Moral Dilemmas and Ethical Decisions

Introduction

Emergencies often require timely and valid decisions to prevent the apparent risk to patient health, including death. However, the policies and protocols intended to systematize the decision-making process often create complex ethical and moral issues. The following paper highlights the ethical issues in the emergency setting and outlines the strategies that are expected to minimize their occurrence.

Policies and Protocols

Due to the high intensity of the operations in emergency departments, the decision-making process in EDs is assisted by protocols that allow for a highly time-efficient assessment to take place upon the patient’s arrival to the unit. Since only a fraction of the patients can receive care immediately, the nurse decides which case requires immediate attention. One of the protocols used for the purpose is the Emergency Severity Index – a tool that measures how long the patients can wait without increasing the threat to their health.

Depending on the policies in use in specific settings, various scales can be used, with three-level and five-level ones being the most widespread. Currently, the five-level triage scale proposed by ENA and ACEP is considered sufficiently reliable, leading to its growing adoption in the emergency setting. Nevertheless, other systems remain actively used by a significant proportion of providers with relative efficiency.

Impact of Disparities

However, despite the efforts to systematize the process, the decisions of healthcare professionals are still prone to numerous biases. Implicit assumptions made by the staff at the emergency department may influence the outcome of the assessment. In many cases, irrelevant characteristics, such as a patient’s race, gender, or socioeconomic status, may influence the clinician’s perception and alter the course of the treatment.

According to a systematic review by FitzGerald and Hurst (2017), disparities have a significant negative impact on the quality of healthcare through the introduction of a possibility of faulty judgment. The issue of disparities is especially relevant in the emergency setting, where the patients are at increased risk of suffering major adverse health effects as a result of even a slight delay.

Policies for Uninsured Individuals

It is also necessary to acknowledge the existence of a gap in healthcare-related to uninsured individuals. Due to some socio-economic factors, the number of people without medical insurance is increasing. This trend has a detrimental effect on emergency care, which deals with uninsured individuals whose health is in immediate danger. Currently, the main policy that regulates the actions of EDs is the Emergency Medical Treatment and Labor Act (EMTALA).

According to it, every patient that arrives at the emergency department is eligible for care regardless of the insurance status. Currently, uninsured patients are triaged in the same way as the rest of the population, which serves as a major source of expenses for healthcare providers. To address the issue, several expansions to the policy, intended to improve care delivery for the uninsured, have been proposed by the ACEP but are yet to be approved.

Moral and Ethical Challenges

It should be understood that the specificity and systemic approach facilitated by policies and protocols introduces several ethical and moral dilemmas in the process. The most apparent one is based on the fundamental premise of delivering care to anyone regardless of their social, cultural, and economic status. While the principle is intuitively fair, its use inevitably leads to a situation where the nurse is faced with the necessity to choose which patient receives care first.

In a situation where the health of more than one patient is at risk, it can be framed as deciding who is saved and who is not. Another prominent example is a situation where two patients with similar conditions have different social profiles, such as the case at hand. While it is tempting for the nurses to assign higher priority to an individual with a more favorable social profile, such a decision is considered biased and, therefore, inconsistent with the current policies and protocols of emergency departments.

Possible Conflict

Another possible ethical issue is associated with a scenario where an uninsured patient is admitted to an emergency department with a severe injury. From a formal standpoint, the situation has a clear solution – according to the existing policies, the individual is entitled to the same level of access to and quality of care as the insured individuals. However, according to the analysis of data obtained from the National Trauma Databank, the uninsured status is a reliable positive predictor of mortality and a negative predictor of post-hospital care (Gerry, Weiser, Spain, & Staudenmayer, 2016). While the latter result can be attributed to economic constraints, the former is likely to be associated with endogenous factors and is an indicator of the inefficiency of some of the protocols.

Several approaches can be recommended to effectively manage the care of the uninsured and indigent population. First, it is necessary to provide them with alternative sources of care. In many cases, the uninsured seek help in emergency departments due to the scarcity of ambulatory clinics in the area or the lack of awareness. It is thus necessary for emergency unit staff to collaborate with local authorities, educators, and community health organizations to provide the missing alternatives.

Another strategy would be to ensure that only true emergencies are treated in an ED, which would require referring the patients with non-urgent conditions to respective facilities (Kumar & Klein, 2013). With these strategies in place, it will be possible to expect relief in the emergency unit workload and a decreased likelihood of ethical issues.

References

FitzGerald, C., & Hurst, S. (2017). Implicit bias in healthcare professionals: A systematic review. BMC Medical Ethics, 18(1), 1-18.

Gerry, J. M., Weiser, T. G., Spain, D. A., & Staudenmayer, K. L. (2016). Uninsured status may be more predictive of outcomes among the severely injured than minority race. Injury, 47(1), 197-202.

Kumar, G. S., & Klein, R. (2013). Effectiveness of case management strategies in reducing emergency department visits in frequent user patient populations: A systematic review. Journal of Emergency Medicine, 44(3), 717-729.