any treatment except blood transfusion
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| Comments: medicine is inexact science, and physician must find means of helping patient to accept physician’s
paradigm while physician also accepts patient’s paradigm; “some care is better than no care,” and speaker has
become much less rigid in thinking patient has to do treatment exactly physician’s way or not at all; unfortunately,
in some situations, physician faced with compromise of care which he or she knows will not work; must
then decide how to best present options to patient (time constraints biggest problem); example—difficulty with
treating children in renal failure whose religion prohibited blood trasfusion; surgeons had to ask judge to assign
custody of child to university so they could give blood and perform necessary surgery; ethical dilemma—what if
parents then consider child so contaminated as to no longer fit into their religious paradigm? why is it acceptable
for physician to tell parents that their system of belief does not apply to their children? judges maintain that child
must be kept alive until legally old enough to make own decision
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| More on case 3: patient died of his injuries because of lack of blood; speaker questions why patient entitled to put
his wife and children in financial jeopardy (“why can’t we just save his life and let him get back to his religion
later?”); modern medical ethics says he has this choice
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| Case 4: patient who has medical problem that he does not want reported (pilot brought into ED after grand mal seizure
and minor automobile crash)
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| Comments: in California, law requires physician to report every patient with seizure or altered consciousness to Department
of Motor Vehicles (DMV); easier because of law, but dealing with this type of patient can be difficult;
places physician in bind both legally and morally; speaker suggests physician can temporize, telling patient that
ED is not time to make decision and that he or she will not report anything right away, and asking patient to come
back later with his or her spouse/partner to talk about what they should do; in this case, pilot agreed to reporting
for safety reasons; however, some patients less reasonable, and physician must make decision on how much autonomy
and privacy patient entitled to and how much physician owes to society; similar situation—speaker ordered
by court to remove bullet from patient’s leg for forensics testing (speaker questioned benefit of operation
and took position that he could not subject patient to surgery); physicians have to make their own decisions in
these cases; physicians have to decide what laws they are willing to abide by and when they are not willing to let
someone make them practice in way they object to
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| Case 5: rural ED settting; 49-yr-old man with shotgun blast to head arrives simultaneously with 5 teenagers from automobile
crash; everyone needs blood, but according to blood bank, only 5 U available
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| Comments: according to ethics books, correct answer to question of who should get blood is “flip a coin” (ie, everybody
has equal right to scarce resource, so decision must be based on equal probability for everybody);
speaker asks how many people would withhold blood from automobile accident victims to give it to man who
had just murdered somebody, and calls this useful utilitarian argument; speaker thinks it useful to apply utilitarian
argument to resolve this conflict, but tells audience that ethicists would not agree; often, when one looks at
utilitarian argument, one discovers that information incomplete; ask for more data when making ethical decisions,
rather than basing decision on initial information; speaker thinks most physicians more comfortable trying
to meet more than one objective with decision (which speaker feels is point of utilitarianism)
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| Case 6: 29-yr-old man attempts suicide with pistol, inflicting gunshot wound to head; although bullet crossed midline,
and family told patient would not live through night, patient resumes spontaneous respiration; family refuses
permission for neurosurgical intervention
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| Comments: based on plain film of patient’s skull, survival not likely; patient admitted to neurosurgical service and extubated,
with expectation that he would die that night; patient did not die; next morning, new neurosurgical team reintubated
him and said they needed to take him to operating room (OR) and debride bullet wound or patient would
die from abscess; family responded that hospital had already said he would die last night, so why should they let
neurosurgeons operate and run up large bill? speaker called in to consult—upon speaking with family, he discovered
that due to change in neurosurgical teams, family had been told one thing in the middle of night and another
thing next morning; they were angry about patient attempting suicide; they were unhappy, did not know where to
go, and so would not let anybody do anything; speaker explained that physicians want same outcome that family
wants, ie, that son be restored to what he was before he shot himself; only way to get there was by operating on him
to prevent infection and allow his brain to heal; depression treatable, but only if patient alive; family agreed and
consented to surgery; comment—surgery could have been done without family’s permission, because even someone’s
guardian (unless court-appointed) cannot prevent life-saving care for that person; had family refused to consent
to surgery, lawsuit would have resulted; speaker thinks it much better to try to get consent from family by
dealing with source of anger and doing whatever possible to reassure them
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Suggested Reading
Anderson-Shaw L et al: Ethics consultation in the emergency department. JONAS Health Law Ethics Regul 9:32,
2007; Baren JM: Ethical dilemmas in the care of minors in the emergency department. Emerg Med Clin North Am
24:619, 2006; Bookman K, Abbott J: Ethics seminars: withdrawal of treatment in the emergency department--
when and how? Acad Emerg Med 13:1328, 2006; Derse AR: Ethics and the law in emergency medicine. Emerg Med
Clin North Am 24:547, 2006; Derse AR: What part of “no” don’t you understand? Patient refusal of recommended
treatment in the emergency department. Mt Sinai J Med 72:221, 2005; Geiderman JM et al: Privacy and confidentiality
in emergency medicine: obligations and challenges. Emerg Med Clin North Am 24:633, 2006; Goel A, Aggarwal
P: Making choices in an emergency room. Indian J Med Ethics 3:105, 2006; Iserson KV: Ethical principles--
emergency medicine. Emerg Med Clin North Am 24:513, 2006; Iserson KV: The three faces of "yes": consent for
emergency department procedures. Am J Bioeth 7:42, 2007; Kreismann E et al: The interface: ethical decision
making, medical toxicology, and emergency medicine. Emerg Med Clin North Am 24:769, 2006; Larkin GL: Ethical
issues in emergency & disaster medicine. Lijec Vjesn 129 Suppl 5:107, 2007; Marco CA et al: Determination of
“futility” in emergency medicine. Ann Emerg Med 35:604, 2000; Moskop JC: Informed consent and refusal of treatment:
challenges for emergency physicians. Emerg Med Clin North Am 24:605, 2006; No authors listed: Code of
ethics for emergency physicians. Ann Emerg Med 43:686, 2004; Pauls M et al: Ethics in the trenches: preparing for
ethical challenges in the emergency department. CJEM 4:45, 2002; Pauls M et al: Ethics in the trenches: Part 2.
Case studies of ethical challenges in emergency medicine. CJEM 6:363, 2004; Quest TE, Franks NM: Vulnerable
populations: cultural and spiritual direction. Emerg Med Clin North Am 24:687, 2006; Simon JR: Refusal of care: the
physician-patient relationship and decision making capacity. Ann Emerg Med 50:456, 2007; Verheijde JL et al:
Defining the scope of implied consent in the emergency department: shortchanging patients' right to self determination.
Am J Bioeth 7:51, 2007; Witting MD, Iserson K: Ethics and Mandatory Reporting Laws: Emergency Physicians'
Response. J Emerg Med [Epub ahead of print], 2008; Woolley S: Jehovah's Witnesses in the emergency
department: what are their rights? Emerg Med J 22:869, 2005.
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