Ethical behavior is fundamental to emergency medicine and is often embedded in routine medical decision-making. Healthcare professionals in emergency medicine frequently face complex ethical issues while providing patient care in high-stress and time-sensitive scenarios. Such ethical dilemmas include resource allocation, informed consent, do-not-resuscitate (DNR) orders, end-of-life care, cultural and religious considerations, patient privacy and confidentiality, pain management and opioid crisis, mental health crisis intervention, and triaging patients. This paper explores the above ethical dilemmas in-depth, providing explanations from evidence-based research.
Allocating and altering limited resources in emergency medicine is an ethical challenge for many healthcare providers. Limited resources include personnel, hospital beds, medical equipment, and finances. Guided by moral values such as beneficence, justice, nonmaleficence, and autonomy, healthcare providers should ensure that available resources are used best during emergencies. A study by Rawlins et al. (2021) concluded that healthcare providers could allocate limited resources by maximizing benefits, treating people equally, prioritizing the worst off, first come, first serve, and rewarding instrumental value. To maximize benefits, healthcare providers aim to allocate resources to save most lives or years. For instance, if resources can be allocated to save ten lives and lose one, it is justifiable to save a young person and lose an elderly one. However, these decisions should be evaluated based on their strengths depending on the location, time, and available knowledge (Rawlings et al., 2021). In medical emergencies such as the Covid-19 pandemic, resource allocation was also done in favor of rewarding instrumental value, medical personnel are of instrumental value in fighting the pandemic and would be given priority.
During or after some emergencies, patients cannot make informed decisions or consent to treatment. At this point, healthcare providers are in dilemmas on what to do. Legally, obtaining informed consent includes educating patients on the advantages, disadvantages, and possible alternatives to a specific procedure or intervention. The patient must be competent enough to decide whether to voluntarily undergo specific interventions and procedures. When conditions are unsuitable, and patients cannot make their healthcare decisions, healthcare providers are left in a dilemma about who makes the decision. According to Erbay (2016), healthcare providers can consider some cases exceptions, especially in extreme emergencies, and continue different procedures. However, there remains a question about what situations are classified as exceptions.
Emergency healthcare providers also have to make decisions around do-not-resuscitate orders during emergencies. A do-not-resuscitate order (DNR) is a written or verbal warning that states a person should not get cardiopulmonary resuscitation if their heart stops. When patients do not want to spend their last days on life support or believe they have a low chances of surviving, they are likely to give a DNR. This ethical dilemma is made worse when parties involved do not agree; for instance, if a patient and their healthcare provider agree on a DNR but close family members want their loved one resuscitated, it escalates the situation. Following the ethics of autonomy and nonmaleficence, DNR does not equate to “do not treat,” despite the patient’s coding status, there are numerous interventions that can be performed to avoid harm while respecting the patient’s decision (Sultan et al., 2021; Rawlings et al., 2021)
End-of-life care involves helping patients with a disease that is either life-limiting or life-threatening. This kind of care strongly emphasizes controlling symptoms while offering support and comfort physically, mentally, and emotionally. Healthcare providers face ethical dilemmas such as family presence, patient autonomy, non-beneficial care, communication breakdown, and ineffective symptom management during end-of-life care. At the end of life, patients might not be in the right situations to communicate and make the right decisions about their treatment; this leaves healthcare providers in a dilemma on what steps to take. According to Pirschel (2016), healthcare providers must communicate with the patient’s family and ensure they do everything possible to ease the loved ones into the process. Equally, Rawlings et al. (2021) note through research that most families reported benefits from involvement during end-of-life care. Emergency healthcare professionals face dilemmas in balancing treatment side effects and managing the symptoms and pain during this care. Futile CPR and non-beneficial care are also dilemmas during end-of-life care, healthcare providers battle when to give up on a patient, leading to continual care that might be non-beneficial (Rawlings et al., 2021).
Patients bring different religious and cultural beliefs, which are essential to them and should be respected. Emergency healthcare providers find themselves in dilemmas when different patients need or demand particular religious or cultural care. Religion, culture, and spirituality can impact choices about diet, medications made with animal-based ingredients, modesty, timing, and the gender preference of their medical professionals. For instance, religions such as Judaism and Islam observe holy tenets such as uninterrupted prayer at specific times, which can impact treatment. Healthcare providers must communicate with the patient’s family to understand the religious and cultural issues involved in treatment (Swihart et al., 2023). Buddhism requires that patients should not be given any mind-altering mind medication since the mind will influence rebirth in the new life (Swihart et al., 2018).
Historically and legally, healthcare professionals are responsible for protecting patient’s privacy and confidentiality. The Health Insurance Portability and Accountability Act of 1996 requires that a patient’s sensitive information not be disclosed to third parties without the patient’s consent. While protecting a patient’s privacy in normal circumstances is relatively easy, emergencies present unique dilemmas where healthcare providers must make radical decisions in time-sensitive situations. During the emergency, healthcare providers might be in a dilemma about what information to communicate to family members without consent when the patient is unconscious. Other subtle privacies can include eliminating names and identifiers, which are openly visible, and passwords to access patient information (Geiderman et al., 2016). Minding these factors during emergencies when medics fight to save lives presents more challenging ethical dilemmas.
In emergencies, healthcare providers do their best to manage pain and symptoms for the patient. In this, healthcare providers might overlook side effects and focus more on pain management. According to Pirschel (2016), to achieve the best results with pain management, healthcare providers should balance out side effects and pain management, however, this is complicated during emergencies. Escalating opioid dosages to manage pain, for instance, can cause dilemmas related to addiction and create opportunities for drug aversion. Healthcare providers have to understand that some drugs, like opioids, have dangerous side effects, which can lead to more problems in the future. Guided by nonmaleficence, healthcare providers should not harm their patients in caring for them during emergencies.
Mental health issues introduce a different dynamic into emergency healthcare that necessitates more care and introduces unique ethical dilemmas. Sometimes, mental health issues can affect other areas, such as patient autonomy, and introduce dilemmas related to patient privacy and shared decision-making. With mental health issues, people’s capacity to make informed decisions can be compromised, and healthcare providers might find themselves in a dilemma about who to involve in treatment and how much information to reveal to them. Without personal autonomy, healthcare providers and a patient’s family members are tasked with making treatment decisions for the individual, which can sometimes be complicated. Healthcare providers must act in ways that will help during the emergency and ensure the patient’s mental health is not compromised further.
Patient triage involves testing for indications of a significant illness or injury. These warning signals are related to the following: dehydration, airway, breathing, and circulation/Consciousness. Emergency departments use a triage system to cope with overcrowding and sort patients who need urgent care; quick and successful triaging correlates to survival probability (Acharya et al., 2016). Triaging patients presents ethical dilemmas such as compromise in confidentiality and privacy, deciding which life to save, and delay in providing care (Acharya et al., 2016). Since patients in emergencies need immediate care, sometimes their autonomy is compromised in triage; they have to give their information at triage and, in some ways, compromise their confidentiality. After triaging patients, deciding who gets care first introduces more ethical dilemmas; people who appear very sick might not be the ones requiring urgent care, and this can lead to delayed care for patients who do not show severe symptoms yet require emergency care.
In conclusion, emergency services are among the most delicate aspects of medical treatment. In being delicate, emergency medicine introduces many complex ethical dilemmas such as resource allocation, informed consent, do-not-resuscitate (DNR) orders, end-of-life care, cultural and religious considerations, patient privacy, and confidentiality. Emergency healthcare providers must understand these dilemmas from all angles and deal with them through the ethical virtues of justice, personal autonomy, beneficence, and nonmaleficence. Although these ethical dilemmas are part of healthcare, emergency medicine introduces a unique dimension to them, necessitating more care and research.
References
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