Emergency physicians function under a microscope. With marked economic pressures in health care, we may face organizational imperatives to cut costs or increase revenue at the perceived expense of patient-centered decision making. As hospital-based practitioners, emergency physicians may be confronted with institutional policies that conflict with individual viewpoints.

Personal Values in Conflict With Institutional Policy

Prevention or termination of pregnancy may depend upon the moral beliefs of a practitioner or institution to provide such treatment. For example, many hospitals are managed according to Catholic teachings and ban most forms of birth control or abortion. However, organizational beliefs may not be consistent with the values or medical needs of a patient. The patient is not arriving for a scheduled appointment. She is arriving in an emergency department, perhaps after an emotionally traumatic event such as sexual assault. Should a patient’s access to Plan B or termination depend upon the GPS directions selecting a particular hospital?

While providing life-sustaining interventions is the default position in the emergency department, this course may be unacceptable to a patient with a serious progressive illness. If life-sustaining interventions are inconsistent with the patient’s goals, the principle of autonomy should drive their withdrawal. This may be difficult ethically for emergency physicians who disagree with the prognostic assessment of the patient or have moral objections to this treatment course.

A 2007 study showed that 86 percent of physicians supported a moral obligation to discuss all of the medical options with their patients, even if they conflicted with physician personal beliefs.¹ This suggests a near ethical consensus to not impose one’s own moral beliefs upon the patient. The physician is not required to incur the moral distress of personally providing a treatment that contravenes his or her beliefs. Yet patients must be able to trust that physicians and their institutions are placing their patients’ welfare first.

Finding Balance

The simple answer is that if professionalism is to mean anything, it has to mean that emergency physicians should be true to their individual ethical judgments and follow them to provide their perceived best care of the patient. A corollary is that the health care organization’s values should be to support the ethical and medical judgments of their health care providers. However, these ethical dilemmas are rarely a straightforward case of individual conscience being unjustly obstructed by organizational mandates. Rather, these issues require a balance between individual judgments and the practical necessities of mutual dependence between the hospital and the emergency physician.

The better question to ask is how individual conscience can be respected while taking into account institutional requirements. Emergency physicians and their host organizations should anticipate the ethical tensions and develop mechanisms in advance for resolving these conflicts. Such advanced planning may allow solutions such as the availability of alternative providers and ethics service mediation of conflicts.

Reference

1. Curlin FA, Lawrence RE, Chin MH, Lantos JD. Religion, conscience, and controversial clinical practices. N Engl J Med. 2007;356:593-600.

Drs. Venkat, McGrath, DeSandre, and Phillips are members of the ACEP Ethics Committee.