In 1997, the ACEP Board of Directors approved the Code of Ethics for Emergency Physicians, recognizing the unique nature of emergency care, the moral challenges of emergency practice, and the ethical obligations of emergency physicians. Since that time, the ACEP Ethics Committee has recommended and the Board of Directors has adopted a wide number of policy statements that describe further ethical positions that ACEP members should uphold. These statements cover a wide range of topics, including standards in personal conduct, interactions in patient care in the emergency department, and the role of emergency physicians in society. Together, the Code of Ethics and related policy compendium are a statement of the values and standards that ACEP supports, ACEP members endorse, and the organization puts forward to all stakeholders in emergency care.

To ensure that ACEP members, who agree to abide by the Code of Ethics and related policy statements when joining the organization, meet their ethical obligations, ACEP has developed a process by which members can request review of and potential action against other ACEP members for Code of Ethics violations. Over the past 15 years, all received complaints have alleged violations of ACEP’s policies on expert witness testimony. However, the ethical obligations of ACEP members also extend to other areas of personal and professional conduct. In this article, we describe the areas where ACEP members have ethical obligations and issues that may rise to the level of an alleged ethics violation resulting in review.

Ethical Obligations of Emergency Physicians in Personal and Professional Conduct

The Code of Ethics outlines ethical principles that all emergency physicians should uphold in their conduct with patients. The principle of beneficence defines a fundamental duty to serve the best interests of patients by treating disease, preventing injury, and minimizing pain and suffering. Emergency physicians also respect the principles of autonomy and beneficence by protecting the privacy of their patients and the confidentiality of their patients’ information, within constraints of the law. The principle of non-maleficence affirms an obligation to avoid doing harm to patients and directs emergency physicians to consider the potential for adverse consequences to patients when initiating diagnostic or treatment measures. The principle of autonomy most commonly manifests in emergency practice in the realm of informed consent and respect for refusal of interventions by patients after being presented information about the risks and benefits of treatment options.

Equally as important, the Code of Ethics outlines the obligation of emergency physicians to treat all patients in a just manner, with impartiality with regard to race, color, creed, gender, nationality, or other characteristics. As the primary health care providers of the ultimate health care safety net, emergency physicians regularly care for patients who lack regular access to medical care. Therefore, the ethical principle of justice and its application in emergency practice has a vital importance for emergency physicians and their care of patients.

Finally, on a personal level, the Code of Ethics states emergency physicians, as respected members of society, hold a responsibility to not commit crimes of moral turpitude, perhaps best defined as crimes that shock the public conscience as being inherently base, vile, or depraved, or contrary to the rules of morality and the duties owed to individuals or society in general.

The potential for ethical violations in personal and professional conduct in these areas is easily envisioned. Among these are violations of patient confidentiality, egregious clinical practices that put patients’ well-being at risk, discrimination in patient care, or felonious personal conduct. Fortunately, the quality of our ACEP members and the care that they provide has made such conduct exceedingly rare.

Ethical Obligations Surrounding Clinical Care

The Code of Ethics and related policy statements outline additional standards that emergency physicians should uphold when providing clinical care. Among these duties is maintaining patient confidentiality. In a world of smartphones, social media, immediate internet access, and recording devices in every pocket, the threats to confidentiality are significant. Physicians are still morally bound by the standards of the profession and legally bound by the Health Insurance Portability and Accountability Act (HIPAA) and other confidentiality statutes to maintain patient confidentiality. There are many circumstances where the recording (ie, images) of patient care may occur. Physicians may wish to record images from clinical encounters for later patient care, and electronic medical records have the capability to include images, from rashes to colonoscopies. In every circumstance, the patient or surrogate should give consent for the acquisition of images even where the benefits to the patient are clear. Physicians or hospitals may also wish to acquire such images for research, quality review, or education. Similar to a research protocol, patients or surrogates should consent after understanding how the images may be used and that such participation will not necessarily provide a direct personal benefit to the patient.

With the recent popularity of reality television, medical interactions may be recorded (ie, video) for entertainment or for-profit purposes. These recordings do not provide medical benefit to the patient. On the contrary, patients are often recorded in extremely vulnerable or private moments. Commercial recording of patients should only occur when the patient has the capacity to consent to the creation of the recording and, to avoid undue influence, should also require that the patient later consent to the use or dissemination of the recording.

It is common for law enforcement agents to be present in the emergency department and to seek evidence or maintain custodial authority of patients after alleged criminal activity. This interaction can be particularly challenging as emergency physicians balance their ethical commitment to maintain patient confidentiality and avoid measures that may put the patient at risk and the concomitant obligation to obey laws that allow police to obtain evidence in a criminal investigation. The ACEP policy statement Law Enforcement Information Gathering in the Emergency Department recognizes this underlying tension and calls for individual emergency physician discernment when making judgments on what is appropriate while prioritizing preserving patient confidentiality, safety, and well-being.

The risk of accidental interaction with law enforcement may also influence undocumented immigrants who seek medical care. Undocumented immigrants often do not have the forms of identification necessary to obtain insurance or regular outpatient medical care. As a result, many preferentially utilize the emergency department. In its policy statement Delivery of Care to Undocumented Persons, ACEP declares its opposition to governmental initiatives to either force health care providers to report such individuals to immigration authorities when seeking care or to otherwise limit their access to care in the emergency department. Emergency physicians, therefore, have comparable obligations to maintain confidentiality for all patients regardless of immigration status. HIPAA may also require maintenance of confidentiality on issues such as immigration status.

Together, the Code of Ethics and related policy statements place a particular emphasis on maintaining the integrity of the doctor-patient relationship by preserving patient confidentiality in providing emergency care. Ethical violations can clearly arise if emergency physicians violate confidentiality directly or by facilitating unauthorized disclosures by others with competing interests. However, the Code of Ethics also envisions competing obligations that may require confidentiality to be set aside after careful discernment of the importance to disclose certain information in very narrowly defined and specific circumstances (eg, patient protection and public interest).

Ethical Obligations in Commercial Relationships and Interactions with Society

A number of ACEP policies address issues of commercial relationships between emergency physicians and outside entities. These include relationships in practice management, financial influence on clinical decision making, and conflicts of interest. With rapid changes in the health care system and the delivery of emergency care, these areas are evolving as are the ethical challenges they pose.

ACEP policy supports contractual relationships that protect the right of the emergency physician to have a fair, equitable, and supportive environment. This environment is one in which the emergency physician should be informed of any provisions in an employment arrangement that concern termination, as well as the ability to review those components of the groups’ contract with the hospital dealing with termination of the individual physician’s contract. Additionally, the emergency physician should receive early notification if performance problems arise, have the opportunity to address the relevant issues, and have adequate access to a fair evaluation and investigatory process prior to termination. ACEP policy also supports the physician’s right to review the activities of entities that manage billing and collections.

ACEP’s policy statement on emergency physician rights and responsibilities also supports autonomy in clinical decision making that is not restricted by cost-saving guidelines and rights to reasonable compensation, due process, and freedom from unreasonably restrictive agreements limiting the ability to practice medicine after separation. Also listed in this policy statement are the responsibilities of the emergency physician, including to practice ethical, current, and evidence-based medicine and to obtain basic knowledge of the business of emergency medicine, among others.

The Code of Ethics and related policy statements also discuss the potential for conflicts of interest among emergency physicians. At an individual level, ACEP recognizes that emergency physicians should be able to interact with industry representatives, particularly to obtain important product information. Emergency physicians need to consider the purpose and consequences of accepting gifts offered by industry. ACEP believes that treatment choices should be solely based on risks and benefits to the patient. Professional services such as research or providing CME can be compensated by industry but only at fair market value.

On an organizational level, ACEP policy states that those ACEP members in a position of College responsibility and with a fiduciary duty to the College must act in good faith on behalf of the College. Conflicts arise when these individuals have personal, financial, business, or professional interests that could interfere with their ACEP duties. For potential conflicts of interest that do not relate significantly to College duties, disclosure may be sufficient. If potential conflicts do relate to College activities, disclosure and recusal may be required. In the case of a serious irreconcilable conflict, resignation from the position within the College or from the conflicting entity may be indicated.

Clearly, potential ethical violations can arise if commercial influence unduly affects either the employment conditions of emergency physicians or how they provide clinical care. What is unclear is how an ethical violation in this realm might be judged. One can imagine a scenario where one ACEP member alleges a violation by another related to an employment or other commercial relationship. The question of whether the necessary combination of ethical and business expertise exists, without personal conflicts of interest in the College to evaluate such a complaint, is one that will require careful consideration moving forward.

Conclusion

The ACEP Code of Ethics and related policy statements provide a framework by which emergency physicians articulate and uphold their ethical obligations in their professional lives. While, to date, the ethics complaints brought by members have focused on expert witness testimony, the Code of Ethics extends well beyond that issue. This broader context should lead to consideration by ACEP members as to how they meet their obligations, whether other potential ethical violations are taking place, and, if so, how these issues can best be addressed and resolved.

Dr. Venkat is vice chair for research and faculty academic affairs in the department of emergency medicine at Allegheny Health Network in Pittsburgh; professor of emergency medicine at Drexel University College of Medicine in Philadelphia; President-Elect of the Pennsylvania College of Emergency Physicians; and Chair of the ACEP Ethics Committee.

Dr. Chandrasekaran is assistant professor of clinical emergency medicine in the department of emergency medicine at Indiana University School of Medicine in Indianapolis.

Dr. Clayborne is clinical instructor in the department of emergency medicine at the University of Maryland School of Medicine in Baltimore.

Dr. McGrath is director of the John J. Lynch MD Center for Ethics and assistant professor of emergency medicine at Medstar Georgetown University Hospital and Washington Hospital Center in Washington, D.C.

Dr. Martin is professor of emergency medicine and vice chair for education in the department of emergency medicine at The Ohio State University College of Medicine in Columbus.

Dr. Knowles is director of leadership and advocacy in the department of emergency medicine at JPS Health Network in Fort Worth, Texas, and Past-President of the Texas College of Emergency Physicians.