Ethics and Emergency Medicine Part II

Rebecca Burton-MacLeodPreceptor: Dr. Lisa CampfensDec. 4th, 2003

Ethics

Refer to Moritz’s 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...

Today’s topicsPatient autonomyjusticehealth care rationingmoral decisions in disaster medicineethics in researchgender/cultural issues in EM careteaching of traineesbiomedical industry ethics

4 principles of health care ethics

Autonomybeneficence--doing good for your ptnonmaleficence--avoidance of harm

for your ptjustice

Patient autonomyGreek 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)

Patient autonomy

major concept in last half of 20th centuryassociated 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…”

Violations of autonomy

Medical research performed on concentration camp victims in Nazi Germany

USA Tuskegee syphilis study

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 ?

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” (Webster’s dictionary)

distributive justice--”fairness in allocation of resources and obligations” (Rosens)

Why justice?

Aristotle--justice and prudence are primary virtues in “Niomachean Ethics”

Plato--justice principle theme in “Plato’s Republic”

Related to idea of human equalityprinciple evoked when interests of

individuals or groups compete

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

Justice and EM

ACEP Ethic’s Manual, “emergency care is a fundamental individual right and should be available to all who seek it…Denial 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.”

Justice and EM

rationingaccesstriageresearch*may replace autonomy as ordering

principle in 21st century*

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)

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 individual’s health

Health care rationing

2. health care resourcespublic 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

Health care rationing

3. institutional/bedside leveltriage decisions in EMignoring cost considerations on one patient

ignores consequences on other patientsuse resources to benefit patient, without

causing undue burdenhow do we decide if specific treatment

produces benefit, marginal benefit, no benefit, harm ?

Health care rationing

Macroallocation (at level of society) based on distributive justice

microallocation (level of individual) based on beneficence, relies on

distributive justice

Health care rationingEx: 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

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

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 savingspositive outcomes:

uninsured rate significantly reduced covers more people

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

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 Minister’s 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?

Disaster medicine

Imbalance between needs and suppliesEx:

natural disasters war genocide (Rwanda, Yugoslavia, Cambodia) terrorist events large-scale accidents

Disaster medicine

1st principles of mass casualty care: triage

triage based on utilitarian principles to provide greatest benefit to largest number

Triage models

3 possible models: first-come, first-served patient’s best prognosis patient’s social worth

Triage models

1. First-come, first-servedpotential for less bias, but not equitable

resource distribution during catastrophesfavours population that has access to

media, transportation, health carediscriminates against those with

physical/mental disabilities or financial difficulties

Triage models

2. Patient’s best prognosistriage decisions based on patient

survivabilityrequires using clinical skills to provide

maximum benefit to most people from fewest resources

most favourable model in catastrophesmay be hard for the general public to

accept consequences of triage in their environment

Triage models

3. Patient’s social worthage, occupation, statusage should not be a triage factor in itself--

cannot predict individual life expectanciesselecting based on occupation/status uses

the limited resources to save a fewgeneral consensus--social worth is unfair

criteria for triage

Triage

What about health care workers priority for treatment and prophylaxis? Question of individual social worth

Ability to help others--multiplier effectas physicians, should look after own

safety first, then team’s, then patient’s

TriageFactors 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

Triage algorithm

Case 3

“You are at the scene of an accident, and only have 2 chest tubes with you. There are 3 accident victims…all 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?”

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?

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”

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

Research in EM

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

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

Waived consent

Community notification: does not protect personal preferences

of individual enhances community trust, signals

integrity on behalf of researcher

Waived consentFamily 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 researcherBest way to find out what pt may wantsafeguard

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

Vulnerable populations

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

Cultural/gender issues in research

Tuskegee syphilis studies: 1930’s-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

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”)

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?

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 D+C. After conversing with his wife, the husband refuses the procedure. “ what do you do?

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)

Cultural/gender issues in EM

Ideal of culturally competent health care: demonstration of sensitivity valuing cultural differences self-awareness of cultural background

and biases

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?

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

pt’s right to be treated by fully qualified physician

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?

Post-mortem teaching

Pros: “construed

consent” unable to obtain

consent in ED setting

social ethics

Cons: individual

autonomy family possess

“rights of ownership” over deceased’s body

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

Case 7 “A drug company rep in the ED asks to speak with

Sr. resident. They discuss value of his company’s 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?

Biomedical industryEthical 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

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

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

References Marx. Rosen’s 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. 14:1-5. 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. 37;642-646. 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

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. 25;91-94. 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. 341:2088-2091. ACEP. Financial conflicts of interest in biomedical research. Ann Emerg Med. 2002.

40:546-7.

Questions ?