Regular discussions of difficult ethical encounters can better prepare training physicians to deal with what are often the most challenging cases.
There are fundamental flaws in how ethics is taught in medicine. They begin in medical school and are perpetuated throughout graduate medical education. As a subject, ethics in medical education is largely ignored. There are often lectures that will teach Beauchamp and Childress' four core principles of bioethics, and a lecture regarding research ethics, but often the discussion ends there. This may be partly due to teachers and learners not identifying ethics as important subject matter. They may also feel their personal morality will be an adequate guide in every ethically problematic encounter. Or perhaps, as a discipline, we do not know how to effectively teach or learn ethics.
Ethics stems from philosophical and religious teachings; therefore, most bioethicists have historically been philosophers or theologians. They do not have the clinical knowledge or experience to translate ethical theory to the patient's bedside and make it practical in a clinical setting. In turn, clinicians who teach ethics often seem to equate morality with ethics and concentrate too heavily on clinical decisions, while not identifying important ethical considerations.
There is a unique body of medical knowledge that creates the expertise of the emergency physician. Likewise, there exist unique patterns of ethical dilemmas that are regularly encountered in the emergency department. Similar to medical cases, ethics in the emergency department is unique because decisions are based on limited information, limited relationships with patients and families, and limited patient participation. We deal with issues of direct and indirect supervision, futility, end of life, EMTALA, public safety, disaster care, triage, and care of minors, just to name a few. These cases can be identified, discussed, and learned. The proof lies in the seasoned emergency medicine physician who is better equipped to deal with difficult ethical dilemmas than the novice physician. There are clearly skills and techniques for handling these scenarios, and they should be taught to all emergency practitioners.
I contend that ethics in emergency medicine can and must be taught in a comprehensive fashion. Just a small background in ethical theory and analysis can be enough for most ED physicians to analyze ethical cases, draw conclusions, and create strategies that can be used in the acute setting. Additionally, identifying and reviewing ethical cases, and pursuing continued education through repeated case discussions can solidify routine ethical approaches. This will allow residents to easily navigate common cases. Knowingly, you cannot fully prepare for all ethically problematic situations, and even common cases have subtle nuances. However, having basic strategies and approaches already planned out for the most frequent scenarios creates a base of knowledge and strategy that would otherwise not be available.
There are several philosophical approaches that help create a usable ethical analysis tool for emergency physicians. The first that deserves consideration are the principles set forth by Beauchamp and Childress for bioethical analysis; they include autonomy, beneficence, non-maleficence, and justice.1 While it is important to be aware of these principles and appreciate their interplay in any given situation, there are other philosophical approaches to consider. John Rawls described a technique known as the “veil of ignorance.” This technique's goal is to allow the user to ignore external factors and treat everyone the same. The astute physician is aware they are influenced by their own biases and susceptible to “tunnel vision” and negative heuristics. Often when we encounter a challenging clinical situation, we must take a step back, clear our minds, and re-think the case.
Immanuel Kant submits that rules are an excellent way to solve ethical problems. However, if you are going to make a rule, it should be a universal rule, applicable to everyone. Kant thought our duties (such as our duty to the patient) are most important, and we should make rules with our duties in mind. Jon Stuart Mill had a different approach — believing fairness was of paramount importance, and that we should strive for the best outcomes for the most people. This means Mill was concerned about the consequences of our actions, whereas Kant ignored the consequences and developed rules from our duties.2 How this applies in emergency medicine is apparent when you encounter a patient or another physician who lives based on universal rules. We see this all the time — take, for example, the patient's son who states he wants everything done for his elderly mother. Now, in the setting of a terminally ill patient, with no benefit of invasive therapies, you may feel that “doing everything” is not the best course of action. Identifying the rule-based philosophy of the patient may help you discuss the case at hand. The son may not be aware of the consequences of “doing everything,” as his approach to his mother's care is already set as a universal rule.3
Taking a number of these philosophical approaches together, Iserson created an ethical decision tool. When encountering an ethical dilemma, Iserson states you should first ask “Does a rule exist?” Is there one that could help in the presented situation? This is not unlike what Immanuel Kant would ask. If there is no rule, Iserson suggests delaying action. While at first this may seem like dodging an important decision, it could allow for more information to surface. In our case, family members may arrive, or paperwork — such as an advanced directive — may show up. If you have time to delay, it may be an excellent strategy.
If you cannot delay, Iserson suggests applying three rules to your action in question. One, taken from Jon Stuart Mill: Impartiality — would you be willing to have this action performed if you were in the patient's place? Two, taken from Immanuel Kant: Universalizability — would you be willing to use the same solution in all similar cases? And third, taken from Gauthier: Interpersonal justifiability — would you be willing to defend the decision to others, to share the decision with the public?4
Regular discussions of difficult ethical encounters can better prepare training physicians to deal with what are often the most challenging cases. A simple approach to ethical analysis and a basic knowledge of ethical principles can allow all participants to identify important ethical considerations and discuss them effectively. There are resources available for most EM programs, including hospital ethics committees, local organizations that specialize in bioethical issues, and online resources such as the writings from SAEM and ACEP on ethics in emergency medicine.
- Tom Beauchamp and James Childress. Principles of Biomedical Ethics, 5th edition. Oxford University Press 2001.
- Helga Kuhse and Peter Singer. A Companion to Bioethics, 2nd edition. Wiley-Blackwell 2009.
- Kenneth Iserson, Arthur Sanders, Deborah Mathieu. Ethics in Emergency Medicine, 2nd edition. Galen Pr Ltd. 1995.