Ethics Curriculum Emergency Medicine

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Ethics Curriculum for Emergency Medicine Residencies

1994

SAEM Ethics Committee James G Adams

Terri A Schmidt (ChairArthur R !erseGlenn C "reas

#e$is R Goldfran%&enneth ' serson)orm ! &al*fleisch

Samuel M &eimRo*ert & &no++Gregory # #ar%inMarc # ,ollac%!a-id , S%lar



Table of Contents

. ntroduction/ 0asic Ethical "oundations of Clinical Medicine

. A++lying Ethics to Emergency Medicine

. ssues Related to ,atient Autonomy

A. nformed Consent and Refusal

0. ,atient !ecision Ma%ing Ca+acity

C. Treatment of Minors

!. Ad-ance !irecti-es

'. End of #ife !ecisions

A. #imiting Resuscitation

0. "utility

'. The ,hysician,atient Relationshi+

A. Confidentiality

0. Truth Telling and Communication

C. Com+assion and Em+athy

'. ssues Related to Justice

A. 2ealth Care Rationing

0. !uty

C. Moral ssues in !isaster Medicine

!. Research

'. Teaching

'. ,hysician Relationshi+s $ith the 0iomedical ndustry



The +ur+ose of this manual is to +ro-ide a teaching guide to residency directors

and others res+onsi*le for teaching ethics to emergency medicine residents. The

goal is to +ro-ide residents $ith the information necessary to *e a*le to ma%e a

reasoned analysis of ethical conflicts and to allo$ them to de-elo+ the s%ill to

resol-e ethical dilemmas in an a++ro+riate manner.

After an introductory section3 the manual is di-ided into teaching modules.

Each module includes o*ecti-es3 an illustrati-e case3 a discussion3 study 5uestions3

and a *rief *i*liogra+hy. The o*ecti-es define *asic material a resident $ould *e

e6+ected to master after each session. The study 5uestions can *e used to focus

discussion3 +ro-ide *road understanding of the su*ect3 and stimulate thought.

Most of the 5uestions may not ha-e one correct ans$er. #i%e all of medicine3

*iomedical ethics is continually e6+anding. )o effort is made to co-er all as+ects of

each su*ect3 *ut rather3 an attem+t $as made to offer a short3 +ertinent analysis

for *oth the instructor and the resident. This is not intended to *e a com+lete te6t

on ethics in emergency medicine3 *ut a curriculum guide. This guide includes

modules $hich can *e taught to emergency medicine residents throughout their

training.

0efore s+ecific ethical issues are discussed3 the relationshi+ *et$een ethics

and the la$ must *e clarified. ,hysicians must loo% to the la$ for guidance3 *ut the

la$ does not +ro-ide the ans$er to many ethical +ro*lems. n addition3 statutes

may -ary su*stantially *et$een states. Ethical theory should guide +hysicians

to$ard a uni-ersally a++lica*le standard. The la$ may *e am*iguous3 so no clear

guidance is offered3 or it might *e -ery s+ecific3 a++lying only to cases $ith

su*stantially similar circumstances. The la$ also neither addresses the *readth of

ethical im+erati-es $hich o*ligate emergency +hysicians nor does it necessarily

reflect ethical *eha-ior. 7hile the la$ is limited in its a*ility to +ro-ide uni-ersal





I. Basic Ethical Foundation of Clinical Medicine

Objectives

1. !iscuss the moral +rinci+les that underlie the +ractice of medicine.

. !efine ethics.

@. !efine res+ect for autonomy.

4. !efine +aternalism.

. !efine *eneficence.

;. !efine nonmaleficence.

<. !efine ustice.

Ethics studies -alues and moral reasoning. )onnormati-e ethics descri*es

and analyBes moral *eliefs $ithout ma%ing a -alue udgement a*out right and

$rong. )ormati-e ethics attem+ts to define actions that are right and $rong. n

medicine3 the ethical challenge may include deciding *et$een the lesser of t$o

e-ils or the greater of t$o goods. ,u*lic +olicy3 formal codes3 guidelines3

regulations and clinical decision ma%ing should *e *ased on an ethical foundation.

"our +rinci+les are commonly thought to define $estern health care ethics/

res+ect for autonomy3 *eneficence3 nonmaleficence and ustice. The +riority each

is gi-en is determined *y the situation. )o +rinci+le al$ays ta%es +recedence o-er

another.

0eneficence and nonmaleficence are ancient tenants of health care ethics

em*odied in the #atin Primium non nocere3 a*o-e all do no harm. 7hile some

moral +hiloso+hers ma%e no distinction *et$een *eneficence and nonmaleficence3

others feel that a distinction should *e made. 0eneficence can *e -ie$ed as a

+ositi-e action and nonmaleficence as an a-oidance of a negati-e action. Thus3 at

a minimum3 +hysicians must not act in a $ay $hich is detrimental to +atients.



0eneficence re5uires +hysicians to act in the *est interests of their +atients.

,hysicians must *alance goods and +otential harms and act in the *est interests of

the +atient. 0eneficence is em*odied in the 2i++ocratic +hysician?s +ledge to act

for the good of the +atient. There is a s+ecific o*ligation of *eneficence *ased on

the health +ro-ider+atient relationshi+. This is a contractual3 fiduciary o*ligation3

yet the +rofessional?s o*ligation to *enefit a +atient is not *ased on the

+rofessional?s e6+ectation of recei-ing *enefits from the +atient. The o*ligation to

act in the *est interest of the +atient is a fundamental +art of the role of the

+hysician. ,resent day ethics codes strongly em*ody the guiding +rinci+le of

*eneficence. The !eclaration of Gene-a3 s$orn *y many medical students at

graduation3 states3 the health of my +atient $ill *e my first consideration (7orld

Medical Association3 19>@.

Autonomy is deri-ed from t$o Gree% root $ords3 autos and nomos meaning3

self rule. Res+ect for autonomy in health care ethics has only *ecome +rominent in

the last half of the t$entieth century. Changes in our society $hich ha-e

encouraged the rise of res+ect for autonomy include the e6+ansion of +olitical

democracy3 im+ro-ement in the education of American citiBens3 and an increase in

di-ersity of -alues $hich encourages indi-iduals to +rotect their o$n +ersonal

-alues. The need to res+ect autonomy $as highlighted *y the a*uses of medical

research committed *y )aBi Germany on concentration cam+ -ictims3 the 8S

Tus%eegee sy+hilis study3 $hich continued into the 19<=s3 and the 8S go-ernment

s+onsored radiation studies.

Res+ect for autonomy is su++orted *y la$. )e$ Dor% State Su+reme Court

Justice CardoBa said in 1914 that any indi-idual of sound mind has the right to

determine $hat shall *e done to his *ody... 2o$e-er3 informed consent does not

a++ear as +art of American case la$ until 19<. Since then3 the conce+t of +atient

autonomy has +ro-en to *e enduring3 and is no$ fundamental.



The final +rinci+le of health care ethics is ustice. Justice is the +rinci+le $e

consider $hen attem+ting to ma%e decisions a*out com+eting interests3 or

allocation of resources. Justice is often e5uated $ith fairness. Aristotle defined it

as treating e5uals e5ually3 and une5uals une5ually.

Theories of ustice ha-e *een descri*ed as deontological and utilitarian.

8tilitarian theories are *ased on the assum+tion that the right action is the action

that creates the greatest +ossi*le *alance of good o-er harm. 8tilitarianism has

often *een descri*ed as the end ustifies the means. !eontological theories are

*ased on the *elief that some actions are right or $rong *ased on a higher rule or

rules3 not ust *ased on the conse5uence of the action.

Bibliography

0eaucham+ T# and Childress J"/ ,rinci+les of 0iomedical Ethics @rd ed 6ford8ni-ersity ,ress3 )e$ Dor%3 19>9.

Edelstein3 # (194@ The 2i++ocratic ath/ Te6t3 Translational nter+retation 0ulletinof the 2istory of Medicine3 Su++lement 1 0altimore/ The Johns 2o+%ins ,ress3 +. @.

serson &'3 Sanders A03 Mathieu !R3 0uchanan AE (eds/ Ethics in EmergencyMedicine. 0altimore3 7illiams and 7il%ins3 19>;.

Jonsen AR3 Siegler M3 7inslade 7J (eds/ Clinical Ethics3 @nd ed. McGra$2ill3 nc3)e$ Dor%3 199.

#uce JM/ Ethical +rinci+les in critical care. JAMA 199=:;@/;9;<==.



II. Applying Ethics to Eergency Medicine

Objectives

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



of the +atient?s life. t is im+ortant to remem*er that 5uality of life must *e defined

from the +atient?s +oint of -ie$3 not the health care +ro-ider?s. "inally3 conte6tual

features include all the other factors $hich may *e in-ol-ed in a s+ecific situation

such as the $ishes of the family3 the rules of la$3 the effect a decision $ill ha-e on

others3 including the health care $or%ers3 and socioeconomic considerations. This

model assists in the organiBation of the health care +ro-ider?s thought3 and hel+s

a-oid o-erloo%ing any +ertinent as+ect of the situation. Ethical decisions are then

made *ased on the +rinci+les of res+ect for autonomy3 *eneficence3

nonmaleficence and ustice. This model3 $hile thorough3 may sometimes *e too

time consuming to *e hel+ful in emergency settings.

serson has de-elo+ed another model s+ecifically designed to *e hel+ful in

the emergency setting. The first ste+ is to as% the 5uestion3 s this a ty+e of ethics

+ro*lem for $hich you ha-e already $or%ed out a rule or is this at least similar

enough so that a rule could reasona*ly *e e6tended to co-er it. f so3 then follo$

the rule. The second ste+ is to as% the 5uestion3 s there an o+tion $hich $ill *uy

time for deli*eration $ithout e6cessi-e ris% to the +atient. f yes3 *uy time.

"inally3 if the first t$o ste+s do not yield a solution3 then there are three rules to

a++ly to any ethical decision. The three rules are/

1. m+artiality the decision ma%er +laces in the +osition of the +atient *y

saying3 7ould you *e $illing to ha-e this action +erformed if you $ere in the

+atient?s +lace.

. 8ni-ersaliBa*ility7ould you *e $illing to use the same solution in all

similar cases

@. nter+ersonal ustifia*ilityConsider $hether you $ould *e $illing to

defend the decision to others3 to share the decision in +u*lic.

Emergency +hysicians are *ound *y the same o*ligations and are su*ect to

the same +itfalls as any other +hysician. Just as residents must de-elo+ e6+ertise



and sensiti-ity for clinical decision ma%ing3 e6+ertise must *e concurrently

de-elo+ed to address ethical 5uestions.!tudy "uestions

1. n the a*o-e case3 $hat do you %no$ a*out medical indications3 5uality of life3+atient +references and conte6tual features

. 2o$ does that %no$ledge hel+ you to ma%e a decision

@. 8se the serson model to hel+ formulate a decision in this situation.

BibliographyAdams JG3 Arnold R3 Siminoff #3 7olfson A0/ Ethical conflicts in the +rehos+italsetting. Ann Emerg Med 199:1/191;.

Jonsen AR3 Siegler M3 7inslade 7J (eds/ Clinical Ethics3 nd ed. )e$ Dor%3

MacMillan3 199.

serson &'3 Sanders A03 Mathieu !R3 0uchanan AE (eds/ Ethics in EmergencyMedicine. 0altimore3 7illiams and 7il%ins3 19>;.

serson &'/ Emergency medicine and *ioethics/ a +lan for an e6+anded -ie$. JEmerg Med 1991:9/;;;.

Schmidt TA/ nto6icated airline +ilots/ A case *ased ethics model AcademicEmergency Medicine 1994: 1/9.



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



*attery3 *ut +erforming an authoriBed +rocedure $ithout a++ro+riately disclosing

the ris%s constitutes negligence.

The Eergency #ule

The court stated that an emergency e6ce+tion to informed consent e6ists

$hen the +atient is unconscious or other$ise inca+a*le of consenting3 and harm

from a failure to treat is imminent and out$eighs any threatened harm *y the

+ro+osed treatment. 7hen time does not +ermit informed consent3 emergency

ser-ices o+erate under the moral im+erati-e of *eneficence3 acting in the *est

interests of the +atient.

Courts also ha-e held that in time of life threatening crisis3 it is the

+hysician?s duty to do that $hich the occasion demands3 e-en $ithout the consent

of the +atient. 2o$e-er3 it is im+erati-e that the condition of the +atient *e so

se-ere that definiti-e care could not *e delayed until consent is o*tained. The

emergency rule de+ends u+on the +atient?s ina*ility to offer consent as $ell as

urgent circumstances. 2o$ urgent a situation is de+ends +rimarily u+on the

conse5uences to the +atient of a delay in rendering treatment3 or indeed u+on the

conse5uences of a failure to render any treatment at all.

!ubstituted Consent

7hen the +atient is una*le to consent due to +hysical or +sychological

distress3 the nearest relati-e or designated surrogate is turned to for consent (see

+atient decisionma%ing ca+acity. t is then assumed that surrogate decision

ma%ers $ill ma%e decisions *ased either on the +atient?s *est interests or the

+atient?s +re-iously e6+ressed $ishes.



Iplied Consent

m+lied consent is defined as a logical inference from the conduct of the

+atient. The indi-idual +atient?s actions $ould indicate to the health care +ro-ider

that the treatment $as re5uested. This is descri*ed in the case of ?0rien -.

Cunard Steamshi+ Co.. A +assenger sued the steamshi+ com+any for

administering an immuniBation $ithout his consent. The court held that *y the

+laintiff?s act of standing in the line $here inections $ere *eing administered3

rolling u+ his slee-e and su*mitting to the inection3 he +ro-ided a consent im+lied

*y his actions. The ty+ical +rehos+ital or E! encounter may +arallel this situation.

The +atient or a designee re5uests hel+3 and care is administered. The +atient

im+lies consent as he or she +artici+ates in the care3 and acti-ely su*mits to

treatment. E6+ress consent must *e sought for any inter-ention $ith more than

remote ris%s. nformation must *e freely shared $ith +atients. m+lied consent

might e6tend to that necessary to relie-e suffering and +reser-e and +romote the

care of the +atient. All such treatment rendered must *e $ell $ithin the sco+e of

acce+ted thera+y. f the +atient is unconscious or $ithout decision ma%ing

ca+acity3 the emergency rule su+ersedes.

#efusal of Care

As e6+lained in other sections3 informed consent re5uires decision ma%ing

ca+acity. t follo$s that +atients $ith decision ma%ing ca+acity ha-e a right not to

consent to care. The elements of a -alid3 informed refusal are the same as consent/

the +atient must ha-e decision ma%ing ca+acity3 information including significant

ris%s and magnitude of harm must *e +ro-ided3 the +atient must com+rehend the

information and the refusal must *e -oluntary $ithout coercion or duress. 0ecause

refusal of care may conflict $ith the udgement and recommendation of the

+hysician3 it is +rudent for the +hysician to em+hasiBe the ris%s +resented *y

refusing care and outline s+ecific conse5uences to *e e6+ected. The +hysician



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



+atient?s a*ility to ma%e a reasoned decision. Com+etence and decisionma%ing

ca+acity are t$o descri+tors commonly utiliBed to characteriBe this a*ility. The

former is a legal term3 the latter a +hrase recently coined that a++lies the conce+t

of com+etence to a medical setting.

The Medical Concept of &ecision Ma'ing Capacity

All adult +atients are assumed to ha-e a++ro+riate decision ma%ing ca+acity

to acce+t or refuse a +lan of e-aluation or course of thera+y unless there is

e-idence o*tained *y history3 *eha-ior3 or +hysical e6amination that $ould lead the

+hysician to *elie-e that the +atient?s decisionma%ing ca+acity has *een

significantly com+romised. The determination of decision ma%ing ca+acity re5uires

that/

1. The +atient a++reciates he or she has the +o$er to ma%e decisions on his or

her *ehalf

. The +atient understands the medical situation and +rognosis3 the nature of

the recommended e-aluation or care3 the alternati-es3 the ris%s and *enefits

of each3 and the li%ely conse5uences

@. The +atient?s decision is sta*le o-er time3 and is consistent $ith his or her life

-alues or goals.

The degree or le-el of decisionma%ing ca+acity a +atient must sho$ -aries

$ith the degree and +ro*a*ility of ris%3 the degree and +ro*a*ility of *enefit3 and

the +atient?s decision to consent or refuse. The greater the ris% +osed *y the

+atient?s decision3 the more e6acting the standard of decision ma%ing ca+acity

needs to *e. Thus3 a +atient might need only a lo$ le-el of decision ma%ing

ca+acity to consent to a +rocedure $ith su*stantial3 highly +ro*a*le *enefits and



minimal3 lo$ +ro*a*le ris%s3 *ut a high le-el of decision ma%ing ca+acity to refuse

the same treatment.

The Concept of %egal Copetence

n the la$3 com+etence re5uires mental ca+acities sufficient to a++reciate

the nature and conse5uences of such legal rights or res+onsi*ilities as ma%ing a $ill

or contract3 standing trial3 or rearing a child. The degree of understanding re5uired

*y the la$ $ill -ary in relation to the tas% to *e +erformed. The la$ assumes that

adults are com+etent until +ro-en other$ise in a formal legal decree. nce the

+erson is formally udged incom+etent3 a guardian or conser-ator is a++ointed *y

the court to ma%e decisions. !e+ending on the degree of incom+etence3 a +erson

may *e udged incom+etent relati-e to *usiness or financial affairs3 yet com+etent

to consent to or refuse medical e-aluation or treatment.

f a conser-ator is a++ointed to ma%e medical decisions on *ehalf of the

+atient3 then the conser-ator is the indi-idual $ho must gi-e consent3 not the

+atient or mem*ers of his or her family. Each state may ha-e slightly different

criteria for the determination of com+etence. 2o$e-er3 it *ears re+eating that a

+erson is determined to *e incom+etent only after a formal legal +roceeding.

(hen a $atient %ac's &ecision)Ma'ing Capacity

f the +hysician %no$s that a +atient does not ha-e medical decisionma%ing

ca+acity to gi-e an informed consent3 ho$ should medical decisions *e made The

ans$er to this 5uestion de+ends on the s+eed $ith $hich the decision must *e

made3 and $hat information a*out +atient +references is a-aila*le.

f a decision needs to *e made immediately to sa-e a +erson?s life or lim*3

then legally and ethically3 the emergency +hysician is o*ligated to +ro-ide

a++ro+riate care $ithout the need for consent (See Emergency Rule. f time





Emanuel3 EJ and Emanuel3 ## ,ro6y decision ma%ing for incom+etent +atients/ Anethical and em+irical analysis. JAMA 199: ;</=;<=<1.

Jonsen AR3 Siegler M3 7inslade 7J (eds/ Clinical Ethics3 @nd ed. McGra$2ill3 nc3)e$ Dor%3 199.

#o3 0 Assessing decision ma%ing ca+acity. #a$3 Medicine3 and 2ealth Care 199=1>/@("all 19@=1.

#o 03 Rouse "3 !orn*rand #/ "amily decision ma%ing on trial/ 7ho decides forincom+etent +atients ) Engl J Med 199=:@/1>1@.



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

the conflicts $hich may arise.



n addition3 ethical issues surrounding the care of minors in the E! are

intert$ined $ith state la$s that address consent su*stance a*use3

+regnancy3 a*ortion3 and child a*use and neglect. ,hysicians must %no$ the

re5uirements of the la$ in the state in $hich they +ractice.

Although ethics and the la$3 generally +resume that a minor lac%s

decision ma%ing ca+acity3 there are many im+ortant e6ce+tions to this rule.

The emergency rule (see section on informed consent +resumes consent for

anyone3 including minors3 $ith a true emergency. Emergency has *een

construed *y courts to go *eyond ust life threatening or disa*ling disease or

inury to include treatment to alle-iate +ain or suffering from serious *ut

nonemergent conditions.

Many states ha-e la$s $hich allo$ minors to consent $hen they see%

care for +regnancy3 se6ually transmitted diseases3 su*stance a*use3 or child

a*use. n addition3 many states *y statute or common la$ allo$

emanci+ated minors or mature minors to consent for their o$n medical care.

Emanci+ated minors are usually defined as minors $ho li-e

inde+endently of their +arents and are selfsu++orting3 minors $ho are

married3 ha-e *een +regnant3 or $ho are in the armed forces. The mature

minor is a young +erson (usually 1 or older $ho the +hysician *elie-es

+ossesses the re5uisite decision ma%ing ca+acity and demonstrates

understanding of the nature of treatment. 8nder most circumstances the

mature minor can consent to or refuse treatment $hich is of lo$ ris% and to

the minor?s *enefit.

#i%e adult +atients3 minors ha-e a right to +ri-acy and res+ect for

confidentiality. Ethical dilemmas may arise $hen a minor is accom+anied *y

a +arent $ho demands to %no$ the nature of the condition or treatment

$hich in-ol-es one of the e6ce+tions for $hich a minor can gi-e consent



(+regnancy3 child a*use3 etc. and the minor refuses to +ro-ide that

information to the +arent. The +hysician may feel conflicted $hen she or he

*elie-es that in-ol-ing the +arent is in the child?s *est interests. 2o$e-er3 in

general3 the $ishes of the minor +atient should *e res+ected $hen the minor

is allo$ed *y la$ or ethics to consent. n addition3 older minors ha-e a right

to +ri-acy and sensiti-e information should generally not *e shared $ith

+arents or others $ithout first discussing disclosure $ith the minor.

!tudy "uestions*

1. 2o$ should you resol-e the a*o-e case Can you treat this teenager

against his $ill

. !escri*e treatments for $hich a mature minor may gi-e consent3 and

treatments for $hich the mature minor may not gi-e consent.

@. Can an emanci+ated minor refuse a life sa-ing *lood transfusion on

religious groundsBibliography

2older AR/ ,arents3 courts and refusal of treatment J ,ediatr 19>@: 1=@/11.

Jonsen AR3 Siegler M3 7inslade 7J (eds/ Clinical Ethics3 @nd ed. McGra$2ill3nc3 )e$ Dor%3 199.

#egal Corres+ondent/ Teenage confidence and consent. 0rit Med J19>:9=/14414.

Morrissey J3 2offman A3 Thor+e J/ Consent and Confidentiality in the 2ealthCare of Children and Adolescents/ #egal Guide Macmillan/ The "ree ,ress3

)e$ Dor%3 19>;.

RoBofs%y "/ Consent to Treatment/ A ,ractical Guide nd ed3 #ittle 0ro$n30oston3 199=.

Tsai A&3 Schafermeyer R73 &alifon !3 et al/ E-aluation and treatment ofminors/ Reference on consent. Ann Emerg Med 199@:/11111<.



III. Issues #elated to $atient Autonoy

&. Advance &irectives

Objectives

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

reci+ients.



#i-ing $ills e6+ress the $ishes of +atients regarding lifesustaining

+rocedures in the e-ent of terminal illness. They are legally recogniBed *y

o-er 4 states. #i-ing $ills ha-e s+ecific restrictions $hich state that the

+erson $ould not $ant resuscitation if he or she is terminally ill3 death is

imminent and resuscitation $ould only +rolong the dying +rocess. 0ecause

of these restricti-e +hrases3 li-ing $ills are often of little -alue in the

emergency and +rehos+ital setting. Clarification may *e +ro-ided *y the

+atient?s +hysician or +ro6y decision ma%er. 7hen the a++lica*ility and

circumstances are clear3 ho$e-er3 the emergency +hysician has an o*ligation

to res+ect the li-ing $ill. f the +hysician cannot in good conscious do so3 he

or she should +ro-ide for another +hysician to care for the +atient. "inally3

the +atient can re-o%e a li-ing $ill at any time3 e-en during a time of crisis in

the emergency de+artment.

All states ha-e statutes go-erning dura*le +o$ers of attorney. n

some states3 additional statutes e6+licitly identify that dura*le +o$ers of

attorney may a++ly to health care decisions. A dura*le +o$er of attorney

gi-es to another +erson the authority to ma%e decisions for a +atient if he or

she *ecomes inca+acitated. The +erson then *ecomes a legally recogniBed

+ro6y decision ma%er for the +atient. 7hen a dura*le +o$er of attorney

e6ists3 the emergency +hysician should allo$ the designated +erson to

+artici+ate in decisions regarding the +atient?s medical care. The +ro6y

decision ma%er should not *ase re5uests to initiate or $ithhold resuscitation

on his or her o$n -alues3 *ut must ma%e decisions according to the %no$n

$ishes of the +atient. mmunity is generally granted to the +hysician $ho

carries out the +ro6y?s decision in good faith. ,hysicians should *e a$are of

state la$3 federal guidelines and ethical res+onsi*ilities $hich outline +olicies



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.

JAMA 199:;</=;<=<1.

serson &'/ "ederal ad-ance directi-es legislation/ +otential effects onemergency medicine. J Emerg Med 1991:9/;<<=.

Miles S2/ Ad-anced directi-es to limit treatment/ the need for +orta*ility. JAmer Ger Soc 19><:@/<4<;.

rentlicher !/ Ad-ance medical directi-es. JAMA 199=:;@/@;@;<.

Siner !A/ Ad-ance directi-es in emergency medicine/Medical3legal and ethical im+lications. Ann Emerg Med 19>9:1>/1@;41@;9.



I,. End of %ife &ecisionsA. %iiting #esuscitation

Objectives

1. !efine !o )ot Resuscitate rder (!)R order.

. 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



resuscitate must *e an immediate yes or no decision. Slo$ codes3

su*o+timal effort3 or delayed inter-ention are ne-er medically or ethically

acce+ta*le.

There is a clear need for emergency medical ser-ices to honor do not

resuscitate orders. RecogniBa*le3 standard !)R orders should identify those

+atients $ho $ish to ha-e no resuscitation attem+ts. #i-ing $ills should not

*e used to limit +rehos+ital resuscitation since the a++lica*ility of the

document may not *e clear.

7hile it is ethically a++ro+riate to honor !)R orders in the +rehos+ital

setting3 a num*er of o+erational3 legal3 medical and ethical challenges must

*e o-ercome. The emergency medical ser-ice must rely on the +ersonal

+hysician to +ro-ide a++ro+riate3 $ritten !)R orders $hich are consistent

$ith +atient +references and medical indications. The form used for !)R

orders must *e acce+ta*le to the emergency medical ser-ice and the legal

urisdiction. t must *e clear regarding those inter-entions $hich are to *e

im+lemented and those $hich are to *e $ithheld. Mechanisms must *e in

+lace to ensure that the document reflects the current status of the +atient.

This can *e accom+lished *y re5uiring +eriodic rene$al of the order.

,rehos+ital !)R orders should *e +orta*le3 so the directi-e can *e

honored e5ually in the hos+ital3 nursing home3 +ri-ate home or +u*lic

setting. An ideal system $ould +ossess !)R orders $ith standard

communication and authoriBation +rocedures $hich are easily recogniBa*le

and do not demand inter+retation or cause confusion. The document should

*e familiar to the emergency medical ser-ice3 the family3 the emergency

de+artment3 the +ri-ate +hysician3 and nursing homes.

!tudy "uestions



1. Should the +aramedics ha-e follo$ed state +olicy and attem+tedresuscitation

. 7hat e-idence of +atient $ishes does a +hysician need $ithholdresuscitation attem+ts s a relati-e?s -er*al re5uest enough

@. !oes the age3 a++earance3 or +hysical condition of the +atient matter

Bibliography

Adams JG3 !erse AR3 Gotthold 7E3 Mitchell JM3 Mos%o+ JC3 Sanders A0/Ethical As+ects of Resuscitation Ann Emerg Med 199:1/1<@1<;.

Ayres RJ/ Current contro-ersies in +rehos+ital resuscitation of the terminallyill +atient. ,rehos+ital and !isaster Medicine 199=:/49<.

American College of Emergency ,hysicians/ Guidelines for do not resuscitateorders in the +rehos+ital setting. Ann Emerg Med 19>>:1</11=;11=>.

Miles S23 Crimmins TJ/ rders to limit emergency treatment for anam*ulance ser-ice in a large metro+olitan area. JAMA 19>:4/<.

Ramos T3 Reagan JE/ ?)o? $hen the family says ?go?/ resisting families?re5uests for futile C,R. 19>9:1>/>9>>99.



I,. End of %ife &ecisionsB. Futility

Objectives

1. !efine futility

. !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

des+ite ma6imum thera+y (e6am+les3 o-er$helming se+sis3cardiogenic shoc%.

@. )o sur-i-ors ha-e *een re+orted under the gi-en circumstancesin $elldesigned studies.



Another definition states that if in the last 1== cases a medical

treatment has *een useless3 that treatment is futile. This +ro*a*ility analysis

allo$s for the +ossi*ility that @ successes $ould occur in the ne6t 1== similar

cases. This definition is a++ealing *ecause of its +recision3 and use of

+ro*a*ility3 *ut lea-es in dou*t the inter+retation of useless. A distinction is

made *et$een an effect on one +art of the *ody and a *enefit3 $hich

im+ro-es the +erson as a $hole.

thers ha-e +ointed out the im+ortance of determining the goals $hen

defining futility. A common e6am+le is the +atient for $hich li-ing for a fe$

days $ould *e a *enefit *ecause it $ould allo$ her to say good*ye to family3

or for outofto$n relati-es to arri-e. Thus3 $hile some authors ha-e argued

that +atients and families need not *e consulted in determining futility3 it

ma%es more sense to communicate $ith +atients and families in order to

understand their goals for treatment. 7hile the decision not to +ro-ide a

futile thera+y may rest $ith the +hysician3 only through dialogue can the

+hysician understand the goals of treatment. This a++roach allo$s for

e6+loration of the desired outcome3 acce+ta*ility of *urdens3 and the

+atient?s or family?s $illingness to gam*le $ith the outcome.

There is a +resum+tion in fa-or of resuscitation in dou*tful cases.

Thus3 the sco+e of medical futility in resuscitation decisions is narro$: it does

not include estimates of future 5uality of life. ngoing research into

outcomes of resuscitation should hel+ determine more +recisely the

e6+ected outcome of inter-ention and there*y more clearly indicate $hen

inter-ention is futile.

!tudy "uestions



1. !iscuss situations in $hich you might use futility to sto+ treatment in

the emergency de+artment.

. !iscuss the difference *et$een strict medical futility as no +ossi*ility

of long term sur-i-al3 and futility as lac% of *enefit.

@. !oes this case fit the definition of medical futility 7hat efforts to$ard

resuscitation should *e attem+ted

Bibliography

Jec%er )S3 Schneiderman #J/ Ceasing futile resuscitation in the field/ ethicalconsiderations. Arch nt Med 199:@9@9<.

#oe$y E23 Carlson RA/ "utility and ts 7ider m+lications Arch ntern Med199@: 1@/494@1.

#antos J!3 Singer ,A3 7al%er RM et al/ The llusion of "utility in Clinical,ractice Am J Med 19>9: ></>1>4.

Schneiderman #J3 Jec%er )S3 Jonsen AR/ Medical "utility/ ts Meaning andEthical m+lications Ann ntern Med 199=: 11/94994.

Schneiderman #J and Jec%er )/ "utility in ,ractice Arch ntern Med 199@:

1@/4@<441.

Tomlinson T and 0rody 2/ "utility and the Ethics of Resuscitation JAMA 199=:;4/1<;1>=.

Truog R!3 "rader J/ The +ro*lem $ith futility. ) Eng J Med 199:@;/1;=1;4.



,. 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

2i++ocratic oath states/



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



+ro*a*ility and the magnitude of harm must *e *alanced against the

+rotection of confidentiality. 0eaucham+ and Childress (19>> +rioritiBe four

+ossi*le com*inations of +ro*a*ility and magnitude of harm *y assigning the

follo$ing hierarchy/ 1 maor harm ris%high +ro*a*ility3 minor harmhigh

+ro*a*ility: @ maor harm ris%lo$ +ro*a*ility: and 4 minor harmlo$

+ro*a*ility. According to this scale a lo$er num*er +ro-ides strong

ustification to *reach confidentiality. ndeed3 some ethicists hold that $hen

confronted $ith a situation of maor harm and high +ro*a*ility the +ro-ider is

not merely ethically ustified in *reaching confidentiality3 *ut is ethically

re5uired to do so.

Moral grounds for honoring confidentiality3 ho$e-er con-incing3 may

sometimes yield to stronger moral grounds for disclosure. The follo$ing

situations ustify disclosure/1. Re+orting related to +u*lic health la$s $hich may include

'ital statistics (*irth and death certificatesContagious diseasesChild and elder a*use

Criminally inflicted inuries,oisoning#oss of consciousness

. #egal +roceedings

@. Fuality assurance re-ie$

4. ,rotection of a third +arty from mortal harm.

n general3 +hysicians may disclose confidential information $hen

+atients agree to disclose or $hen disclosure is re5uired in order to fulfill a

stronger moral duty to +re-ent harm or to o*ey ust la$s. !isclosure to

+rofessionals directly in-ol-ed in the care of the +atient3 in most instances3

can *e understood as ha-ing the +atient?s im+lied consent. The +hysician?s



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.

0eaucham+ T#3 Childress J" (eds/ ,rinci+les of 0iomedical Ethics @rd ed3 )e$ Dor%3 6ford 8ni-ersity ,ress3 19>9.

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.

Siegler M/ Confidentiality in medicineA decre+it conce+t. ) Engl J Med19>:@=</11>11.



,. 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



tell a +atient of a diagnosis of cancer. t $as not until 19<< that 9< of

+hysicians fa-ored telling +atients? their diagnosis.

A num*er of factors ser-ed to change +hysicians? attitudes. The first

$as the de-elo+ment in the common la$ of the doctrine of informed consent

(see section on informed consent. Another factor $as the rise in em+hasis

on ci-il rights and +atient autonomy. "inally3 the scandals in-ol-ing rights of

+atients in-ol-ed in e6+erimentation led to the national commission for the

+rotection of human su*ects of *iomedical and *eha-ioral research. This

commission issued a re+ort summariBing *asic ethical +rinci+les3 and setting

out re5uirements of informed consent3 assessment of ris%s and *enefits to

the su*ects of research3 and fair +rocedures in the selection of human

su*ects.

!es+ite this ne$ em+hasis on truth telling3 the thera+eutic +ri-ilege is

still acce+ted as morally licit $hen there is su*stantial e-idence that offering

the +atient the truth has a significant +ro*a*ility of causing harm. 2o$e-er3

+hysicians must *e -ery cautious in using this +aternalistic argument for not

sharing *ad ne$s $ith the +atient. Studies sho$ that +atients generally do

$ant to %no$ their diagnoses $hen +hysicians assume they do not3 and that

harms from disclosure are less than +hysicians thin%3 and the *enefits are

greater.

"urther3 telling the truth may *e more difficult for the +hysician than

the +atient3 es+ecially $hen the emergency +hysician must *ear stressful

ne$s such as the death of a lo-ed one to the family. "inally3 the em+hasis

on truth telling in medical ethics is culturally *ased. n some cultures

+atients may still e6+ect that *ad ne$s $ill *e con-eyed only to the family.

7e are only one generation remo-ed from a centuries? old medical

norm that +racticed *ene-olent dece+tion. The *etter +ractice is to



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



+hysician3 at *est3 ignorant of the +atient?s +ers+ecti-e. Com+assion and

em+athy im+ro-e +atient and +hysician satisfaction *y +romoting

communication3 minimiBing conflict3 and ma6imiBes +atient confidence in the

diagnosis and treatment +lan.!tudy +uestions

1. 2o$ should the +hysician res+ond in the a*o-e case

. Can em+athy *e taught

@. 2o$ do $e encourage em+athy in +hysicians and trainees

Bibliography

0ellet ,3 Maloney M/ The im+ortance of em+athy as an inter-ie$ing s%ill. JAMA 1991:;;/1>@11>@.

Grumet G/ ,andemonium in the modern hos+ital. ) Engl J Med 199@:@>/4@@4@<.

&atB J/ The Silent 7orld of !octor and ,atient The "ree ,ress3 )e$ Dor%319>4.

)o-ac% !23 !u*e C3 Goldstein MG/ Teaching medical inter-ie$ing Arch ntern

Med 199: 1/1>141>=.

)elson AR/ 2umanism and the art of medicine. JAMA 19>9:;/1>1@=.

S+iro 23 McCrea Curnen MG3 ,eschel E3 St. James ! (ed Em+athy and the,ractice of Medicine Dale 8ni-ersity ,ress3 )e$ 2a-en3 199@.



,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.



7ithout health care reform3 it is estimated that health care $ill account for

= of the G), *y the year ===. Gi-en our limited resources and gro$ing

*udget deficit3 continued increases in health care e6+enditures $ill result in

reductions in other +rograms.

At a second le-el3 distri*uti-e ustice affects allocation decisions

in-ol-ing health care resources. 2ealth care is rationed (rationing is defined

as the distri*ution of a limited amount of goods and ser-ices in all societies:

the maor difference is the criteria used for rationing. These criteria should

*e de-elo+ed at the societal le-el3 not the *edside. Such decisions should *e

*ased on medical need3 cost effecti-eness3 and +ro+er distri*ution of *enefits

and *urdens in society. ur society must decide the a++ro+riate allocation of

limited resources to -arious medical inter-entions such as +u*lic health and

+re-enti-e medicine3 child and maternal health3 ne$ technologies3

+rehos+ital and emergency care3 comfort and +alliation. 7e must also

consider the im+act of +oor nutrition3 lac% of ade5uate housing3 inade5uate

education3 +ollution and -iolence on an indi-idual?s health. The effect of

these +ro*lems on health demonstrates the com+le6ity of the relationshi+

*et$een social issues and health care.

At a third le-el3 distri*uti-e ustice affects allocation at the institutional

le-el and *edside. n emergency medicine3 allocation of scarce resources is

the ethical +rinci+le under+inning triage decisions. ,hysicians also consider

distri*uti-e ustice $hen ma%ing decisions a*out costs and resource

allocation. Although some +hysicians *elie-e it is unethical to allo$ costs to

influence clinical decisions3 a +hysician $ho ignores all cost considerations

ignores the ad-erse conse5uences such decisions $ill ha-e on their +atient

as $ell as others.



,hysicians ha-e enormous influence on health care e6+enditures

*ecause $e decide $hich resources are needed to diagnose and treat

+atients. ne of the *asic tenets of our +rofession is the duty to $or% for the

*est interests of our +atients. This im+lies that +hysicians should use

resources $hich *enefit the +atient3 $ithout creating undue *urden.

8nfortunately3 $e fre5uently lac% the outcome data to determine $hether a

s+ecific treatment +roduces *enefit3 marginal *enefit3 no *enefit or harm. n

these cases $e must use our *est udgement a*out the +otential *enefit to

our +atients. Cost can and should *e a +art of that consideration. !es+ite

the con-entional -ie$ that +hysicians and +atients ma%e decisions at the

*edside *ased solely on the *est interests of the +atient3 many e6ternal

factors including a*ility to +ay3 health insurance co-erage3 insurance

mandates for a second o+inion and scarcity of resources may influence the

decision ma%ing +rocess.

As emergency +hysicians3 $e see the conse5uences of allo$ing

distri*ution of health care to *e *ased on the a*ility to +ay. ,atients $ith no

health insurance see% medical care for nonemergent +ro*lems in the

emergency de+artment. A++ro+riate care often re5uires follo$u+ *y a

+rimary care +hysician $ho may not *e a-aila*le to these +atients. The

im+ortance of health insurance $as highlighted *y a recent study that

re+orted an association *et$een lac% of insurance and increased mortality.

!ecisions a*out health care allocation must *e made *oth at the le-el

of society (macroallocation and at the le-el of the indi-idual +atient

(microallocation. Although *eneficence must *e the guiding +rinci+le for

microallocation decisions3 distri*uti-e ustice guides macroallocation

decisions and also +lays a role in microallocation decisions in our current

system.



!tudy "uestions1. 7hat is distri*uti-e ustice and ho$ does it a++ly to health care

. 2o$ does this case illustrate +ro*lems in our current deli-ery of healthcare

@. 2o$ do $e currently ration health care

4. n your o+inion3 ho$ should $e ration health care

Bibliography

American College of ,hysicians Ethics Manual Ann ntern Med 199: 11</94<9;=.

0eaucham+ T#3 Childress J" (eds/ ,rinci+les of 0iomedical Ethics @rd ed3 )e$ Dor%3 6ford 8ni-ersity ,ress3 19>9.

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@><.



,I. Issues #elated to -usticeB. &uty

Objectives

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



Bibliography

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;=.



,I. Issues #elated to -usticeC. Moral Issues in &isaster Medicine

Objectives

1. !iscuss the sco+e and limits of medical effecti-eness in disaster

situations.

. dentify the moral +rinci+les underlying triage.

@. !iscuss criteria for ma%ing triage decisions and their ethical

ustification.

A +lane crashes3 resulting in inury to many +atients. The -ictims range in

age from 1 year old to 9@ years old. ne of the -ictims is a 8S senator.

Some of the +atients ha-e se-ere *urns3 others *lunt head3 a*dominal or

chest trauma. There are > +atients in cardio+ulmonary arrest. ne +atient

has agonal res+irations3 and another has almost 1== *ody *urns. A $oman

is in la*or and at least +atients a++ear to *e in shoc%. At least 1 +atients

ha-e minor inuries. Dou are the sole +hysician +resent.

n disasters3 $hen resources are scarce3 the +rimary ethical +rinci+le

*ecomes ustice. The goal is to treat +eo+le e5uita*ly and fairly. This has

led to the conce+t of triage. Triage is *ased on the utilitarian ethical

+rinci+le of +ro-iding the greatest *enefit to the greatest num*er. 2o$e-er3

there $ill al$ays *e some uncertainty as to $hat *enefit a +articular +atient

$ill deri-e from any action. 0ased on this +rinci+le3 +riority should *e

gi-en to firefighters3 +u*lic safety3 and medical +ersonnel $ho might *e a*le

to return to the rescue effort. n addition3 those inuries most amena*le to

treatment3 such as air$ay o*struction and *leeding3 and those acti-ities

most useful in alle-iating suffering3 such as administration of +ain

medication3 should *e em+hasiBed.



Should there *e any differentiation *ased on age or social $orth The

most famous case of triage *y social $orth is the Seattle committee that

made decisions a*out $ho $ould recei-e %idney dialysis. ,hysicians

de-elo+ed a list of +eo+le $ho could +otentially *enefit from this ne$

medical inter-ention. Then3 a committee of non+hysicians chose the

indi-iduals $ho $ould recei-e this then scarce resource. ,riority $as gi-en

to indi-iduals $ith +roducti-e o*s3 or a family to su++ort. The result $as

that most of the early reci+ients of dialysis $ere middle class3 $hite males.

Although the committee $as certainly $ell meaning3 many later felt that

their system of social $orth led to *iases against the +oor3 $omen and

minorities. Thus3 although it is tem+ting to consider the -alue of the -arious

-ictims3 the general consensus of most ethicists is that social $orth is an

unfair criteria for the distri*ution of resources. Rather3 treatment is *ased on

medical need and the li%elihood of *enefit.

!tudy +uestions

1. 2o$ should you +roceed to care for +atients in this case

. 7ould you gi-e some +riority attention to the 8S Senator

@. Could any +atient distract you and cause you to +ay e6tra attention or

+ro-ide longer3 more attenti-e care

Bibliography

0ell )&/ Triage in medical +ractices/ An unacce+ta*le model Soc Sci Med19>1:1"/111;.

Jonsen AR3 Siegler M3 7inslade 7J/ Clinical Ethics @rd ed3 McGra$2ill nc3)e$ Dor%3 1993 + 1@9.

,ledger 2G/ Triage of casualties after nuclear attac%. #ancet 19>;:;<>;<9.



Triage in Reich 7 (ed Encyclo+edia of 0ioethics nd ed The "ree ,ress3 )e$ Dor%3 199.

7inslo$ GR/ ,rinci+les for triage3 in Triage and Justice3 0er%eley3 8ni-ersityof California ,ress3 19>3 ++ ;=1=9.





officials3 and medical +rofessionals to esta*lish guidelines that $ill ensure

the integrity of *iomedical research.

0ecause +hysicians de+end on research to im+ro-e +atient care3 $e

should *e con-ersant $ith the ethical issues in research. Among the most

im+ortant issues are scientific misconduct (fraud3 +lagiarism3 fa*rication of

data3 unethical treatment of human and nonhuman su*ects3 conflict of

interest3 and res+onsi*ilities to colleagues3 student and other trainees.

A +articularly difficult area for emergency medicine is informed

consent for resuscitation and other research $hen time is critical and the

+atient does not ha-e decision ma%ing ca+acity. n the +ast3 guidelines ha-e

allo$ed the use of deferred consent3 in $hich consent $as o*tained after the

study inter-ention. !eferred consent is criticiBed as an illogical conce+t3 and

recent de-elo+ments suggest that $ai-ed consent ma%es more sense. The

current criteria for $ai-ed consent are 1 minimal ris% to su*ects3 the

$ai-er $ill not ad-ersely affect the rights and $elfare of the su*ects3 @ the

research could not *e carried out $ithout the $ai-er3 and 4 su*ects $ill *e

+ro-ided information follo$ing +artici+ation.

n recent years3 the federal go-ernment3 +rofessional organiBations

and institutions ha-e de-elo+ed +olicies and +rocedures to address some

other ethical concerns. ne e6am+le of this is the 8niform Re5uirements for

Manuscri+ts Su*mitted to 0iomedical Journals. This $as de-elo+ed *y the

nternational Committee of Medical Journal Editors. n addition to descri*ing

the format for su*missions3 the Committee addressed the issues of

authorshi+ as $ell as +rior and du+licate +u*lication.

!tudy "uestions





,II. Teaching

Objectives

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



the same time our students and residents $ill continue to need access to

+atients and learning o++ortunities.

Ac5uiring technical s%ills such as endotracheal intu*ation3 central line

+lacement3 and chest tu*e thoracostomy re5uires that the trainee ha-e

a++ro+riate +ractice +rior to +erforming it in time of crisis. ,ractice is

a++ro+riately ac5uired on +lastic manne5uins3 *ut the manne5uin remains

an im+erfect model. n addition3 these s%ills can *e learned in more

controlled settings such as o+erating room intu*ation3 central line +lacement

in sta*le C8 +atients and chest tu*es in the sta*le +atient $ith a

s+ontaneous +neumothora6. 2o$e-er3 these forms of training may not

al$ays *e ade5uate.

The /se of Models for Teaching

Contro-ersy e6ists a*out the use of animals3 as $ell as the use of

recently deceased human *eings. Grou+s concerned a*out the use of

animals in teaching and e6+erimentation e6+ress t$o ethical concerns a*out

the use of animals. Those $ho su++ort animal rights e6+ress the *elie-e that

animals3 li%e humans3 ha-e certain *asic rights as sentient *eings. Animals

are inca+a*le of gi-ing informed consent and should3 therefore3 not *e used

for teaching or e6+erimentation. thers3 $hile not e6+ressing concern a*out

the rights of animals are concerned a*out animal $elfare. These +eo+le are

concerned a*out inhumane treatment and unnecessary harm.

nstitutions ha-e de-elo+ed committees $hich address issues

surrounding the use of animals in the same $ay that institutional re-ie$

*oards address research on human su*ects. Any use of animals re5uires

treatment and care that is as humane and discomfortfree as +ossi*le.

Contro-ersy also e6ists a*out +erforming +rocedures on the ne$ly

dead. Those $ho o++ose +racticing +rocedures on the ne$ly dead raise



concerns a*out res+ect for autonomy. The +atient is una*le to gi-e consent3

and generally em+athy and com+assion +reclude us from as%ing the

*erea-ed family for consent. 2o$e-er3 it may *e argued that res+ect for

autonomy is *ased on +rinci+les of freedom and li*erty $hich do not a++ly to

the dead. n addition3 *ased on utility3 little or no harm is done to the

deceased and much might *e gained *y resident education. Some also ma%e

a distinction *et$een nondisfiguring +rocedures such as intu*ation3 and

more in-asi-e +rocedure such as chest tu*es.

!tudy "uestions

1. !oes your institution allo$ or encourage +ractice of in-asi-e s%ills on

recently deceased +atients

. Should consent *e o*tained from the family

@. Should an attending +hysician see e-ery +atient $ho comes to the

emergency de+artment of a teaching hos+ital

4. 7hat guidelines does your institution ha-e on the use of animals for

teaching Are these guidelines ethically ustified

. 7hat do you *elie-e a*out the use of animal model in teaching The

use of the ne$ly dead

Bibliography

serson &'/ The su+er-ision of +hysicians in training/ aneducational and ethical dilemma. Medical Teacher 19>>: 1=/19=1.

serson &'/ Re5uiring consent to +ractice and teach using the recently dead. J Emerg Med 1991: 9/=91=.

serson &'/ ,ostmortem +rocedures in the emergency de+artment/ using therecently dead to +ractice and teach. J Med Eth June 199@.



'arner GE/ The +ros+ects for consensus and con-ergence in the animal rightsde*ate 2astings Center Re+ort 1994: 4 (1/4>.

7in%en$erder 7/ Ethical dilemmas for house staff +hysicians. JAMA 19>:4/@44@4<.



,III. #elationships 0ith the Bioedical Industry

Objectives

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





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Ethics Curriculum Emergency Medicine

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