Ethics and Emergency Medicine Part II

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Ethics and Emergency Medicine Part II

• Rebecca Burton-MacLeod
• Preceptor Dr. Lisa Campfens
• Dec. 4th, 2003

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Ethics

• Refer to Moritzs presentation on Ethics in June
  5th, 2003 for topics relating to consent,
  capacity, end of life issues, confidentiality,
  physician-assisted suicide
• so that leaves us to talk about...

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Todays topics

• Patient autonomy
• justice
• health care rationing
• moral decisions in disaster medicine
• ethics in research
• gender/cultural issues in EM care
• teaching of trainees
• biomedical industry ethics

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4 principles of health care ethics

• Autonomy
• beneficence--doing good for your pt
• nonmaleficence--avoidance of harm for your pt
• justice

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Patient autonomy

• Greek words autos and nomos meaning self rule
• pt autonomy--adults right to accept/reject
  recommendations for medical care if capable of
  appropriate decision-making capacity (Rosens)

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Patient autonomy

• major concept in last half of 20th century
• associated with spreading democracy, improvement
  in education, increase in diversity of
  values--encourages people to protect personal
  values
• 1914, USA Court Justice Cardoza, any individual
  of sound mind has the right to determine what
  shall be done to his body

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Violations of autonomy

• Medical research performed on concentration camp
  victims in Nazi Germany
• USA Tuskegee syphilis study

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Case 1

• a 52y.o. gentleman presents to the ED
  complaining that he had a fall yesterday and hit
  his head. He denies any LOC, nor any symptoms
  since the event. However, he is concerned he may
  have injured his brain. He demands to have a
  CT head.
• Is the pt ethically able to ask for possibly
  superfluous tests?
• Does your answer to him depend on time of day,
  number of people waiting in dept, radiologist on
  call, strength of demand ?

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Justice

• One of 4 principles of western health care ethics
• justice--upholding of what is right and lawful,
  especially fair treatment or punishment in
  accordance with honour, standards, or law
  (Websters dictionary)
• distributive justice--fairness in allocation of
  resources and obligations (Rosens)

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Why justice?

• Aristotle--justice and prudence are primary
  virtues in Niomachean Ethics
• Plato--justice principle theme in Platos
  Republic
• Related to idea of human equality
• principle evoked when interests of individuals or
  groups compete

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Theories of justice

• Utilitarian
• should follow action that creates greatest
  possible balance of good vs. harm
• the end justifies the means

• Deontological
• belief that actions are either right or wrong,
  based on higher rule or rules
• not based on consequence of action

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Justice and EM

• ACEP Ethics Manual, emergency care is a
  fundamental individual right and should be
  available to all who seek itDenial of emergency
  care or delay in providing emergency services
  based on race, religion, gender, ethnic
  background, social status, type of
  illness/injury, or ability to pay is unethical.

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Justice and EM

• rationing
• access
• triage
• research
• may replace autonomy as ordering principle in
  21st century

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Health care rationing

• Under distributive justice, require equitable
  (but not always equal) allocation of health care
  resources
• no information barriers, financial barriers,
  supply anomalies which prevent decent basic
  minimum of health care (Daniels, 1985)

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Health care rationing

• 3 levels of rationing
• 1. societal interests
• health care vs. education vs. defense vs.
  environment
• effects of poor nutrition, inadequate housing,
  inadequate education, pollution, violence on an
  individuals health

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Health care rationing

• 2. health care resources
• public health/preventative medicine vs.
  child/maternal health vs. new technologies vs.
  prehospital/emergency care vs. comfort/palliation
• distribution based on medical need, cost
  effectiveness, and sharing of benefits/burdens in
  society

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Health care rationing

• 3. institutional/bedside level
• triage decisions in EM
• ignoring cost considerations on one patient
  ignores consequences on other patients
• use resources to benefit patient, without causing
  undue burden
• how do we decide if specific treatment produces
  benefit, marginal benefit, no benefit, harm ?

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Health care rationing

• Macroallocation (at level of society)
• based on distributive justice
• microallocation (level of individual)
• based on beneficence, relies on distributive
  justice

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Health care rationing

• Ex Oregon Health Plan
• in 1987, 7y.o. Coby Howard died from leukemia
  after not receiving bone marrow transplant
• Oregon tried to pass legislation restoring
  Medicaid funding for bone marrow transplants
• John Kitzhaber (emerg doc and later Oregon
  governor) argued that better use of resources to
  expand insurance to cover everyone, instead of
  paying for costly services for few

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Oregon Health Plan

• Expanded Medicaid to cover all residents below
  poverty line, but in return would ration health
  care services
• rank list compiled of condition/treatment
  pairs--based on community priorities, physicians
  opinions, data on effectiveness of treatment
  outcomes
• delisting occurred if financial shortfall

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Oregon health plan

• Problems with the plan
• little rationing actually took place (physician
  noncompliance, political concessions to move
  medical services on the list)
• no substantial savings
• positive outcomes
• uninsured rate significantly reduced
• covers more people

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Oregon health plan

• Similar delisting experiences in Britain, New
  Zealand, Netherlands, Ontario
• when rationing decisions made public, less likely
  to be able to ration services

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Case 2

• A plane crashes, resulting in injury to many
  patients. Victims range in age from 1y.o. to
  93y.o. One victim is Prime Ministers son. One
  victim has 90 body burns. Some patients have
  blunt head, abdominal, or chest trauma. Eight
  patients are in cardiopulmonary arrest. A woman
  is in labour. Five patients are in shock. You
  are the sole physician.
• how would you proceed to care for these patients?

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Disaster medicine

• Imbalance between needs and supplies
• Ex
• natural disasters
• war
• genocide (Rwanda, Yugoslavia, Cambodia)
• terrorist events
• large-scale accidents

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Disaster medicine

• 1st principles of mass casualty care triage
• triage based on utilitarian principles to provide
  greatest benefit to largest number

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Triage models

• 3 possible models
• first-come, first-served
• patients best prognosis
• patients social worth

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Triage models

• 1. First-come, first-served
• potential for less bias, but not equitable
  resource distribution during catastrophes
• favours population that has access to media,
  transportation, health care
• discriminates against those with physical/mental
  disabilities or financial difficulties

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Triage models

• 2. Patients best prognosis
• triage decisions based on patient survivability
• requires using clinical skills to provide maximum
  benefit to most people from fewest resources
• most favourable model in catastrophes
• may be hard for the general public to accept
  consequences of triage in their environment

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Triage models

• 3. Patients social worth
• age, occupation, status
• age should not be a triage factor in
  itself--cannot predict individual life
  expectancies
• selecting based on occupation/status uses the
  limited resources to save a few
• general consensus--social worth is unfair
  criteria for triage

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Triage

• What about health care workers priority for
  treatment and prophylaxis?
• Question of individual social worth
• Ability to help others--multiplier effect
• as physicians, should look after own safety
  first, then teams, then patients

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Triage

• Factors to consider
• likelihood of benefit
• effect on improving quality of life
• duration of benefit
• urgency of pt condition
• direct multiplier effect
• amount of resources required for successful
  treatment

• Factors NOT to consider
• age, ethnicity, sex
• talents, abilities, disabilities, deformities
• socioeconomic status, social worth, political
  position
• coexistent conditions that do not affect
  short-term prognosis
• drug/alcohol abuse
• antisocial/aggressive behaviour

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Triage algorithm
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Case 3

• You are at the scene of an accident, and only
  have 2 chest tubes with you. There are 3
  accident victimsall of whom require chest tubes.
  2 of the patients each only need one tube, while
  the 3rd patient requires bilateral chest tubes.
  To whom do you give your 2 chest tubes?

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Case 4

• a 39y.o. man took 30mg of lorazepam. He was
  somnolent but arousable and his vitals were
  stable. He and his family were informed he would
  be transported to the medical center across town
  since they have a medicine to treat this
  overdose (the center was conducting trials with
  a benzodiazepine antagonist).
• is it appropriate for this pt to be transported
  in order to enroll them in a research protocol?

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Research

• Ethical principles for biomedical research
• respect for people as autonomous agents
• truth telling
• beneficence in maximizing the benefits and
  minimizing the burdens for research subjects
• justice in equitably distributing the
  benefits/burdens of research (participating as
  subject in research is altruistic act)
• ACEP Code of Ethics, accurate, compassionate,
  competent, impartial, honest conduct of
  scientific research

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Research

• Ethical issues in research
• scientific misconduct (plagiarism, inappropriate
  stat tests, neglecting negative results, omitting
  missing data points, data dredging, fabrication
  of data)
• unethical treatment of human/non-human subjects
• conflict of interest
• responsibilities to colleagues/students/trainees

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Research in EM

• Informed consent for resuscitation and other
  research when pt does not have capacity to decide
• deferred consent (illogical concept)
• waived consent

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Waived consent

• Requirements
• necessity for research
• prospect for direct benefit to subjects
• informed consent from pt representatives will be
  pursued
• f/u consent will be pursued
• community disclosures must be performed
• obtaining informed consent must not be feasible

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Waived consent

• Community notification
• does not protect personal preferences of
  individual
• enhances community trust, signals integrity on
  behalf of researcher

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Waived consent

• Family notification
• who is defined as family member?
• Related by blood or affinity whose close
  relationship is equivalent of family
• How do you respect pts need for confidentiality?
• Careful balance of confidentiality and disclosure
  is responsibility of researcher
• Best way to find out what pt may want
• safeguard

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Waived consent

• Independent physician and data monitoring
  committee
• evaluates necessity/value of the research
• composed of individuals with no investment or
  connection to research
• increases integrity and fairness of study

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Vulnerable populations

• Particular circumstances that bring them as
  potential research subjects
• medical condition
• limitation of intellectual function
• social setting
• psychosocial stressors

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Cultural/gender issues in research

• Tuskegee syphilis studies
• 1930s-1972, US Public Health Service
• black males with tertiary syphilis (mostly poor
  and illiterate) no informed consent
• study natural course of disease not provide
  treatment
• even when penicillin available, decided not to
  treat subjects

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Cultural/gender issues in research

• concerned about racial bias in research /
  treatments
• Seattle committee for kidney dialysis pts--pt
  with productive jobs or family to support (middle
  class, white males)
• trauma centers concentrated in inner cities where
  minority gps tend to live, more violent crime
• black pts under care of white physicians,
  homosexuals involved in AIDS research (socially
  franchised studied the socially disenfranchised)

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Cultural/gender issues in EM

• 2 studies shown that Hispanics and
  African-Americans receive fewer analgesics for
  extremity , than white pts in ED no difference
  in pain sensation
• failure in communication, or racial
  profiling/discrimination?

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Case 5

• A 19y.o. North African female presents to the ED
  with her husband. She speaks no English, and her
  husband is acting as interpreter. She is 8wks
  pregnant and is hemorrhaging vaginally. She is
  hemodynamically unstable. You think she needs an
  emergent DC. After conversing with his wife,
  the husband refuses the procedure.
• what do you do?

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Cultural/gender issues in EM

• Interpreters
• inadequate interpretation is form of
  discrimination
• often only available if pt brings family/friend
  (confidentiality issues)
• untrained medical translators give translation
  errors (omissions, additions, substitutions)

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Cultural/gender issues in EM

• Ideal of culturally competent health care
• demonstration of sensitivity
• valuing cultural differences
• self-awareness of cultural background and biases

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Case 6

• A hospitalized, elderly pt is being coded (full
  CPR). The code has gone on for 20min without
  evidence of success. You believe the pt will not
  survive the attempt. There is adequate IV
  access. Someone asks if you, as junior resident,
  would like to attempt a femoral venous line for
  practice, since the pt is going to die anyways.
  
• Is this ethical?

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Teaching issues

• Ethical issues of who provides care
• obligation of academic physicians to ensure that
  residents have adequate skills to provide good
  medical care
• resident must acquire knowledge, technical
  abilities before assuming full responsibility for
  pt care
• pts right to be treated by fully qualified
  physician

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Teaching issues

• Options for teaching
• animals--is it ethical to inflict suffering on
  animals, when alternatives are available?
• Mannequins--an imperfect model
• cadavers--do not realistically mimic tissue of
  real pt
• newly dead--respect for autonomy? Does it apply?
• Living--pt autonomy and nonmaleficence?

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Post-mortem teaching

• Pros
• construed consent
• unable to obtain consent in ED setting
• social ethics

• Cons
• individual autonomy
• family possess rights of ownership over
  deceaseds body

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Teaching issues--back to case

• Survey of 234 house officers (47 1st yr postgrad
  training)
• 34 thought sometimes appropriate to insert FVC
  for practice during CPR
• 26 had observed someone insert FVC for practice
  during CPR
• 16 had attempted this
• significant association b/w the experience of
  inserting FVC during CPR for practice and
  subsequent belief it may be appropriate to
  perform this

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Case 7

• A drug company rep in the ED asks to speak with
  Sr. resident. They discuss value of his
  companys new antibiotic for ED use, vs. others
  on the market. He distributes promotional
  material to the Sr. resident and other residents
  in the area. Then passes out company pens, note
  pads, penlights, and gives a textbook on
  infectious diseases for the residents library.
  Leaves his card and says he can bring food to
  future conferences, pay for guest speaker to come
  and present on infectious diseases.
• any ethical issues involved with this visit?

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Biomedical industry

• Ethical concerns
• biomedical industry is a business and is allowed
  to advertise
• physicians must base practice on scientific
  literature
• biomedical industry presentations are
  fundamentally biased
• physicians may not be aware of the influence of
  promotional materials/gifts, on their clinical
  decisions

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Biomedical industry

• ACEP guidelines for research
• avoid conflicts of interest
• must disclose financial relationships in research
• must not allow investments from sponsors to
  jeopardize rights of subjects, compromise
  integrity of results
• financial compensation must be at fair market
  value
• must establish agreements in writing before
  initiating research

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Biomedical industry

• ACEP guidelines for gifts/subsidies
• should be of minimal value and either benefit
  pts, or serve educational purpose
• EP must be willing to disclose all gifts received
• conference attendees should not accept direct
  subsidies to pay for costs of personal expenses
• academic training programs may accept subsidies
  to enable physicians to attend appropriately
  accredited programs
• conference faculty should disclose all financial,
  material, or research support from industry

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References

• Marx. Rosens Textbook of Emergency Medicine.
• Www.saem.org/download/ethics.doc
• larkin, G et al. Essential ethics for EMS
  cardinal virtues and core principles. Emerg Med
  Clin North Am. 2002. 20(4).
• Oberlander, J et al. Rationing medical care
  rhetoric and reality in the Oregon Health Plan.
  CMAJ. 2001. 164(11).
• Iserson, K et al. Are emergency departments
  really a safety net for the medically indigent?
  AJEM. 1996. 141-5.
• Marco, C et al. Determination of futility in
  emergency medicine. Ann Emerg Med. 2000.
  35(6)604-612.
• Domres, B. Ethics and triage. Prehospital
  Disaster Med. 2001. 16(1)53-8.
• Pesik, N et al. Terrorism and the ethics of
  emergency medical care. Ann Emerg Med. 2001.
  37642-646.
• Burkle, F. Mass casualty management of a
  large-scale bioterrorist event an
  epidemiological approach that shapes triage
  decisions. 2002. 20(2).
• Milzman, D. Pre-existing disease in trauma
  patients a predictor of fate independent of age
  and injury severity score. J Trauma. 1992.
  32(2)236-43.
• Marco, C. Research ethics ethical issues of
  data reporting and the quest for authenticity.
  Acad Emerg med. 2000. 7(6)691-4

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References

• Adams, J et al. Acting without asking an
  ethical analysis of the Food and Drug
  Administration waiver of informed consent for
  emergency research. Ann Emerg Med. 1999.
  33(2)218-223.
• Quest, T. Ethics seminars vulnerable
  populations in emergency medicine research. Acad
  Emerg Med. 2003. 10(11)1294-8.
• Schmidt, T. The legacy of the Tuskegee syphilis
  experiments for emergency exception from informed
  consent. Ann Emerg Med. 2003. 41(1).
• Multiculturalism and cultural competency.
  Www.mdconsult.com
• iserson, K. Postmortem procedures in the
  emergency department using the recently dead to
  practise and teach. J Med Ethics. 1993.
  19(2)92-8.
• Iserson, K. Law versus life the ethical
  imperative to practice and teach using the newly
  dead emergency department patient. Ann Emerg
  Med. 1995. 2591-94.
• Moore, G. Ethics seminars the practice of
  medical procedures on newly dead patients--is
  consent warranted? Acad Emerg Med. 2001.
  8(4)389-92.
• Kaldjian, L et al. Insertion of femoral vein
  catheters for practice by medical house officers
  during cardiopulmonary resuscitation. NEJM.
  1999. 3412088-2091.
• ACEP. Financial conflicts of interest in
  biomedical research. Ann Emerg Med. 2002.
  40546-7.

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Questions ?