Ethics in Emergency Medicine
Department of Bioethics
Learning objective
Students should be able to:
• Recognize the differences between primary care
and emergency practice
• Identify ethical issues in emergency practice
• Give ethical justification in emergency practice
Reference
• Larkin GL. Evaluating Professionalism in Emergency Medicine: Clinical
Ethical Competence. Academic Emergency Medicine ,1999; 6:302-11
• Rucoba, RJ. Ethical, legal concerns for emergency medical care. AAP News,
25 July 2011
• SAEM Ethics Committee Ethics Curriculum for Emergency Medicine
Residencies,1994
• Iserson KV. Ethical Considerations in Emergency Care. Israeli Journal of
Emergency Medicine, 2004; 4: 10-17
• Pauls M et al. Ethics in the trenches: Part 2. Case studies of ethical
challenges in emergency medicine. Can J Emerg Med, 2004;6(5):363-6
• Marco CA et al. Ethics Curriculum for Emergency Medicine Graduate
Medical Education. The Journal of Emergency Medicine, 2010; pp. 1–7
• Franklin JS et al. Ethical Dilemmas in Emergency Medicine. Emergency
Medicine and Critical Care, 2008; 12-14
Differences between Emergency and Primary Care Practice
(Iserson, 2004)
Emergency Practice Primary Care Practice
Brought in by ambulance, police, etc. Patient’s choice to enter service
Patient does not choose physician Patient chooses physician (?)
ED personnel do not know patient Often know patient+values
Patient experiences acute change Patient has chronic medical problems
Anxiety, pain, alcohol and altered mental Less frequent
status are frequent
Decisions are made quickly Time for discussion+ deliberation
Decisions made independently Greater opportunity to consult
Physician represents institution Represents self or medical group
Environment open + less controlled Work environment private+controlled
Stressful work schedule Schedule often set
“Emergency patients rely heavily on the
interpersonal skills, moral behavior,
emotional maturity, goodwill, and ethical
capacity of emergency providers.”
(Larkin, 1999)
Ethical issues related to emergency
medicine
1. Informed Consent and Refusal
2. Patient Decision Making Capacity
3. Treatment of Minors
4. Advance Directives
5. Limiting Resuscitation
6. Futility
7. Confidentiality
8. Truth Telling and Communication
9. Compassion and Empathy
10. Moral Issues in Disaster Medicine
Respect of
Limited time
autonomy
Scarcity Saving life
Emergency rule
1. Patient unconscious or otherwise incapable of consenting
exception to informed consent
2. Limited time emergency services operate under the moral
imperative of beneficence, acting in the best interests of the patient
3. In time of life threatening crisis physician's duty to do that
which the occasion demands, even without the consent of the
patient
How urgent a situation is depends upon:
consequences of a delay in giving treatment,
or
consequences of a failure to give any treatment at all.
Refusal
1. Patients with decision making capacity
(capacity) have a right not to consent to care.
2. The elements of a valid, informed refusal are
the same as consent: capacity & comprehension
of information (risks & harm)
3. Refusal of care may conflict with physician’s
judgment & recommendation emphasize the
risks & consequences
4. Both consent and refusal must be made
voluntary, without coercion/duress.
5. Physicians should provide treatment despite:
- a verbal refusal in patients with no capacity,
or
- life threat is so acute no time to assess
refusal.
6. When patients do not have capacity benefit
must outweigh the potential risk of harm
When patient lack of capacity to
consent
• How should medical decisions be made?
depends on:
- the speed with which the decision must be
made
- what information about patient preferences is
available
• When patients previously expressed wishes are
known, based on the principle of respect for
autonomy, those wishes should generally be
honored
Limiting rescucitation
• Withholding & withdrawing: no moral difference
• Legally+ethically acceptable to withhold
resuscitation attempts on patients who have
expressed clear wishes (Indonesia?)
• Challenge communication must be legally,
ethically, and medically sound (ex: form with
patient & physician signature, patient arm-band,
etc.)
• Emergency setting patient's wishes, medical
condition, and prognosis are usually unknown.
• If there is doubt resuscitative efforts should be
initiated.
• The decision to resuscitate must be an immediate
yes or no decision.
• "Slow codes," suboptimal effort, or delayed
intervention are never medically or ethically
acceptable.
