Emergency Medicine and the Ethical Dilemmas
December 5, 2010
Picture this scenario: You are working in the emergency room of a public hospital where the inflow of patients is higher than the available beds. You are treating an elderly man who is breathless and cyanosed. While you assess whether he has chronic obstructive pulmonary disease or heart failure, he becomes drowsy and starts gasping. You quickly intubate him with some difficulty, prolonging his period of hypoxia, and put him on ventilator support. You then get a phone call from a senior consultant in the hospital that an important social activist is about to arrive with chest pain and will need to be admitted. You are directed to arrange a bed for him. The activist arrives; you walk up to him and make him comfortable on an examination couch. Your clinical acumen tells you that he is suffering from a benign disorder and does not need emergency attention. His aides are anxious and demanding. A comatose woman is now brought in. You find out that she has a fulminant, post-par tum illness for the previous three days. She is very sick and toxic. You have one vacant bed and three patients. What would you do (Goel, Aggarwal, 2006)?
Emergency physicians have unique ethical issues in their practice of medicine. Working in the emergency room is the most unique place to work, because of the several different scenarios that can happen there. It sometimes involves quick scenarios, unexpected patients, and a special sense of urgency to most of the cases. These physicians have to make quick decisions, and as a result, have many ethical issues to deal with. The unique ethical perspectives encountered by the physician have not been dealt with adequately in most of the literature pertaining to medical ethics. The patient may come to the emergency department for treatment not because of his choice but due to the urgency and acuteness of the problem. The physician would most likely not have a pre-existing physician-patient relationship with this patient. For this patient, the ability to pay is not an issue considered up front. Emergency treatment will be rendered first as deemed appropriate. Decision making time for any procedure he may require is short. Decisions are often being made to 'play safe', many times erring on the side of caution. In this paper, we will look at the ethics of the emergency room more closely, and examine what these physicians and staff have to deal with on a daily basis.
When a patient comes to the ER, depending on the situation, there is little time to get basic information from them. Decisions have to be made quickly sometimes, and most often goes by the symptoms that are present rather than the patient's health history. This makes the concept of being ethical a challenge to these physicians. The American College of Emergency Physicians have developed a unique ethic guide for the emergency room, the Principles of Ethics for Emergency Physicians. It addresses the unique duties that an emergency room physician has. It states that the unique setting and goals of emergency medicine give rise to a number of distinctive ethical concerns. Among the special moral challenges confronted by emergency physicians are the following: First, patients often arrive at the emergency department with acute illnesses or injuries that require immediate care. In these emergent situations, emergency physicians have little time to gather additional data, consult with others, or deliberate about alternative treatments. Instead, there is a presumption for quick action guided by predetermined treatment protocols. Second, patients in the emergency department often are unable to participate in decisions regarding their health care because of acute changes in their mental state. When patients lack decision-making capacity, emergency physicians cannot secure their informed consent to treatment. Third,...
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