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Special Aspects Of
Ethics in Emergency Medicine
Last Updated: February 13, 2006
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Synonyms and related keywords: ethics in emergency medicine, ethics in medicine,
Section 1 of 9
Glossary Of Terms
A Framework For Ethical Decision
Medical Decision Making
Sample Case 1
Sample Case 2
, Director of Quality Improvement, Associate Clinical Professor,
Department of Emergency Services, San Francisco General Hospital
, Staff Physician, Division of Emergency Medicine,
Stanford Hospital and Clinics
Eric Isaacs, MD, is a member of the following medical societies:
American Academy of
American College of Emergency Physicians
Academic Emergency Medicine
Editor(s): Robert M McNamara, MD, FAAEM, Professor of Emergency Medicine, Temple
University; Chief, Department of Internal Medicine, Section of Emergency Medicine,
Temple University Hospital; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor,
eMedicine; Gino A Farina, MD, Program Director, Associate Professor of Clinical
Emergency Medicine, Department of Emergency Medicine, Long Island Jewish Medical
Center, Albert Einstein College of Medicine; John Halamka, MD, Chief Information
Officer, CareGroup Healthcare System, Assistant Professor of Medicine, Department of
Emergency Medicine, Beth Israel Deaconess Medical Center; Assistant Professor of
Medicine, Harvard Medical School; and Steven C Dronen, MD, FAAEM, Director of
Emergency Services, Director of Chest Pain Center, Department of Emergency Medicine,
Ft Sanders Sevier Medical Center
Medical Decision Making
Most physicians are trustworthy, honest, and ethical. All benefit from a deeper
understanding of medical ethics because they often encounter situations in which a clear
"right thing to do" does not exist. Ethical decisions must be made when strong reasons
for and against a particular course of action are present.
Emergency physicians may feel that they do not have time to consider ethical dilemmas.
During a busy clinical shift, time to ponder either diagnostic dilemmas or ethical dilemmas
usually does not exist. How then, should emergency physicians handle difficult decisions
that must be made in a limited time frame, often under considerable stress? They develop
guidelines based on scientific or ethical principles that direct their handling of common
difficult situations. For example, in cardiac arrest and trauma resuscitations, clear
procedural guidelines exist. Because each clinical situation is different and often
demands prompt decision-making, the clinician must adapt accepted guidelines to
individual cases to give the most appropriate and ethical care.
Why develop a framework for ethical decision-making? Medicine is a dynamic field. Not
only does human knowledge continue to grow and change, but new situations present
themselves regularly. In addition, continually changing societal attitudes subsequently
influence thinking about old problems. Issues such as medical futility and
physician-assisted suicide are in the forefront of current societal thinking and require a
Sample Case 2
Click for related
CME currently not
offered for this topic.
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No substitute for clinical experience exists. One of the key tenants of ethical
decision-making is to apply rules created in the past to situations in the present. Observe
how these rules fit, and make adjustments as needed. A framework for ethical
decision-making can assist in delineating those issues that may need adjustment for a
For excellent patient education resources, visit eMedicine's
Public Health Center
see eMedicine's patient education articles
Interpretation of terms used in discussions of medical ethics is as dynamic as other
changes in medicine. The following is a brief description of terms used in the discussion
of medical ethics consistent with the current interpretation by most authors:
Patients have the right to choose actions consistent with their values, goals, and life
plan, even if their choices are not in agreement with the wishes of family members or the
recommendation of the physician. Choices should be free from interference and control by
Beneficence refers to acting in the best interests of the patients. This concept often is
confused with nonmaleficence, or "do no harm." Doing what is best for the patient often
involves serious risks.
Respecting a patient's privacy and maintaining confidentiality allows people to seek
treatment and discuss their problems frankly.
The term futility may be used in several situations, including the following: The
intervention has no pathophysiologic rationale. Maximal treatment is failing. The
intervention has already failed. The intervention will not achieve the goals of care.
Informed consent is the process by which a patient receives all pertinent information
necessary to make a rational autonomous choice. Disclosure standards, comprehension,
voluntary action (free of control of others), competence, and consent are the 5 elements
of informed consent.
Justice refers to fairness in the allocation of healthcare resources.
Veracity is truth telling and honesty; recognize that it is not uncommon for healthcare
providers to misrepresent a situation without technically lying.
A FRAMEWORK FOR ETHICAL DECISION MAKING
Each ethical dilemma may be approached by assessing the issues, naming the dilemma
(conflicting ethical principles), considering alternative courses of action, implementation,
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What is the medical situation? This question is about emergency physicians' goals as
caregivers. What is the appropriate medical intervention? What is the benefit to the
What are the patient's preferences? These may be ascertained by determining the
patient's goals. Patients may choose to live their lives differently than their treating
physician. For example, the possibility of losing use of the hands may cause a patient to
refuse a neuropathy-inducing chemotherapy. Assessing the patient's values, needs,
expectations, and competency; whether the patient is fully informed; and whether consent
is voluntary is important.
What are the consequences of accepting or refusing the intervention? How will quality of
life be affected (eg, maintain, restore, improve)? Will patients be able to pursue their own
goals? What are the external issues involved?
Issues outside of medical fact that both appropriately and inappropriately impact the
decision-making process include family and social pressures, economics, emotions,
interpersonal conflict, legal issues, communication, and time pressure.
Name the dilemma.
Take the time to clearly identify the issues in conflict that have lead to the dilemma being
addressed. Look over the glossary of terms for a list of basic ethical terms and issues.
Consider alternative courses of action.
List the alternative courses of action focusing on the pros and cons of each choice so
that the decision is most consistent with medical opinion and the patient's values and
Once a plan of action is created, it must be implemented.
An evaluation component is important in the overall process of solving ethical dilemmas,
particularly when formulating plans to be utilized in future situations. During evaluation,
include assessment of the actual outcome in regard to patient's goals, values, needs,
and interaction with external pressures and issues.
MEDICAL DECISION MAKING
A Framework For Ethical Decision Making
Faced with a decision regarding their medical care, patients usually agree to at least one of the medically
acceptable physician recommendations. Occasionally, patient preferences conflict with physician's
recommendations and a potential ethical dilemma is born. For example, a patient with a potential life-threatening
infection requiring intravenous antibiotics may demand to leave the hospital without any treatment. The provider
must determine whether the patient has the capacity to make this medical decision to refuse care. The capacity
to make medical decisions is distinct from the issue of competence. Capacity is a clinical determination
addressing mental functions and a person's ability to make a decision. Competency is a legal definition
addressing societal interest in restricting an individual's actions or right to make decisions if he or she cannot be
held accountable for the consequences of his or her decisions and actions.
A patient is considered competent unless a legal determination of incompetence has been made in a court of
In the early 1980s, the President's Commission for the Study of Ethical Problems in Medicine and Biomedical and
The patient must have a set of values and goals and the ability to make reasonably consistent choices.
The patient must have the ability to give and receive information as well as have the conceptual skills to
understand the information and the alternatives.
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Emergency physicians face special challenges in trying to determine in a short amount of time whether someone
they have just met is capable of making choices and whether those choices are consistent with the patient's
values and goals. In addition to the limited time available for data gathering, emergency department (ED) patients
present special challenges due to medical issues, such as pain, altered mental status, or psychiatric illness,
that limit their capacity to fully understand their choices. In general, a more stringent standard of capacity is
applied to refusals of life-saving treatments than diagnoses of lesser morbidity. The patient must be able to
adequately demonstrate understanding of the risks of refusal to give an informed refusal. The physician has an
ethical duty to ensure that a patient truly understands the risks of leaving, which requires more than just having
the patient sign an against medical advice (AMA) form. Every effort should be made to understand why a patient
wishes to leaveand attempts should be made to present a solution resulting in the optimal outcome for the
A common scenario in the ED is the need to make critical decisions when the patient is clearly unable to do so.
Questions regarding intubation, pressors, blood products, and other invasive procedures in patients who cannot
communicate their choices are frequently left to decision makers designated by the patient or selected by
providers or family to represent choices in line with the patient's values. The governing principle is that these
surrogate decision makers are expected to make choices based on the patient's values, not their own values.
SAMPLE CASE 1
Section 6 of 9
An 85-year-old Cantonese-speaking patient is brought to the ED by her family for shortness of breath. Her son
translates and provides much of the history. The patient is tachypneic and hypoxic on room air, and the ED
physician is considering intubation. The initial physical examination reveals moderate respiratory distress with
decreased breath sounds on the right side. The son denies any medical problems, but says his mother has had
fluid in her chest before that has needed to be drained. The patient keeps crying out during the examination, and
the son reports she is pleading “help me!” A STAT chest radiograph shows a large right pleural effusion.
After the initial examination, the son pulls the physician aside and says his mother has a known diagnosis of
metastatic colon cancer with a history of pleural effusions. She does not yet know of her diagnosis and lets her
son make all her medical decisions. Her husband died of lung cancer last year, and the family feels the patient
would have an undue burden knowing her diagnosis. She is being monitored by an oncologist, and the family has
decided on supportive care instead of aggressive treatment. The son says his mother would not want to be
intubated, although she has never signed any advance directives. He asks that the physician treat his mother
for her symptoms, including a thoracentesis if needed, but not mention the word "cancer" in front of her as she
knows what this word means from her multiple visits with her husband.
What should the ED physician do? Follow the framework for ethical decision making.
Assess the issues.
What is the medical situation? The patient has been brought by family members to the ED with worsening
shortness of breath. Her condition is likely to worsen without acute intervention. She will need a thoracentesis to
relieve her symptoms; however, this procedure requires informed consent. The emergency physician is
considering intubation for respiratory distress, although the son is reporting she would not want to be put on
mechanical ventilation. Unfortunately, the language barrier and cultural divide currently prevents communication
with the patient.
What are the patient's preferences? Without an independent medical interpreter, knowing the answer to this
question is impossible. The son is telling the physician that the family feels it is better for the patient to not know
her diagnosis and is willing to act as a surrogate decision maker. The family presumably has a better
understanding of the cultural and familial issues involved. How does the emergency physician know that the
family is making decisions in accordance with the patient's values and goals when he or she has just met the
patient for the first time? Presumably, the patient has been seen and evaluated by an oncologist, who has had
more time to deal with some of these critical issues and has decided not to pursue aggressive treatment. The
emergency physician hopes the oncologist has made a wise choice based on compiling all available information.
Who will provide the consent? The son appears very involved in his mother's care and he may be able to provide
consent on his mother's behalf. Without paperwork stating that his mother wants him to make all her medical
decisions, what is necessary to secure this permission? The patient does not know her diagnosis, so
explanation of the need for the procedure is not possible without telling the patient more information. How much
information is necessary? If the decision is made to speak with the patient herself, is it possible to get informed
consent for the procedure while respecting the wishes of the family not to disclose the primary diagnosis? Is the
patient's acute medical condition (hypoxia) interfering with her capacity to make significant medical decisions?
What are the legal ramifications? The emergency physician faces the challenge of potentially intubating a patient
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patient providing written advanced directives. In addition, performing a thoracentesis in this situation may require
What are the pragmatic issues? The emergency physician has very limited information during the brief
interaction. Are other family members involved in the mother's care who feel she would want to be intubated?
Perhaps if the patient knew she had cancer, she would refuse the thoracentesis, or perhaps she would be
interested in aggressive treatment. Time is of the essence in the ED, and if the patient is in distress, there is
little time to investigate all of the possibilities.
This case involves autonomy, beneficence, informed consent, and veracity.
Consider alternative courses of action. Potential courses of action might include the following:
Perform the thoracentesis as requested by the son with the son's consent.
Find an interpreter and either confirm that the patient would want her son to make her medical decisions or
discuss the case with the patient including her diagnosis. Alternatively, the physician may obtain consent
for the procedure to “remove fluid from around her lungs” for symptomatic relief without disclosing the
cause of the fluid accumulation.
Attempt to contact the patient's oncologist to discuss the case further and confirm what the son has told
the physician. This option may not be possible depending on the call schedule and time of day.
Try bilevel positive airway pressure (BiPAP) as a noninvasive method to improve respiratory status.
Intubate the patient, providing more time to pursue additional family members to provide input and allowing
input from an intensivist as well as the patient's oncologist. Ethically, there is no distinction between
withholding and withdrawing care. In fact, unless patients and providers are allowed to discontinue care,
they may never try potentially life-saving interventions.
Implement the action.
After considering the alternatives and their likely outcomes, the physician must choose the path that he or she
feels would lead to the outcome most desired by the patient.
Evaluate the outcome.
Strong arguments can be made both for and against multiple courses of action in this case. Many of the
treatment decisions depend on choices made early in the case. The challenge for the emergency physician is to
take limited information and systematically place it within an ethical framework in a short timeframe.
After taking action, the physician must see if the actual outcome was as predicted. The physician can use this
information should a similar case arise in the future.
SAMPLE CASE 2
Section 7 of 9
Ethical dilemmas in the ED frequently involve legal issues. Physicians often confuse the two, looking to the law
for answers to an ethical question. Physicians must realize that ethics and the law are separate entities
frequently resulting in conflicting recommendations.
Patient refusal and the law
Two city police officers bring a 28-year-old woman into the ED at 1 am. She is under arrest for suspicion of crack
cocaine possession with intention to sell. The officers relate that crack dealers routinely position a woman a half
block away to distribute crack to the buyer after the sale is made. At times, women who distribute drugs may
hide small plastic bags of drugs in their vaginas after observing nearby police. While engaged in undercover
operations in an area of high volume drug dealing, the arresting officers report that they saw this woman put her
hands down her pants as they approached her for questioning.
The officers ask the ED physician to perform a vaginal examination and procure the suspected drugs. The
woman says, "With all due respect, doctor, I am refusing your examination." Her vital signs are pulse 68, blood
pressure 114/72, respirations 16, and temperature 37.1.
In anticipation of this refusal, the police have procured a search warrant directing a doctor or a nurse to examine
the woman's vaginal cavity for contraband.
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The first step in the process of handling an ethical dilemma is to determine if a rule already exists for a similar
situation. Are other patients brought to the ED by law enforcement officers for a diagnostic procedure against
the patient's will in the interests of justice? Certainly, patients brought for legal blood draws while in custody for
driving while intoxicated would fit this scenario. In these cases, if no danger to the patient and staff exists, the
blood draw is performed. Is this situation different?
Follow the framework for ethical decision-making.
Assess the issues.
What is the medical situation? Does an indication for the examination exist? At the moment, the patient's vital
signs do not indicate any toxicity from a sympathomimetic agent.
Should an examination be performed against the patient's will because a reliable observer noted potentially risky
Would performing the procedure benefit the patient? If cocaine or crack is present in her body, she may become
toxic and susceptible to a morbid outcome.
Is the examination risky? A pelvic examination may be painful, uncomfortable, and embarrassing but few health
care professionals would find it risky. However, if the patient is not cooperative during the examination, injury
may result. In addition, forcing an examination on a patient may be risky because she may be hesitant to seek
care in the future as a result of this experience.
What are the patient's preferences? The patient clearly has expressed her opposition to receiving a pelvic
examination. However, the patient may not have had time to assess her values and needs. How much time does
Is she competent to make this decision while in custody? While incarcerated prisoners have lost many personal
freedoms, they still are entitled to make medical decisions with regard to their own well being.
Are her expectations of medical care realistic? The physician should act in the patient's best interests and not
be in partnership with law enforcement. In addition, if additional signs and symptoms develop, the patient should
expect access to later medical care despite the current refusal of care.
Given her state of custody and duress, can her decisions be considered as voluntary; does this issue matter in
this case? What are the consequences of her decision and the potential actions of emergency physicians? She
may be at risk of physical harm if she has cocaine and it is not retrieved. Forcing an examination on her also
may cause physical harm. Is emotional harm possible, as well?
Refusing to heed the patient's wishes would violate any present and future doctor-patient relationship. Does this
relationship take precedence over all others, including a physician's duty to society and justice?
The ED physician may be in contempt of court with a refusal to follow the legal orders of a search warrant.
What are the pragmatic issues? The law appears to be the overriding pragmatic issue tempering our actions in
this situation. No family is present to consult. Economics is not an issue, unless the contract for reimbursement
between the ED and the Department of Corrections is scheduled for negotiation. Time pressures surface
because law enforcement officials prefer to spend time on the street rather than waiting in the ED.
Consider the concepts of autonomy, consent, beneficence, and nonmaleficence.
Alternative courses of action might include the following:
Do nothing and discharge the patient.
Talk to risk management.
Perform the examination.
Collect urine and send it for a toxicology screen.
Perform ultrasonography to look for intravaginal foreign bodies.
Obtain radiographs of the patient and look for foreign bodies.
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Follow through with a course of action.
Consider what really happened. In the example above, police obtained a search warrant instructing the ED to
search the woman's vagina for illegal drugs. The patient continued to refuse any examination and her vital signs
remained normal during her time in the ED.
The physician on duty believed the patient was competent to refuse the examination and decided to respect her
autonomy. The physician did not believe that any exceptions mandating waiver of informed consent were
present. He chose to observe the patient, hoping for a change in the patient's condition indicating a need to
remove the offending agent. This situation never arose.
The judge suggested radiography or ultrasonography to detect any foreign body. The patient refused all imaging
procedures. These procedures were considered invasive enough by the attending physician that he heeded the
The judge suggested a toxicology screen, but the attending physician pointed out that this would be evidence of
prior use but not possession in the vaginal cavity.
After several hours of research, the hospital attorney felt that the physician legally was required to obey the
search warrant. However, the attending physician refused to examine the patient against her wishes.
After 12 hours of observation, the patient finally agreed to be examined. No illegal drugs were found.
Section 8 of 9
Emergency physicians are faced with ethical dilemmas nearly every day. Most are solved through previous
experience and sharing opinions with colleagues.
A framework for ethical decision-making is useful in gaining needed experience and in helping to formulate ideas
and opinions that may be shared with patients, colleagues, and friends.
Section 9 of 9
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