Downloaded from http://emj.bmj.com/ on November 7, 2014 - Published by group.bmj.com
EMJ Online First, published on October 31, 2014 as 10.1136/emermed-2014-204252 Commentary
A moral or an ethical issue? Mary Dawood Emergency care by its very nature is challenging where questions of ethics commonly arise. Issues such as crowding, access, urgency, sick patients and threat to life all combine to create uniquely fertile grounds for ethical dilemmas.1–4 Ethics in healthcare means doing the right thing for the patient, doing no harm, providing care and treatment that benefits the patient while at the same time respecting the patient’s autonomy and right to selfdetermination. Our sense of right and wrong and the duty of care we owe our patients are central to this. Determining the right course of action in complex circumstances can be difficult and ethical decision making demands much more than a decision of what is right or wrong; it requires critical reflection. Beauchamp and Childress suggest that this reflection needs to guide what we ought to do in a specific situation by asking us to consider and reconsider ordinary actions, the rationales for those actions and the judgements we make.5 Such an ethical debate in clinical settings can be positive, instructive and can contribute to quality patient care, but moral issues that often arise simultaneously can muddy the waters. A person’s moral code is usually constant, but the ethical codes governing practice may be dependent on the context and setting and be at odds with moral feelings. In the great diversity that is healthcare and the limitations of our working environment it is often moral rather than ethical issues that give rise to angst and disequilibrium. The difference between ethics and morals is subtle, both refer to right and wrong conduct, but ethics have a consensual component and refer to the standards and codes of behaviour of the profession; in this case, medicine. Morals, on the other hand, refer to the individual’s own principles of right or wrong and can be much more arbitrary depending on the sociocultural background and belief system of the person. Modern codes of medical ethics follow the Physician’s Oath which was adopted by the General Assembly of the World Medical Association, Geneva, in 19486 and Correspondence to Mary Dawood, Emergency Department, Imperial College NHS Trust, Praed St, Paddington, London W2 1NY, UK; Mary.dawood@ imperial.nhs.uk
subsequently amended by the 22nd World Medical Assembly in 1968 in Australia. This declaration states “the health of my patient will be my first consideration.” This broad statement is uncompromising and mandates that physicians everywhere act in the best interests of the patient irrespective of circumstances. Emergency medicine is a relatively new specialty and the nuances between ethics and morals have not been widely explored, or at least not to the extent they have in intensive care,7 but in their paper Zafar describes the moral experiences and ethical challenges in an emergency department (ED) in Pakistan from the physicians’ perspective.8 Using Kleinman’s theory of moral experience and the ED as the ‘local moral world’, the study focused on the physicians’ ‘lived experiences’ of trying to balance the demands of their profession against the constraints under which they operate.9 The aim of this study was to identify the unique challenges emergency physicians face on a daily basis so as to address such issues in residents’ training and in departmental practice guidelines. Pakistan is a lower middle-income country with a population of 185 million; only 21.9% of this vast population has some form of health coverage, the remainder pay at the point of care if they can afford to and although emergency care in public hospitals is free, resources are limited. As a result, physicians are regularly faced with ethical and moral challenges in trying to deliver the best care for their patients with what they have available to them. While the Pakistani physicians’ experiences may not immediately resonate or be seen as being applicable to physicians in Western health economies, this would be to deny the universality of morality and ethical decision making. Ethical dilemmas are relative to the environment in which they occur; they are part and parcel of emergency care and are often the inevitable outcome of trying to deliver equity and quality care with limited resources. Many of the issues cited by the Pakistani physicians as challenging mirror issues encountered in emergency settings globally, irrespective of the economic status of the nation. These issues relate to consent, privacy, confidentiality, pressure to provide treatment of no clinical benefit and end-of-life decisions.1–4
Moreover, most of the physicians in the study like their Western counterparts cited withholding information from the patient at the family’s request as an ethical challenge demonstrating they were operating within a pragmatic/utilitarian rather than a deontological framework. This finding counters previous assertions in the literature which describe the ‘withholding of information from patients’ as an example of how understandings of morality may differ across cultures.10 11 Interestingly, physicians in this study also found the hospital ethics committee of little help in resolving the ethical issues in the ED, which perhaps points to the unique nature and complexity of ethical dilemmas in emergency settings and the relative newness of the specialty. This paper also touches on the concept of moral distress, a phenomenon first described by Jameton in 1984 where one knows the right action to take but is constrained from taking it due to internal or external restrictions.12 Moral distress has long been recognised as a problem for nursing and has been linked to burnout, job satisfaction and attrition.13–15 Thus, research in this area until now has mainly focused on nurses, but more recently this phenomenon has also been described in doctors but to a much lesser extent.16 Nonetheless, the concept lacks clear definition and needs to be differentiated from moral stress where individuals struggle to make clinical decisions involving conflicting ethical principles.15 The key component of moral distress is the sense of powerlessness of the individual.17 Arguably, nurses may have greater predisposition to moral distress as they traditionally have had less autonomy or control over decision making and work in a hierarchical organisation which is well recognised for having a strong authority gradient where moral assertiveness on the part of nurses may be the exception rather than the rule. Ethical decision making in the ED unlike the ward or intensive care can be compounded by time constraints and little if any information about the patient. Thus, emergency physicians on a daily basis may find themselves grappling with ethical and indeed moral issues and sometimes subjugating their own wishes or deeply held beliefs in the interests of their patient’s well-being. Ultimately, the decisions made may be ethically correct, but may not sit comfortably with the physician’s moral compass. Zafar has not expanded on this theme but given the pressures emergency care
Dawood M. Emerg Med J Month 2014 Vol 0 No 0
Copyright Article author (or their employer) 2014. Produced by BMJ Publishing Group Ltd under licence.
1
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Commentary is facing globally in terms of rising patient numbers, shortage and attrition of skilled emergency physicians and finite resources, there is clearly a need for emergency medical trainees to have greater exposure to ethical reasoning and assertiveness training in medical education programmes. Perhaps more importantly, the inexorable rise of consumer-driven healthcare as opposed to clinically driven healthcare globally has created great opportunities for engineers, medical technology, financial services and information technology. Where this benefits patients it is to be embraced, but such developments will inevitably challenge medical wisdom and judgement and emergency physicians need to be well equipped to respond with equanimity. Medical ethics has long been influenced by philosophy and to a lesser extent anthropology, sociology and theology as medical humanities. The pace of change and the challenges presenting mean there is an increasing need for emergency physicians to engage with medical humanities to provide a framework for further multicentre research and resolutions for the future moral and ethical issues that will inevitably arise in emergency medicine around the world.
2
Competing interests None. Provenance and peer review Not commissioned; externally peer reviewed.
6
7
To cite Dawood M. Emerg Med J Published Online First: [ please include Day Month Year] doi:10.1136/ emermed-2014-204252 Accepted 6 October 2014
8
9
▸ http://dx.doi.org/10.1136/emermed-2014-204081 Emerg Med J 2014;0:1–2. doi:10.1136/emermed-2014-204252
10 11
REFERENCES 1
2
3
4
5
Moskop JC, Sklar DP, Geiderman JM, et al. Emergency department crowding, part 1. Concept causes and moral consequences. Ann Emerg Med 2009;53:605–11. Moskop JC. Informed consent in the emergency department. Emerg Med Clin North Am 1999;17:327–40. Larkin GL, Marco CA, Abbott JT. Emergency determination of decision-making capacity: balancing autonomy and beneficence in the emergency department. Acad Emerg Med 2001;8:282–4. Moskop JC, Marco CA, Larkin GL, et al. From Hippocrates to HIPAA: privacy and confidentiality in emergency medicine-part II: challenges in the emergency department. Ann Emerg Med 2005;45:60–7. Beauchamp TL, Childress JF. Principles of biomedical ethics. Oxford, 1983
12 13
14
15 16
17
Declaration of Geneva. Adopted by the General Assembly of World Medical Association at Geneva Switzerland, September 1948. Schneidermann LJ, Gilmer T, Teetzel HD, et al. Effect of ethics consultations on non-beneficial life-sustaining treatments in the intensive care setting. JAMA 2003;290:1166–72. Zafar W. Moral experience and ethical challenges in an emergency department in Pakistan. Emergency physicians ‘perspectives. Emerg Med J Published Online First: 18 Sep 2014 doi:10.1136/emermed2014-204081 Kleinman A. Moral experience and ethical reflection: can ethnography reconcile them? A quandary for “the new bioethics”. Daedalus 1999;128:69–97. Orona C, Koenig B, Davis A. Cultural aspects of nondisclosure. Camb Q Healthc Ethics 1994;3:338–46. Lapine A, Wang-Cheng R, Goldstein M, et al. When cultures clash: physician, patient, and family wishes in truth disclosure for dying patients. J Palliat Med 2001;4:475–80. Jameton A. Nursing practice: the ethical issues. Prentice Hall, 1984. Corley M, Elswick R, Gorman M, et al. Development and evaluation of a moral distress scale. J Adv Nurs 2001;33:250–6. Meltzer LS, Huckabay LM. Critical care nurses’ perceptions of futile care and its effect on burnout. Am J Crit Care 2004;13:202–8. Forde R, Aasland OG. Moral distress among Norwegian doctors. J Med Ethics 2008;34:521–5. Zuzelo PR. Exploring the moral distress of registered nurses. Nurs Ethics 2007;14:344–59. Sage Publications. Jameton A. Dilemmas of moral distress: moral responsibility and nursing practice. AWHONNS Clin Issues Perinat Womens Health Nurs 1993;4:542–51.
Dawood M. Emerg Med J Month 2014 Vol 0 No 0
Downloaded from http://emj.bmj.com/ on November 7, 2014 - Published by group.bmj.com
A moral or an ethical issue? Mary Dawood Emerg Med J published online October 31, 2014
Updated information and services can be found at: http://emj.bmj.com/content/early/2014/10/31/emermed-2014-204252
These include:
References Email alerting service
This article cites 13 articles, 3 of which you can access for free at: http://emj.bmj.com/content/early/2014/10/31/emermed-2014-204252 #BIBL Receive free email alerts when new articles cite this article. Sign up in the box at the top right corner of the online article.
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To request permissions go to: http://group.bmj.com/group/rights-licensing/permissions To order reprints go to: http://journals.bmj.com/cgi/reprintform To subscribe to BMJ go to: http://group.bmj.com/subscribe/
EMJ Online First, published on October 31, 2014 as 10.1136/emermed-2014-204252 Commentary
A moral or an ethical issue? Mary Dawood Emergency care by its very nature is challenging where questions of ethics commonly arise. Issues such as crowding, access, urgency, sick patients and threat to life all combine to create uniquely fertile grounds for ethical dilemmas.1–4 Ethics in healthcare means doing the right thing for the patient, doing no harm, providing care and treatment that benefits the patient while at the same time respecting the patient’s autonomy and right to selfdetermination. Our sense of right and wrong and the duty of care we owe our patients are central to this. Determining the right course of action in complex circumstances can be difficult and ethical decision making demands much more than a decision of what is right or wrong; it requires critical reflection. Beauchamp and Childress suggest that this reflection needs to guide what we ought to do in a specific situation by asking us to consider and reconsider ordinary actions, the rationales for those actions and the judgements we make.5 Such an ethical debate in clinical settings can be positive, instructive and can contribute to quality patient care, but moral issues that often arise simultaneously can muddy the waters. A person’s moral code is usually constant, but the ethical codes governing practice may be dependent on the context and setting and be at odds with moral feelings. In the great diversity that is healthcare and the limitations of our working environment it is often moral rather than ethical issues that give rise to angst and disequilibrium. The difference between ethics and morals is subtle, both refer to right and wrong conduct, but ethics have a consensual component and refer to the standards and codes of behaviour of the profession; in this case, medicine. Morals, on the other hand, refer to the individual’s own principles of right or wrong and can be much more arbitrary depending on the sociocultural background and belief system of the person. Modern codes of medical ethics follow the Physician’s Oath which was adopted by the General Assembly of the World Medical Association, Geneva, in 19486 and Correspondence to Mary Dawood, Emergency Department, Imperial College NHS Trust, Praed St, Paddington, London W2 1NY, UK; Mary.dawood@ imperial.nhs.uk
subsequently amended by the 22nd World Medical Assembly in 1968 in Australia. This declaration states “the health of my patient will be my first consideration.” This broad statement is uncompromising and mandates that physicians everywhere act in the best interests of the patient irrespective of circumstances. Emergency medicine is a relatively new specialty and the nuances between ethics and morals have not been widely explored, or at least not to the extent they have in intensive care,7 but in their paper Zafar describes the moral experiences and ethical challenges in an emergency department (ED) in Pakistan from the physicians’ perspective.8 Using Kleinman’s theory of moral experience and the ED as the ‘local moral world’, the study focused on the physicians’ ‘lived experiences’ of trying to balance the demands of their profession against the constraints under which they operate.9 The aim of this study was to identify the unique challenges emergency physicians face on a daily basis so as to address such issues in residents’ training and in departmental practice guidelines. Pakistan is a lower middle-income country with a population of 185 million; only 21.9% of this vast population has some form of health coverage, the remainder pay at the point of care if they can afford to and although emergency care in public hospitals is free, resources are limited. As a result, physicians are regularly faced with ethical and moral challenges in trying to deliver the best care for their patients with what they have available to them. While the Pakistani physicians’ experiences may not immediately resonate or be seen as being applicable to physicians in Western health economies, this would be to deny the universality of morality and ethical decision making. Ethical dilemmas are relative to the environment in which they occur; they are part and parcel of emergency care and are often the inevitable outcome of trying to deliver equity and quality care with limited resources. Many of the issues cited by the Pakistani physicians as challenging mirror issues encountered in emergency settings globally, irrespective of the economic status of the nation. These issues relate to consent, privacy, confidentiality, pressure to provide treatment of no clinical benefit and end-of-life decisions.1–4
Moreover, most of the physicians in the study like their Western counterparts cited withholding information from the patient at the family’s request as an ethical challenge demonstrating they were operating within a pragmatic/utilitarian rather than a deontological framework. This finding counters previous assertions in the literature which describe the ‘withholding of information from patients’ as an example of how understandings of morality may differ across cultures.10 11 Interestingly, physicians in this study also found the hospital ethics committee of little help in resolving the ethical issues in the ED, which perhaps points to the unique nature and complexity of ethical dilemmas in emergency settings and the relative newness of the specialty. This paper also touches on the concept of moral distress, a phenomenon first described by Jameton in 1984 where one knows the right action to take but is constrained from taking it due to internal or external restrictions.12 Moral distress has long been recognised as a problem for nursing and has been linked to burnout, job satisfaction and attrition.13–15 Thus, research in this area until now has mainly focused on nurses, but more recently this phenomenon has also been described in doctors but to a much lesser extent.16 Nonetheless, the concept lacks clear definition and needs to be differentiated from moral stress where individuals struggle to make clinical decisions involving conflicting ethical principles.15 The key component of moral distress is the sense of powerlessness of the individual.17 Arguably, nurses may have greater predisposition to moral distress as they traditionally have had less autonomy or control over decision making and work in a hierarchical organisation which is well recognised for having a strong authority gradient where moral assertiveness on the part of nurses may be the exception rather than the rule. Ethical decision making in the ED unlike the ward or intensive care can be compounded by time constraints and little if any information about the patient. Thus, emergency physicians on a daily basis may find themselves grappling with ethical and indeed moral issues and sometimes subjugating their own wishes or deeply held beliefs in the interests of their patient’s well-being. Ultimately, the decisions made may be ethically correct, but may not sit comfortably with the physician’s moral compass. Zafar has not expanded on this theme but given the pressures emergency care
Dawood M. Emerg Med J Month 2014 Vol 0 No 0
Copyright Article author (or their employer) 2014. Produced by BMJ Publishing Group Ltd under licence.
1
Downloaded from http://emj.bmj.com/ on November 7, 2014 - Published by group.bmj.com
Commentary is facing globally in terms of rising patient numbers, shortage and attrition of skilled emergency physicians and finite resources, there is clearly a need for emergency medical trainees to have greater exposure to ethical reasoning and assertiveness training in medical education programmes. Perhaps more importantly, the inexorable rise of consumer-driven healthcare as opposed to clinically driven healthcare globally has created great opportunities for engineers, medical technology, financial services and information technology. Where this benefits patients it is to be embraced, but such developments will inevitably challenge medical wisdom and judgement and emergency physicians need to be well equipped to respond with equanimity. Medical ethics has long been influenced by philosophy and to a lesser extent anthropology, sociology and theology as medical humanities. The pace of change and the challenges presenting mean there is an increasing need for emergency physicians to engage with medical humanities to provide a framework for further multicentre research and resolutions for the future moral and ethical issues that will inevitably arise in emergency medicine around the world.
2
Competing interests None. Provenance and peer review Not commissioned; externally peer reviewed.
6
7
To cite Dawood M. Emerg Med J Published Online First: [ please include Day Month Year] doi:10.1136/ emermed-2014-204252 Accepted 6 October 2014
8
9
▸ http://dx.doi.org/10.1136/emermed-2014-204081 Emerg Med J 2014;0:1–2. doi:10.1136/emermed-2014-204252
10 11
REFERENCES 1
2
3
4
5
Moskop JC, Sklar DP, Geiderman JM, et al. Emergency department crowding, part 1. Concept causes and moral consequences. Ann Emerg Med 2009;53:605–11. Moskop JC. Informed consent in the emergency department. Emerg Med Clin North Am 1999;17:327–40. Larkin GL, Marco CA, Abbott JT. Emergency determination of decision-making capacity: balancing autonomy and beneficence in the emergency department. Acad Emerg Med 2001;8:282–4. Moskop JC, Marco CA, Larkin GL, et al. From Hippocrates to HIPAA: privacy and confidentiality in emergency medicine-part II: challenges in the emergency department. Ann Emerg Med 2005;45:60–7. Beauchamp TL, Childress JF. Principles of biomedical ethics. Oxford, 1983
12 13
14
15 16
17
Declaration of Geneva. Adopted by the General Assembly of World Medical Association at Geneva Switzerland, September 1948. Schneidermann LJ, Gilmer T, Teetzel HD, et al. Effect of ethics consultations on non-beneficial life-sustaining treatments in the intensive care setting. JAMA 2003;290:1166–72. Zafar W. Moral experience and ethical challenges in an emergency department in Pakistan. Emergency physicians ‘perspectives. Emerg Med J Published Online First: 18 Sep 2014 doi:10.1136/emermed2014-204081 Kleinman A. Moral experience and ethical reflection: can ethnography reconcile them? A quandary for “the new bioethics”. Daedalus 1999;128:69–97. Orona C, Koenig B, Davis A. Cultural aspects of nondisclosure. Camb Q Healthc Ethics 1994;3:338–46. Lapine A, Wang-Cheng R, Goldstein M, et al. When cultures clash: physician, patient, and family wishes in truth disclosure for dying patients. J Palliat Med 2001;4:475–80. Jameton A. Nursing practice: the ethical issues. Prentice Hall, 1984. Corley M, Elswick R, Gorman M, et al. Development and evaluation of a moral distress scale. J Adv Nurs 2001;33:250–6. Meltzer LS, Huckabay LM. Critical care nurses’ perceptions of futile care and its effect on burnout. Am J Crit Care 2004;13:202–8. Forde R, Aasland OG. Moral distress among Norwegian doctors. J Med Ethics 2008;34:521–5. Zuzelo PR. Exploring the moral distress of registered nurses. Nurs Ethics 2007;14:344–59. Sage Publications. Jameton A. Dilemmas of moral distress: moral responsibility and nursing practice. AWHONNS Clin Issues Perinat Womens Health Nurs 1993;4:542–51.
Dawood M. Emerg Med J Month 2014 Vol 0 No 0
Downloaded from http://emj.bmj.com/ on November 7, 2014 - Published by group.bmj.com
A moral or an ethical issue? Mary Dawood Emerg Med J published online October 31, 2014
Updated information and services can be found at: http://emj.bmj.com/content/early/2014/10/31/emermed-2014-204252
These include:
References Email alerting service
This article cites 13 articles, 3 of which you can access for free at: http://emj.bmj.com/content/early/2014/10/31/emermed-2014-204252 #BIBL Receive free email alerts when new articles cite this article. Sign up in the box at the top right corner of the online article.
Notes
To request permissions go to: http://group.bmj.com/group/rights-licensing/permissions To order reprints go to: http://journals.bmj.com/cgi/reprintform To subscribe to BMJ go to: http://group.bmj.com/subscribe/
