Ethical Dilemmas in Emergency Medicine Part 1

Reconciliation by Scott A. Harvest.  http://www.elfwood.com/~scotimus/Reconciliation.3197669.html

 

Emergency Medicine is a specialty that you may not think involves a lot of ethical dilemmas. The obvious issues like abortion, euthanasia and reproductive ethics affect other people. However, ethics is actually really central to our practice. We might not realise it, but there are ethical implications for every single decision we make. The Ethical Dilemmas in Emergency Medicine series at St. Emlyn’s is going to explore that and will hopefully get you asking questions about your practice that you hadn’t realised need answering.

 

In this blog post, I’m going to present a hypothetical scenario to get us started. It’s a bit fantastical and this particular scenario itself doesn’t relate to anyone’s everyday practice because it’s so extreme. However, the choices we make here have huge implications for all of the more mundane decisions that we make in practice. In the posts that follow, we’ll start to see why.

 

We really want your input on this. Have a think about the scenario and please post your comments below. I’m sure there’s going to be a huge range of opinions on this so please don’t be afraid to share your tuppence worth with us. It will help us to take our subsequent posts in the best direction to explore some of the issues that might be raised.

 

So here’s the hypothetical scenario…

 

You’re called  to the scene of a road traffic collision on a bridge.  When you arrive, you find an elderly man trapped underneath a car, which is hanging over the edge of the bridge.  You triage this man and find that he’s stable – but you’re going to need the fire crew to get him out, and that will take time.

 

In the car that’s hanging over the edge of the bridge is a family of 5 people.  They are all fully conscious and have no apparent serious injuries.  As you’re making your initial assessments, the car starts to sway.  You realise that it’s going to fall off the edge of the bridge.   If it does fall, it will land on the road below, 50 feet down, which will kill the 5 people in the car.  Your judgement tells you that if you and your colleague push down on the back of the car, you’ll tip the balance and the car will stay on the bridge, saving the 5 people in the car.  However, you can also see that this will crush the elderly man beneath the car and you feel sure that this will kill him.

 

What are you going to do?  Will you watch and let the car fall, in which case the family of 5 will die but the elderly man will survive?  Or will you act to stop the car from falling, in which case the family will survive but the elderly man will die?  Remember, though, that if you choose to act and save the family, the elderly man won’t just die.  You’ll have killed him.  If you let the car fall, the family will have died – but you won’t have killed them – they just died.

 

I hope this is some food for thought for you.  It’s a little abstract but your answers do have implications for our everyday practice.  Please let us know what you think.  In part 2 we’re going to move things on and explore the implications of the decision either way!

 

Rick

 

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  1. An important topic to think about. This looks like one of the scenarios that can lead to a debate about whether euthanising people to harvest organs for transplant is ethical or not. In this particular scenario though, there are five identified individuals who will die if you make the choice to do nothing, and one who will die if you choose to take a particular action. The outcomes are pretty clear-cut, and the individuals have not been selected in any way by yourself (rather by chance or ‘fate’), and so I believe the right choice is to save the family.

    I don’t think this necessarily generalises to other superficially similar situations however.

  2. This is a nice rephrasing of the classic “Trolley Problem” in moral/ethical philosophy. There was a really interesting study done once about asking this question in 2 different ways. In both situations, you can kill 1 to save 5 or not. The variability of the question was in how removed you were from the killing. Do you flip a switch? or do you push a man off a cliff to his death? Subsequent fMRI studies found patterns of brain activity that corresponded to the answer of each (9 out of 10 would flip a switch, 9 out of ten would not push a man off a cliff).

    The context of the discussion I heard about this study was a group of people discussing the biologic root of our moral compass. We likely have evolved a sense of duty to not kill (9/10 not pushing a man off a cliff) and also a duty to save lives (flip a switch to improve mathematical outcome). Questions like this tease our evolved neurologic pathways when we want to do 2 things at the same time.

    I love this question.

  3. Excellent idea for the blog. Look forward to reading more!

    Agree on paper this is clear cut. Do the most for the most. Would struggle more with this in reality for the reasons you have outlined.

    However, I also struggle to picture the patient who is simultaneously trapped by the car and waiting to be crushed by it if you save the family.

    Possibly this misses the point, but is there a third way? Can the man be dragged free at the expense or greater injury rather than left where he is? Can something be placed under the car to take the weight off him but still allow you to stabilize the car?

  4. Would suggest reading the book “What’s wrong with eating people?” by Peter Cave. A host of similar ethical debates which move logically but become deeply uncomfortable as they progress.

    If instead of an old man under the car it is a fat man hanging onto the front and the solution is to knock him off….

    In Emergency Medicine we take the decision that seems to be the best at the time and mange the consequences. In your example either outcome will be distressing and difficult to reconcile. Often in similar circumstances everyone else runs away to avoid personal risk and those that stay have to carry the burden.

  5. I would

    – Push down on the car to save the family
    – Use my prehospital bag as a wedge to avoid crushing the old chap
    – Perform a Rapid extrication
    – Fire service to secure vehicle stat and ensure egress of the family of five

    Interesting discussion over on DoctorsNetUK last week on hemicorporectomy. The old geezer aint gonna survive, is he!

    I guess you;re angling towards a wider discussion of spending $$$$ ont eh one crook man in front of us, rather than saving the $$$ to save the others who arent imminently at risk

    Medicine, particularly in prehospital field, may be all about compromise.

    AS bit like marriage,

  6. Hi Rick – love to see a bit of ethical chatter on the blog.

    The dilemma has an interesting background – in that it has been used as a research tool by a few big name researchers looking for “universal moral grammar” in humans, the idea being that our brains are evolved / hard-wired to make certain moral decisions – eg. active vs. passive harm.
    The theory suggetss that we are not alone – even other primates may possess the same innate “moral fibre”. Tough to prove, but the responses to these scenarios are consistent across a wide range of cultures.
    In a fascinating, ironical twist – Marc Hauser – the leading psych researcher from Harvard who wrote a book called “Moral Minds” about this type of question was subsequently found by the university to have falsified data in subsequent research. So being aware of morality doesn’t seem to enforce it!

    As a doctor it is common to perform interventions in which we actively put a person at risk eg. everytime we induce anaesthesia. These “active” harms always seem more heinous and generate a lot more soul-searching than the more passive harms that occur in the health system eg. nosocomial transfer of infection, VTEs… and yet we are the means by which these bad things occur – fascinating stuff!

    Looking forward to the series. Great work
    Casey

  7. very interesting debate.

    “first do no harm” – you can’t actively cause the death of the patient under the car, no matter what good may come of it.

    “autonomy” – could you ask the man under the car if he is willing to take the risk of saving the family?

  8. I think I would find a third way- save the family without killing the old man. When you created this particular scenario it opens up the possibility of this type of technical solution that saves all.

    But of course, if it ever truly came to a choice of who should be spared if one party had to die, I would save the family.

  9. “St Emlyns Doctor charged with murder – George Brown, 72, was killed by Dr Jones whilst saving the Smith family car from falling from the A2432 bridge on Saturday evening. Mr Brown was out walking his dog when he was involved in an accident leaving him trapped under the car.
    Subsequent investigations have shown that Emlynshire Fire and Rescue were only minutes away, and an AA recovery van near to the bridge could have been used to prevent the car from falling, allowing all involved to be saved…”

    “St Emlyns Doctor found dead. Dr Jones was found at the base of the A2432 bridge on Saturday evening, police are treating the death as suicide. It is understood that Dr Jones was hit very hard by the deaths of 4 members of the Smith family, and the life-changing injuries to Daisy Smith (now 5) when their car plunged from the same bridge one year ago. Dr Jones had decided not to press down on the back of the Smiths’ family car, due to an elderly man, George Brown, being trapped under the car. Mr Brown died 2 weeks after the accident, due to complications following a fractured hip caused by the accident.”

    I suspect whatever might be done would have far-reaching implications – and wouldn’t like to be in that situation!

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  11. Ah, age old questions. Objectively no clear difference between letting die and killing. But it feels different, not least because of the less than clear pathways between our actions and their unintended consequences. (See Ann, above.) I’ll forego the easy answer of 5>1, and go with: when the scenario is a clear, direct and lifesaving choice, make the Machiavellian call of ends justify the means. If it is within your personal moral compass to do so, kill the old man. To those above who long for that clever option that avoids the “tyranny of OR”, I applaud you. When you aren’t given one, kill the old man.

    And now that I’ve given my pat answer, I think: what if it were a young man, trapped (perhaps w/ a family) and three old ladies in the car? So utilitarianism now has to weigh the value of each life. (To society? To the general public? To their families?) Ah crap. And I was doing so well.

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