Medical Ethics in the Emergency Department: Part I

Ethical theories represent the most general approach to how members of society should act with respect to others. These theories tend to be ephemeral, providing a general guideline for right and wrong. Western medical ethics draw from several ethical theories including Natural Law, Deontology, Utilitarianism, and Virtue theory. Of these, utilitarianism and virtue theory influence healthcare decision-making the most.

1) Utilitarianism asks, “How can the best outcome for the most people be achieved?” It is less concerned with the means and more concerned with outcomes, such that they should be net positive. This framework works best when applied to population-level decision-making. The limit to utilitarianism is its lack of subjectivity i.e. in the classic trolley-car dilemma; the values change if the decision-maker has a family member on the trolley track. In this moral dilemma the reader is allowed to choose between the deaths of three vs five people, most would choose to allow three to perish over five. If, however, there is a family member of the decision-maker in the group of three the decision is more complex and it would be difficult to fault someone choosing to allow the five to perish in favor of the group of three with a family member’s life at stake.

2) Virtue theory is emerging as a more widely accepted ethical theory in modern medicine, especially emergency medicine. It broadly asks “What would a good person do in this situation?” Virtue in this view is not simply performative or prescriptive, it is inherent values deeply entrenched in an adherent’s value system. As an example: a person with the virtue of “honesty” is not simply someone who tells the truth because the truth is required and lies are prohibited. They value honesty such that they choose to surround themselves with honest people, deplore dishonesty, are unsurprised when honesty triumphs and are distressed by dishonesty. These, however, are not perfect virtues and even the most virtuous may fall short on occasion. Current ethical codes for ED physicians include the 1999 Society for Academic Emergency Medicine (SAEM) Ethical Code, as well as the 2023 American College of Emergency Physicians (ACEP) Policy Statement: Code of Ethics for Emergency Physicians.[3][4] These aspirational guidelines espouse virtue theory and advocate for fostering virtue as moral vaccination against ethical pitfalls inherent in emergency medical practice. The virtues advocated for by ACEP are courage, justice, vigilance, impartiality, trustworthiness, and resilience.

Ethical principles are derived from ethical theories and provide a guide for how to apply a given ethical theory. Values are the subjective standards we learn from an early age, typically from generic, cultural, legal, religious or professional codes. Values are concerned with promoting what the actor considers good and minimizing what they consider bad. For example, the principle of autonomy demands that I respect the person’s right of self-determination and the value of honesty means I will fully inform patients before procedures, therapies, etc.

The caveat here is that in a pluralistic society, we are commonly serving patients with different value systems: the Rastafarian with untreated hypertension who expresses an understanding of his disease process and risks, yet declines to take medications, is not going to benefit from me giving amlodipine 10 mg to treat a blood pressure of 186/98 mmHg because it does not comport with his value system, beliefs, or traditions.[5] It is important to understand that ethical values and principles are not universal, and patients come to the ED with their own moral imperatives, norms, and expectations. The competent emergency provider will learn and incorporate these values into their care plan.

In Western medicine, we have espoused four principles of medical ethics that are largely ubiquitous across the spectrum of medical codes of ethics: respect for autonomy, beneficence, non-maleficence, and justice.[6]

1) Of these principles, respect for autonomy is the strongest and often the most challenging for physicians for several reasons. The strength of this principle is drawn from the humanistic and judicial understanding that a person with capacity to make their own medical decisions must be granted the opportunity to decide for or against the proposed treatment. Violation of this principle constitutes assault and a tort violation.[7] The challenges to physicians are multiple; first, respecting a patient’s autonomy means that the doctor-patient relationship must be collaborative rather than prescriptive. Secondly, physicians must become educators to their patients, removing medical jargon and making complex pathophysiology and therapies understandable for the patient. This can be particularly challenging if the patient population is of low educational attainment, made up of a high proportion of immigrants, non-native English speaking, or from a different culture. Lastly, physicians must accept that patients may choose to do something other than their recommendations. In some patient populations, these challenges are more pronounced than in others, requiring greater effort on the part of the provider to empower patients in their decision-making. It is no surprise that “patient’s circumstances and preferences” is considered one of the three pillars of evidence-based medicine (along with “research” and “clinical judgment”).[8]

2) Beneficence, or doing good, is perhaps the most superfluous of principles. Most healthcare professionals entered their fields precisely for this reason - to do good for others. The entire practice of medicine revolves around removing suffering and restoring health. Beneficence is essentially inherent in the practice of medicine. The principle of beneficence is extended when a provider renders aid outside of the ED in supererogatory or Good Samaritan actions such as on site of a motor vehicle crash, on airplanes, following a natural disaster, etc. These actions are not required duties, but they comport with the principle and virtue of “doing good.” Despite the seemingly obvious and immutable nature of this principle, patients such as Mr. Thompan who are frequently seen in the ED, who may wreak of waste, may have bed bugs, may behave disrespectfully, these patients test the emergency provider’s commitment to beneficence on a daily basis.

3) Non-maleficence is the imperative that the physician must not only do no harm; they must prevent harm, as well as remove harmful conditions. It would be incorrect to say that all interactions with the medical industry are innocuous. For example, consider the lessons learned following the Tuskegee Syphilis Study in which poor Black patients were deliberately exposed to syphilis and prevented from accessing curative medicine. Or, consider the more recent Institute of Medicine report, “To Err is Human” that estimated as many as 98,000 patients die of preventable medical errors annually in the US. These are both sobering reminders that we are less than perfect and while perfection remains an unattainable goal, we should do all we can to prevent harm and promote healing above personal or professional aspirations even if the knowledge gained through immediately harmful actions might be beneficial in the long run. 

4) Justice, as the final pillar of medical ethics, is challenging to define in a clinical context as it is typically understood as distributive justice or resource allocation, especially in times of scarcity. This designation places it more in the realm of social healthcare policy. In the ED, however, justice can be considered in terms of patient triage, where the more severely ill are prioritized using a combination of utility and strict equity based on the Emergency Severity Index. A patient’s Emergency Severity Index is determined by their chief complaint, general appearance, and their vital signs.[9]  In layman’s terms an Emergency Severity Index is an estimation of how likely the patient is to die without acute, immediate intervention. Justice demands that this assessment take place without the influence of irrelevant characteristics such as race, ethnicity, creed, gender, nationality, sexual orientation. Justice further demands that the EP utilize resources responsibly. However, it fails to account for factors such as relationship, housing, substance use, mental health, poverty, and other forms of marginalization which are predictors of health outcomes.[10]

The application of the principle of Justice may be expounded upon to consider societal justice, and the role of the emergency provider when confronted with social injustices affecting their patients’ healthcare outcomes. This is recognised in the ACEP Policy Statement on the EP’s duty to society, especially regarding the health needs of impoverished or marginalized patients.[3]

In Part II we will wrap up with a discussion on institutional ethics and return to our case.