Conscientious objections (bad orders)

An 18-year-old asthmatic with an acute exacerbation of her condition arrives in the emergency department. The examining physician asks the nurse to give the patient 0.3 cc of epinephrine, 1:10,000 dilution.

Physician attitudes toward patients

An 8-year-old child with a minor head injury is brought in to the emergency department and is judged by the physician to be completely normal. The parents say that a sibling had a skull fracture under similar circumstances and that they would sleep much better if a skull x-ray were taken.

What is ethics?

There is considerable difference of opinion and even confusion about what ethics is. Sometimes, the term “ethics” is used to refer to the conduct of a person or a group, as when it is said “His ethics are questionable”.

An approach to ethical problems in emergency medicine

A two-car accident occurs in central Amityville. The driver of one car is taken to Amity General, where he is found to be severely injured. The driver of the other vehicle is taken in critical condition to the Crosstown emergency department (ED).

Informed participation in decisions

A 50-year-old man is brought to the emergency department for evaluation of lethargy. The patient has alcohol on his breath. There were also some sleeping pills in his apartment when his friend found him.

Solo nurse in the emergency department

A 24-year-old man arrives in the small community emergency department in the middle of the night with epistaxis (nosebleed). The nursing staff are the only ones present in the hospital.

Answering questions from “relatives” on the phone or in person

The emergency department in the hospital nearest a certain college campus has admitted four 22-year-old college seniors in the past half hour.

Are community standards for when to resuscitate valid?

A 24-year-old man is involved in a motorcycle accident one block from the com­munity hospital. An empty ambulance passes by, scoops him up, and brings him into the emergency department.

Role of emergency medical technicians and paramedics: observer-trainees

The paramedic trainee has had three years of ambulance experience and eighty additional hours of classroom training in emergency care. He is currently enrolled in additional classes.

Legal requirements for notification

A 30-year-old man comes to the emergency department claiming that he has been shot. He states that he is willing to undergo emergency tests and treatment only if the physician agrees not to call the police and that he will leave the emergency department if the physician does not promise this.

Denial of antipregnancy prophylaxis to a rape victim

A 20-year-old woman is brought to St. Agnes Hospital emergency department after being raped. Medical treatment, begun immediately by emergency department personnel, includes psychological support, a general physical examination, and the standard me­dicolegal rape examination.


Paramedics are called to the scene of a possible drug overdose by a man who told them that his wife had taken 50 sleeping pills about 15 minutes earlier. When the paramedics arrive, they find the woman waiting for them in the living room.

Physician calls concerning DNR orders

A community physician on staff at Alpha Hospital calls the emergency department there and informs the physician on duty that a patient of his, a 43-year-old woman, is going to arrive in extremis from “terminal” breast carcinoma.

Uncertain diagnosis and the uncooperative patient

A 23-year-old female drug abuser presents with a history of malaise, generalized weakness, and fevers for the past month. She uses heroin intravenously and several other drugs intermittently.

No payment — adult or child

A 24-year-old unemployed man presents to the emergency department with a complaint of a sore knee which has not been injured recently but occasionally gives way (most likely, a chronic injury of the cartilage of the knee joint).

Referral back to a poor primary health care provider

A 24-year-old woman arrives in the emergency department complaining that she has felt dizzy for the past month. On this occasion, she was in town shopping when she felt dizzy, and her mother brought her in.

Human subjects in cardiopulmonary resuscitation research

Researchers have shown, in an animal model, that alterations in the technique of cardiopulmonary resuscitation improve blood flow to vital organs and increase survival of animals in cardiac arrest.

Resuscitating a patient with no vital signs

A 25-year-old man is involved in a motorcycle accident and suffers multisystem trauma. When the paramedics arrive on the scene, the patient has no blood pressure, pulse, or spontaneous respirations.

Allocation of resources: economic factors

A “wino” with pneumonia and septic shock arrives in an emergency department, obviously requiring admission to an ICU bed, but the hospital has no available beds.

Pediatric patients — do we try too hard?

A two-year-old child is brought into the emergency department on a warm summer day after having been found floating in a backyard swimming pool.

Responsibilities for monitoring and maintaining quality of care - mistakes

A 14-week-old infant is brought to the emergency department at 3 a.m. by his mother, who explains that he has been irritable all night and not sleeping well. On exam, the patient has a temperature of 37.9°C.

Telephone orders from a local physician

A physician on the staff of Omega Hospital calls the Omega emergency department and speaks to one of the nurses. He says that a patient of his is coming in with a migraine headache, and he wants the nurse to give the patient 100 mg of Demeral intramuscularly (a normal adult dose).

Fee-for-service system of care

A 28-year-old female executive was jogging on her lunch hour and twisted her ankle. Although the soft tissues are swollen, and some support for the ankle is indicated, no fracture is evident on x-ray.

Good samaritan behavior and failure-to-stop laws

You are driving to work when you come upon a two-car motor vehicle accident which has obviously just occurred. It appears that a number of people may be injured.

Rights of minors

An eight-year-old boy walks into the emergency department saying he was riding his bicycle home from school and fell on his wrist. He lives only two blocks away, and because his wrist hurts, he decided to stop by the emergency department to determine whether any treatment is needed.

When not to resuscitate

Seventy-year-old Morris Brook is brought into the emergency department by ambulance. His family explains that his breathing has been getting progressively worse over the past two days and that he has metastatic cancer of the prostate for which he has been receiving only palliative treatment.

Allocation of resources: social and political factors

Two patients in the emergency department require admission to the intensive care unit (ICU). At this time only one bed is open, so one of the patients must be transferred to another hospital.

“Gatekeepers” role

A two-year-old child with a rectal temperature of 102°F is brought into the emer­gency department at 2:00 a.m. by his parents because of the fever. He is fussy and is pulling at his left ear.

Increased charges for third-party pay patients

The emergency physician began his shift an hour ago and has already seen five patients, all with the viral syndrome that is going around. None of these patients have insurance, so the physician bills them at a minimal rate for his services.

Delegating the notification of death to others

Paramedics were summoned to aid a 70-year-old woman in cardiac arrest. They attempted to resuscitate her, but on arrival at the emergency department the patient was still unresponsive and was pronounced dead.

Telephone consultations to families and other health care providers

A registered nurse working in a busy emergency department receives a call from a mother whose two-year-old child has diarrhea and is vomiting. The mother wants to know what to do.

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.

Legal setting of emergency medicine

Why have a legal introduction in a website on ethical issues in emergency medicine? Certainly not because ethics and law are synonymous, even though attempts to discuss ethical choices are frequently reduced by the pressures of the moment to worries about legal obligations and risks.

The question of competence

The next set of case studies, in which three patients with varying degrees of injury and different prognoses are described, is designed to raise the question of the role of the severity of the patient’s injury in the determination of his competence.

Security of the emergency medical service system (emss) radio network

Two paramedics radio to the hospital that they are bringing in a 54-year-old man with chronic lung disease. They state that he is on “10 or 20” medications, but he does not have them all with him, and he does not know what they are.

Human subjects in trauma research

The primary cause of mortality in children and young adults is trauma. Injuries from motor vehicle accidents, bicycle accidents, home injuries, and violent crime take a large toll of our young, otherwise healthy population.

Postmortem cesarean section: removing and resuscitating a fetus from a dead patient

A 16-year-old single girl arrives in the emergency department with a gunshot wound to the head. The entrance wound is just above one ear, and the exit, with brain protruding, is above the other ear (generally a rapidly lethal injury).

Resuscitation of an AIDS victim

A 30-year-old man collapses in the downtown area of a large city. He is thin and looks chronically ill. A friend is with him and asks people passing by if they know CPR.

Patient transfers

Two paramedics are called to the home of a 60-year-old man (Mr. Smith) suffering from chest pain. Vital signs reveal a blood pressure of 90/60, a pulse of 50 and irregular, and respirations of 24.

Physicians quality of life versus quality of patient care

One of Alpha Hospital’s emergency physicians has an opportunity to go on a four-day raft trip, a vacation he has been looking forward to for a long time.

Manipulative patient, irresponsible family, and nursing home “dump”

A 40-year-old man walks into a freestanding emergency clinic with a bloody bandage on his head. He explains that he had been in a fight earlier in the evening and is still bleeding; he thinks he probably needs stitches in his head.