Emergency Medicine Journal
April 2015, Volume 32, Issue 4
http://emj.bmj.com/content/current

Editorial
A moral or an ethical issue?
Mary Dawood
Correspondence to Mary Dawood, Emergency Department, Imperial College NHS Trust, Praed St, Paddington, London W2 1NY, UK; Mary.dawood@imperial.nhs.uk
Accepted 6 October 2014
Published Online First 31 October 2014
[Extract]
Emergency care by its very nature is challenging where questions of ethics commonly arise. Issues such as crowding, access, urgency, sick patients and threat to life all combine to create uniquely fertile grounds for ethical dilemmas.1–4 Ethics in healthcare means doing the right thing for the patient, doing no harm, providing care and treatment that benefits the patient while at the same time respecting the patient’s autonomy and right to self-determination. Our sense of right and wrong and the duty of care we owe our patients are central to this.

Determining the right course of action in complex circumstances can be difficult and ethical decision making demands much more than a decision of what is right or wrong; it requires critical reflection. Beauchamp and Childress suggest that this reflection needs to guide what we ought to do in a specific situation by asking us to consider and reconsider ordinary actions, the rationales for those actions and the judgements we make.5

Such an ethical debate in clinical settings can be positive, instructive and can contribute to quality patient care, but moral issues that often arise simultaneously can muddy the waters. A person’s moral code is usually constant, but the ethical codes governing practice may be dependent on the context and setting and be at odds with moral feelings. In the great diversity that is healthcare and the limitations of our working environment it is often moral rather than ethical issues that give rise to angst and disequilibrium. The difference between ethics and morals is subtle, …

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Original article
Moral experience and ethical challenges in an emergency department in Pakistan: emergency physicians’ perspectives
Waleed Zafar
Correspondence to Dr Waleed Zafar, Department of Emergency Medicine, Aga Khan University, Stadium Road, P.O. Box 3500, Karachi 74800, Pakistan; waleed.zafar@aku.edu
Received 6 June 2014
Revised 1 August 2014
Accepted 15 August 2014
Published Online First 18 September 2014
Abstract
Introduction
Emergency departments (ED) are often stressful environments posing unique ethical challenges—issues that primarily raise moral rather than clinical concerns—in patient care. Despite this, there are very few reports of what emergency physicians find ethically challenging in their everyday work. Emergency medicine (EM) is a relatively young but rapidly growing specialty that is gaining acceptance worldwide. The aim of this study was to explore the perspectives of EM residents and physicians regarding the common ethical challenges they face during patient care in one of only two academic EM departments in Pakistan. These challenges could then be addressed in residents’ training and departmental practice guidelines.
Methods
A qualitative research design was employed and in-depth interviews were conducted with ED physicians. Participants were encouraged to think of specific examples from their work, to highlight the particular ethical concerns raised and to describe in detail the process by which those concerns were addressed or left unresolved. Transcripts were analysed using grounded theory methods.
Results
Thirteen participants were interviewed and they described four key challenges: how to provide highest quality care with limited resources; how to be truthful to patients; what to do when it is not possible to provide or continue treatment to patients; and when (and when not) to offer life-sustaining treatments. Participants’ accounts provided important insights into how physicians tried to resolve these challenges in the ‘local moral world’ of an ED in Pakistan.
Conclusions
The study highlights the need for developing systematic and contextually appropriate mechanisms for resolving common ethical challenges in the EDs and for training residents in moral problem solving.