Author: Aaron S. Conway, MD
Resident Editor: Philippe Ayres, MD
Guest Faculty Editor: James Willis, MD
This is a continuation of Part I
III. Institutional Ethics
Healthcare institutions may also have their own value system based on creational intent, sources of funding, academic affiliation, and services offered. Religiously oriented, non-profit, and safety net hospitals are prime examples of institutions that may place higher priority on the biopsychosocial model of healthcare and incorporate more social services into a patient’s stay. This attentiveness belies not only the values an institution embraces, but the virtues it will look for in its staff.
Safety net hospitals have a special designation based on the proportion of uninsured or underinsured patients they see. These hospitals tend to be teaching hospitals with large inpatient units, located in large metropolitan areas. These institutions serve disproportionately Black and Hispanic patients, living at or below the poverty level, and suffer from increased rates of untreated or undertreated mental health and substance use disorders. Safety net hospitals also serve unhoused people, prisoners, legal and undocumented immigrants at significantly higher rates than non-safety net hospitals. Additionally, these patients are more likely to rely on EDs as episodic primary care centers. The fiscal reality of caring for these patients is that Medicare and Medicaid, insurers most heavily represented in low-income settings, tend to reimburse hospitals significantly less than private insurers, which are more common in affluent areas. This leaves safety net hospitals scrounging for resources and personnel, and shutting down some services, all to the detriment of their highly vulnerable patient population.
In the ED, we face many Mr. Thompans - these are patients who test our patience. A purely principled approach to caring for these patients may fail to grasp the complexities present in this common ED occurrence. The incorporation of a virtue-based ethic serves to buttress decision-making and support ED providers. There are many virtues that define an emergency provider at an urban safety net hospital. Courage, positive regard, charity, and compassion are those which I find most compelling.
The virtue of courage allows the ED provider to approach and care for a potentially violent patient, a patient with a communicable disease, a malodorous patient, and a patient who maintains an unpleasant demeanor. This does not mean that we should put ourselves in danger, but that we must not evade potentially unpleasant situations or avoid doing what is right for the sake of ease. Courage means showing kindness, gentleness, and support even in the face of unpleasant circumstances.
Next, the virtue of unconditional positive regard, closely aligned with the principle of justice, recognizes that if we are to treat patients with fairness, we must first recognize their worth as human beings. This worth remains despite low social standing, intoxication, illegal actions, and poor demeanor. Charity as a virtue denotes a willingness to go beyond what is required to serve a person in need. It may require self-sacrifice, death to self-interest, or altruism incarnate. Charity is the pinnacle of virtue because at its core, it is about genuine caring and selfless giving. Lastly, the virtue of compassion combines empathy, sympathy, humility, understanding, tact, and gentleness. Compassion can be considered equally as important as technical competence because without compassion the patient will not trust that you have their best interests in mind.
If we apply each of these virtues to our interaction with Mr. Thompan or the multitude of similar patients that test the limits of our virtues, we can begin to develop a framework for how to manage them in the ED. Courage will allow us to approach, knowing that the interaction may be unpleasant. Positive regard allows us to see the patient as deserving the same medical care we would give to anyone else. Charity asks us to consider what additional resources we have at our disposal that may benefit the patient. And compassion compels us to meet the patient where they’re at, with truth and sincerity, providing the best care we can, even if that “best care” is just a bed, blanket, and turkey sandwich.
Despite the aforementioned one could easily argue that once a medical screening exam has been completed, and it has been determined that there is no immediate medical condition requiring further inpatient treatment, Mr. Thompan should be discharged back to the street. This would be a morally defensible opinion. Based on the principle of beneficence he has been seen and evaluated by a medical professional, if he was hungry he was fed, if he was cold he was clothed, all to the best of our capability as an overused and under-resourced ED. Based on the principle of non-maleficence he is not being discharged in worse or to worse conditions than what he experiences every day; unfortunately some people have sad existences but a longer stay in the emergency department is not going to fix his entire life. Based on respect for autonomy he has chosen not to go to a shelter or other such facility where he has been referred to countless times, he also refuses medications for his many medical conditions. Additionally, the principle of justice, strictly applied in terms of resource allocation, recognizes that occupancy by this non-critical patient limits the number of beds available to patients in the waiting room who have true medical emergencies requiring attention. On a busy ER shift Mr. Thompan would rightly be sent away.
I would argue that in addition to the feel-good virtues outlined above, there are practical reasons for allowing an undomiciled person to sleep overnight in the ED on a cold night. These outweigh the potential harm caused by discharging them to the street. Allow me to preface this argument by stipulating that this person’s presence must not be disruptive to the emergency department’s functioning. This means they cannot be yelling or getting in fights with the staff or other patients, they cannot smoke cigarettes or other substances in the bathrooms, and they cannot be stealing anything, all of which would rightly cause them to be removed post-haste.
First, Mr. Thompan is legitimately a sick old man. He has unmanaged medical comorbidities including heart failure, coronary artery disease, diabetes, crack cocaine abuse, schizophrenia, and homelessness, all of which increase his risk for premature death.[10] As with any geriatric patient, discharging them at 2 A.M. when they couldn’t get into a shelter even if they wanted to, is morally unconscionable and violates one of the central tenets of the EP relationship with society as put forth in ACEP’s Policy Statement (i.e. adequate resources must be available to protect patient interests).[3]
Second, Mr. Thompan’s method of malingering adds very little to the EP’s cognitive burden. An attending or senior resident familiar with him and his regular presentation will quickly evaluate him and determine there is no immediately life-threatening condition. Mr. Thompan and others like him will often acknowledge they simply have nowhere to go, or they’re just hungry.
Third, these types of high utilizers have demonstrated on several occasions that if they are discharged from one hospital in the middle of the night they will present at another hospital’s emergency department. If they are not well known to the second ED they may be extensively worked up based on their chief complaint and comorbidities. When average inpatient ACS work up costs are well over $20,000 it seems more fiscally responsible to let the man sleep until morning.[11]
“Let all who serve here remember that this institution is dedicated to the care of all who are helpless and afflicted. This before all else.” - Unknown
1) Zwick T, Sharp C, Severn D, Simpson SA. Malingering in the Emergency Setting. Cureus. 2021 Jun 15;13(6):e15670. doi: 10.7759/cureus.15670. PMID: 34277261; PMCID: PMC8282263.
2) Zibulewsky J. The Emergency Medical Treatment and Active Labor Act (EMTALA): what it is and what it means for physicians. Proc (Bayl Univ Med Cent). 2001 Oct;14(4):339-46. doi: 10.1080/08998280.2001.11927785. PMID: 16369643; PMCID: PMC1305897.
3) American College of Emergency Physicians Policy Statement: Code of Ethics for Emergency Physicians; 2023.
4) Syverud S. SAEM ethical guidelines for academic emergency physicians who provide medical malpractice consultation. SAEM Ethics Committee. Society for Academic Emergency Medicine. Acad Emerg Med. 1999 Oct;6(10):1066. doi: 10.1111/j.1553-2712.1999.tb01195.x. PMID: 10530668.
5) Brown R, Bateman CJ, Gossell-Williams M. Influence of Jamaican Cultural and Religious Beliefs on Adherence to Pharmacotherapy for Non-Communicable Diseases: A Pharmacovigilance Perspective. Front Pharmacol. 2022 Mar 14;13:858947. doi: 10.3389/fphar.2022.858947. PMID: 35359857; PMCID: PMC8963898.
6) Varkey B. Principles of Clinical Ethics and Their Application to Practice. Med Princ Pract. 2021;30(1):17-28. doi: 10.1159/000509119. Epub 2020 Jun 4. PMID: 32498071; PMCID: PMC7923912.
7) Hwan Kim, Albert Lee, How patient autonomy drives the legal liabilities of medical practitioners and the practical ways to mitigate and resolve them, Postgraduate Medical Journal, Volume 99, Issue 1168, February 2023, Pages 83–88
8) Szajewska H. Evidence-Based Medicine and Clinical Research: Both Are Needed, Neither Is Perfect. Ann Nutr Metab. 2018;72 Suppl 3:13-23. doi: 10.1159/000487375. Epub 2018 Apr 9. PMID: 29631266.
9) Aacharya, R.P., Gastmans, C. & Denier, Y. Emergency department triage: an ethical analysis. BMC Emerg Med 11, 16 (2011).
10) Aldridge RW, Story A, Hwang SW, Nordentoft M, Luchenski SA, Hartwell G, Tweed EJ, Lewer D, Vittal Katikireddi S, Hayward AC. Morbidity and mortality in homeless individuals, prisoners, sex workers, and individuals with substance use disorders in high-income countries: a systematic review and meta-analysis. Lancet. 2018 Jan 20;391(10117):241-250. doi: 10.1016/S0140-6736(17)31869-X. Epub 2017 Nov 12. PMID: 29137869; PMCID: PMC5803132.
11) Oseran AS, Ati S, Feldman WB, Gondi S, Yeh RW, Wadhera RK. Assessment of Prices for Cardiovascular Tests and Procedures at Top-Ranked US Hospitals. JAMA Intern Med. 2022;182(9):996–999. doi:10.1001/jamainternmed.2022.2602
12) Hursthouse, Rosalind and Glen Pettigrove, "Virtue Ethics", The Stanford Encyclopedia of Philosophy (Fall 2023 Edition), Edward N. Zalta & Uri Nodelman (eds.)
13) To Err Is Human: Building a Safer Health System. Washington, DC: Institute of Medicine; 1999.
14) Institute of Medicine (US) Committee on the Changing Market, Managed Care, and the Future Viability of Safety Net Providers; Ein Lewin M, Altman S, editors. Americas's Health Care Safety Net: Intact but Endangered. Washington (DC): National Academies Press (US); 2000. 2, The Core Safety Net and the Safety Net System. Available from:
15) Whelehan DF, Conlon KC, Ridgway PF. Medicine and heuristics: cognitive biases and medical decision-making. Ir J Med Sci. 2020 Nov;189(4):1477-1484. doi: 10.1007/s11845-020-02235-1. Epub 2020 May 14. PMID: 32409947.
16) Larkin, G.L., Iserson, K., Kassutto, Z., Freas, G., Delaney, K., Krimm, J., Schmidt, T., Simon, J., Calkins, A. and Adams, J. (2009), Virtue in Emergency Medicine. Academic Emergency Medicine, 16: 51-55.
17) Institute of Medicine (US) Committee on Quality of Health Care in America. To Err is Human: Building a Safer Health System. Kohn LT, Corrigan JM, Donaldson MS, editors. Washington (DC): National Academies Press (US); 2000. PMID: 25077248.
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