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Ethics in Emergency Medicine, 2nd ed.

A Rapid Approach to Ethical Problems

From: Ethics In Emergency Medicine, Second Edition

Iserson KV, Sanders AB, Mathieu D (Editors)

ISBN 1-883620-14-7
$39.95 Soft Cover
589 pages, Bibliography, index
©Galen Press, Ltd., Tucson, AZ, 1995

The Impartiality Test
          Would you be willing to have this action performed if you were in the other person's (the patient's) place? This is, in essence, a version of the Golden Rule. Do unto others as you would have done unto you. According to John Stuart Mill, this espouses "the complete spirit of the ethics of utility." It is not an infallible rule that will yield a right answer every time. It is intended, however, to correct for one obvious source of moral error-partiality, or self-interested bias. It asks practitioners to switch their point of view, to take the other person's perspective. Usually, that is useful to do and can at least help avoid a grievous error.

The Universalizability Test
        Are you willing to have this action performed in all relevantly similar circumstances? This generalizes the action and asks whether developing a universal rule for the contemplated behavior is reasonable-an application of Kant's categorical imperative. Is what you are about to do in this particular case something you would approve of if it were generalized to all cases of this sort? The usefulness of this test is that it can help eliminate not only bias and partiality, but also shortsightedness. In particular, it enables us to evaluate a particular action by viewing it as an example of general practice in relevantly similar circumstances. In some cases, we might approve of a particular action if we viewed it on its own account, in complete isolation, but find it unacceptable to adopt it as general practice. To the extent that we are concerned with finding useful rules of action, focusing on types of action-rather than particular actions in isolation-seems appropriate, since rules are always to some extent general and hence apply to types of actions. Justifying one particular instance that falls under a rule is not sufficient for justifying the practice of acting on that rule.

The Interpersonal Justifiability Test
         Are you able to provide good reasons to justify your actions to others? Will peers, superiors, or the public be satisfied with the answers? Could you justify or defend your decision if it were questioned by someone else? Could you give reasons for the course of action you took? And, importantly, can you give reasons that you would be willing to state publicly? This test uses David Gauthier's basic theory of consensus values as a
final screen for a proposed action.
When ethical situations arise where no time exists for further deliberation, it is probably best to go ahead and act on the rule or perform the action that allows all three tests to be answered in the affirmative with some degree of confidence. Once the crisis has subsided, however, the practitioner should review the decision with the aid of colleagues and bioethicists to refine his emergency ethical decision-making abilities. In particular, it is crucial to ask whether the most basic ethical values have been served by the decision-making process. Were the actions taken in the emergency situation really consonant with showing the kind of respect for patient autonomy which you believe appropriate? Were the ethical decisions really in the patient's best interest, or were you unduly influenced by the interests of others or considerations of your own convenience or psychological comfort? Were people treated fairly, justly, and equitably?

Ethical problems, like emergency clinical problems, require action for resolution. Ideally, one would have extensive discussions and time to reflect on each ethical decision before needing to act on the decision. This, of course, is not possible for many emergency care decisions. Nevertheless, by making a sincere effort to anticipate recurring types of problems, by subjecting them to ethical analysis in advance, and by conscientiously reviewing decisions after they have been made, the emergency care professional can better fulfill his or her ethical responsibilities. The fact that a decision is an emergency decision, therefore, does not remove it from the realm of ethical evaluation.