ETHICS COMMITTEE
Respect for Autonomy Melissa Myers, MD FAAEM and Alfredo Urdaneta, MD FAAEM
E
mergency physicians (EP) deal with ethical dilemmas every day while on shift. Without guidance, EPs do their best, which is often based on their individual training and, to a lesser extent, on the sum total of experiences in their lives. Cultural, religious, and other environmental factors all play a role in
decisions can help overcome inherent unconscious biases and improve patient care on a daily basis. The AAEM Ethics Committee has been tasked with ensuring that AAEM members are aware of these core bioethical principles and how they are applied in daily interactions EP have with patients. There are seven bioethical principles, which we will cover in articles in Common Sense over the course of the year. These principles are respect for autonomy, non-maleficence, beneficence, justice, health maximization, efficiency, and proportionality. The first bioethical principle we will cover is the principle of autonomy also known as the “right to self-determination.” This bioethical principle states that a person who has capacity has the right to make decisions for themselves, even if those decisions go against the advice of a physician or loved one. Medicine in the United States has moved from a beneficence model, in which the physician dictates care, to an autonomy model. In this model, we acknowledge that a patient has the right to make decisions about their own health, and has information regarding their life and health which is unavailable to the physician.
>>BIOETHICS IS NOT
SIMPLE OR STRAIGHT FORWARD. RIGHTS AND DUTIES HAVE LIMITS AND ARE NOT ABSOLUTES.
influencing these experiences. As a result EPs are at risk of allowing their personal biases influence their decisions to the detriment of patients. Becoming aware of and respecting others’ values can help minimize such biases. Emotional Intelligence, or EQ as it is commonly referred, is one such skill that is important in an EP’s relations with all individuals. Learning bioethical principles and what underlies these
The classic example of this principle is the patient who declines a blood transfusion for religious reasons. Take the case of a 30-yearold woman who presents after a year of heavy menstrual bleeding, tachycardic, and hypotensive. Lab work demonstrates severe anemia.
While a blood transfusion would be the typically recommended medical option, the principle of autonomy says that the patient has the right to refuse that transfusion for reasons which make sense to her, even if they don’t make sense to the treating physician. She could refuse this transfusion, even if refusal would result in harm or death. It then becomes the responsibility of the treating physician to find an alternative acceptable treatment. When this case was presented to emergency medicine trainees recently, their suggestions for alternative care included tranexamic acid, estrogen, and iron transfusions. This is a relatively straightforward example, let us go a step further. What if the same 30-year-old woman is being admitted to the hospital for her alternative therapy and monitoring. She informs the hospital staff that she has not been vaccinated against COVID19, and refuses to wear a mask or be tested for the virus prior to being admitted to the hospital, as is required by hospital policy. She tells you that she will leave the hospital if she is required to do any of these things. She has the right to autonomy and to decline these tests. However, where do her rights end and those of the other patients in the hospital begin? Does her autonomy over her own body mean that she has the right to expose others to risk? As demonstrated with this case, bioethics is not simple, and often multiple principles will be in conflict. While we may not agree with the patient, based upon the bioethical principle of autonomy they have the right to make the decision they feel is best for them, as long as they are provided with the appropriate information about risks, benefits, and alternatives. However, the bioethical principles are not absolute. Imagine an intoxicated patient with a severe injury who desires to leave the hospital against medical advice. If they leave, they will sustain irreparable harm. If they are unable to demonstrate the capacity to understand the harm that will result from their decision to decline care and leave the hospital, then the principle of nonmaleficence or “do no harm” requires Countinued on page 20 >>
COMMON SENSE NOVEMBER/DECEMBER 2022
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