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Ethics Curriculum for Emergency Medicine Residencies


SAEM Ethics Committee James G Adams Terri A Schmidt (Chair Arthur R !erse Glenn C "reas #e$is R Goldfran% &enneth ' (serson )orm ! &al*fleisch Samuel M &eim Ro*ert & &no++ Gregory # #ar%in Marc # ,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 ,hysician1,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*4ecti-es3 an illustrati-e case3 a discussion3 study 5uestions3 and a *rief *i*liogra+hy. The o*4ecti-es define *asic material a resident $ould *e e6+ected to master after each session. The study 5uestions can *e used to focus discussion3 +ro-ide *road understanding of the su*4ect3 and stimulate thought. Most of the 5uestions may not ha-e one correct ans$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*4ect3 *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

guidance and direction3 ethical analysis should +ro-ide a frame$or% for determining moral duty3 o*ligation and conduct. Similarly3 ethical analysis does not su*stitute for a++ro+riate legal guidance. 7hen dealing $ith dilemmas3 $hen initiating +olicy and +rotocols3 or $hen u+dating e6isting +rocedures3 informed legal ad-ice is encouraged. An attorney familiar $ith emergency medicine and $ell1-ersed in rele-ant statutory and case la$ $ill hel+ to define legally acce+ta*le actions. Bibliography Ales &#3 Charlson ME3 7illiams1Russo ,3 Allengrante J,/ 8sing faculty consensus to de-elo+ and im+lement a medical ethics course. Academic Medicine 1999:;</4=;1 4=>. Crimmins TJ/ Ethics3 la$3 and emergency medicine. Minnesota Medicine 19>>:<1/<=>1<1=. Mos%o+ JC3 Mitchell JM3 Ray 'G/ An ethics curriculum for teaching emergency medicine residents. Ann Emerg Med 199=: 19/1><1199. Strong C3 Commelly JE3 "orro$ #/ Teachers? +erce+tions of difficulties in teaching ethics in residencies. Academic Medicine 1999:;</@9>14=9. 7inden$erder 7/ Ethical dilemmas for housestaff +hysicians. JAMA 19>A:9A4/@4A41 @4A<.

I. Basic Ethical Foundation of Clinical Medicine Objectives 1. !iscuss the moral +rinci+les that underlie the +ractice of medicine. 9. !efine ethics. @. !efine res+ect for autonomy. 4. !efine +aternalism. A. !efine *eneficence. ;. !efine non1maleficence. <. !efine 4ustice.

Ethics studies -alues and moral reasoning. )on1normati-e ethics descri*es and analyBes moral *eliefs $ithout ma%ing a -alue 4udgement 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 $estern health care ethics/ res+ect for autonomy3 *eneficence3 nonmaleficence and 4ustice. The +riority each is gi-en is determined *y the situation. )o +rinci+le al$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 Ca*o-e all do no harmC. 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-ider1+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 Cthe health of my +atient $ill *e my first considerationC (7orld Medical Association3 19>@ . Autonomy is deri-ed from t$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 8S1 Tus%eegee sy+hilis study3 $hich continued into the 19<=s3 and the 8S go-ernment1 s+onsored radiation studies. Res+ect for autonomy is su++orted *y la$. )e$ Dor% State Su+reme Court Justice CardoBa said in 1914 that Cany indi-idual of sound mind has the right to determine $hat shall *e done to his *ody...C 2o$e-er3 informed consent does not a++ear as +art of American case la$ until 19A<. 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 4ustice. 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 4ustice 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 Cthe end 4ustifies the means. !eontological theories are *ased on the *elief that some actions are right or $rong *ased on a higher rule or rules3 not 4ust *ased on the conse5uence of the action. Bibliography 0eaucham+ T# and Childress J"/ ,rinci+les of 0iomedical Ethics @rd ed E6ford 8ni-ersity ,ress3 )e$ Dor%3 19>9. Edelstein3 # (194@ The 2i++ocratic Eath/ Te6t3 Translational (nter+retation 0ulletin of the 2istory of Medicine3 Su++lement 1 0altimore/ The Johns 2o+%ins ,ress3 +. @. (serson &'3 Sanders A03 Mathieu !R3 0uchanan AE (eds / Ethics in Emergency Medicine. 0altimore3 7illiams and 7il%ins3 19>;. Jonsen AR3 Siegler M3 7inslade 7J (eds / Clinical Ethics3 @nd ed. McGra$12ill3 (nc3 )e$ Dor%3 1999. #uce JM/ Ethical +rinci+les in critical care. JAMA 199=:9;@/;9;1<==.

II. Applying Ethics to E Objectives

ergency Medicine

1. #ist s+ecial +ro*lems associated $ith ethical decision1ma%ing in emergency medicine. 9. !escri*e t$o models for ethical decision1ma%ing in emergency medicine. @. #ist ad-antages and disad-antages of the t$o models in emergency medicine. A 99 year old man in acute res+iratory distress is *rought into the emergency de+artment from a nursing home. 2e had *een at the nursing home for ; months and is descri*ed as normally alert and oriented3 *ut *edridden due to his end stage congesti-e heart failure. 2e has no family in the area. 2e a++ears frail and de*ilitated3 and cannot ans$er any 5uestions. 2is *lood +ressure is 9= systolic3 heart rate is 19= 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 +references regarding resuscitation or Ccode status.C Shortly after arri-al3 his daughter from out of state calls and states her father $ould not $ant Caggressi-e treatmentC. The E! is not only a com+le6 medical en-ironment3 *ut +resents com+le6 ethical challenges as $ell. Eur 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 4ust as $e use models to ma%e other clinical decisions. Ene 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 4ustice. 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 C(s this a ty+e of ethics +ro*lem for $hich you ha-e already $or%ed out a rule or is this at least similar enough so that a rule could reasona*ly *e e6tended to co-er itGC. (f so3 then follo$ the rule. The second ste+ is to as% the 5uestion3 C(s there an o+tion $hich $ill *uy time for deli*eration $ithout e6cessi-e ris% to the +atientGC. (f yes3 *uy time. "inally3 if the first t$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+artiality11 the decision ma%er +laces in the +osition of the +atient *y saying3 C7ould you *e $illing to ha-e this action +erformed if you $ere in the +atient?s +laceGC. 9. 8ni-ersaliBa*ility117ould you *e $illing to use the same solution in all similar casesG @. (nter+ersonal 4ustifia*ility11Consider $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*4ect 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 featuresG 9. 2o$ does that %no$ledge hel+ you to ma%e a decisionG @. 8se the (serson model to hel+ formulate a decision in this situation. Bibliography Adams JG3 Arnold R3 Siminoff #3 7olfson A0/ Ethical conflicts in the +rehos+ital setting. Ann Emerg Med 1999:91/19A9119;A. Jonsen AR3 Siegler M3 7inslade 7J (eds / Clinical Ethics3 9nd ed. )e$ Dor%3 MacMillan3 1999. (serson &'3 Sanders A03 Mathieu !R3 0uchanan AE (eds / Ethics in Emergency Medicine. 0altimore3 7illiams and 7il%ins3 19>;. (serson &'/ Emergency medicine and *ioethics/ a +lan for an e6+anded -ie$. J Emerg Med 1991:9/;A1;;. Schmidt TA/ (nto6icated airline +ilots/ A case *ased ethics model Academic Emergency Medicine 1994: 1/AA1A9.

III. Issues #elated to $atient Autono A. Infor ed Consent Objectives

1. E6+lain $hy informed consent is o*tained for treatment. 9. #ist the critical elements in the consent +rocess. @. !efine the emergency rule. 4. !efine e6+ress consent. A. !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 of headaches3 *ut this e+isode is $orse than usual. There is no fe-er3 and the +atient has a non1focal neurological e6amination: the +atient?s sensorium is clear. 2ead CT scan 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 self1determination and $ell *eing. Although +atient self1determination 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 infor ed 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 that E-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 $ithout his +atient?s consent commits an assault for $hich he is lia*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<93 $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 E

ergency #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 decision1ma%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.

plied Consent C(m+lied consentC 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 E?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 in4ections $ere *eing administered3 rolling u+ his slee-e and su*mitting to the in4ection3 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 4udgement 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 consentG 9. !o you need to o*tain $ritten consent from this +atientG @. 7hy does a +hysician o*tain informed consent for treatmentG 4. 2o$ do the +rinci+les of *eneficence and autonomy relate to consent issuesG

Bibliography A++lelaum ,S3 #idB C73 Meisel J!/ (nformed Consent/ #egal Theory and Clinical ,ractice E6ford 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;/;91;<. 0roc% !7/ (nformed +artici+ation and decisions in (serson &'3 Sanders A03 Mathieu !R3 0uchanan AE (eds / Ethics in Emergency Medicine. 0altimore3 7illiams and 7il%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+tualiBation Crit Care Med 19>9: 1</1@4;11@A4.

III. Issues #elated to $atient Autono B. $atient &ecision Ma'ing Capacity Objectives 1. 9. !efine decision ma%ing ca+acity

Contrast medical inter+retations of decision ma%ing ca+acity $ith the legal definition of com+etence.

@. 4.

!efine surrogate decision ma%er and health care +ro6y #ist the $ays decisions can *e made $hen a +atient lac%s decision1 ma%ing ca+acity.

A AA year old male +atient came to an E! com+laining of nausea and chest +ain o-er the +ast t$o hours. An E&G immediately u+on arri-al re-ealed significant (@ mm ST de+ression in an anterio1se+tal distri*ution (' 914 . The +atient?s chest +ain $as relie-ed after a third su*lingual nitroglycerin ta*let $as administered. Su*se5uent E&G re-ealed 119mm ST de+ression. 2e has not seen a +hysician in the +ast A years. 2e ta%es no medications and smo%es 1 +ac% of cigarettes a day. 2e refuses to *e admitted to the hos+ital and demands that he immediately *e released. !es+ite all efforts *y the +hysician to con-ince him to stay3 he demands that he *e allo$ed to go home. 7hen a +atient arri-es in an emergency de+artment and an e-aluation *y a +hysician is *egun3 a +hysician1+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 9 the legal right of self1determination3 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 decision1ma%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 $ould lead the +hysician to *elie-e that the +atient?s decision1ma%ing ca+acity has *een significantly com+romised. The determination of decision ma%ing ca+acity re5uires that/ 1. The +atient a++reciates he or she has the +o$er to ma%e decisions on his or her *ehalf 9. 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 $ith his or her life -alues or goals. The degree or le-el of decision1ma%ing ca+acity a +atient must sho$ -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 Co


(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. Ence the +erson is formally 4udged 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 4udged 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 decision1ma%ing ca+acity to gi-e an informed consent3 ho$ should medical decisions *e madeG 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

+ermits and there is a legal decree that the +atient is incom+etent3 then the emergency +hysician should contact the conser-ator of the +atient $ho $ould ha-e legal res+onsi*ility for medical decision ma%ing. (n addition3 +atients may ha-e a dura*le +o$er of attorney for health care3 li-ing $ill or +re-iously e6+ressed $ishes to family or others $hich should *e honored (see section on ad-ance directi-es . 7hen +atients +re-iously e6+ressed $ishes are %no$n3 *ased on the +rinci+le of res+ect for autonomy3 those $ishes should generally *e honored. 2istorically3 there $as su*stantial ethical and legal consensus su++orting the conce+t of surrogate decision ma%ing *y family mem*ers. 2o$e-er3 recent legal cases suggest that courts may *e less reliant on family mem*ers to act as surrogate decision ma%ers. Still3 each state has la$s that descri*e the hierarchy of authority for family surrogate decision ma%ing. Surrogate decision1ma%ers may *e acce+ta*le in the emergency setting3 *ut the time re5uired to confirm surrogate identity3 e6+lain the medical circumstances and +rognosis3 and assure sound reasoning3 may *e +rohi*iti-e $hen there is a medical im+erati-e to inter-ene. 7hen dou*t e6ists3 a conser-ati-e course (resuscitationHsta*iliBation is $arranted. !tudy "uestions 1. (n the case +resented3 $hat must *e discussed $ith the +atient $hile counselling him regarding his refusalG 9. @. 7hat must you %no$ so that you can ade5uately counsel himG 2o$ $ould you assess $hether the +atient +ossessed ade5uate decision1 ma%ing ca+acityG Bibliography A++le*aum ,S3 Grisso T/ Assessing +atients? ca+acities to consent to treatment. ) Engl J Med 19>>: @19/1;@A11;@>. 0roc%3 ! and 7artman3 SA 7hen com+etent +atients ma%e irrational choices. ) Eng J Med @99/1A9A11A99.

Emanuel3 EJ and Emanuel3 ## ,ro6y decision ma%ing for incom+etent +atients/ An ethical and em+irical analysis. JAMA 1999: 9;</9=;<19=<1. Jonsen AR3 Siegler M3 7inslade 7J (eds / Clinical Ethics3 @nd ed. McGra$12ill3 (nc3 )e$ Dor%3 1999. #o3 0 Assessing decision ma%ing ca+acity. #a$3 Medicine3 and 2ealth Care 199= 1>/@("all 19@19=1. #o 03 Rouse "3 !orn*rand #/ "amily decision ma%ing on trial/ 7ho decides for incom+etent +atientsG ) Engl J Med 199=:@99/199>119@9.

III. Issues #elated to $atient Autono C. Treat ent of inors Objectives* 1. 9. @.

E6+lain ho$ consent for minors is o*tained. E6+lain ho$ the Cemergency ruleC 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. A.

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 is using mari4uana. The +atient refuses to su*mit to any e6am or +roduce a urine 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 $ith a true emergency. Emergency has *een construed *y courts to go *eyond 4ust life threatening or disa*ling disease or in4ury to include treatment to alle-iate +ain or suffering from serious *ut nonemergent conditions. Many states ha-e la$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 self1su++orting3 minors $ho are married3 ha-e *een +regnant3 or $ho are in the armed forces. The mature minor is a young +erson (usually 1A 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 caseG Can you treat this teenager against his $illG 9. !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 groundsG Bibliography 2older AR/ ,arents3 courts and refusal of treatment J ,ediatr 19>@: 1=@/A1A1 A91. Jonsen AR3 Siegler M3 7inslade 7J (eds / Clinical Ethics3 @nd ed. McGra$12ill3 (nc3 )e$ Dor%3 1999. #egal Corres+ondent/ Teenage confidence and consent. 0rit Med J 19>A:99=/144114A. Morrissey J3 2offman A3 Thor+e J/ Consent and Confidentiality in the 2ealth Care of Children and Adolescents/ #egal Guide Macmillan/ The "ree ,ress3 )e$ Dor%3 19>;. RoBofs%y "/ Consent to Treatment/ A ,ractical Guide 9nd ed3 #ittle 0ro$n3 0oston3 199=. Tsai A&3 Schafermeyer R73 &alifon !3 et al/ E-aluation and treatment of minors/ Reference on consent. Ann Emerg Med 199@:99/19111191<.

III. Issues #elated to $atient Autono &. Advance &irectives Objectives

1. !efine ad-ance directi-es/ dura*le +o$er of attorney for health care and li-ing $ills 9. State the +ur+ose of an ad-ance directi-e and descri*e the re5uirements for a -alid ad-ance directi-e. @. E6+lain your state la$s regarding ad-ance directi-es. 4. E6+lain the conditions $hich ma%e an ad-ance directi-e a++lica*le. A 4A 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 until yesterday $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 the com+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 life1sustaining +rocedures in the e-ent of terminal illness. They are legally recogniBed *y o-er 4A 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$s as they relate to ad-ance directi-esG 7hich forms of ad-ance directi-es are allo$edG 9. (n this case3 $ho has decision ma%ing +o$er for this +ersonG @. 7ho $ould you consult for decisions if the +arents also came to the emergency de+artment and re5uested to ma%e decisions for their sonG Bibliography Annas GJ/ The health care +ro6y and the li-ing $ill. ) Engl J Med 1991:@94/191=1191@. Emanuel EJ3 Emanuel ##/ ,ro6y decision ma%ing for incom+etent +atients. JAMA 1999:9;</9=;<19=<1. (serson &'/ "ederal ad-ance directi-es legislation/ +otential effects on emergency medicine. J Emerg Med 1991:9/;<1<=. Miles S2/ Ad-anced directi-es to limit treatment/ the need for +orta*ility. J Amer Ger Soc 19><:@A/<41<;. Erentlicher !/ Ad-ance medical directi-es. JAMA 199=:9;@/9@;A19@;<. Siner !A/ Ad-ance directi-es in emergency medicine/ Medical3legal and ethical im+lications. Ann Emerg Med 19>9:1>/1@;411@;9.

I,. End of %ife &ecisions A. %i iting #esuscitation Objectives

1. 9.

!efine C!o )ot Resuscitate ErderC (!)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 $as not to *e resuscitated in the e-ent of cardiac arrest. State EMS +olicy3 ho$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 Cdead on arri-alC.

(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 arm1*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. CSlo$ codes3C 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 Cdo not resuscitateC 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 4urisdiction. (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+ted resuscitationG 9. @. 7hat e-idence of +atient $ishes does a +hysician need $ithhold resuscitation attem+tsG (s a relati-e?s -er*al re5uest enoughG !oes the age3 a++earance3 or +hysical condition of the +atient matterG

Bibliography Adams JG3 !erse AR3 Gotthold 7E3 Mitchell JM3 Mos%o+ JC3 Sanders A0/ Ethical As+ects of Resuscitation Ann Emerg Med 1999:91/19<@119<;. Ayres RJ/ Current contro-ersies in +rehos+ital resuscitation of the terminally ill +atient. ,rehos+ital and !isaster Medicine 199=:A/491A<. American College of Emergency ,hysicians/ Guidelines for Cdo not resuscitate ordersC in the +rehos+ital setting. Ann Emerg Med 19>>:1</11=;111=>. Miles S23 Crimmins TJ/ Erders to limit emergency treatment for an am*ulance ser-ice in a large metro+olitan area. JAMA 19>A:9A4/A9A1A9<. Ramos T3 Reagan JE/ ?)o? $hen the family says ?go?/ resisting families? re5uests for futile C,R. 19>9:1>/>9>1>99.

I,. End of %ife &ecisions B. Futility Objectives 1. !efine futility 9. !escri*e situations in $hich futility may *e used to $ithhold treatment in the emergency de+artment and out of hos+ital setting. A 9A year old male is *rought to the emergency de+artment *y +aramedics after sustaining a gunshot $ound to his head. 2e arri-es $ith agonal res+irations3 and a *lood +ressure of ;= systolic. The *ullet entered at the left tem+le and there is a large e6it $ould $ith e6truding *rain from the right tem+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 $ithout restoration of circulation. 9. )o +hysiologic *enefit can *e e6+ected from A#S and 0#S *ecause the +atient?s +hysiologic functions are deteriorating des+ite ma6imum thera+y (e6am+les3 o-er$helming se+sis3 cardiogenic shoc% . )o sur-i-ors ha-e *een re+orted under the gi-en circumstances in $ell1designed 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. Ethers 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 out1of1to$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. Engoing 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


!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 futilityG 7hat efforts to$ard resuscitation should *e attem+tedG

Bibliography Jec%er )S3 Schneiderman #J/ Ceasing futile resuscitation in the field/ ethical considerations. Arch (nt Med 1999:9@9919@9<. #oe$y E23 Carlson RA/ "utility and (ts 7ider (m+lications Arch (ntern Med 199@: 1A@/49914@1. #antos J!3 Singer ,A3 7al%er RM et al/ The (llusion of "utility in Clinical ,ractice Am J Med 19>9: ></>11>4. Schneiderman #J3 Jec%er )S3 Jonsen AR/ Medical "utility/ (ts Meaning and Ethical (m+lications Ann (ntern Med 199=: 119/94919A4. Schneiderman #J and Jec%er )/ "utility in ,ractice Arch (ntern Med 199@: 1A@/4@<1441. Tomlinson T and 0rody 2/ "utility and the Ethics of Resuscitation JAMA 199=: 9;4/19<;119>=. Truog R!3 "rader J/ The +ro*lem $ith futility. ) Eng J Med 1999:@9;/1A;=1 1A;4.

,. The $hysician)$atient #elationship A. Confidentiality Objectives 1. !efine confidentiality. 9. !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 @9 year1old +aramedic comes to the emergency de+artment in a +ost1ictal state. 2e $as $itnessed to ha-e a grand mal seiBure. After a*out an hour3 he *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 of consciousness.

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 ( shall see or hear amid the li-es of men3 $hich ought not to *e noised a*road3 as to this ( $ill %ee+ silence3 holding such things 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 +hysician should not re-eal confidential information $ithout the consent of the +atient3 unless +ro-ided *y la$ or *y the need to +rotect the $elfare of the indi-idual or the +u*lic interest. Thus3 *oth ancient and modern +hysicians ha-e recogniBed the im+ortance of confidentiality and ha-e included it in -arious oaths3 +rinci+les3 and rules of +rofessional conduct. American common la$ 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. En 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$ing hierarchy/ 1 ma4or harm ris%1high +ro*a*ility3 9 minor harm1high +ro*a*ility: @ ma4or harm ris%1lo$ +ro*a*ility: and 4 minor harm1lo$ +ro*a*ility. According to this scale a lo$er num*er +ro-ides strong 4ustification to *reach confidentiality. (ndeed3 some ethicists hold that $hen confronted $ith a situation of ma4or harm and high +ro*a*ility the +ro-ider is not merely ethically 4ustified in *reaching confidentiality3 *ut is ethically re5uired to do so. Moral grounds for honoring confidentiality3 ho$e-er con-incing3 may sometimes yield to stronger moral grounds for disclosure. The follo$ing situations 4ustify disclosure/ 1. Re+orting related to +u*lic health la$s $hich may include 'ital statistics (*irth and death certificates Contagious diseases Child and elder a*use Criminally inflicted in4uries ,oisoning #oss of consciousness 9. #egal +roceedings @. Fuality assurance re-ie$ 4. ,rotection of a third +arty from mortal harm. (n general3 +hysicians may disclose confidential information $hen +atients agree to disclose or $hen disclosure is re5uired in order to fulfill a stronger moral duty to +re-ent harm or to o*ey 4ust la$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'G 7hat are the conflicting ethical +rinci+lesG (f the +atient $as a highly -isi*le +u*lic figure $hat3 if anything3 $ould you re+ort to either the media or !M'G (f the +atient -oluntarily agreed not to dri-e $ould this affect your decision to re+ortG



Bibliography American Medical Association/ Council on Ethical and Judicial Affairs/ Current o+inions of the Council on Ethical and Judicial Affairs3 Chicago3 19>;3 IA.=9. Annas GJ/The rights of +atients/ The *asic AC#8 guide to +atients rights 9nd ed3 #i*rary of Congress cataloging1in1,u*lication !ata3 19>93 ++.1<A119A. 0eaucham+ T#3 Childress J" (eds / ,rinci+les of 0iomedical Ethics @rd ed3 )e$ Dor%3 E6ford 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 disclosure S+ecialty #a$ !igest 2ealth Care 199=: 1@4/<149. Siegel !M/ Confidentiality in Emergency Ris% Management ACE,3 !allas3 ++. 1>111>4. Siegler M/ Confidentiality in medicine1A decre+it conce+t. ) Engl J Med 19>9:@=</1A1>11A91.

,. The $hysician)$atient #elationship B. Truth telling and Co unication Objectives 1. E6+lain $hy truth telling is im+ortant. 9. !iscuss circumstances $hen one might not tell a +atient the truth. @. E6+lain the ethical foundations mandating honest +atient1+hysician communication. 4. !iscuss *arriers to effecti-e communication in the E!. A A; year1old man $ith a ;= +ac% year history of smo%ing comes to the emergency de+artment $ith shortness of *reath. 2is chest 61ray sho$s a large mass. (n +re+aring to admit the +atient3 he as%s $hat his 61ray sho$s. 7hen told of the mass3 $hich you thin% is +ro*a*ly cancer3 the +atient as%s3 C(t?s not li%ely to *e cancer3 is it3 doctorCG Dou say3 C7e can?t *e sure at this timeC. The +atient +ersists in %no$ing $hat you thin% it is. 7hat do you tell himG

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 truth1 telling in medicine has actually only recently *ecome an ethical issue and in certain cultures such as Ja+an and (taly3 truth1telling 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 4ustified *y the +rinci+le of nonmaleficence and continued into this century. (n 19;13 9=J of +hysicians still $ould not

tell a +atient of a diagnosis of cancer. (t $as not until 19<< that 9<J 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 $as the rise in em+hasis on ci-il rights and +atient autonomy. "inally3 the scandals in-ol-ing rights of +atients in-ol-ed in e6+erimentation led to the national commission for the +rotection of human su*4ects of *iomedical and *eha-ioral research. This commission issued a re+ort summariBing *asic ethical +rinci+les3 and setting out re5uirements of informed consent3 assessment of ris%s and *enefits to the su*4ects of research3 and fair +rocedures in the selection of human su*4ects. !es+ite this ne$ 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 $hat has *een a++ro+riately called braving the truth. !tudy "uestions 1. 7hat ans$er should *e gi-en to the +atient in this situationG 9. Dou diagnose a +atient $ith gonorrhea and *elie-e his $ife needs treatment. 2e as%s you to treat her3 *ut not tell her no$ she ac5uired the infection. 7hat should you say to the man?s $ifeG A +atient comes to the emergency de+artment re5uesting o+iate +ain medication for his *ac% +ain. 2e is %no$n to ha-e a history of drug a*use. Dou +rescri*e an in4ecta*le anti1inflammatory medication. The +atient as%s $hat he is getting. (s it ethically 4ustified to lie or Cstretch the truthCG !oes it ma%e a difference if the +atient has engaged in dece+tionG


Bibliography )o-ac% !23 !etering 0J3 Arnold R et al/ ,hysicians attitudes to$ard using dece+tion to resol-e difficult ethical +ro*lems JAMA 19>9: 9;1/99>=199>A. ,ellegrino E!/ (s truth telling to the +atient a cultural artifactG JAMA 1999: 9;>/1<@411<@A. Schmidt TA3 )orton R#3 Tolle S7/ Sudden death in the E!/ Educating residents to com+assionately inform families J Emerg Med 1999: 1=/;4@1;4<.

,. The $hysician)$atient #elationship C. Co passion and E pathy Objectives

1. 9.

!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 C+ain shotC. 2e is on !ilaudid3 *ut lately the *one +ain is se-ere. 2e is una*le to ta%e oral medications *ecause of se-ere nausea and -omiting. 2e is an6ious and frightened a*out dying. The de+artment is *usy3 *ut he $ants to tal% to you a*out his fears. 7hat ethical +rinci+les a++ly to this situationG 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 C( am youC or C( could *e youC3 $hile sym+athy creates the message3 C( $ant to hel+ youC. 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 non1com+liant. Ma4or tragedy may rarely mo-e us3 $e may scoff at the CminorC 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 caseG 9. Can em+athy *e taughtG @. 2o$ do $e encourage em+athy in +hysicians and traineesG

Bibliography 0ellet ,3 Maloney M/ The im+ortance of em+athy as an inter-ie$ing s%ill. JAMA 1991:9;;/1>@111>@9. Grumet G/ ,andemonium in the modern hos+ital. ) Engl J Med 199@:@9>/4@@1 4@<. &atB J/ The Silent 7orld of !octor and ,atient The "ree ,ress3 )e$ Dor%3 19>4. )o-ac% !23 !u*e C3 Goldstein MG/ Teaching medical inter-ie$ing Arch (ntern Med 1999: 1A9/1>1411>9=. )elson AR/ 2umanism and the art of medicine. JAMA 19>9:9;9/199>119@=. S+iro 23 McCrea Curnen MG3 ,eschel E3 St. James ! (ed Em+athy and the ,ractice of Medicine Dale 8ni-ersity ,ress3 )e$ 2a-en3 199@.

,I. Issues #elated to -ustice A. .ealth Care #ationing Objectives 1. 9. @. !efine rationing. !efine allocation. E6+lain ho$ rationing and allocation im+act emergency care.

A 4A year old man cuts his finger and then goes to the emergency de+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 ACE inhi*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 contacts each of the +hysicians to $hom he $as referred and none of them $ill acce+t ne$ 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$1u+. !istri*uti-e 4ustice3 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 4ustice 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 Cdecent *asic minimumC of health care. !istri*uti-e 4ustice 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 $ith other interests including housing3 education3 defense and the en-ironment. Currently health care accounts for 14J of the gross national +roduct (G), 3 and has *een gro$ing more ra+idly than any other go-ernment +rogram.

7ithout health care reform3 it is estimated that health care $ill account for 9=J of the G), *y the year 9===. Gi-en our limited resources and gro$ing *udget deficit3 continued increases in health care e6+enditures $ill result in reductions in other +rograms. At a second le-el3 distri*uti-e 4ustice affects allocation decisions in-ol-ing health care resources. 2ealth care is rationed (rationing is defined as the distri*ution of a limited amount of goods and ser-ices in all societies: the ma4or difference is the criteria used for rationing. These criteria should *e de-elo+ed at the societal le-el3 not the *edside. Such decisions should *e *ased on medical need3 cost effecti-eness3 and +ro+er distri*ution of *enefits and *urdens in society. Eur society must decide the a++ro+riate allocation of limited resources to -arious medical inter-entions such as +u*lic health and +re-enti-e medicine3 child and maternal health3 ne$ 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 4ustice 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 4ustice $hen ma%ing decisions a*out costs and resource allocation. Although some +hysicians *elie-e it is unethical to allo$ 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. Ene 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 $e must use our *est 4udgement a*out the +otential *enefit to our +atients. Cost can and should *e a +art of that consideration. !es+ite the con-entional -ie$ 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$1u+ *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 4ustice guides macroallocation decisions and also +lays a role in microallocation decisions in our current system.

!tudy "uestions 1. 7hat is distri*uti-e 4ustice and ho$ does it a++ly to health careG 9. 2o$ does this case illustrate +ro*lems in our current deli-ery of health careG @. 2o$ do $e currently ration health careG 4. (n your o+inion3 ho$ should $e ration health careG Bibliography American College of ,hysicians Ethics Manual Ann (ntern Med 1999: 11</94<1 9;=. 0eaucham+ T#3 Childress J" (eds / ,rinci+les of 0iomedical Ethics @rd ed3 )e$ Dor%3 E6ford 8ni-ersity ,ress3 19>9. Callahan !/ Rationing medical +rogress/ the $ay to afforda*le health care. ) Engl J Med 199=:@99/1>1=11>1@. !aniels )/ Just 2ealth Care Cam*ridge 8ni-ersity ,ress3 Cam*ridge3 19>A. Eddy !M/ Rationing *y +atient choice. JAMA 1991:9;A/1=A11=>. (serson &'/ Assessing -alues/ Rationing emergency de+artment care. Am J Emerg Med 1999:1=/9;@19;4. Society for Academic Emergency Medicine Ethics Committee/ An ethical foundation for health care/ An emergency medicine +ers+ecti-e Ann of Emerg Med 1999: 91/1@>111@><.

,I. Issues #elated to -ustice B. &uty Objectives 1. !efine the CGood SamaritanC statute in your state.

9. E6+lain the a++lica*ility of the CGood SamaritanC 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 and mild diarrhea. The +atient *elongs to an 2ME $hich re5uires +re1a++ro-al for emergency care. The 2ME 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 is not 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 $ell as 4ustice. This o*ligation also has *een codified into federal la$ *y the CE0RA 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 in4ury 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 Cgate%ee+ersC 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 4o*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 $ith e6+ertise is not on the 4o*. CGood SamaritanC statutes ha-e *een instituted to ser-e this end. These la$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 CGood SamaritanC 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 caseG 9. 8nder $hat circumstances might you refuse treatment to a +atientG @. (s it acce+ta*le for the emergency +hysician to loo% at the +atient3 *riefly e6amine the a*domen3 and +ro-ide detailed3 $ritten instructions of signs and sym+toms that signify an emergencyG

Bibliography American College of Emergency ,hysicians/ Emergency care/ res+onsi*ilities and +rinci+les. +olicy statement3 June 1991. American College of Emergency ,hysicians/ Guidelines concerning $or% sto++ages and slo$do$ns. Ann Emerg Med 19>A:14/<<. Curran 7J/ Economic and legal considerations in emergency care. ) Engl J Med 19>A:@19/@<41@<A. !erlet R73 )ishio !A/ Refusing care to +atients $ho +resent to an emergency de+artment/ Ann Emerg Med 199=/19/9;919;<. (serson &'/ Refusal of care/ the ethical dilemma. (letter Ann Emerg Med 199=:19/119<. Miles S2/ 7hat are $e teaching a*out indigent +atientsG JAMA 1999:9;>/9A;119A;9. Sha$ &)3 Sel*st SM3 Gill "M/ (ndigent children $ho are denied care in the emergency de+artment. Ann Emerg Med 199=:19/A91;9. Kuger A/ +rofessional res+onsi*ilities in the A(!S generation. 2astings Cent Re+ June 19><:1</1;19=.

,I. Issues #elated to -ustice C. Moral Issues in &isaster Medicine Objectives 1. !iscuss the sco+e and limits of medical effecti-eness in disaster situations. 9. @. (dentify the moral +rinci+les underlying triage. !iscuss criteria for ma%ing triage decisions and their ethical 4ustification.

A +lane crashes3 resulting in in4ury to many +atients. The -ictims range in age from 1 year old to 9@ years old. Ene 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. Ene +atient has agonal res+irations3 and another has almost 1==J *ody *urns. A $oman is in la*or and at least A +atients a++ear to *e in shoc%. At least 1A +atients ha-e minor in4uries. Dou are the sole +hysician +resent. (n disasters3 $hen resources are scarce3 the +rimary ethical +rinci+le *ecomes 4ustice. The goal is to treat +eo+le e5uita*ly and fairly. This has led to the conce+t of triage. Triage is *ased on the utilitarian ethical +rinci+le of +ro-iding the greatest *enefit to the greatest num*er. 2o$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 $ho might *e a*le to return to the rescue effort. (n addition3 those in4uries most amena*le to treatment3 such as air$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 $orthG 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 non1+hysicians chose the indi-iduals $ho $ould recei-e this then scarce resource. ,riority $as gi-en to indi-iduals $ith +roducti-e 4o*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 caseG 9. 7ould you gi-e some +riority attention to the 8S SenatorG @. Could any +atient distract you and cause you to +ay e6tra attention or +ro-ide longer3 more attenti-e careG Bibliography 0ell )&/ Triage in medical +ractices/ An unacce+ta*le modelG Soc Sci Med 19>1:1A"/1A111A;. Jonsen AR3 Siegler M3 7inslade 7J/ Clinical Ethics @rd ed3 McGra$12ill (nc3 )e$ Dor%3 19993 + 1@9. ,ledger 2G/ Triage of casualties after nuclear attac%. #ancet 19>;:;<>1;<9.

Triage in Reich 7 (ed Encyclo+edia of 0ioethics 9nd ed The "ree ,ress3 )e$ Dor%3 1999. 7inslo$ GR/ ,rinci+les for triage3 in Triage and Justice3 0er%eley3 8ni-ersity of California ,ress3 19>93 ++ ;=11=9.

,I. Issues #elated to -ustice &. #esearch Objectives 1. 9. !efine the moral +rinci+les for research on human su*4ects. !escri*e the uni5ue moral challenges $hich face research in an

emergency setting. @. !escri*e ho$ to o*tain informed consent for research.

A @9 year old man too% @= mg of loraBe+am. 2e $as somnolent *ut arousa*le and his -ital signs $ere sta*le. 2e and his family $ere informed that he $ould *e trans+orted to the medical center across to$n Csince they ha-e a medicine to treat this o-erdose.C (The center $as conducting trials $ith a *enBodiaBe+ine antagonist .

As a result of the atrocities of medical e6+eriments carried out *y the )aBis in 7orld 7ar ((3 the infamous Tus%egee Sy+hilis Study and other unethical research3 go-ernments and +rofessional organiBations made a concerted effort to de-elo+ ethical +rinci+les for *iomedical research. The )urem*erg Code3 the 2elsin%i !eclaration and the 0elmont Re+ort ser-e as a foundation for de-elo+ing ethical +rinci+les for research. These +rinci+les include res+ect for +eo+le as autonomous agents3 truth telling3 *eneficence in ma6imiBing the *enefits and minimiBing the *urdens for research su*4ects3 and 4ustice in e5uita*ly distri*uting the *enefits and *urdens of research. !uring the +ast decade3 $e ha-e $itnessed a dramatic increase in re+orts of unethical conduct in *iomedical research. 7hether this re+resents an increased incidence of unethical conduct or rather a com*ination of increased recognition and re+orting of such occurrences is unclear. )e-ertheless3 the result has *een an outcry from the +u*lic3 go-ernment

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 data 3 unethical treatment of human and nonhuman su*4ects3 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*4ects3 9 the $ai-er $ill not ad-ersely affect the rights and $elfare of the su*4ects3 @ the research could not *e carried out $ithout the $ai-er3 and 4 su*4ects $ill *e +ro-ided information follo$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. Ene e6am+le of this is the C8niform Re5uirements for Manuscri+ts Su*mitted to 0iomedical JournalsC. 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


(s it a++ro+riate for +atients to *e trans+orted to a +articular hos+ital in order to enroll them in a research +rotocolG

9. @.

2o$ should consent *e o*tained for resuscitation researchG (s it +ossi*le to o*tain informed consent for emergency researchG

Bibliography 0inder #/ (nformed consent in emergency medicine research SAEM )e$sletter Se+tem*er3 199@. (nternational Committee of Medical Journal Editors/ 8niform re5uirements for manuscri+ts su*mitted to *iomedical 4ournals Ann (ntern Med 19>>: 1=>/9A>1 9;A. Sie*er JE/ Ethical considerations in +lanning and conducting research on human su*4ects Academic Medicine 199@: ;> (su++ /s91s1@. S+i-ey 723 A*ramson )S3 (serson &'3 Mac&ay CR3 Cohen M,/ (nformed consent for *iomedical research in acute care medicine. Ann Emerg Med 1991:9=/19A1119;A. 8S Go-ernment/ The 0elmont Re+ort/ Ethical ,rinci+les and Guidelines for the ,rotection of 2uman Su*4ects of Research 8S Go-ernment ,rinting Effice3 7ashington !.C.3 19>>.

,II. Teaching Objectives 1. !escri*e the ethical issues surrounding the use of animals for teaching and research. 9. !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 @A minutes. Ene of the residents as%ed if anyone $ould mind if he e6tu*ated and re1intu*ated the +atient to +ractice. Clinical Teaching

A ma4or 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 $hen they hold themsel-es out as medical +rofessionals. The uns%illed +rofessional1in1training must ac5uire the +rofessional attri*utes +rior to assuming full res+onsi*ility for +atient care. These +rofessional attri*utes include the re5uisite %no$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. Ethers3 $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*4ects. Any use of animals re5uires treatment and care that is as humane and discomfort1free 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 non1disfiguring +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 +atientsG 9. @. Should consent *e o*tained from the familyG Should an attending +hysician see e-ery +atient $ho comes to the emergency de+artment of a teaching hos+italG 4. 7hat guidelines does your institution ha-e on the use of animals for teachingG Are these guidelines ethically 4ustifiedG A. 7hat do you *elie-e a*out the use of animal model in teachingG The use of the ne$ly deadG Bibliography (serson &'/ The su+er-ision of +hysicians in training/ an educational and ethical dilemma. Medical Teacher 19>>: 1=/19A19=1. (serson &'/ Re5uiring consent to +ractice and teach using the recently dead. J Emerg Med 1991: 9/A=91A1=. (serson &'/ ,ostmortem +rocedures in the emergency de+artment/ using the recently dead to +ractice and teach. J Med Eth June 199@.

'arner GE/ The +ros+ects for consensus and con-ergence in the animal rights de*ate 2astings Center Re+ort 1994: 94 (1 /9419>. 7in%en$erder 7/ Ethical dilemmas for house staff +hysicians. JAMA 19>A: 9A4/@4A41@4A<.

,III. #elationships 0ith the Bio Objectives 1. 9. @.

edical Industry

!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 ethically a++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 $ith the re+resentati-e in the charting area3 and they discuss the -alue of his com+any?s ne$ anti*iotic for an emergency de+artment use3 -ersus other +roducts on the mar%et. The re+resentati-e distri*utes +romotional material on the anti*iotic to the resident and other residents in the area. The re+resentati-e then reaches into his shoulder *ag and +asses out com+any +ens3 note +ads3 and +enlights to the residents3 and +resents a Cte6t*oo%C on infectious diseases for the resident?s E! li*rary. The resident than%s the re+resentati-e for his gratuities. The re+resentati-e +asses out his card and offers to *ring food to one of the future resident conferences3 or +ay for a noted emergency medicine s+ea%er to come and +resent a grand rounds on infectious 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*4ecti-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

fundamentally moti-ated to +romote only their +roduct3 and therefore3 a +resentation from them is inherently *iased. S+ea%ers $ho recei-e e6cessi-e com+ensation may also ha-e a conflict of interest. (n-itations to s+ea% at residency or CME conferences should come from the residency organiBation itself and not from the *iomedical com+any. (t is the residency +rogram?s res+onsi*ility to ensure that a *alanced3 un*iased -ie$ of the scientific data is +resented. Academic +rograms should set u+ guidelines to regulate the interaction of residents $ith the *iomedical industry. A gift acce+ted *y a resident +hysician should +ro-ide an education to the +hysician3 or a direct *enefit to the +hysician?s +atients. Residents of a +rogram may acce+t te6t*oo%s of reasona*le -alue3 +ro-ided they are +u*lications not s+ecifically +roduced *y the *iomedical com+any. (t is common for +hysicians to acce+t gifts of nominal -alue such as +ens3 +enlights3 note +ads. Gifts of significant -alue such as tic%ets to s+orting functions3 e6+ensi-e dinners3 or hos+itality suite +arties should *e a-oided. Ene standard to 4udge $hether the gift is a++ro+riate is to as% the 5uestion3 C7ould ( *e $illing to defend this gift to my +atientsGC )o gift should *e acce+ted if it is gi-en to re$ard a s+ecific +rescri*ing +attern or other +hysician *eha-ior. A healthy ethical relationshi+ $ith the *iomedical industry can e6ist. Scholarshi+s3 residency +rogram su++ort3 monies to stimulate resident research or education could *e directed to the residency organiBation itself3 *y+assing indi-idual +hysician influence. 0oth the ethics committee and the research committee of the Society for Academic Emergency Medicine ha-e de-elo+ed guidelines for interaction $ith *iomedical com+anies. These +a+ers descri*e +otential ethical conflicts in the relationshi+ *et$een

+hysicians and the *iomedical industry and suggest ethical guidelines for +hysicians and researchers. Emergency medicine residents and faculty should *e con-ersant $ith these guidelines. !tudy "uestions 1. 9. 7hy do *iomedical +romotional acti-ities3 such as gift gi-ing3 +resent +otential ethical conflicts to the emergency +hysicianG 7hat as+ects of +romotional materials and +resentations *y com+any1 s+onsored s+ea%ers could su*-ert a *alanced3 un*iased medical educationG 2o$ can +hysicians and residency +rograms interact to +romote ethical relationshi+s $ith the *iomedical industryG


Bibliography 1. American Medical Association/ Gifts To ,hysicians "rom (ndustry. JAMA3 1991: 9;A/A=1. 9. &essler !A3 ,ines 7#/ The "ederal Regulation of ,rescri+tion !rug Ad-ertising and ,romotion. JAMA3 199=: 9;4/94=91941A. @. Chren MM3 #andefeld S3 Murray T2/ !octors3 !rug Com+anies3 and Gifts. JAMA 19>9:9;9/@44>1@4A1. 4. Sanders A03 &eim SM3 S%lar !3 Adams J/ Emergency ,hysicians and the 0iomedical (ndustry. Ann Emerg Med 1999:91/AA;1AA>. A. A-orn J3 Chen M3 2artley R/ Scientific -ersus Commercial Sources of (nfluence En the ,rescri*ing 0eha-ior of ,hysicians. AM J ME! 19>9:<@/41>.