Ethics in emergency medicine

Introduction

To be ethical in emergency medicine is to do the right thing for the patient. However, this can be challenging in the context of urgency, uncertainty and impaired patient competence.

How do we know if we should let the intoxicated head-injured patient leave the emergency department (ED) without being fully assessed? How do we decide if the decision of the elderly lady with a fractured neck of femur not to have surgery should be honoured? How could we possibly know what the unconscious cardiac arrest patient wants?

The pragmatic tools described in this chapter, based on current popular bioethics, can guide clinicians who work among the ethical complexities of emergency medicine. In this area, standardized processes are popular, and this tool kit suggests a standardized approach to ethics. However, in practice, ethics must be individualized to the patient in front of us. Good clinicians need to superimpose their own morality and understanding of the patient and the patient’s context. This involves a unique interaction with the person the patient is. Ultimately, the aim is to facilitate a process whereby the patient’s true autonomous wishes are honoured. The nature of emergency medicine makes this challenging, but not impossible.

Ethics and law

The ethics methodology described here is a relatively simple approach, to be applied in specific cases, taking into account the peculiarities of the patient’s medical condition and the patient’s ‘world view’. However, this methodology, and ethics in general, involves the struggle to arrive at indisputable, definitive answers. The law also intends to arrive at a definitive answer so that a determination can be made regarding the lawfulness of what was done. The law uses a combination of statute (written law) and precedents (previous interpretation of written law in specific cases) to come to this determination. It is a complex methodology that is best applied retrospectively once all the facts are known. In emergency medicine, ethics is an easier model to use as it can be applied prospectively while there is still uncertainty. However, from time to time the law is called upon to determine the ‘rightness’ of medical decision making. Good ethics, well documented, should see the law get behind the medical decision making. However, the decisions of emergency physicians must be consistent with local law. In reality, this places the emergency physician in a difficult situation, being required to act in keeping with the law yet with an incomplete knowledge of the law and, at the time of decision making, dealing with many unknowns. Generally the law is sufficiently consistent to enable the application of ethics with confidence. Furthermore, there are local differences, particularly regarding how consent might be obtained and who might give it (e.g. the acceptance of proxy consent – that is, consent from relatives), which should be well known in relevant EDs.

Ethical decision making – influences and processes

The words ‘ethics’ and ‘morals’ have origins in different languages, but they have similar meanings – ‘the done thing’ or ‘the right thing to do’. The use of these words in the English language generally considers morals or morality as qualities of an individual and ethics as a description or study of those qualities. However, they both relate to doing the right thing.