AMA Journal of Ethics®

Illuminating the art of medicine

Journal of Ethics Header

AMA Journal of Ethics®

Illuminating the art of medicine

Virtual Mentor. June 2010, Volume 12, Number 6: 455-458.

Medical Education

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Preparing for the Unexpected—Teaching ER Ethics

The authors outline three strategies for teaching students to make ethical (and clinical) decisions in time-sensitive cases.

Kelly A. Edwards, PhD, and Thomas Robey, MD, PhD

It should go without saying that the fast-paced environment of the emergency department (ED) requires a different kind of deliberative approach to ethical dilemmas. As the cases in this issue of Virtual Mentor demonstrate, clinicians in the ED are presented with dire situations and little information, yet need to act quickly. This is truly a catch-22. Precisely when you need the time to call a team or family meeting or gather more data, as you would on the medicine floor, you do not have that luxury. So what can an ethical ED clinician do? In this report from two ethics educators, we offer three possibilities for emergency medicine training clinicians to build ethics reasoning skills suited for the ED.

Strategy 1: Anticipating and Practicing

This first strategy underlies most undergraduate ethics education. That is, if you can present medical students with case scenarios they are likely to encounter in their clinical rotations, they can (a) begin to recognize and anticipate the kinds of issues that will come up, (b) learn relevant rules, laws, policies, expert opinions, and guidelines that have professional consensus about the kinds of cases they will see, (c) learn from their classmates and role models, and (d) begin to test and practice their own responses. By thinking cases through in advance of being confronted with the actual situation, trainees have the time to work through difficult scenarios that are likely to be quite new, and sometimes disturbing, to most students. The rationale behind this strategy is that “chance favors the prepared mind.” If the student has wrestled with a case or has heard how various people would respond to a specific situation, he or she can more quickly act in the moment.

Opportunities for slotting case discussions into the curriculum are almost unlimited. They can be included in noon conferences, journal clubs, required ethics courses, or in electives aimed at those going into emergency medicine. Having facilitators on hand who have both ethics and clinical expertise can be especially useful for grounding the cases.

Strategy 2: Using Ethical Frameworks for the ED Setting

As common as the above rationale is for most ethics education, and as essential a first step as it is in the professional development of a trainee, it is not sufficient. Students who have not yet been in the clinic may consider the scenarios abstractions, and the real crux of the case will not be clear until they are in the moment and have more clinical experience to bring to bear. An alternative or additional strategy is to have a quick-and-dirty decision making tool to help the trainee in the moment.

Most ethical decision-making frameworks and tools are intended for longer clinical ethics consultation settings [1]. These are excellent, but, unless the user is familiar with the frameworks, they can bog down the process rather than facilitate it. Emergency medicine professor Kenneth Iserson has proposed a decision-making tool that can be used in the chaos of the ED. He has written about this extensively elsewhere [2], so we will just summarize his basic approach here. In brief, when confronted with a dilemma the clinician should employ the following decision tree:

  1. If there is a rule (law, policy, precedent) that is close enough to apply to the dilemma at hand, follow it.
  2. If no rule clearly applies, is there an option that can buy time and does not pose additional risk to the patient? If so, take it and use that time (as much as you have) to pursue other data gathering or consultation.
  3. If action cannot be delayed, use a practiced reasoning technique to arrive at an outcome [2].

Iserson suggests further that asking three questions as part of step 3 can help you decide what to do next. These are: a golden rule test (What would you want if you were the patient?), a universality test (Would your decision work in every other instance?) and a liability test (Could you justify your actions to others?). These questions can be helpful as trainees work to gain additional experience with clinical and ethical situations that help them effectively work through the primary steps of Iserson’s process.

Strategy 3: Building Scaffolding for ED Ethical Decision Making

Dr. Iserson’s model is most useful for experienced clinicians who can very quickly comprehend a situation, appraise available options, and make an assessment about best course of action. Many trainees will default to the decision-making step if they are not familiar with case precedent or medical techniques that buy time. A simple framework we have used in some of our ethics teaching asks the trainee or clinician to respond (quickly) to a series of questions. At the University of Washington, we have loosely adapted moral psychologist James Rest’s four dimensions of moral life [3], and created the Four Skills of Ethics, which we use in our Ethics and Professionalism Benchmarks and as a guide in curriculum planning and teaching. These questions can be taught in conjunction with Iserson’s, and can stand alone once they have been internalized.

  1. Recognition: What is the ethics issue in this case? Before you can figure out whether there is a relevant rule (Step 1 in Iserson above) you have to recognize what kind of case this is, e.g., treatment refusal, withholding life-sustaining treatment, questionable decisional capacity, inappropriate surrogate, triage, etc.
  2. Reasoning: What options are there, and what are the potential harms and benefits of each? What is at stake in this decision? This stage can be expanded or contracted depending on time, but would supplement Iserson’s steps 2 and 3 above.
  3. Responsibility: What are my professional obligations? This question can get at professional guidelines and standards, as well as eliciting more interpretive questions such as: What kind of clinician do I want to be? Responses could include reference to some of the professional virtues identified by leaders in the field [4].
  4. Respond: What will I do, and why? Justifying one’s course of action should be a combination of considering the rules, consequences of actions, professional standards, and one’s own professional moral compass.

The goal for future emergency physicians is to charge through these questions quickly when in the throes of decision making. The ED environment by its nature imposes limits on time and information; whether it be a clinical or ethical dilemma, the clinician must make a decision, and quickly. In the case of most ethical dilemmas, reasonable people will disagree about the best course of action. In the end, emergency practitioners must become competent in quickly recognizing and justifying choices amidst competing values. Clinicians who have anticipated the issues, used a coherent approach to decision making, then documented the justification, will be able to defend their positions well against anyone who may challenge it.


The added challenges of working in the emergency department reinforce the need for an accessible and easy-to-remember approach to ethical decision making. We have offered three strategies here which can be used separately, together, or in combinations, as is useful to the trainee, teacher, or clinician. The goal of ethics education is to prepare trainees to be efficient and ethical decision makers and to provide the right kind of scaffolding to help facilitate decision making that will lead to better outcomes for patients, family, and care team members.


  1. Jonsen AR, Siegler M, Winslade W. Clinical Ethics: A Practical Approach to Ethical Decisions in Clinical Medicine. 6th ed. New York, NY: McGraw-Hill Medical; 2006.
  2. Iserson KV, Sanders AB, Mathieu D, eds. Ethics in Emergency Medicine. 2nd ed. Tucson, AZ: Galen Press; 1995.
  3. Rest J, Narvaez D, eds. Moral Development in the Professions: Psychology and Applied Ethics. Hillsdale, NJ: Lawrence Erlbaum; 1994.
  4. Larkin GL, Iserson K, Kassutto Z, et al. Virtue in emergency medicine. Acad Emerg Med. 2009;16(1):51-55.

Kelly A. Edwards, PhD, is an associate professor in the Department of Bioethics and Humanities at the University of Washington School of Medicine in Seattle and core faculty for the Institute for Public Health Genetics. She received an MA in medical ethics and a PhD in philosophy of education from the University of Washington. Her teaching programs for medical students, faculty, and graduate students are used throughout the WWAMI (Washington, Wyoming, Alaska, Montana, Idaho) system. Dr. Edwards co-chairs the professionalism working group that has developed benchmarks for ethics and professionalism for the medical student program and has consulted with several clinical clerkships on professionalism evaluation.

Thomas Robey, MD, PhD, is an emergency medicine resident at Yale-New Haven Hospital. He studied medicine and bioengineering at the University of Washington and biology, engineering, and the history and philosophy of science as an undergraduate at the University of Pittsburgh. Dr. Robey co-founded Seattle’s Forum on Science, Ethics, and Policy and has taught ethics to medical and undergraduate students. He derives great meaning from being one strand in the health care safety net.

Resource Allocation Shake-Up, June 2010

Make It OK That This Life Is Ending, June 2010

Taking No for an Answer: Refusal of Life-Sustaining Treatment, June 2010

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