Case: An adult, competent patient presents to triage complaining of ankle pain after stepping in a hole. The patient is examined and found to have an ankle sprain. The medical screening exam identifies no emergency medical condition. The patient is offered further care after he checks in at the registration booth, where a request for pre-payment of service, is made, with the understanding that no further care will be given unless the patient provides insurance information or money. The patient is told he can seek care at the community clinic, but there is no guarantee when and whether he will be seen. The waiting room has twenty other patients awaiting an ED bed.

Question: What is the right thing to do? What are the ethical issues and how do they inform decision-making in self-limited, non-emergent medical care?

Although the Constitution guarantees life, liberty and the pursuit of happiness to its citizens, health care is not among these rights - with one important exception. EMTALA, The Emergency Medical Treatment and Active Labor Act, requires a medical screening exam and stabilizing treatment for all patients presenting to an emergency department in the United States. Nonetheless, there is a cultural expectation among some that the ED is where one goes for all care, not just "emergency" care. The ability to give this care may be threatened by insufficient capacity, inadequate community resources, and the un-insured and under-insured who have no other resource. The operative ethical principle that helps clarify competing claims to this limited resource is "distributive justice," the application of which results in an equal sharing of benefits and burdens amongst members of a society. How then do we provide the highest possible quality of care and a just system in which all persons have reasonable access to care?

After appropriate communication is assured, such that we can reliably rule out a true medical emergency, we are still left with significant ethical dilemmas. Do we treat first, even at the expense of others, without requiring patient payment up front - as would be expected in the private physician's office? Financial screening and the associated practice of "triaging out" patients who are deemed not to have "an emergency medical condition" present ethical and practical difficulties to the emergency physician. Legitimate interests of the patient, the physician, the hospital and other stakeholders often collide at this crossroads. The emergency physician has the unenviable task of attempting to resolve conflicting obligations owed to the patient (the primary obligation), and those owed to the institution, third party payers, legal institutions, professional organizations, state and federal agencies, nursing and allied health care providers, one's colleagues and oneself. Complicating these relationships is a growing awareness that physicians in general, and emergency physicians in particular, are responsible for the utilization and cost-containment of an expensive and increasingly scarce medical resource, which finds its expression in the growing use of emergency medicine services, with its attendant overcrowding and increasingly limited bed supply. The increasing frequency of ED closures, ambulance diversions, rising census, and demographic trends have resulted in increased demand for existing services and is likely to worsen as the "baby boomer" population ages.

The patient also has multiple and often conflicting ethical obligations: those to family and friends, to third party payers, to the institution as made explicit in a patient bill of rights and obligations, and to self (in an attempt to insure one's own health). An essential ethical question is how the financing of medical care should influence individual medical decision-making. How should the legitimate interests of third parties be factored into clinical decisions about appropriate care? This intersection of the ethical principles of patient autonomy along with social justice and physician clinical autonomy helps to define the appropriateness of the clinical encounter, which is mediated by institutional policy.

To examine an ethical issue such as financial screening, a method of critical analysis is helpful. Jonsen et al¹ recommend an analysis based upon four critical features: 1) medical indications 2) patient preferences 3) quality of life and 4) contextual features. Any attempt to analyze an ethical case in emergency medicine must be based upon the clinical encounter, as opposed to the more abstract considerations of public policy or philosophy. We assume, for purposes of argument, that the clinical encounters we are discussing are in fact non-emergent, have passed the medical screening exam as required by law, and are considered medically stable. This determination itself is often difficult, risky and problematic. For purposes of illustration, we will consider the above example of a patient with an ankle sprain.

Medical indications (clinical autonomy): This concept relates to the diagnosis, prognosis, and treatment of a patient's condition. "First, do no harm" embodies the Hippocratic principle of non-maleficence. In the above clinical case this principle is upheld by restricting access to the ED, i.e. no harm would be expected to befall these patients if no treatment was emergently given. However, the second obligation of the physician to these patients is one of maximizing health, or that of beneficence. To achieve this goal, we are obligated to insure that the patient can receive follow up care in our department or another, more appropriate medical setting.

Patient preferences (patient autonomy): Patients have an ethical right to decide what happens in their own health care based upon their own values and assessments. There is a significant power asymmetry between the physician and the patient, whereby the physician often has greater control during the encounter, both in terms of knowledge and access to tests and treatments. Little research has been done to measure the effect of greater patient control on clinical outcome and quality of care.² In addition, with a right of greater control comes also the financial responsibility for that care. In the examples mentioned above, the patient retains the right of control over decisions made on his behalf (given the limitations imposed by intellectual capacity and cognition). For instance, if no medical emergency exists, having the patient undergo triage does not violate the principle of patient autonomy. Although patients have certain rights as autonomous individuals, they do not have the right to dictate medical care, which is appropriately determined by the treating physician.

Quality of life: Any illness or perceived "dis-ease" threatens quality of life from the individual's perspective. Patients present to the ED for relief of illness, injury or discomfort and are ethically entitled to receive that care. The provision of non-emergency care in the ED to the unfunded, indigent population in the context of EMTALA regulations has become culturally viewed by some as "free care." The attempt by institutions to relieve themselves of this burden has resulted in some areas in triage of patients to other medical sites. The ethical principle of proportionate care (a corollary of the principle of distributive justice) states that a medical treatment is ethically mandatory to the extent that it is likely to confer greater benefits than burdens upon the patient.³ Financial burdens should be discussed with the patient in order to arrive at an adequate decision as to the benefit/burden ratio.

Contextual issues: Emergency care is given within a context of multiple responsibilities and obligations. Emergency medicine must consider the larger context - that of the institution and the social environment - which impacts upon the ethics of care. The central ethical principle of Justice - the equitable distribution of burdens and benefits to members of a social institution - best informs these decisions. Previous authors⁴ have discussed the broader topic of the ethical implications of "triaging out" and financial screening primarily from the perspective of access and the threat to the medical safety net which emergency medicine provides. They reasonably argue that emergency medicine must be concerned only with the individual patient-physician encounter, and that issues of equitable distribution of resources are best left to the institution or the society to define.

American and common law place a high priority on the individual physician-patient relationship, but with the growing demand on emergency health care, the principle of Justice may at times trump that of Loyalty between an individual patient and physician. The provision of non-emergency care in the ED after completing the MSE may at times interfere with the delivery of emergency care to other patients, such as the unseen patient in the waiting room, or the boarded patient. Some would argue that the individual patient-physician relationship is sacrosanct, standing above societal or institutional financial considerations. This "professional model"⁵ argues that concern for the welfare of others at the expense of the individual patient is a breach of ethical duty, and that medical decisions should only be based on clinical judgment to the exclusion of economic concerns. The "economic model"⁶ requires the physician to assess not only the risk-benefit ratio and patient preferences (autonomy), but also its cost-effectiveness, based ideally on outcome data of the cost-effectiveness and marginal benefit to the patient. In this case, not every patient would get every intervention, despite their preferences. The risk inherent in this model is that hospital will use this argument simply as a way to balance budgets on the backs of patients in need of care.

Autonomy is a legitimate right of patients, assuming adequate individual intellectual capacity, cognitive ability, and objectivity. Medical decisions result in costs that are sometimes the obligation of the individual (as opposed to third party payers) such as deductibles, co-pays, and self-pay. The principles of beneficience and non-maleficence require the treating physician to make a reasonable effort to become informed about and disclose these costs to the affected individual. Often, however, physicians are ignorant of these costs or are hesitant to turn over power or decision making to the patient.⁷ Hippocratic writings include this proviso: "if there is an opportunity to serve a stranger in financial straits, give full assistance . . . love of humankind and love of the medical art go together" (Precepts VI). Emergency medicine physicians have an ethical obligation to lobby in their institution on behalf of those in urgent need of service. It is, however, a legitimate right of the institution to limit non-emergency care if it affects the solvency of the hospital (no margin, no mission) in the name of the ethical principle of Justice. On the other hand, the institution has the ethical obligation to direct non-emergency care to the appropriate setting in fulfilling its role as a public trust. In general, though, patient-centered care that focuses on medical indications and patient preferences should retain priority. Practical solutions (calling in extra nurses including the use of on-duty nurse administrators, delivering care outside of hospital policy restrictions, moving patients to their ward while their beds are being cleaned, using non-traditional providers) should resolve these issues in most cases.

We agree with the following practical considerations articulated by SAEM⁷, as follows

1. Patients who present to an ED should be given an examination informed by the best clinical judgment, and taking into account the patient's personal preferences, to determine whether the patient has a medical emergency and can be safely triaged to another health care setting
2. Arrangements should be made with alternative providers to provide care without the patient having to undergo further screening
3. The patient will be seen in a timely fashion
4. The patient can physically get to the alternative site or is given the means

In summary, the act of financial screening must be carefully weighed against the individual rights of the patient to care, the obligations of the clinician and institution in providing that care, and the right of the clinician and institution to be paid for that care. The concept of "triaging out" must be replaced with the concept of "triaging to" an alternative provider to ensure the best care for our patients. In addition, the role of the hospital in providing adequate in-patient beds must be factored into any plan which limits care of any patient due to overcrowding. We have a moral obligation to lobby for the benefit of all of our patients, not only those with true emergencies, and we must be cognizant of the legitimate rights of our patients, the institutions in which we practice, and the communities within which that practice occurs.

References

1. Jonsen AR, Siegler M, Winslade W. Clinical Ethics: A practical approach to ethical decisions in clinical medicine-5th edition. McGraw Hill Companies; 2002:1-11.
2. Auerbach SM. Should patients have control over their own health care? Empirical evidence and research issues. Ann Behav Med. 2000;22(3):246-259.
3. Jonsen AR, Siegler M, Winslade W. Clinical Ethics: A practical approach to ethical decisions in clinical medicine-5th edition. McGraw Hill Companies; 2002:131.
4. Schmidt TA, Iserson KV, Freas GC et al. Ethics of emergency department triage: SAEM position statement. Acad Emerg Med. 1995; 2:990-995.
5. Jonsen AR, Siegler M, Winslade W. Clinical Ethics: A practical approach to ethical decisions in clinical medicine-5th edition. McGraw Hill Companies; 2002;163-4.
6. Ibid.
7. Schmidt T, Iserson K, Feas G et al. Ethics of Emergency Department Triage: SAEM Position Statement. Acad. Emerg Med. 1995; 2:995.

Submitted by the Ethics Committee – August 2005