From the Editor
Feb 2003
In this issue of Virtual Mentor (VM), we explore the complex, sometimes unique, ethical aspects of caring for patients in emergency medicine. As our regular readers know, VM has recently changed to a theme-based format, and, periodically, an issue of VM will focus on a given medical specialty. This editorial change is designed to highlight what is common and what is different about practicing medicine in various specialties. From a practical perspective, we hope this new format will be more user-friendly for students and teachers of medicine.
This month's VM issue provides our readers with a forum for exploring ethical challenges in emergency medicine. Often individuals treated in the emergency room do not have established histories with the physician. This lack of familiarity makes already difficult encounters—dealing with patients who want to leave AMA (against medical advice) or communicating with families about their deceased loved ones' desires to be organ donors—that much more challenging. At the same time, there are other patients who are all too familiar to emergency room physicians. Many of these patients use the ER as their source of primary care because they lack health insurance. These uncompensated ER "office visits" place significant cost burdens on hospitals. But ability or inability to pay cannot determine whether a person receives care in a potentially life-threatening situation; it is not consistent with medicine's tradition to provide charity care—and it is against the law.
Because of their unique obligations, emergency physicians wear "hats" that colleagues in other specialties usually do not. As front-line responders during disasters, ER physicians must triage and treat large numbers of the sick and injured. Sadly, future disasters may involve terrorist acts with biological agents. ER physicians will have to learn how to diagnose and manage diseases such as anthrax, and will soon have to decide, after weighing the risks and benefits, whether to get vaccinated for smallpox.
As physicians who frequently treat victims of domestic violence or child abuse, ER physicians are confronted with how to manage the social components of illness and trauma. Sometimes physicians are required to report suspected violence to the police or other authorities. With such reporting responsibilities, ER physicians' roles as trusted, non-judgmental caregivers to all, including victims and perpetrators, can come into conflict with their duty to the state.
ER physicians are depicted in popular TV dramas and filmed for reality shows. While the reality shows aim, in part, to educate the public, we must not allow the filming of vulnerable patients for commercial television to undermine our professional responsibility to protect patient privacy and confidentiality.
The learning objectives for this month's issue on emergency medicine are:
- Understand the professionalism and ethics issues that are specific to, or more prevalent in, the emergency room setting.
- Recognize the challenges presented by the absence of a patient-physician relationship.
- Learn the obligations for providing emergency care to indigent and uninsured patients under EMTALA.
- Understand the professional responsibility emergency physicians have to respond to disasters.
- Understand emergency physicians' reporting responsibilities to law enforcement officials.
As always, I welcome your thoughts and suggestions about making VM better.
