Ethical issues are a common challenge for practicing emergency physicians. The ACEP Ethics Committee first surveyed ACEP members in 2006 on their views of the most common and challenging ethical issues they faced in clinical practice. Given the passage of time and the evolving nature of emergency medicine, the ACEP Board of Directors set an objective for the committee to reassess members’ views of the current application of the ACEP Code of Ethics and to discover what changing or additional ethical challenges confront practicing emergency physicians today.

Updated Results

The survey instrument was originally developed in 2006 by a panel of emergency physicians who are members of the ACEP Ethics Committee. To update the original survey, it was piloted among a focus group of 34 emergency physicians and revised based on their feedback. This updated survey reflects current issues and was delivered to 26,102 ACEP members by email on Feb. 12, 2016; it was available online until March 17, 2016. Reminders were published March 1–5, 2016, in ACEP’s Emergency Medicine Today eNewsBriefing.

The email survey had a total of 7,040 unique opens, representing a 27 percent open rate. A total of 1,006 participated (3.9 percent). Most participants were male (73 percent), and the most common practice environment was community (53 percent), followed by urban (32 percent), university affiliate (16 percent), university (12 percent), and rural (13 percent).

Respondents identified the most important ethical issues in their practice, in order, as access to care, end-of-life issues, psychiatric care, and third-party interference into the practice of medicine (see table below, uses the Likert Scale of 1=Not Important to 5=Most Important).

Respondents were also asked to comment in general on ethical issues in the practice of emergency medicine. The most common issues included the inappropriate influence of money, patient satisfaction driving patient care, end-of-life care, and disagreements with consulting physicians. The most common issues that have made respondents question their career choice or consider a career change or early retirement were third-party interference (hospital administration, regulations), patient satisfaction demands, and increased volume/complexity.

Most respondents indicated that they’re aware that ACEP has a Code of Ethics (see sidebar below) (n = 788; 79 percent). The elements they find the most challenging to implement are Principle 10 (“Support societal efforts to improve public health and safety, reduce the effects of injury and illness, and secure access to emergency and other basic health care for all”) and Principle 9 (“Act as responsible stewards of the health care resources entrusted to them”). Respondents indicated that they use ACEP Now articles, ACEP information papers, ACEP legislative advocacy issues, ACEP educational courses, and ACEP policies for assistance or education regarding ethical issues.

When this survey was compared to the similar survey in 2006, several important differences become noticeable. In 2006, the most important ethical issues in emergency medicine identified were access to care, end-of-life care, professional issues, stewardship of health care resources, and societal expectations. Although the top-two issues remain access to care and end-of-life decision making, the availability of psychiatric resources for patients and perceived third-party interference have risen to the third- and fourth-most important issues, respectively.

One area that was identified by respondents on two different open-ended questions (ethical issues and threats to professional longevity) was the general preoccupation with patient satisfaction. Companies like Press Ganey and related satisfaction tools are fraught with validity issues, survey sampling problems, and measurement error; these are problems over which emergency physicians have little, if any, control. Given that EM is perennially associated with high burnout rates and that emergency physicians link satisfaction scores to both ethical issues and career choice dissatisfaction, invalid metrics pose a serious threat to moral integrity and professional longevity among ACEP members.

Note: All authors are members of the ACEP Ethics Committee. To view the committee’s annual report and objectives, please click here.

Dr. Marco is professor of emergency medicine at Wright State University Boonshoft School of Medicine in Dayton, Ohio.

Dr. Venkat is Chair of the Ethics Committees of Allegheny General Hospital and Allegheny Health Network in Pittsburgh, Pennsylvania and Professor of Emergency Medicine, Drexel University College of Medicine.

Dr. Larkin is Professor & Chair of Emergency Medicine University of Auckland and Adjunct Professor New York University School of Medicine.

Dr. Brenner is an Associate Professor of Emergency Medicine at SUNY-Upstate Medical University in Syracuse, New York.

Dr. Nadeem is an Emergency Medicine Resident at the Baylor College of Medicine in Houston, Texas.

Dr. Limehouse is Associate Professor on the Clinician Educator track in The Department of Medicine at the Medical University of South Carolina, Charleston, South Carolina.

Dr. Knowles is the Director of Leadership and Advocacy with Integrative Emergency Services and core faculty at John Peter Smith Health Network Emergency Medicine Residency Program, Fort Worth, Texas.

Dr. Iserson, Professor Emeritus of Emergency Medicine at the University of Arizona, is currently Lead Physician, McMurdo Station, Antarctica.