John C. Moskop

INFORMED CONSENT IN THE EMERGENCY DEPARTMENT

This article reviews the doctrine of informed consent to treatment, with particular attention to its role in the emergency department. The article begins with a brief look at the moral and legal foundations of informed consent. The article then examines the three essential features of informed consent, patient capacity, disclosure of information, and voluntariness. After a review of five exceptions to the duty to obtain informed consent, the article concludes with a brief summary of issues of special significance for emergency physicians.

Fight or flight: the ethics of emergency physician disaster response

Most disaster plans depend on using emergency physicians, nurses, emergency department support staff, and out-of-hospital personnel to maintain the health care system’s front line during crises that involve personal risk to themselves or their families. Planners automatically assume that emergency health care workers will respond. However, we need to ask: Should they, and will they, work rather than flee? The answer involves basic moral and personal issues. This article identifies and examines the factors that influence health care workers’ decisions in these situations. After reviewing physicians’ response to past disasters and epidemics, we evaluate how much danger they actually faced. Next, we examine guidelines from medical professional organizations about physicians’ duty to provide care despite personal risks, although we acknowledge that individuals will interpret and apply professional expectations and norms according to their own situation and values. The article goes on to articulate moral arguments for a duty to treat during disasters and social crises, as well as moral reasons that may limit or override such a duty. How fear influences behavior is examined, as are the institutional and social measures that can be taken to control fear and to encourage health professionals to provide treatment in crisis situations. Finally, the article emphasizes the importance of effective risk communication in enabling health care professionals and the public to make informed and defensible decisions during disasters. We conclude that the decision to stay or leave will ultimately depend on individuals’ risk assessment and their value systems. Preparations for the next pandemic or disaster should include policies that encourage emergency physicians, who are inevitably among those at highest risk, to “stay and fight.”

From hippocrates to HIPAA: Privacy and confidentiality in emergency medicine: Part II: Challenges in the emergency department

Part I of this article reviewed the concepts of privacy and confidentiality and described the moral and legal foundations and limits of these values in health care. Part II highlights specific privacy and confidentiality issues encountered in the emergency department (ED). Discussed first are physical privacy issues in the ED, including problems of ED design and crowding, issues of patient and staff safety, the presence of visitors, law enforcement officers, students, and other observers, and filming activities. The article then examines confidentiality issues in the ED, including protecting medical records, the duty to warn, reportable conditions, telephone inquiries, media requests, communication among health care professionals, habitual patient files, the use of patient images, electronic communication, and information about minor patients.

The Baby Doe Rule: Still a Threat

Current federal policy, as reflected in the final Baby Doe rule, will have a chilling effect on the ability of doctors to care appropriately for severely disabled infants. The policy threatens to prolong life unjustifiably for such infants. It will force physicians to violate a duty to do no harm without compensating benefit. And it raises serious problems for the just distribution of health care.

American College of Emergency Physicians Ethics Manual

Ethical concerns are a major part of the clinical practice of emergency medicine. The emergency physician must make hard choices, not only with regard to the scientific/technical aspects but also with regard to the moral aspects of caring for emergency patients. By the nature of the specialty, emergency physicians face ethical dilemmas often requiring prompt decisions with limited information. This manual identifies important moral principles and values in emergency medicine. The underlying assumption is that a knowledge of moral principles and ethical values helps the emergency physician make responsible moral choices. Neither the scientific nor the moral aspects of clinical decision making can be reduced to simple formulas. Nevertheless, decisions must be made. Emergency physicians should, therefore, be cognizant of the ethical principles that are important for emergency medicine, understand the process of ethical reasoning, and be capable of making rational moral decisions based on a stable framework of values.

An ethics curriculum for teaching emergency medicine residents

Instruction in medical ethics has become standard in undergraduate medical education within the past decade; more recently, several specialty boards have formally endorsed ethics teaching and evaluation for residents as well. However, the current emergency medicine Core Content, representing emergency medicines central body of knowledge, makes no specific mention of ethics. An ethics curriculum is proposed to remedy this gap in the emergency medicine residency curriculum. Issues frequently encountered in the emergency department are emphasized, and topics include moral foundations of clinical medicine, the unique ethical concerns of emergency medicine, patient competence, informed consent and refusal of treatment, truthfulness, confidentiality, foregoing life-sustaining treatment, duty to provide care, moral issues in disaster medicine, allocation of health care, and research and teaching involving human subjects. Educational objectives and readings for each of these topics are presented along with sample case scenarios to be used in a small group discussion format.

The Moral Limits to Federal Funding for Kidney Disease

In the current era of cost-containment, Congress may reconsider its support for the End-Stage Renal Disease Program. Substantial reductions in funding for this program could be made by eliminating non-beneficial, marginally beneficial, and relatively inefficient modes of treatment. These measures, however, will only postpone the inevitable day when clearly beneficial treatment must be withheld.

Resource utilization in the emergency department: The duty of stewardship

As the pool of available health care resources continues to evaporate, emergency physicians will be increasingly required to guard against the provision of expensive, unnecessary, and marginally beneficial care. This article proposes that emergency physicians embrace the ethic of prudent resource stewardship to ensure the continued availability of emergency services to all who need them. When making resource allocation decisions, emergency physicians must consider the likelihood, magnitude, and duration of benefits to patients, the urgency of the condition, and the cost and burdens of treatment to patients, payers, and society. These considerations go beyond professional duties to individual patients and suggest that ignoring the burdens of emergency department microallocation decisions is socially and morally irresponsible.

Organ transplantation in children: Ethical issues

For several years, organ transplantation has been one of the most highly publicized therapies of modern medicine, a kind of symbol of our high-technology, high-cost efforts to save lives. Children have played an important role in this history; the media focused public attention on Charles and Marilyn Fiskes search for a donated liver for their daughter Jamie in late 1982 ~ and on Baby Faes 20-day survival in 1984 with a transplanted baboon heart. 2 These cases, especially that of Baby Fae, evoked a flood of controversy and raised a host of complicated issues. In reviewing ethical issues in transplantation for children, this paper touches on some of the medical, scientific, economic, political, and social issues with which ethical issues are unavoidably linked. Three principles of ethics--beneficence, autonomy, and justice--form a framework for the discussion. First, consider the principle of beneficence, which enjoins us to act for the benefit or good of another or others. Benefitting the sick is arguably the fundamental goal of health care and the fundamental professional commitment of the physician. 3 In the case of transplantation, the primary benefits we seek to provide are the preservation of life (a necessary condition for any other benefit) and the improvement of its quality. Thus we speak of organ donors as giving the gift of life. The mere intention to benefit someone, however, is not by itself a sufficient justification for action. If it were, Dr. Baileys belief that a baboon heart could be of benefit to Baby Fae 4 would have been enough to justify the transplant, and the widespread questioning of his grounds for that belief 59 would be irrelevant to the question of whether that experiment should have been attempted. Rather, scientific medicine demands that our beneficent intentions be well grounded in fact, and thus we look first to animal research

The Ethics of Health Care Reform: Impact on Emergency Medicine

The recent enactment of the Patient Protection and Affordable Care Act (ACA) of 2010, and the ongoing debate over reform of the U.S. health care system, raise numerous important ethical issues. This article reviews basic provisions of the ACA; examines underlying moral and policy issues in the U.S. health care reform debate; and addresses health care reforms likely effects on access to care, emergency department (ED) crowding, and end-of-life care. The article concludes with several suggested actions that emergency physicians (EPs) should take to contribute to the success of health care reform in America.