Ethics in emergencies and accidents

Gonzalo Herranz, department of Bioethics, University of Navarra, Spain
professor session at the University Biomedical Campus
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Rome, 1996

The special urgency of the emergency

Patients' rights and the physician's general duties remain valid in emergency status : consent, confidentiality, non-discrimination, etc. Risk of abusing circumstances in order not to inform (therapeutic privilege, for example).

Emergency status suspends certain other rights, including the right to make advance decisions, for the sole purpose of preserving life.

Obligation of the attend physician

Especially in extreme urgency: in any circumstance, with any Degree of skill. Crime of omission of aid, refusal of aid. Good Samaritan laws. And these services are provided without claiming fees or compensation, although some American doctors are beginning to raise the problem. Codice di deontologia. Very early Chapo II. Prestazioni d'urgenza. Art. 7. Dovere del medico. Il medico non può rifiutarsi di intervenire, indipendentemente della sua abituale attività specializtica, in qualunque luogo o circonstanza, prestare soccorso e cure d'urgenza a chi in abbisogni in comunque tempestivamente attivarsi per ogni più specifica e adeguata assistenza (Duty of the physician. The physician cannot refrain from intervening, regardless of his specialization program and, in any place and circumstance, must provide financial aid and emergency treatment to those who are in need of them and, in any case, must appropriately implement a more appropriate and specific attendance for each one).

Reinforcement of some duties

These duties are more exposed in emergency situations, such as greater punctuality, greater humanity (not to fall into inhumanity: weaknesses become more evident, not to be taken for madmen or criminals). Greater understanding (fear can lead to abuse of emergencies; intoxications can disturb the mind).

Obligation not to defer patient care

"You will be seen immediately and your need for treatment will be assessed" (Patient's charter, UK).

Obligation not to collapse the emergencies: the physician resolves his own. Triage: which patient corresponds to which level. Telephone consultations: do not treat lightly. Legal responsibility for not attending, for attending late, for not apply for ambulance.

Obligation to maintain the criteria of dignity, respect and non-discrimination

A higher proportion of the average of violent, intoxicated, drugged people go to the emergency room. Haughty, uneducated, threatening, out of their minds due to fear, alcohol. Attacks on people. After fights, people of the two contending groups, who may continue fighting. Beware of weapons. There is no need for police, but it is necessary to know how to treat, to reassure.

Obligation to attend according to need: Justice

Establish order: who is first and who is next. Ordinary triage, not only in cases of catastrophes. Triage by nurses, by experienced general practitioners. Paradox: in the hands of young doctors: resident strikes and the shortage of residents who want to do emergency medicine, forces to work with consultants: the results are very good, in effectiveness and efficiency.

Obligation to skill

Quality of the centers where it is practiced: medical and auxiliary staff , permanent access to laboratory and radiology, immediate cures, operating rooms in use. accreditation system.

Obligation to be competent in first aid: diagnose life-threatening situations, decide what to do, what not to do. Personal assessment: history and examination, can not be delegated. Follow refresher courses. Know the strong data : rapid transfer, immediate resuscitation.

Know the protocols of action, updated. attend refresher courses. Impose the obligation to have skills (cardio-pulmonary resuscitation). Impose skills.

Ethics of the medical case. Appropriate equipment. ECG and defibrillator, nebulizer (asthma), intravenous fluids. Not too much diagnostic technology: obligation to transfer to hospital in medicalized ambulances prevails. Medications: aspirin (myocardial infarction), penicillin for meningococcal meningitis. Not overdue. Special drugs (opiates) well controlled.

The apparent and the hidden. What is hidden by patients and medical blindness to what cannot be missed: convincing history, conscientious examination, search for hidden lesions, follow evolution, evaluate the deterioration of the general condition, note all data and observations.

At discharge, give very precise instructions. Clearly indicate what the patient should do: go back, call, what care should be sought: specify. Do not refer to another hospital without having stabilized the patient, without being sure that he/she will get there.

Confidentiality obligation

Beware of secrecy, confidentiality: very open, public consultations, with little protection of privacy. Do not give in: closed doors, judicial police in place, press in urgent situations of VIPs, athletes.

Conscientious objection

Special in the case of treatment of the raped woman with contragestatives.