saem ethics committee...kitab al-tibb al-ruhani [the book of medicine of the soul] states that the...

SAEM Ethics CommitteeSAEM Ethics Committee

ETHICS IN EMERGENCY ETHICS IN EMERGENCY MEDICINE:MEDICINE:

Honesty and Integrity in Training Honesty and Integrity in Training and Practiceand Practice

Society for Academic Emergency Medicine

What is Professionalism?What is Professionalism?

““Those attitudes and behaviors that serve to Those attitudes and behaviors that serve to maintain patient interest above physician maintain patient interest above physician self-interest”self-interest”

- ABIM, 1995- ABIM, 1995


Medical Professionalism:Medical Professionalism:

““A set of values, attitudes, and behaviors that A set of values, attitudes, and behaviors that result in serving the interests of patients and result in serving the interests of patients and society before one’s own.”society before one’s own.”

- Ann Intern Med 1991- Ann Intern Med 1991


Elements of ProfessionalismElements of Professionalism

Suspension of self-interestSuspension of self-interestHonestyHonestyTechnical competenceTechnical competenceAuthorityAuthorityAccountabilityAccountabilityCommunicationCommunicationJusticeJusticeHumilityHumility


There are different approaches to There are different approaches to conceptualizing medical conceptualizing medical

professionalism and ethics. Some professionalism and ethics. Some are based in history.are based in history.


““Let his disposition be that of a man of honor, Let his disposition be that of a man of honor, let him behave to all honorable men with a let him behave to all honorable men with a

friendly and easy spirit.”friendly and easy spirit.”

- Hippocrates- Hippocrates


Hippocratic OathHippocratic Oath

““I swear by Apollo the Physician…to keep according to I swear by Apollo the Physician…to keep according to my ability and judgment the following oath”my ability and judgment the following oath”

““I will prescribe regimen for the good of my patients I will prescribe regimen for the good of my patients according to my ability and my judgment and never according to my ability and my judgment and never do harm to anyone” do harm to anyone”

The Oath of Hippocrates of Kos, 5th Century BCThe Oath of Hippocrates of Kos, 5th Century BC


Hippocratic OathHippocratic Oath

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

- Circa 400 BC- Circa 400 BC


Other approaches are based on sets of Other approaches are based on sets of principles elucidated by the organizing principles elucidated by the organizing

bodies of medicinebodies of medicine


Declaration of Professional Responsibility :Declaration of Professional Responsibility :Medicine’s Social Contract with HumanityMedicine’s Social Contract with Humanity

Developed by the AMA in 2001Developed by the AMA in 2001

- Addresses 21- Addresses 21stst century issues for physicians century issues for physicians in all geographic areas, all specialtiesin all geographic areas, all specialties

- Translated in numerous languages- Translated in numerous languages



We, the members of the world community of physicians, solemnly commit We, the members of the world community of physicians, solemnly commit ourselves to:ourselves to:

1. Respect human life and the dignity of every individual.1. Respect human life and the dignity of every individual.

2. Refrain from supporting or committing crimes against humanity and condemn 2. Refrain from supporting or committing crimes against humanity and condemn any such acts.any such acts.

3. Treat the sick and injured with competence and compassion and without 3. Treat the sick and injured with competence and compassion and without prejudice.prejudice.

4. Apply our knowledge and skills when needed, though doing so may put us at 4. Apply our knowledge and skills when needed, though doing so may put us at risk.risk.

5. Protect the privacy and confidentiality of those for whom we care and breach 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 that confidence only when keeping it would seriously threaten their health and safety or that of others.safety or that of others.



6. Work freely with colleagues to discover, develop, and promote advances 6. Work freely with colleagues to discover, develop, and promote advances in medicine and public health that ameliorate suffering and contribute to in medicine and public health that ameliorate suffering and contribute to human well-being.human well-being.

7. Educate the public and polity about present and future threats to the 7. Educate the public and polity about present and future threats to the health of humanity.health of humanity.

8. Advocate for social, economic, educational, and political changes that 8. Advocate for social, economic, educational, and political changes that ameliorate suffering and contribute to human well-being.ameliorate suffering and contribute to human well-being.

9. Teach and mentor those who follow us for they are the future of our 9. Teach and mentor those who follow us for they are the future of our caring profession.caring profession.

We make these promises solemnly, freely, and upon our personal and We make these promises solemnly, freely, and upon our personal and professional honor.professional honor.


AMA: Principles of Medical EthicsAMA: Principles of Medical Ethics

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

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


AMA: Principles of Medical Ethics AMA: Principles of Medical Ethics

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




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




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




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



AMA: Principles of Medical Ethics (cont.)AMA: Principles of Medical Ethics (cont.)

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




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




- A physician shall, while caring for a patient, - A physician shall, while caring for a patient, regard responsibility to the patient as regard responsibility to the patient as paramount.paramount.

- A physician shall support access to medical - A physician shall support access to medical care for all people. care for all people.


Other Codes of EthicsOther Codes of Ethics

- World Medical Association: Declaration of - World Medical Association: Declaration of HelsinkiHelsinki

- ACEP Code of Ethics- ACEP Code of Ethics

- SAEM Code of Conduct- SAEM Code of Conduct

- Numerous others- Numerous others


ACEP Code of EthicsACEP Code of Ethics

Emergency physicians shall:Emergency physicians shall:1. 1. Embrace patient welfare Embrace patient welfare as their primary professional as their primary professional

responsibility. responsibility.

2. 2. Respond promptly and expertlyRespond promptly and expertly, without prejudice or , without prejudice or partiality, to the need for emergency medical care. partiality, to the need for emergency medical care.

3. 3. Respect the rights and strive to protect the best Respect the rights and strive to protect the best interests of their patientsinterests of their patients, particularly the most , particularly the most vulnerable and those unable to make treatment choices due vulnerable and those unable to make treatment choices due to diminished decision-making capacity. to diminished decision-making capacity.



4. 4. Communicate truthfully with patients Communicate truthfully with patients and secure their and secure their informed consent for treatment, unless the urgency of the informed consent for treatment, unless the urgency of the patient's condition demands an immediate response. patient's condition demands an immediate response.

5. 5. Respect patient privacyRespect patient privacy and disclose confidential information and disclose confidential information only with consent of the patient or when required by an only with consent of the patient or when required by an overriding duty such as the duty to protect others or to obey the overriding duty such as the duty to protect others or to obey the law. law.

6. 6. Deal fairly and honestly with colleagues Deal fairly and honestly with colleagues and take appropriate and take appropriate action to protect patients from health care providers who are action to protect patients from health care providers who are impaired or incompetent, or who engage in fraud or deception. impaired or incompetent, or who engage in fraud or deception.



7. 7. Work cooperatively with others Work cooperatively with others who care for, and about, who care for, and about, emergency patients. emergency patients.

8. 8. Engage in continuing study Engage in continuing study to maintain the knowledge and skills to maintain the knowledge and skills necessary to provide high quality care for emergency patients. necessary to provide high quality care for emergency patients.

9. 9. Act as responsible stewards Act as responsible stewards of the health care resources entrusted of the health care resources entrusted to them. to them.

10. 10. Support societal efforts to improve public health and safetySupport societal efforts to improve public health and safety, , reduce the effects of injury and illness, and secure access to reduce the effects of injury and illness, and secure access to emergency and other basic health care for all.emergency and other basic health care for all.

(http://acep.org/practres.aspx?id=29144)(http://acep.org/practres.aspx?id=29144)


SAEM Code of Conduct

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


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; 6:45.)


Basic Principles of Medical EthicsBasic Principles of Medical Ethics

- Autonomy- Autonomy

- Beneficence- Beneficence

- Nonmaleficence- Nonmaleficence

- Justice- Justice


AutonomyAutonomy

Individual self-determinationIndividual self-determination

- Informed consent- Informed consent

- Disclosure- Disclosure

- Understanding- Understanding

- Voluntariness- Voluntariness

- Surrogate decision making- Surrogate decision making


Non-Non-maleficencemaleficence

““First do no harm”First do no harm”

- Optional treatments and obligatory treatments- Optional treatments and obligatory treatments

- Killing and letting die- Killing and letting die

- Assisted suicide- Assisted suicide

- Decision making for incompetent patients- Decision making for incompetent patients


BeneficenceBeneficence

Act in the patient’s best interestsAct in the patient’s best interests

- Paternalism- Paternalism

- Balancing benefits, costs, and risks- Balancing benefits, costs, and risks

- Value and quality of life- Value and quality of life


JusticeJustice

Fairness and equalityFairness and equality

- Right to health care- Right to health care

- Allocation of health care resources- Allocation of health care resources

- Rationing through priorities in health care- Rationing through priorities in health care

- Rationing of scarce resources- Rationing of scarce resources


There are alternative approaches There are alternative approaches to medical ethics. One emerging to medical ethics. One emerging

system is called “Virtue-based system is called “Virtue-based Ethics”Ethics”


Virtue-based EthicsVirtue-based Ethics

- In contrast to principalism, virtue based ethics seeks to - In contrast to principalism, virtue based ethics seeks to reform personal character through embodying virtuesreform personal character through embodying virtues

- These virtues are replete in philosophical writings and - These virtues are replete in philosophical writings and religious codesreligious codes

- Attention to virtue brings about personal character change - Attention to virtue brings about personal character change and excellence in one’s actionsand excellence in one’s actions

- Grounded in the idea that moral excellence leads to physical - Grounded in the idea that moral excellence leads to physical health benefitshealth benefits


Virtue-based EthicsVirtue-based Ethics

- Aristotle noted 4 cardinal virtues- Aristotle noted 4 cardinal virtues1.1. CourageCourage

2.2. JusticeJustice

3.3. PrudencePrudence

4.4. TemperanceTemperance

- Religious traditions also cultivated virtue-based ethics - Religious traditions also cultivated virtue-based ethics as a means to develop moral and ethical characteras a means to develop moral and ethical character


Religious VirtuesReligious Virtues

- St. Thomas Aquinas added 3 more virtues to - St. Thomas Aquinas added 3 more virtues to Aristotle’s list:Aristotle’s list:

- Faith- Faith

- Hope - Hope

- Charity- Charity

- Moses Maimonides contrasts these virtues with - Moses Maimonides contrasts these virtues with vices to avoidvices to avoid

- “Thirst for profit”- “Thirst for profit”

- “Ambition for renown”- “Ambition for renown”


Religious VirtuesReligious Virtues

- Similarly Muslim Physicians of the Ancient era blended - Similarly Muslim Physicians of the Ancient era blended professional ethics with religious teachingsprofessional ethics with religious teachings

- For example, Abu Bakr al Razi (Rhazes) author of the - For example, Abu Bakr al Razi (Rhazes) author of the Kitab al-Tibb al-Ruhani [the Book of Medicine of the Kitab al-Tibb al-Ruhani [the Book of Medicine of the Soul]Soul] states that the physician “must cultivate good states that the physician “must cultivate good moral character, good health, and be cultured in moral character, good health, and be cultured in manners”manners”

- Such character can be attained by being “one who truly - Such character can be attained by being “one who truly fears God” stated al-Ruhawi the author of the corpus fears God” stated al-Ruhawi the author of the corpus ““Adab al-Tabib [Ettiquettes of the Physician]”Adab al-Tabib [Ettiquettes of the Physician]”


Virtue in Emergency MedicineVirtue in Emergency Medicine

- Prudence- Prudence- Courage- Courage- Temperance- Temperance- Justice- Justice- Unconditional positive - Unconditional positive

regardregard

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

1996 SAEM Ethics Committee created a list of virtues that 1996 SAEM Ethics Committee created a list of virtues that each EM practitioner should embodyeach EM practitioner should embody


The Role of Medical EthicsThe Role of Medical Ethics

Adding another layer of complexity to a Adding another layer of complexity to a demanding jobdemanding job

oror

Providing the true meaning for what we doProviding the true meaning for what we do

Cases for Honesty and Cases for Honesty and IntegrityIntegrity


Many of the challenges that an Many of the challenges that an emergency physician has to confront emergency physician has to confront

in the course of a shift will be in the course of a shift will be unanticipated, not readily solvable in unanticipated, not readily solvable in the frameworks outlined above, and the frameworks outlined above, and will require solution in a time frame will require solution in a time frame

of minutes. of minutes.


- We present cases involving patients, colleagues and staff- We present cases involving patients, colleagues and staff

- Please discuss each case in 10 minutes or less- Please discuss each case in 10 minutes or less

- These cases are organized around the issues of- These cases are organized around the issues of

• honesty to patienthonesty to patient

• honesty to selfhonesty to self

• honesty to peer group honesty to peer group

• integrityintegrity


Honesty to PatientsHonesty to Patients


CASECASE

- 5 y/o child with a very large scalp laceration needs - 5 y/o child with a very large scalp laceration needs suturing. This is a mixed-age ED without the ability suturing. This is a mixed-age ED without the ability to do procedural sedation on kids. to do procedural sedation on kids.

The child asks before lidocaine: The child asks before lidocaine:

““Will this hurt?”Will this hurt?”


Issues -Issues -

- Honesty- Honesty

- Your awareness that studies show that - Your awareness that studies show that telling a child about upcoming pain, telling a child about upcoming pain, increases that child’s perception of pain increases that child’s perception of pain during the procedure: non-maleficenceduring the procedure: non-maleficence

- That child’s trust in doctors in the future- That child’s trust in doctors in the future

- Respect for autonomy- Respect for autonomy


CASECASE

- A schizophrenic patient has been open and - A schizophrenic patient has been open and trusting with you and the psych social trusting with you and the psych social worker on-call about her hallucinations and worker on-call about her hallucinations and her desire to kill her father.her desire to kill her father.

- She is awaiting transport to a locked facility - She is awaiting transport to a locked facility and just as your shift ends, she calls out:and just as your shift ends, she calls out:

““Doctor! Can I go home soon?”Doctor! Can I go home soon?”


Issues -Issues -

- Honesty- Honesty

- Safety of staff and other patients- Safety of staff and other patients

- Non-maleficence- Non-maleficence

- Respect for autonomy- Respect for autonomy

- Desire to leave without a raucous scene- Desire to leave without a raucous scene


CASECASE

- 66 y/o recently retired male comes in for vague - 66 y/o recently retired male comes in for vague headache. headache.

- Undergoing out-patient work-up for abnormal - Undergoing out-patient work-up for abnormal chest x-ray. chest x-ray.

- CT brain shows lesions consistent with - CT brain shows lesions consistent with metastasesmetastases

His wife, before patient returns to room, insists His wife, before patient returns to room, insists on knowing “what you think”on knowing “what you think”


Issues -Issues -

- Honesty- Honesty

- Breaking bad news- Breaking bad news

- Ownership of medical information/respect - Ownership of medical information/respect for autonomyfor autonomy



CASECASE

- Patient with abrupt onset of worst headache - Patient with abrupt onset of worst headache of life, who rates her pain as 10/10, asks the of life, who rates her pain as 10/10, asks the Intern prior to the LP:Intern prior to the LP:

““How many of these have you done???”How many of these have you done???”


Issues -Issues -

- Honesty- Honesty



- Teaching/supervising role- Teaching/supervising role

- “Teaching-hospital” discussion – need for resident - “Teaching-hospital” discussion – need for resident educationeducation


CASECASE

- Roll-over motor-vehicle accident- Roll-over motor-vehicle accident

- Unrestrained passenger is ejected at scene - Unrestrained passenger is ejected at scene and loses VS on way to ED; code called and loses VS on way to ED; code called soon after arrival soon after arrival

- Driver, intoxicated, multiple c/o pain and - Driver, intoxicated, multiple c/o pain and potential for serious injury, asks: potential for serious injury, asks:

““What happened to my husband?”.What happened to my husband?”.


Issues -Issues -

- Honesty- Honesty


- HIPAA/patient confidentiality- HIPAA/patient confidentiality

- Breaking bad news- Breaking bad news


CASECASE

-A patient has what clearly appears to be a -A patient has what clearly appears to be a viral syndrome is demanding antibiotics viral syndrome is demanding antibiotics loudly and argumentativelyloudly and argumentatively

Your Attending states “Give him what he Your Attending states “Give him what he wants. We’ve got to move patients through wants. We’ve got to move patients through

here”here”


Issues -Issues -

- Non-maleficence - Non-maleficence


- Autonomy of patient vs medical decision-making - Autonomy of patient vs medical decision-making and best-practicesand best-practices

- Honesty - Honesty

- Practicality - Practicality

- Bullying- Bullying


Honesty to PeersHonesty to Peers


CASECASE

- A 52 year old woman presents with chest - A 52 year old woman presents with chest painpain

- Your workup yields little information- Your workup yields little information

- You consider his case to be a low risk - You consider his case to be a low risk cardiac rule outcardiac rule out

Your Attending asks you to ‘beef up the story Your Attending asks you to ‘beef up the story a bit’ to convince the PCP to admit hera bit’ to convince the PCP to admit her


Issues -Issues -

- Honesty- Honesty



- Future dealings with the person you lied to, - Future dealings with the person you lied to, or future patients who may be compromisedor future patients who may be compromised


CASECASE

- A colleague (another resident, an Attending, A colleague (another resident, an Attending, an RN that you frequently work with) asks an RN that you frequently work with) asks you to write an opiod prescription (‘I can’t you to write an opiod prescription (‘I can’t get in touch with my doc’). get in touch with my doc’).

In three months, you get the same request In three months, you get the same request


Issues -Issues -

- Non-maleficence - Non-maleficence

- Truth-telling- Truth-telling

- State law or dept. policy on writing scripts - State law or dept. policy on writing scripts for colleaguesfor colleagues

- Future patients of a colleague who may be - Future patients of a colleague who may be abusing narcotics, and our obligation to abusing narcotics, and our obligation to report suspected impairmentreport suspected impairment


Honesty to SelfHonesty to Self


CASECASE

- You are prepping for your oral boards- You are prepping for your oral boards

- An attending who was two years ahead of - An attending who was two years ahead of you in residency gives you the following you in residency gives you the following offer:offer:

““I can give you my cases from last year, and I can give you my cases from last year, and the ones from two years ago…”the ones from two years ago…”


Issues -Issues -

- Honesty- Honesty

- Justice for those who don’t have the same - Justice for those who don’t have the same advantage advantage

- Your future patients’ safety- Your future patients’ safety

(not to mention the issue of whether your (not to mention the issue of whether your attending got the case right, and really knows attending got the case right, and really knows

what it’s about….)what it’s about….)


CASECASE

- There is an Attending who is abrasive, - There is an Attending who is abrasive, verging on abusive during case verging on abusive during case presentations, who asks “and what did the presentations, who asks “and what did the rectal show??”rectal show??”

You haven’t yet done it, but feel it will be You haven’t yet done it, but feel it will be negative…negative…


Issues -Issues -

- Honesty- Honesty


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


CASECASE

- An Attending describes a procedure to you, - An Attending describes a procedure to you, goes in the room with you to do it, asks goes in the room with you to do it, asks “You feel comfortable doing this alone, “You feel comfortable doing this alone, right?” and leaves you to do the procedure.right?” and leaves you to do the procedure.

On the paperwork, she signs as though On the paperwork, she signs as though present for the entire procedure. present for the entire procedure.


Issues -Issues -

- Honesty- Honesty

- Responsibility of a teacher/supervisor- Responsibility of a teacher/supervisor

- Patient safety- Patient safety


- Stewardship/improper billing- Stewardship/improper billing


CASECASE

- A patient comes in with a complaint about his - A patient comes in with a complaint about his chronic back pain. chronic back pain.

- He seems intoxicated, and is at first disruptive, - He seems intoxicated, and is at first disruptive, followed by quiet. followed by quiet.

- You are called over when he is found apneic, - You are called over when he is found apneic, pulseless and cold. Your last note from 5 minutes pulseless and cold. Your last note from 5 minutes earlier states: “patient is resting comfortably.” earlier states: “patient is resting comfortably.”

Should you re-write it?Should you re-write it?


Issues -Issues -

- Honesty- Honesty

- Integrity of medical records- Integrity of medical records

- Patient safety and adequacy of initial evaluation- Patient safety and adequacy of initial evaluation


REFERENCES:

- American Board of Internal Medicine. Project Professionalism. Philadelphia, PA: American Board of Internal Medicine 1994:2.

- Adams J, Schmidt T, Sanders A et al: Professionalism in Emergency Medicine. Acad Emerg Med 1998; 5:12.

- 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.

saem ethics committee...kitab al-tibb al-ruhani [the book of medicine of the soul] states that the...

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