Aspects of ethics in emergency medicine

A basic thesis of this website is that ethical problems are common in the emergency department – much more common than is usually recognized. The difficult ethical dilemmas of emergency medicine have not attracted the widespread attention enjoyed by other areas of medicine, however.

Most medical ethics websites tend to concentrate on care for chronic – or at least relatively stable – problems rather than on the acute, episodic care typical in the emergency department.

Much has been written about the moral problems raised by the treatment of Baby Doe, Baby Fae, and Karen Ann Quinlan, by abortion, by euthanasia, and so on.

In cases such as these, many of the important ethical decisions can be made only after reflection and deliberation and after a process of communication that reveals the values and interests of the patient and / or the patient’s family. Emergency care presents a very different picture, however.

Cases in the emer­gency department often involve acute changes in the patient’s health, and decisions with important ethical implications must be made immediately by health care professionals who are not familiar with the patient or his family.

Another peculiarity of emergency practice is the interdependence of emergency departments and various forms of emergency prehospital care.

The concept and systems of prehospital care have been developed only within the past decade. As these systems have evolved, they have created the need for new ethical choices.

For instance, paramedics sometimes must weigh conflicting responsibilities to their patients, base station hos­pitals, physicians, ambulance companies, and police authorities.

And they sometimes must deal with angry, hostile patients who are under the influence of alcohol or other drugs, making it very difficult for the paramedic to respect the patient’s autonomy while evaluating his competence and his medical condition.

Other problems relate to the issue of privacy. For example, how much information about a certain patient should be given over radio communications networks that may be monitored by people not associated with the medical treatment of the patient?

In order to appreciate fully the distinctive ethical dilemmas raised by emergency medicine, it is useful to contrast in detail the physician-patient relationship in the emergency department with that in other medical care settings.

These contrasts are perhaps most striking when emergency practice is compared with primary care practice. Table highlights some of the differences.

The ethical imlications of the differences between primary care and emergency care presented in Table are, in some cases, profound.

As is made clear throughout this website, emergency department professionals daily face difficult ethical dilemmas that are unknown or at least rare in other areas of medicine.

There are many different types of health care and healings: holistic medicine, faith healing, high-technology medicine, preventive medicine, and so on.

Generally, our so­ciety respects a competent adult’s right to seek whatever kind of medical care he wishes, even if he chooses to seek none at all for a life-threatening condition. Thus primary care physicians usually only see those (adult) patients who have chosen to enter the traditional medical care system.

In contrast, emergency departments often see patients who are brought in by someone else: victims of automobile accidents, drug abusers, attempted suicides, and so on.

These patients have not chosen to seek help in the emergency department; someone else has decided that that is the form of treatment they require.

For example, an ambulance driver will not deliver an accident victim to a Christian Science reading room even if the patient wants to go there; the victim is brought to an emergency department regardless of his belief systems and his desires to be elsewhere.

Thus the emergency department staff may have to deal with a patient whose value system conflicts strongly with theirs – for example, a Jehovah’s Witness who is a victim of an automobile accident and who needs blood transfusions.

Differences between Emergency Practice and Primary Care Practice.

Emergency Practice

  • Patient often is brought in by ambulance, police, etc.
  • Patient does not choose physician.
  • Physician must gain patient trust.
  • Physician does not know patient, family, values, etc.
  • Patient experiences an acute change in health.
  • Anxiety, pain, alcohol, and altered mental status are frequent.
  • Decisions are made quickly.
  • Physician makes decisions on his own.
  • Physician represents institution and medical staff.
  • Work environment is open and less controlled.
  • Physician frequently has a stressful work schedule.

Primary Care Practice

  • Patient chooses to enter medical care system.
  • Patient chooses physician.
  • Physician already enjoys patient’s confidence and trust.
  • Physician knows patient, family, values, etc.
  • Patient suffers from chronic medical problems.
  • Anxiety, pain, alcohol, and altered mental status are less frequent.
  • Usually there is time for reflection and deliberation.
  • Physician has a greater opportunity for consultations with the patient, family, other physicians, ethics committees, lawyers, courts, ethicists, etc.
  • Physician represents himself or medical group.
  • Work environment is private and controlled.
  • Work schedule is set or is canceled by the physician.

The patient who seeks primary care often chooses not only the medical care system but also the individual practitioner. A patient who continues to seek medical care from a primary care physician usually does so because he has confidence in that individual.

The advantages of this on-going relationship to the course of treatment are enormous: the physician is able to appreciate better the patients’s medical history, he is able to seek informed consent from the patient for all medical procedures, and the trust rela­tionship itself can sometimes be therapeutic.

In addition, the physician has the oppor­tunity to get to know the patient, the family, and their values.

The emergency department staff, on the other hand, is often confronted with a patient whom they do not know, who did not choose them and may not have confidence in them, and whose medical history may not be clear. The difficulties these factors present to providing good medical care are obvious.

Another difference between primary care practice and emergency medicine is based on the types of patients usually presented in the two settings.

In primary care practice, patients generally present with chronic medical problems, while patients who come to the emergency department usually do so because of acute changes – or at least the perception of acute changes – in their health.

In addition, patients in the emergency department are more frequently under the influence of alcohol or drugs and anxious and in great pain than are patients who come to the primary care physician’s office.

These factors may have critical effects on the patient’s ability to make rational decisions.

What is especially worrisome is that it is often difficult to determine whether the patient’s erratic behavior is a result of trauma or a chronic disability, and the extent to which the patient’s competence is compromised often can be determined accurately only in retrospect.

For instance, it is only after the emergency department team has restrained the hostile drunk and obtained a normal CT scan that they can determine that his irritability was not caused by a head injury.

Another difficulty raised by the type of cases frequently seen in the emergency department as opposed to those usually found in the primary care physician’s office is the lack of time available in which to make the right decision.

Emergency cases often require immediate action, often with no time to consult other physicians or the family and little time to review the patient’s medical history even if it is available.

Chronic care cases, on the other hand, usually allow time for reflection, deliberation, and consultation with a variety of sources: the family, hospital ethics committees, social workers, ethicists, clergy, the courts.

The health care professionals in the emergency department represent the hospital and entire medical staff.

Indeed, a patient may choose a particular emergency department because of the hospital’s reputation or because of the fact that his regular physician is on the medical staff.

Thus the emergency department staff has obligations not only to the patient but also to the hospital and medical staff and is expected to follow their rules, regulations, and requests.

Although the expectations often are less than fully exlicit, the emergency staffs contract frequently depends on the fulfillment of these latter obligations.

In contrast, the primary care physician often represents only himself or a small medical group, and so his or her obligations and responsibilities are more limited.

Primary care physicians are more in control of their environment than are emer­gency department staff members.

The physicians may have a private office in which to talk with patients and their families, a series of separate examination rooms, and a laboratory. All are very private and conducive to personal interaction.

In contrast, an emergency department is often divided into small cubicles with only thin shades dividing patients, and one patient can hear what is happening in the adjoining cubicle.

In addition, the emergency medical service personnel, nurses, security guards, police, and others generally walk freely throughout the emergency department. These factors make sen­sitive, private conversations difficult to accomplish.

Primary care physicians are more in control of their work schedules than are emergency department staff members.

For instance, a physician may set 45 minutes for a new patient, and 15 minutes for a revisit, with no appointments on Tuesday and Thursday mornings. And if the physician is sick, his or her secretary cancels all ap­pointments.

In contrast, the work schedules in the emergency department are erratic, not subject to the physician’s control, and often stressful.

Long shifts without food or rest are not uncommon in a busy emergency department. This raises questions con­cerning the quality of care provided at the end of a long and sleepless night.

The contrasts between emergency care and forms of practice other than primary care are sometimes not as pronounced.

For example, many patients who are treated at tertiary care facilities have no prior relationship with the physician who becomes re­sponsible for their care.

Nonetheless, the distinctive features occur more frequently in emergency practice than in other practice settings.

It is not surprising, then, that the ethical dilemmas in emergency medicine often differ profoundly from those in the other areas of medicine and that a detailed examination of the wide variety of these dilemmas is much needed.