An Approach to Ethical Problems in Emergency Medicine

A two-car accident occurs in central Amityville. The driver of one car is taken to Amity General, where he is found to be severely injured. The driver of the other vehicle is taken in critical condition to the Crosstown emergency department (ED). The emer­gency physician at Amity General, Dr. Roy, is presented with a patient who is apneic (not breathing) and has obvious severe head and chest injuries. Despite aggressive therapy, the patient dies.

The patient at Crosstown ED has significant abdominal injuries. After appropriate therapy, he is readied for surgery. At this point he asks Dr. Stanley, the emergency physician, the condition of the patient from the other car. Dr. Stanley has just been notified by the police that the other person is dead.


Both Drs. Roy and Stanley are presented here with situations in which dynamic problem solving must take place. Dr. Roy has the more common medical problem of attempting to resuscitate a critically traumatized patient. Dr. Stanley has the ethical problem of responding to an emotionally laden question from a patient who is in critical condition.

Let's look at Dr. Roy's situation first — he is faced with a multiply-injured patient who has stopped breathing. If there is to be any chance of saving the patient's life, he must act quickly. But how?

His actions can take one of three forms:

a) He can follow a course of action which he has previously developed for just such a situation. This may have been amended by reading about similar cases or attending courses about treatment of the multiply-injured patient or may be based upon personal prior experiences with similar situations;

b) He can consider this patient as a unique problem and try to find a solution and treatment for the patient's critical injuries;

c) He can do nothing. This would have the most immediately decisive consequences, since the patient would quickly die.

In the clinical arena, it is quite clear that the first option is the only acceptable course of action in most cases; the second option would be reserved for the highly unusual variant in a clinical setting. Emergency physicians spend many hours constantly updating their knowledge and skills to be prepared for appropriate action in "routine" emergencies. Finally, under most circumstances the third option would be both bad medical practice and ethically wrong.


Over at Crosstown ED, Dr. Stanley has successfully resuscitated and assessed his patient. In critical condition, he now is about to be moved to the operating room for definitive repair of his injuries. Before leaving the Emergency Department, he asks Dr. Stanley about the driver of the other car. Dr. Stanley faces an inescapable choice: he must either reply or not reply to his patient's question. And, as in the situation faced by Dr. Roy, he has several choices.

He can: a) follow a rule or procedure developed on the basis of previous readings, lectures, or experiences in such situations; b) treat this as a unique problem, applying what knowledge and problem-solving skills he has avail­able; or c) not take any positive action by simply ignoring the request. As in the case of choosing not to resuscitate, not replying is itself a choice, and it is an action that is subject to moral assessment.

Unfortunately, since emergency physicians, like most phy­sicians, tend to spend little time explicitly devoted to identifying and learning to deal with ethical problems, Dr. Stanley probably is less prepared to cope with his need to make an ethical choice than Dr. Roy is to make his clinical choice.


These clinical and ethical situations are very similar. Both require action. In both cases the choice of an appropriate action depends upon solving the problem at hand, and the problem-solving methods are surprisingly similar.

To prepare for common emergency clinical situations, physicians have developed and internalized a conceptual framework designed to generate specific actions necessary to deal with particular medical crises. These have, in part, been formalized into the American Heart Association's Advanced Cardiac Life Support (ACLS), the American College of Surgeon's Advanced Trauma Life Support (ATLS), and the Advanced Pediatric Life Support (APLS) course. These courses enable the physician to learn a systematic approach to critical medical situations. The rules encompassed in these programs give specific benchmarks and guidelines for action.

Similarly, ethical theory gives a structure upon which plans for action can be developed for dealing with ethical problems. Howard Brody offers a form of delib­eration which we can adopt to analyze the ethical dilemma confronting Dr. Stanley. His method for ethical decision making is useful to us because it corresponds closely to the decision-making processes frequently utilized by emergency professionals when making medical decisions.

ETHICAL DECISION MAKING


Figure demonstrates the steps in this process of ethical decision making.

The first step of the procedure is to identify the ethical problem — in this case, it is whether or not Dr. Stanley should give his critically ill patient the potentially upsetting information he has requested. The second step is to list the options. Here, Dr. Stanley has at least five:

1. Tell the patient the truth — that the driver of the other car is dead.

2. Deny knowledge of the other person's condition.

3. Lie — state that the other driver is well.

4. Ignore the question.

5. Use a delaying statement — "Don't worry about that right now, just rest."


Method for ethical decision making.



The third step is to list the ethical values and important interests at stake. A common list of values of traditional and common sense ethics is as follows:

1. Patient well-being.

2. Patient self-determination.

3. Fairness (distributive justice).

4. Nonmaleficence (noninfliction of harm).

5. Beneficence (production of benefit).

6. Fidelity (including confidentiality and nondeception).

7. Reparation (restitution or compensation for wrong).

8. Gratitude.

9. Self-improvement.

Even in a relatively simple situation like this, the values and interests are manifold. For instance, Dr. Stanley should at least consider the following: the patient's well-being and his right of self-determination, and the physician's duty not to inflict harm and his duty to aid the patient. These values and interests may well conflict; if Dr. Stanley considers his duty to aid his patient to be the most important value at stake, he may come to a different conclusion than he would if he weighed the patient's autonomy as the highest value.


The next step is to choose one of the alternatives and frame it as a general ethical statement or rule. Suppose Dr. Stanley chooses the second alternative, that is, denying knowledge of the other driver's condition, and attempts to formulate a general ethical rule which could support this particular decision. Such a rule would have to specify at least three parameters of ethical decisions:

1. What ought to be done?

2. Who ought to do it?

3. Under what conditions ought the action to be done?

In this manner, Dr. Stanley develops Rule A: "When critically ill patients request information about persons who are either critically ill or dead, and you are aware of the information, deny any knowledge of the situation."

Dr. Stanley should now consider the possible consequences — both long and short term — of the general application of Rule A (that is, the consequences of all physicians' following this rule). Possible immediate consequences include the following: a) The patient will not receive information he does not really want; b) the patient will not be depressed and so his recovery will be speeded; c) the physician will not encounter hostility as the bearer of bad news and so will continue to enjoy the patient's trust; d) the patient will not begin to adjust to the present reality.

Possible long-term conse­quences include the following: a) Very ill patients begin to distrust doctors; b) physicians will lie more frequently to patients; c) legal action is taken against physicians to prevent this type of falsification; d) critically ill patients cease to ask potentially upsetting questions just before being admitted to surgery.


The next step is to compare the possible consequences with the important ethical values and interests at stake. Two examples will give an idea of the complexity of this process. Dr. Stanley must take into consideration, for instance, that he will be disre­garding the patient's right of self-determination in order to speed his recovery, a practice which may result in an eventual rift in the patient-physician relationship. He also must consider that although he will be faithful to his duty to aid his patient in some respects, his actions may contribute to the patient's inability to adjust to reality.

Let us suppose that Dr. Stanley concludes that he cannot adopt Rule A as a general ethical rule. He now has two choices: he can try an entirely different approach, or he can modify Rule A. Let us suppose that Dr. Stanley chooses the latter alternative and changes his rule in order to limit severely the number of patients that are included and limit the time frame during which the rule applies. Now he has Rule B: "When critically ill patients who are about to go into the operating room ask for information about persons who are dead, and you have that information, deny knowledge until the patient's condition improves."

Dr. Stanley must now go back to the beginning, and apply all the questions and tests above to Rule B. Let us suppose that he decides that this new rule still fails — perhaps because it does not appreciate sufficiently the patient's right of self-determi­nation — so he is reluctant to adopt it as a general moral rule. He again has two choices: He may try a different approach altogether, or he may try to reformulate Rule В so that it is more consistent with his value system. But even after this painstaking process, he still may not be able to arrive at a general ethical rule with which he is entirely com­fortable, and the best he can do is to choose the least objectionable course.


It should be noted that in many cases, prior ethical reflection and analysis will not insure a simple or unique solution to an emergency ethical problem. The issue, though, is not whether such an approach will conclusively resolve all ethical dilemmas, nor even whether it will give us some substantive guidance on every problem we may encounter. Instead, a systematic approach to ethical problems is vindicated if it improves decision making on average.

It also should be noted that this complex method of ethical decision making is useful only when there is time in which to ponder deeply and weigh the alternative courses of action. It would be extremely useful to the emergency practitioner in working out ahead of time possible courses of action for common ethical dilemmas. It is also useful as a tool for dissecting and reflecting on past dilemmas. But there are occasions in which the emergency practitioner is confronted with an ethical dilemma about which he has no time to go through the involved process described. In this situation, it is necessary to have a more rapid approach to ethical decision making.

AN APPROACH TO ETHICAL PROBLEMS IN EMERGENCY MEDICINE WHEN EXTENDED DELIBERATION IS IMPOSSIBLE


Figure provides a set of "rules of thumb," so that even in cases where there is not time to go through a detailed, systematic process of ethical deliberation, there is still something to rely on that is not simply flipping a coin or doing whatever happens to correspond to the feeling in your gut. This approach, while somewhat oversimplified, offers some guidance to those who are under severe time pressures and who wish to make decisions they can live with ethically.


The first question to ask in using this approach is "Is this ethical problem an instance of a type of ethical problem for which I have already worked out a rule?", or "Is it, at least, similar enough to such cases that the rule could be reasonably extended to cover it?" In other words, if there had been time in the past to think cooly about the issues, discuss them with colleagues, and develop some rough guidelines, could any of this be used in this case? If the case that you are now dealing with really fits under one of those guidelines that you have arrived at through critical reflection and you do not have time to analyze the situation any further, the most reasonable step would be to follow the rule.

Such rules of course must be periodically evaluated. It is necessary to ask yourself if the kind of results obtained from following this rule truly are appropriate. Are they consonant with the intention of the rule and with the values that underlie it? This is to emphasize that it would be unrealistic and ethically irresponsible to believe that one can simply sit down once in a professional career and work out ethical rules to be mechanically applied from then on. Similarly, it would be unrealistic and irresponsible to continue to perform a medical procedure just as one learned it in medical school, regardless of whether it proves efficacious and regardless of whether better techniques have been developed subsequently.

A rapid approach to emergency ethical problems that is to be used for decisions where there is insufficient time for detailed ethical analysis.

Is this a type of ethical problem for which you have already worked out a rule or at least similar enough so that the rule could reasonably be extended to cover it?


But suppose that the case in this particular time-pressure situation does not fit under any rule that you have had time to think about and in which you have confidence. At this point, you should ask yourself if there is an option which will buy you time for deliberation without excessive risk to the patient. Is there something that can relieve the time pressure? If there is, and this does not involve unacceptable risks to the patient, this would be the reasonable course to take. By use of that delaying tactic, there may be time for consulting with other professionals, talking with the family, and developing an ethically appropriate action.


If there is no delaying tactic that can be used without unreasonable risk to the patient, a set of three tests can be applied to possible courses of action to help make a decision. These are often what people use instinctively when confronted with ethical issues, whether medical or otherwise. They are based on three widely used principles that are central in Judeo-Christian ethics and in secular philosophical ethics as well.

Impartiality Test


Would you be willing to have this action performed if you were in the other person's (the patient's) place? This test is, in essence, a version of the Golden Rule. It is not an infallible rule that will yield a right answer every time. But it is intended to correct for one obvious source of moral error — partiality or self-interested bias. It asks you to switch the point of view, to take the other person's perspective. Usually, that is useful to do and can at least help avoid a grievous error.

Universalizability Test


Are you willing to have this action performed in all relevantly similar circum­stances? Is what you are about to do in this particular case something you would approve of if it were generalized to all cases of this sort? The usefulness of this test is that it can help eliminate not only bias and partiality but also shortsightedness. In particular, it enables us to evaluate a particular action by viewing it as falling under a general practice of doing that type of action in relevantly similar circumstances.


In some cases, we might approve of a particular action if we viewed it on its own account, in complete isolation, but we might find it unacceptable to adopt a practice of doing that type of action. To the extent that we are concerned with finding useful rules of action, focusing on types of action rather than particular actions in isolation seems appropriate, since rules are always to some extent general and hence apply to types of actions. Justifying one par­ticular instance that falls under a rule is not sufficient for justifying the practice of acting on that rule.

Interpersonal Justifiability Test


Are you able to provide good reasons to justify your actions to others? Could you justify or defend your decision if it was questioned by someone else? Could you give reasons for the course of action you took? And, importantly, can you give reasons which you would be willing to state publicly?

In those situations in which there is not time for further deliberation, if all three tests can be answered with some degree of confidence in the affirmative, it is probably best to go ahead and act on the rule or perform the action that satisfies the tests. However, acting in this way is only acceptable if every effort is made to review and refine one's emergency ethical decision making when the pressure of the crisis has subsided.


In particular, it is crucial to ask whether the most basic ethical values have been served by the decision-making process. Were the actions taken in the emergency situation really consonant with showing the kind of respect for patient autonomy which you believe appropriate? Were the ethical decisions really in the patient's best interest, or were you unduly influenced by the interests of others or considerations of your own convenience or psychological comfort? Were people treated fairly, justly, and equitably?

Ethical problems, like emergency clinical problems, require action for resolution. Extensive discussion and personal reflection in advance of each particular decision to be made would be ideal. This will not be possible, however, for many emergency care decisions. Nevertheless, by making a sincere effort to anticipate recurring types of problems and subject them to ethical analysis in advance and by conscientiously re­viewing decisions after they have been made, the emergency care professional can better fulfill his or her ethical responsibilities. That a decision is an emergency decision, therefore, does not remove it from the realm of ethical evaluation.

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