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Amidst chaos, ethical principles remind emergency physicians why we do what we do.

It’s that time of the year again…new interns and new medical students are trying hard to impress us for a chance at a late autumn interview. After explaining for what seemed to be the 10th time this shift that “all patients discharged needed a re-evaluation note showing potential plaintiff attorneys a happy and improved patient leaving our establishment,” an impetuous fourth-year medical student asked: “Why must we take care of all these people with so many psycho-social, non-medical issues in the ER? Couldn’t they go to the Salvation Army or some better organized outpatient setting?”


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I took a deep breath.  As it so happened, I had just come back from a meeting at the Hard Rock Cafe in Vegas and was inundated by their history and founding, so I thought I’d draw some parallels between the founding of EM as a specialty, and that other, much vaunted Vegas establishment..

EM Ethics: 101

The American College of Emergency Physicians (ACEP) began in 1968, the same year that MLK and RFK were assassinated. However, unlike these high profile murders in Memphis and LA, the contemporaneous crimes of Tuskegee AL and Willowbrook NY were largely unknown. In those days, the term “bioethics” had not been coined, and no one was yet worried about IRB approvals or EMTALA violations. “CCMs” were high-end hockey skates, not “Chronic Care Management” billing codes.


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But over the ensuing decades, a mushroom cloud of additional acronyms (ACOs, APNs, CMS, EMR, HIPAA, PQRS, etc…) has radiated exponentially around the practice of Emergency Medicine (EM), leaving moral injury and a type of ethical and regulatory fallout unrecognizable to ACEP’s founders, the Drs. Mills & Wiegenstein of yesteryear.

Life in House of Medicine changed in the decades that followed, even as the specialty of Emergency Medicine grew. Encroaching financial considerations, overcrowding, Managed Care policies, EMTALA and the rest of the aforementioned alphabet soup ushered in new challenges for Emergency Physicians. By 1996, ACEP’s then-president, Dr. Gregory L. Henry knew a re-dedication was needed. This classics-trained physician recognized a new code could serve as both an anchor and a rudder, beyond both Shakespeare and Hippocrates, to provide steadiness and moral direction for our young, Cutty Sark specialty.

Henry and ACEP Ethics Committee leadership saw that the American Medical Association (AMA) 1996 Principles of Ethics for Physicians were not an adequate fit for EM.  Among other issues, the AMA Principles argued for physician choice in deciding whom to serve and when, a choice that we happy few on the front lines of healthcare willingly surrendered.  Against this dynamic backdrop in 1997, the ACEP Code of Ethics was born.

Of the 10 Principles of Ethics for Emergency Physicians, the first two are pivotal:


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  1. Emergency physicians shall embrace patient welfare as their primary professional responsibility.
  2. Emergency physicians shall respond promptly and expertly, without prejudice or partiality, to the need for emergency medical care.

Ideally, all clinicians care about patients; but my fourth-year student didn’t yet see that EPs are a breed apart.  We do not have the ability to close our offices, neither for lunch, nor for holidays, nor when we are sick.  We do not even have the ability to fire a patient from our service due to their failure, for example, to follow our recommendations and comply with care.

We cannot refuse “frequent fliers,” mass murderers, or even non-acute patients whose insurances we do not accept; in fact, we are obligated to provide a federally mandated medical screening examination for any and all who enter our campus, or risk fines and citations. Our ethics are clear: we care for anyone and everyone, including those who don’t particularly care for themselves. All else is derivative.

This first principle is followed by an important second: our need to put aside our own personal biases and prejudices in providing care to any and all that enter our domain seeking medical assistance. Another former ACEP President, Dr. Larry Bedard, said it well during his tenure: “No shoes? No shirt? No sobriety?—No Problem! You’re my patient and I’m your doctor.”

One might think that in choosing to go into a field that sees all ages, colors, genders, cultures, sexual orientations, religions and national origins, the Archie Bunkers in the class would opt out of EM for something a little less requiring of an open, non-judgmental mind. However, we must recognize that even the best of us have biases, conscious or otherwise.  While at times, law enforcement and other public servants have failed to put aside personal prejudice, the best emergency physicians consistently strive to generate an unconditional positive regard for all patients, lest they add insult to injury.

As Emergency Physicians, we advocate for the vulnerable and those at risk of receiving suboptimal care based on an impaired mental status or an inability to make decisions for themselves.  Think of the mentally-challenged assault victim or the intoxicated person who might have been an EM provider himself, many bottles ago.  They all need our compassion, and a voice that speaks for them when no other agent or agency will.

Few among us have not rolled our eyes when, instead of jail, our Emergency Department (ED) becomes the favorite port-of-call for police to deposit yet another publicly inebriated citizen.  Yet, how many of us have had the ED epiphany that tonight’s stuporous intoxicant was not merely playing host to his friend, Jack Daniels, but his cranium was also entertaining an expanding epidural?  Imagine that in a prison cell…  Even the agnostics and non-drinkers among us can understand the humility and wisdom of the adage, “there but for the grace of God go I.”

Opioids or alcohol? Rich or poor? Clothed or naked? Man or woman? Young or old?  Passport or visa? Irrelevant!  Politically neutral and judgment-free, the ED is a great equalizer, a medical Switzerland in an otherwise deeply divided world.

While our Principles of Emergency Medical Ethics give us an anchor, it is up to each one of us to interpret how we live out those principles as we sail through another long ED shift.   It is important to fend off the barnacles of burnout to be able to relate to this patient-centered ethic (adequate sleep, wellness activities, time off, gratitude journaling, etc. can all help).  Self-care and awareness of our human interconnection, like a forest of aspen trees with their shared root system, may help us relate to each other as well as with our patients.

Reverence for strangers

“What if God was one of us?
Just a slob like one of us?
Just a stranger on the bus
Trying to make His way home?”
[1]

On the EMS “bus” or in the ED, strangers are largely all we see. EPs, more than most physicians, understand bioethicist David Rothman’s treatise, “Strangers at the Bedside.” [2]   Our Principles reflect this idea, as does the Mosaic tradition with its (Torah) guidance on showing care for the strangers in our midst:

Do not oppress a stranger; you yourselves know how it feels to be a stranger [literally, “you know the soul of a stranger”], because you were strangers in Egypt.[3]

Exodus 23:9

The ED is our house and patients are more than strangers, they are our guests. Scriptural codes of conduct for ancient Hindus incorporated the mantra Atithi Devo Bhava, (Sanskrit अतिथिदेवो भव); which translates in English to

‘The guest is equivalent to God.’  [4]                                                                                                                  Taittiriya Upanishad, Shikshavalli I.11.2

Reverence toward guests, strangers, and the unwell, was beautifully personified in the last century by the late Mother Teresa of Kolkata (1910-97).   When this diminutive Macedonian nun wrote, “Let no one ever come to you without leaving happier,” [5] we can surmise she was referring to compassion and kindness, versus an Rx for Percocet. Genuinely caring for and about others was her legacy; it is also ours.

…Even the really tough customers

One day, during an interview, Mother Teresa was asked what she does everyday working with people in the gutter; without pretense, she replied:

“I go out and search for Jesus, in all of his most distressing disguises.”[6]

And while we may not be personally aligned nor moved by such piety in our own personal lives, we know well the disguises of which she spoke: the body odor of the homeless; the gangrene of the pulseless diabetic foot; the paranoid aggression of the psychotic.   For like the streets of Kolkata, the ED can be an assault to the senses:  inhumane sights; anaerobic smells; and a seemingly ceaseless ocean of sounds: cacophonous alarms, caterwauling patients in pain, inebriates spewing expletives, and the clattering clack of five more charts thrown into the rack.

Add to this, a litany of other distressing disguises: Munchausen’s manipulators, borderline cutters, work-note seekers, malingering malcontents, rude consultants, demeaning bean-counting bureaucrats, character-assassinating attorneys, and soon enough, Jesus is just some dude getting wheels for your 5-series BMW on the cheap.

In these cynical moments, we have little doubt that Dr. Carl Linnaeus, the Swedish physician and “father of modern taxonomy,” who in 1758 coined the term Homo sapiens (Latin for “wise man”), never removed a vibrator from a patient’s rectum at 3 a.m. on New Year’s Eve.

Despite the tough shifts and the forces of natural selection before us, we must resist the temptation of social Darwinism and aspire instead to be what Linnaeus intended: true Homo sapiens, “wise men and women,” who care for and about others with genuine wisdom, competence and compassion.

Student Summary

While not always the work of saints, ours is perhaps the work of very special sinners who understand both the humanity and inhumanity of it all.  Amidst the chaos, our ethical principles give us patient-focus and a firm resolve to be present, in the moment, here and now, 24/7/365, as acute care alchemists, turning the base metal of trauma into gold.  Indeed, for some reason, we chose this young rewarding specialty (or perhaps EM chose us?), with its unique mission, special setting and humanistic Code of Ethics. [7]

As members of the professional genus Medice, species Medicus subitus, (subitus, Latin for “emergency”) we might remind our new students, new interns and our old selves to guard against our own deep-seated biases and prejudices.

Indeed, we should be both humble in our shared humanity and yet proud of our calling to work in the Hard Rock Café of Healthcare.  Like EM itself, the music-themed Hard Rock restaurants began nearly half a century ago (1971, London) with a singular guiding principle:

Love all, serve all. [8,9]

…arguably, the only principle of emergency medical ethics we’ll ever need to know.

References:

  1. Bazilian E. One of Us. https://en.wikipedia.org/wiki/One_of_Us
  2. Rothman, DJ., Strangers at the bedside: a history of how law and bioethics transformed medical decision making, New York, Basic Books, 1991, pp. xi, 303,
  3. Exodus 23:9
  4. Taittiriya Upanishad, Shikshavalli I.11.2
  5. Kelly-Gangi C. Quotable Wisdom: Mother Teresa. Fall River Press, Sterling Publishing, New York, 2014; 34.
  6. Kelly-Gangi C. Quotable Wisdom: Mother Teresa. Fall River Press, Sterling Publishing, New York, 2014, VIII.
  7. ACEP Ethics Committee: https://www.acep.org/patient-care/policy-statements/code-of-ethics-for-emergency-physicians/
  8. Bhagavan Sri Sathya Sai Baba https://www.sathyasai.org/files2010/LoveAllServeAll.pdf
  9. Hard Rock Café Motto. Available at https://www.hardrockhotels.com/culture.

 

 

ABOUT THE AUTHORS

G. Luke Larkin, MD, MS, MSPH, FACEP FACEM is professor at the Northeast Ohio Medical University, founding professor and Emeritus Lion Chair of EM at the University of Auckland, author of SAEM’s Code of Conduct and ACEPs Principles of Ethics, and serves on the Board of the IFEM Foundation.

Al Giwa, MD, is the associate professor at Icahn School of Medicine at Mount Sinai in New York City. Ethics, law, and emergency resuscitation are just a few of his specialties both as a civilian and as an officer in the USARMY Reserve.

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