SAEM Ethics Committee

1
SAEM Ethics Committee

• ETHICS IN EMERGENCY MEDICINE
• Honesty and Integrity in Training and Practice

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What is Professionalism?

• Those attitudes and behaviors that serve to
  maintain patient interest above physician
  self-interest
• - ABIM, 1995

3
Medical Professionalism

• A set of values, attitudes, and behaviors that
  result in serving the interests of patients and
  society before ones own.
• - Ann Intern Med 1991

4
Elements of Professionalism

• Suspension of self-interest
• Honesty
• Technical competence
• Authority
• Accountability
• Communication
• Justice
• Humility

5
There are different approaches to
conceptualizing medical professionalism and
ethics. Some are based in history.
6

• Let his disposition be that of a man of honor,
  let him behave to all honorable men with a
  friendly and easy spirit.
• - Hippocrates

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Hippocratic Oath

• I swear by Apollo the Physicianto keep
  according to my ability and judgment the
  following oath
• I will prescribe regimen for the good of my
  patients according to my ability and my judgment
  and never do harm to anyone
• The Oath of Hippocrates of Kos, 5th Century BC

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Hippocratic Oath

• All that may come to my knowledge in the
  exercise of my profession or in daily commerce
  with men, which ought not to be spread abroad, I
  will keep secret and will never reveal
• - Circa 400 BC

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Other approaches are based on sets of principles
elucidated by the organizing bodies of medicine
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Declaration of Professional Responsibility
Medicines Social Contract with Humanity

• Developed by the AMA in 2001
• - Addresses 21st century issues for physicians in
  all geographic areas, all specialties
• - Translated in numerous languages

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Declaration of Professional Responsibility
Medicines Social Contract with Humanity

• We, the members of the world community of
  physicians, solemnly commit ourselves to
• 1. Respect human life and the dignity of every
  individual.
• 2. Refrain from supporting or committing crimes
  against humanity and condemn any such acts.
• 3. Treat the sick and injured with competence and
  compassion and without prejudice.
• 4. Apply our knowledge and skills when needed,
  though doing so may put us at risk.
• 5. Protect the privacy and confidentiality of
  those for whom we care and breach that confidence
  only when keeping it would seriously threaten
  their health and safety or that of others.

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Declaration of Professional Responsibility
Medicines Social Contract with Humanity

• 6. Work freely with colleagues to discover,
  develop, and promote advances in medicine and
  public health that ameliorate suffering and
  contribute to human well-being.
• 7. Educate the public and polity about present
  and future threats to the health of humanity.
• 8. Advocate for social, economic, educational,
  and political changes that ameliorate suffering
  and contribute to human well-being.
• 9. Teach and mentor those who follow us for they
  are the future of our caring profession.
• We make these promises solemnly, freely, and upon
  our personal and professional honor.

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AMA Principles of Medical Ethics

• - A physician shall be dedicated to providing
  competent medical care, with compassion and
  respect for human dignity and rights.

Adopted by the AMA's House of Delegates June 17,
2001
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AMA Principles of Medical Ethics

• - A physician shall uphold the standards of
  professionalism, be honest in all professional
  interactions, and strive to report physicians
  deficient in character or competence, or engaging
  in fraud or deception, to appropriate entities.

Adopted by the AMA's House of Delegates June 17,
2001
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AMA Principles of Medical Ethics

• - A physician shall respect the law and also
  recognize a responsibility to seek changes in
  those requirements which are contrary to the best
  interests of the patient.

Adopted by the AMA's House of Delegates June 17,
2001
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AMA Principles of Medical Ethics

• - A physician shall respect the rights of
  patients, colleagues, and other health
  professionals, and shall safeguard patient
  confidences and privacy within the constraints of
  the law.

Adopted by the AMA's House of Delegates June 17,
2001
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AMA Principles of Medical Ethics

• - A physician shall continue to study, apply, and
  advance scientific knowledge, maintain a
  commitment to medical education, make relevant
  information available to patients, colleagues,
  and the public, obtain consultation, and use the
  talents of other health professionals when
  indicated.

Adopted by the AMA's House of Delegates June 17,
2001
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AMA Principles of Medical Ethics (cont.)

• - A physician shall, in the provision of
  appropriate patient care, except in emergencies,
  be free to choose whom to serve, with whom to
  associate, and the environment in which to
  provide medical care.

Adopted by the AMA's House of Delegates June 17,
2001
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AMA Principles of Medical Ethics (cont.)

• - A physician shall recognize a responsibility to
  participate in activities contributing to the
  improvement of the community and the betterment
  of public health.

Adopted by the AMA's House of Delegates June 17,
2001
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AMA Principles of Medical Ethics (cont.)

• - A physician shall, while caring for a patient,
  regard responsibility to the patient as
  paramount.
• - A physician shall support access to medical
  care for all people.

21
Other Codes of Ethics

• - World Medical Association Declaration of
  Helsinki
• - ACEP Code of Ethics
• - SAEM Code of Conduct
• - Numerous others

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ACEP Code of Ethics

• Emergency physicians shall
• 1. Embrace patient welfare as their primary
  professional responsibility.  
• 2. Respond promptly and expertly, without
  prejudice or partiality, to the need for
  emergency medical care.  
• 3. Respect the rights and strive to protect the
  best interests of their patients, particularly
  the most vulnerable and those unable to make
  treatment choices due to diminished
  decision-making capacity.  

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ACEP Code of Ethics

• 4. Communicate truthfully with patients and
  secure their informed consent for treatment,
  unless the urgency of the patient's condition
  demands an immediate response.  
• 5. Respect patient privacy and disclose
  confidential information only with consent of the
  patient or when required by an overriding duty
  such as the duty to protect others or to obey the
  law.  
• 6. Deal fairly and honestly with colleagues and
  take appropriate action to protect patients from
  health care providers who are impaired or
  incompetent, or who engage in fraud or deception.
   

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ACEP Code of Ethics

• 7. Work cooperatively with others who care for,
  and about, emergency patients.  
• 8. Engage in continuing study to maintain the
  knowledge and skills necessary to provide high
  quality care for emergency patients.  
• 9. Act as responsible stewards of the health care
  resources entrusted to them.  
• 10. Support societal efforts to improve public
  health and safety, reduce the effects of injury
  and illness, and secure access to emergency and
  other basic health care for all.
• (http//acep.org/practres.aspx?id29144)

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SAEM Code of Conduct

• As a researcher of emergency medicine I vow
• Competence
• Compassion
• Respect
• Impartiality
• Integrity
• Responsibility

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SAEM Code of Conduct

• As a teacher of emergency medicine I vow
• Altruism
• A commitment to excellence
• Respect
• Fairness
• Honesty
• Mentorship
• (Larkin GL, for the SAEM Ethics Committee A Code
  of Conduct for Academic Emergency Medicine, Acad
  Emerg Med 1999 645.)

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Basic Principles of Medical Ethics

• - Autonomy
• - Beneficence
• - Nonmaleficence
• - Justice

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Autonomy

• Individual self-determination
• - Informed consent
• - Disclosure
• - Understanding
• - Voluntariness
• - Surrogate decision making

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Non-maleficence

• First do no harm
• - Optional treatments and obligatory treatments
• - Killing and letting die
• - Assisted suicide
• - Decision making for incompetent patients

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Beneficence

• Act in the patients best interests
• - Paternalism
• - Balancing benefits, costs, and risks
• - Value and quality of life

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Justice

• Fairness and equality
• - Right to health care
• - Allocation of health care resources
• - Rationing through priorities in health care
• - Rationing of scarce resources

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• There are alternative approaches to medical
  ethics. One emerging system is called
  Virtue-based Ethics

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Virtue-based Ethics

• - In contrast to principalism, virtue based
  ethics seeks to reform personal character through
  embodying virtues
• - These virtues are replete in philosophical
  writings and religious codes
• - Attention to virtue brings about personal
  character change and excellence in ones actions
• - Grounded in the idea that moral excellence
  leads to physical health benefits

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Virtue-based Ethics

• - Aristotle noted 4 cardinal virtues
• Courage
• Justice
• Prudence
• Temperance
• - Religious traditions also cultivated
  virtue-based ethics as a means to develop moral
  and ethical character

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Religious Virtues

• - St. Thomas Aquinas added 3 more virtues to
  Aristotles list
• - Faith
• - Hope
• - Charity
• - Moses Maimonides contrasts these virtues with
  vices to avoid
• - Thirst for profit
• - Ambition for renown

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Religious Virtues

• - Similarly Muslim Physicians of the Ancient era
  blended professional ethics with religious
  teachings
• - For example, Abu Bakr al Razi (Rhazes) author
  of the Kitab al-Tibb al-Ruhani the Book of
  Medicine of the Soul states that the physician
  must cultivate good moral character, good
  health, and be cultured in manners
• - Such character can be attained by being one
  who truly fears God stated al-Ruhawi the author
  of the corpus Adab al-Tabib Ettiquettes of the
  Physician

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Virtue in Emergency Medicine
1996 SAEM Ethics Committee created a list of
virtues that each EM practitioner should embody

• - Prudence
• - Courage
• - Temperance
• - Justice
• - Unconditional positive regard

• - Charity
• - Compassion
• - Trustworthiness
• - Vigilance
• - Agility

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The Role of Medical Ethics

• Adding another layer of complexity to a
  demanding job
• or
• Providing the true meaning for what we do

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• Cases for Honesty and Integrity

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Many of the challenges that an emergency
physician has to confront in the course of a
shift will be unanticipated, not readily solvable
in the frameworks outlined above, and will
require solution in a time frame of minutes.
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• - We present cases involving patients, colleagues
  and staff
• - Please discuss each case in 10 minutes or less
• - These cases are organized around the issues of
• honesty to patient
• honesty to self
• honesty to peer group
• integrity

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Honesty to Patients
43
CASE

• - 5 y/o child with a very large scalp laceration
  needs suturing. This is a mixed-age ED without
  the ability to do procedural sedation on kids.
• The child asks before lidocaine
• Will this hurt?

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Issues -

• - Honesty
• - Your awareness that studies show that telling a
  child about upcoming pain, increases that childs
  perception of pain during the procedure
  non-maleficence
• - That childs trust in doctors in the future
• - Respect for autonomy

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CASE

• - A schizophrenic patient has been open and
  trusting with you and the psych social worker
  on-call about her hallucinations and her desire
  to kill her father.
• - She is awaiting transport to a locked facility
  and just as your shift ends, she calls out
• Doctor! Can I go home soon?

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Issues -

• - Honesty
• - Safety of staff and other patients
• - Non-maleficence
• - Respect for autonomy
• - Desire to leave without a raucous scene

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CASE

• - 66 y/o recently retired male comes in for vague
  headache.
• - Undergoing out-patient work-up for abnormal
  chest x-ray.
• - CT brain shows lesions consistent with
  metastases
• His wife, before patient returns to room, insists
  on knowing what you think

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Issues -

• - Honesty
• - Breaking bad news
• - Ownership of medical information/respect for
  autonomy
• - Non-maleficence

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CASE

• - Patient with abrupt onset of worst headache of
  life, who rates her pain as 10/10, asks the
  Intern prior to the LP
• How many of these have you done???

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Issues -

• - Honesty
• - Non-maleficence
• - Beneficence
• - Teaching/supervising role
• - Teaching-hospital discussion need for
  resident education

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CASE

• - Roll-over motor-vehicle accident
• - Unrestrained passenger is ejected at scene and
  loses VS on way to ED code called soon after
  arrival
• - Driver, intoxicated, multiple c/o pain and
  potential for serious injury, asks
• What happened to my husband?.

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Issues -

• - Honesty
• - Non-maleficence
• - HIPAA/patient confidentiality
• - Breaking bad news

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CASE

• -A patient has what clearly appears to be a viral
  syndrome is demanding antibiotics loudly and
  argumentatively
• Your Attending states Give him what he wants.
  Weve got to move patients through here

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Issues -

• - Non-maleficence
• - Beneficence
• - Autonomy of patient vs medical decision-making
  and best-practices
• - Honesty
• - Practicality
• - Bullying

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Honesty to Peers
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CASE

• - A 52 year old woman presents with chest pain
• - Your workup yields little information
• - You consider his case to be a low risk cardiac
  rule out
• Your Attending asks you to beef up the story a
  bit to convince the PCP to admit her

57
Issues -

• - Honesty
• - Non-maleficence
• - Bullying
• - Future dealings with the person you lied to, or
  future patients who may be compromised

58
CASE

• A colleague (another resident, an Attending, an
  RN that you frequently work with) asks you to
  write an opiod prescription (I cant get in
  touch with my doc).
• In three months, you get the same request

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Issues -

• - Non-maleficence
• - Truth-telling
• - State law or dept. policy on writing scripts
  for colleagues
• - Future patients of a colleague who may be
  abusing narcotics, and our obligation to report
  suspected impairment

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Honesty to Self
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CASE

• - You are prepping for your oral boards
• - An attending who was two years ahead of you in
  residency gives you the following offer
• I can give you my cases from last year, and the
  ones from two years ago

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Issues -

• - Honesty
• - Justice for those who dont have the same
  advantage
• - Your future patients safety
• (not to mention the issue of whether your
  attending got the case right, and really knows
  what its about.)

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CASE

• - There is an Attending who is abrasive, verging
  on abusive during case presentations, who asks
  and what did the rectal show??
• You havent yet done it, but feel it will be
  negative

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Issues -

• - Honesty
• - Bullying
• - What to do about a patient who has an
  unanticipated result (e.g., grossly bloody) or a
  result no-one else checks on, since you said you
  had

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CASE

• - An Attending describes a procedure to you, goes
  in the room with you to do it, asks You feel
  comfortable doing this alone, right? and leaves
  you to do the procedure.
• On the paperwork, she signs as though present for
  the entire procedure.

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Issues -

• - Honesty
• - Responsibility of a teacher/supervisor
• - Patient safety
• - Bullying
• - Stewardship/improper billing

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CASE

• - A patient comes in with a complaint about his
  chronic back pain.
• - He seems intoxicated, and is at first
  disruptive, followed by quiet.
• - You are called over when he is found apneic,
  pulseless and cold. Your last note from 5
  minutes earlier states patient is resting
  comfortably.
• Should you re-write it?

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Issues -

• - Honesty
• - Integrity of medical records
• - Patient safety and adequacy of initial
  evaluation

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REFERENCES - American Board of Internal
Medicine. Project Professionalism. Philadelphia,
PA American Board of Internal Medicine
19942.- Adams J, Schmidt T, Sanders A et al
Professionalism in Emergency Medicine. Acad Emerg
Med 1998 512.- Bryan CS The Seven Basic
Virtue in Medicine Summing Up. J S C Med Assoc
2007 103 135-137.- SAEM Ethics Committee
Virtue in Emergency Medicine. Acad Emerg Med
1996 3 961-966.