Search

More than 100,000 Americans with failing organs await transplantation, mostly from dead donors. Yet only a fraction of patients declared dead by neurological criteria (DNC) become organ donors.Emergency physicians (EPs) can improve solid organ donation in the following ways: providing perimortem critical care support to potential organ donors, promptly notifying organ procurement organizations (OPOs), asking neurocritical care specialists to evaluate selected emergency department patients for death based on established neurologic criteria, participating in research to advance these developments, implementing automatic OPO notification technologies, and educating the professional and lay communities about organ donation and transplantation, including exploration of opt-out (presumed consent) organ recovery policies.With future improvements in organ preservation and DNC assessment, EPs may become even more involved in the donation process. EPs should support and engage in efforts to promote organ donation and transplantation.

Civility is an essential feature of health care, as it is in so many other areas of human interaction. The article examines the meaning of civility, reviews its origins, and provides reasons for its moral significance in health care. It describes common types of uncivil behavior by health care professionals, patients, and visitors in hospitals and other health care settings, and it suggests strategies to prevent and respond to uncivil behavior, including institutional codes of conduct and disciplinary procedures. The article concludes that uncivil behavior toward health care professionals, patients, and others subverts the moral goals of health care and is therefore unacceptable. Civility is a basic professional duty that health care professionals should embrace, model, and teach.

Millions of patients present to US EDs each year with symptoms concerning for acute coronary syndrome (ACS), but fewer than 10% are ultimately diagnosed with ACS. Well-tested and externally validated accelerated diagnostic protocols were developed to aid providers in risk stratifying patients with possible ACS and have become central components of current ED practice guidelines. Nevertheless, the fear of missing ACS continues to be a strong motivator for ED providers to pursue further testing for their patients. An ethical dilemma arises when the provider must balance the risk of ACS if the patient is discharged compared with the potential harms caused by a cardiac workup. Providers should be familiar with the ethical principles relevant to this dilemma in order to determine what is in the best interests of the patient.

Although voluntarily stopping eating and drinking (VSED) as a way to hasten one’s death is not yet a widely recognized practice in the United States, it has received increasing attention in the medical and bioethics literature in recent years. After a brief review of the broader context of human death and dying, this article poses and examines 11 conceptual, personal, and public policy questions about VSED. The article identifies essential features of VSED and discusses whether VSED is a type of suicide. It identifies reasons why people may or may not choose VSED, and it considers responses by family members and professional caregivers to people who have chosen VSED. It also considers how public policies may permit and regulate or restrict the practice of VSED. Examination of these questions is designed to increase understanding of VSED and to inform moral evaluation of this practice.

Artificial intelligence (AI) can be described as the use of computers to perform tasks that formerly required human cognition. The American Medical Association prefers the term 'augmented intelligence' over 'artificial intelligence' to emphasize the assistive role of computers in enhancing physician skills as opposed to replacing them. The integration of AI into emergency medicine, and clinical practice at large, has increased in recent years, and that trend is likely to continue.AI has demonstrated substantial potential benefit for physicians and patients. These benefits are transforming the therapeutic relationship from the traditional physician-patient dyad into a triadic doctor-patient-machine relationship. New AI technologies, however, require careful vetting, legal standards, patient safeguards, and provider education. Emergency physicians (EPs) should recognize the limits and risks of AI as well as its potential benefits.EPs must learn to partner with, not capitulate to, AI. AI has proven to be superior to, or on a par with, certain physician skills, such as interpreting radiographs and making diagnoses based on visual cues, such as skin cancer. AI can provide cognitive assistance, but EPs must interpret AI results within the clinical context of individual patients. They must also advocate for patient confidentiality, professional liability coverage, and the essential role of specialty-trained EPs.

This commentary examines themes identified in twelve physicians' narratives recounting their experiences in caring for seriously ill family members. In these narratives, physicians describe heavy emotional burdens and other impediments to sound medical decision-making with and for their loved ones. The physicians struggled to balance their roles as physicians and as loving family members, and they employed their professional role in a variety of different ways. Several physicians became personal physicians to their family members, and others deliberately avoided that role. Serving as personal physician to a close family member is widely viewed as a violation of a professional boundary, and adopting that role may expose physicians to sanctions. These narratives offer lessons to physicians regarding their roles in caring for family members and in supporting family members of patients with grave illnesses.

Emergency physicians frequently interact with law enforcement officers and patients in their custody. As always, the emergency physician's primary professional responsibility is to promote patient welfare, and his or her first duty is to the patient. Emergency physicians should treat criminals, suspects, and prisoners with the same respect and attention they afford other patients while ensuring the safety of staff, visitors, and other patients. Respect for patient privacy and protection of confidentiality are of paramount importance to the patient-physician relationship. Simultaneously, emergency physicians should attempt to accommodate law enforcement personnel in a professional manner, enlisting their aid when necessary. Often this relates to the emergency physician's socially imposed duties, governed by state laws, to report infectious diseases, suspicion of abuse or neglect, and threats of harm. It is the emergency physician's duty to maintain patient confidentiality while complying with Health Insurance Portability and Accountability Act regulations and state law.

There is considerable diversity in compensation models in the specialty of Emergency Medicine (EM). We review different compensation models and examine moral consequences possibly associated with the use of various models. The article will consider how different models may promote or undermine health care's quadruple aim of providing quality care, improving population health, reducing health care costs, and improving the work-life balance of health care professionals. It will also assess how different models may promote or undermine the basic bioethical principles of beneficence, non-maleficence, respect for autonomy, and justice.

Physician-assisted death (PAD) has long been a strongly debated moral and public policy issue in the United States, and an increasing number of jurisdictions have legalized this practice under certain circumstances. In light of changing terminology, laws, public and professional attitudes, and the availability of published data about the practice, we review key concepts and terms in the ongoing PAD debate, moral arguments for and against PAD, the current legal status of PAD in the United States and in other nations, and data on the reported experience with PAD in those U.S. jurisdictions where it is a legal practice. We then identify situations in which emergency physicians (EPs) may encounter patients who request PAD or have attempted to end their lives with physician assistance and consider EP responses in those situations. Based on our analysis, we offer recommendations for emergency medical practice and professional association policy.

This article revisits the persistent problem of crowding in US hospital emergency departments (EDs). It begins with a brief review of origins of this problem, terms used to refer to ED crowding, proposed definitions and measures of crowding, and causal factors. The article then summarizes recent studies that document adverse moral consequences of ED crowding, including poorer patient outcomes; increased medical errors; compromises in patient physical privacy, confidentiality, and communication; and provider moral distress. It describes several organizational strategies implemented to relieve crowding and implications of ED crowding for individual practitioners. The article concludes that ED crowding remains a morally significant problem and calls on emergency physicians, ED and hospital leaders, emergency medicine professional associations, and policymakers to collaborate on solutions.

Moral conflicts over medical treatment that are the result of differences in fundamental moral commitments of the stakeholders, including religiously grounded commitments, can present difficult challenges for clinical ethics consultants. This article begins with a case example that poses such a conflict, then examines how consultants might use different approaches to clinical ethics consultation in an effort to facilitate the resolution of conflicts of this kind. Among the approaches considered are the authoritarian approach, the pure consensus approach, and the ethics facilitation approach described in the Core Competencies for Healthcare Ethics Consultation report of the American Society for Bioethics and Humanities, as well as a patient advocate approach, a clinician advocate approach, and an institutional advocate approach. The article identifies clear limitations to each of these approaches. An analysis of the introductory case illustrates those limitations, and the article concludes that deep-seated conflicts of this kind may reveal inescapable limits of current approaches to clinical ethics consultation.

Ambulance diversion is a common and controversial method used by emergency departments (EDs) to reduce stress on individual departments and providers and relieve mismatches in the supply and demand for ED beds. Under this strategy, ambulances bound for one hospital are redirected to another, usually under policies established by regional emergency medical services systems. Other responses to this mismatch include maladaptive behaviors (such as "boarding" in "hallway beds") and the development of terminology intended to normalize these practices, all of which are reviewed in this article. We examine the history and causes of diversion as well as the ethical foundations and practical consequences of it. We contend that (1) from a moral viewpoint, the most important stakeholder is the individual patient because diversion decisions are usually relative rather than absolute; (2) decisions regarding ambulance diversion should be made with careful consideration of individual patient preferences, local and state emergency medical services laws, and institutional surge capacity; and (3) authorities should consider the potential positive effects of a regional or statewide ban on diversion.

The five chapters in Part I of this volume provide a general introduction to the field of health care ethics, including its purpose, history, methods, and relation to the domains of law and culture. The account of the nature, scope, and limits of health care ethics provided in these chapters is designed to set the stage for examination of the multiple specific topics in ethics and health care in the subsequent chapters of the book. Chapter 1, “The role of ethics in health care,” begins with a description of several concepts of ethics, common sources of moral guidance, and methods for resolving moral disagreements. It then considers the relation of ethics and health care, arguing that ethical issues are especially prominent in health care. This prominence is a result both of the importance of the human interests at stake and of the complexity of many treatment decisions. Ethics can guide difficult choices in health care, but decisions also depend on factual information, and even the most careful moral reasoning may not produce a unique and definitive “correct” solution. Chapter 2, “A brief history of health care ethics and clinical ethics consultation in the United States,” describes the emergence of health care ethics as a new field of inquiry and practice in the latter half of the twentieth century. This review highlights major changes in the US health care system during this period. It also identifies three high-profile events that called public attention to moral issues in medical research and practice: investigative reports condemning the decades-long Tuskegee Study of Untreated Syphilis in poor black men, the US Supreme Court abortion decision in Roe v. Wade , and the New Jersey Supreme Court Quinlan decision on rights to refuse life-sustaining medical treatment. Chapter 2 also outlines the development of the practice of clinical ethics consultation in US health care facilities. From its origins in the 1970s, clinical ethics consultation has become a widely available service designed to help health care professionals, patients, and families make difficult moral choices about medical treatment. Chapter 3, “Methods of health care ethics,” summarizes a variety of different approaches that scholars have proposed for moral reasoning in health care settings. These approaches recommend different theoretical tools and strategies to guide moral deliberation, including basic principles, paradigmatic cases, moral rules, and moral virtues. This chapter also describes a simple, step-by-step procedure for analyzing health care ethics cases.

Case example Thirty-year-old Mr. Edward Dawson, an investment manager in a large bank, collapses one afternoon in his office. His assistant immediately calls 911. Emergency medical technicians respond rapidly, recognize that Mr. Dawson is in cardiac arrest, begin cardiopulmonary resuscitation, intubate Mr. Dawson, and transport him to nearby Downtown Medical Center, where he is placed on a ventilator and admitted to the medical intensive care unit. Physical examination and diagnostic imaging reveal that he has suffered a severe anoxic brain injury, and he does not regain consciousness. Eight weeks later, Mr. Dawson's medical condition is unchanged. A consulting neurologist informs his wife that, although he does not satisfy all of the neurologic criteria for the determination of death, his brain injury is extensive and irreversible. The neurologist explains that it is highly unlikely that Mr. Dawson will ever regain consciousness or the ability to breathe on his own . Mr. Dawson had been married just four months before this accident. Dr. Milam, his attending physician, offers Mrs. Dawson the option that ventilator support be withdrawn and Mr. Dawson be allowed to die. Mrs. Dawson agrees with this treatment plan, but requests that, before the ventilator is withdrawn, her husband's sperm be recovered for artificial insemination at a later date. She reports that they had intended to have children in the course of the marriage, and that she would like to fulfill that goal. How should Dr. Milam respond? Overcoming infertility Reproduction is, of course, a natural process essential for the survival of any biological species, but not all individual organisms have the ability or the opportunity to reproduce. For most human beings, reproduction is also a life-changing event with great personal and moral significance. People who desire children and who experience difficulty reproducing may therefore seek medical assistance in achieving that goal. Human infertility is, in fact, a relatively common condition. According to a US National Survey of Family Growth conducted between 2006 and 2010, 6 percent of all married women aged 15–44 (1.5 million women) were infertile, where infertility was defined as having been sexually active without using contraceptive measures over the past twelve months and not having become pregnant. In the same survey, 11.5 percent of all men aged 25–44 who were not surgically sterile reported inability or difficulty fathering a child.

Therapeutic relationships between patients and professionals are at the center of health care; they are the primary mechanism for realizing its cherished goals of health, healing, and comfort. Part II of this volume examines six moral foundations of these therapeutic relationships: • respect for patient privacy and confidentiality • truthful communication • informed consent to treatment • surrogate decision-making for patients who lack decision-making capacity • respect for professional boundaries • responsible stewardship of health care resources These six foundations are widely recognized as essential for the provision of effective, equitable, and respectful health care. Chapter 6, “Privacy and confidentiality,” first examines the meaning of these concepts and their application in health care settings. Then it argues that respect for privacy and confidentiality preserves patient autonomy, promotes beneficial treatment outcomes, and protects patients from harm. The chapter acknowledges that respect for privacy and confidentiality may be limited by other duties, including duties to obey the law and to protect both patients and third parties from harm. Chapter 7, “Truthfulness,” explores professional duties to communicate truthfully with patients. It bases these duties on respect for patients’ rights to know about their condition and its treatment, the ability of patients to accept even bad news, and the benefits to patients of making decisions based on a clear understanding of their condition, prognosis, and treatment alternatives. Chapter 7 describes and endorses an account of what it means to be truthful that was proposed by physician Richard Cabot. It distinguishes duties to provide truthful information from duties to protect the confidentiality of that information, and it recognizes that patients may choose to waive their right to receive personal health information. Chapter 8 is devoted to examination of patient rights to give or withhold, and professional duties to obtain, informed consent to medical treatment. After a brief summary of the legal origins and moral foundations of informed consent, the chapter describes the three essential elements of informed consent, namely, the patient must have the capacity to consent, the health care professional must provide relevant information about the treatment decision, and the patient must be free to choose.

Case example On April 15, 1975, 21-year-old Karen Ann Quinlan attended a friend's birthday party at a bar near her home in New Jersey. Karen was on a strict diet at the time, and she was also taking the anti-anxiety drug diazepam (Valium ® ). After several drinks at the party, Karen felt faint, and friends took her home and put her to bed. When they checked on her fifteen minutes later, she had stopped breathing. They attempted to revive her and called for assistance. Emergency medical technicians arrived, continued cardio-pulmonary resuscitation efforts, and transported Karen to a nearby hospital, where she was placed on a mechanical ventilator . Karen remained hospitalized, on ventilator support, for the next several months, but she did not regain consciousness. Neurologists diagnosed her condition as a “persistent vegetative state,” a form of irreversible unconsciousness caused by lack of oxygen to her brain during the time when she was not breathing. Karen did, however, retain some brain activity. She did not meet established brain-oriented legal and medical criteria for death (sometimes called “brain death”), since those criteria require a finding of “irreversible cessation of total brain function.” Her physicians were convinced that Karen could not survive without ongoing ventilator support . Karen's parents, Joseph and Julia Quinlan, had consented to all recommended life-sustaining treatments for their daughter during the first three months of her hospitalization. By the end of July 1975, however, they reached the conclusion that Karen would not want continuing life-sustaining treatment in a state of permanent unconsciousness. The Quinlans were devout Roman Catholics; after consultation with their parish priest, they requested that Karen's ventilator support be discontinued and that she be allowed to die. Karen's physicians responded that they could not honor this request, on the grounds that removing Karen's ventilator support would be a form of euthanasia that would be immoral, illegal, and contrary to medical standards of care. Karen was a patient at St. Claire's Hospital, and the hospital supported the physicians’ decision to continue ventilator support. What should have been done to resolve this disagreement? With the rapid expansion of health care services in the United States in the decades immediately following World War II, patients, health care professionals, and the American public at large confronted new and challenging moral questions about what treatments should be offered and provided, especially near the beginning and the end of human life.

Part I. Ethics in Health Care: Role, History, and Methods: 1. The role of ethics in health care 2. A brief history of health care ethics and clinical ethics consultation in the United States 3. Methods of health care ethics 4. Law and ethics in health care 5. Culture and ethics in health care Part II. Moral Foundations of the Therapeutic Relationship: 6. Privacy and confidentiality 7. Truthfulness 8. Informed consent to treatment 9. Surrogate decision-making 10. Professionalism: responsibilities and privileges 11. Resource stewardship Part III. Controversies in Health Care Ethics: Treatment Choices at the Beginning and at the End of Life: 12. Assisted reproductive technologies 13. Abortion 14. Maternal-fetal conflict 15. Advance care planning and advance directives 16. Moral conflicts in end-of-life care 17. Medical futility 18. Aid in dying Part IV. Ethics in Special Contexts: Biomedical Research, Genetics, and Organ Transplantation: 19. Research on human subjects 20. The genetic revolution 21. Organ transplantation For further reading References Index.

The recent enactment of the Patient Protection and Affordable Care Act (ACA) of 2010, and the ongoing debate over reform of the U.S. health care system, raise numerous important ethical issues. This article reviews basic provisions of the ACA; examines underlying moral and policy issues in the U.S. health care reform debate; and addresses health care reform's likely effects on access to care, emergency department (ED) crowding, and end-of-life care. The article concludes with several suggested actions that emergency physicians (EPs) should take to contribute to the success of health care reform in America.

In October 2009, the board of directors of the American College of Emergency Physicians (ACEP) approved a major revision to ACEP's "Gifts to Emergency Physicians from Industry" policy. The revised policy is a response to increasing debate and calls for restriction of the long-standing biomedical industry practice of giving promotional gifts to individual physicians. This article outlines the history of professional attention to gift giving and reviews recent contributions to the ongoing debate over its justifiability, including professional association recommendations for limitation or prohibition of the practice. The article concludes with a description of the provisions of the revised ACEP gifts policy and brief reflection on the future of this practice.

Part 1 of this 2-article series reviews serious moral problems created by emergency department (ED) crowding. In this second part of the series, we identify and describe operational and financial barriers to resolving the crisis of ED crowding, along with a variety of institutional and public policy strategies proposed or implemented to overcome those barriers. Finally, the article evaluates 2 additional actions designed to address the problem of ED crowding, namely, distribution of a warning statement to ED patients and implementation of a "reverse triage" system for safe early discharge of hospital inpatients.

Most disaster plans depend on using emergency physicians, nurses, emergency department support staff, and out-of-hospital personnel to maintain the health care system's front line during crises that involve personal risk to themselves or their families. Planners automatically assume that emergency health care workers will respond. However, we need to ask: Should they, and will they, work rather than flee? The answer involves basic moral and personal issues. This article identifies and examines the factors that influence health care workers' decisions in these situations. After reviewing physicians' response to past disasters and epidemics, we evaluate how much danger they actually faced. Next, we examine guidelines from medical professional organizations about physicians' duty to provide care despite personal risks, although we acknowledge that individuals will interpret and apply professional expectations and norms according to their own situation and values. The article goes on to articulate moral arguments for a duty to treat during disasters and social crises, as well as moral reasons that may limit or override such a duty. How fear influences behavior is examined, as are the institutional and social measures that can be taken to control fear and to encourage health professionals to provide treatment in crisis situations. Finally, the article emphasizes the importance of effective risk communication in enabling health care professionals and the public to make informed and defensible decisions during disasters. We conclude that the decision to stay or leave will ultimately depend on individuals' risk assessment and their value systems. Preparations for the next pandemic or disaster should include policies that encourage emergency physicians, who are inevitably among those at highest risk, to "stay and fight."

Background Physicians strive to respect the autonomy of patients. The emergent care of Jehovah's Witnesses, however, leaves health care providers struggling with ethical and legal questions. These are further compounded when the patient in question is a minor. Case A girl aged 15 years presented with anemia, a large ovarian mass, massive hemoperitoneum, and parents who were devout Jehovah's Witnesses who refused administration of blood products. Following discussion of the patient's condition and treatment options with the patient, her family, members of the treatment team, and consultants, the patient was transferred to a hospital that offered a blood conservation program for surgical patients. The patient received surgical management without the need for blood transfusion. Her surgeons, however, reserved the legal right to give blood if an emergent need arose despite the lack of parental consent. Conclusion Society grants considerable legal latitude in dealing with Jehovah's Witness minors, and physicians must be aware of the legal and ethical parameters surrounding the care of such patients.