Understanding ethical dilemmas in the emergency department: views from medical students' essays.

Background: For medical students, the emergency department (ED) often presents ethical problems not encountered in other settings. In many medical schools there is little ethics training during the clinical years. The benefits of reflective essay writing in ethics and professionalism education are well established.

Objectives: The purpose of this study was to determine and categorize the types of ethical dilemmas and scenarios encountered by medical students in the ED through reflective essays.

Methods: During a 4(th)-year emergency medicine rotation, all medical students wrote brief essays on an ethical situation encountered in the ED, and participated in an hour debriefing session about these essays. Qualitative analysis was performed to determine common themes from the essays. The frequency of themes was calculated.

Results: The research team coded 173 essays. The most common ethical themes were autonomy (41%), social justice (32.4%), nonmaleficence (31.8%), beneficence (26.6%), fidelity (12%), and respect (8.7%). Many of the essays contained multiple ethical principles that were often in conflict with each other. In one essay, a student grappled with the decision to intubate a patient despite a preexisting do-not-resuscitate order. This patient encounter was coded with autonomy, beneficence, and nonmaleficence. Common scenarios included ethical concerns when caring for critical patients, treatment of pain, homeless or alcoholic patients, access to care, resource utilization, and appropriateness of care.

Conclusion: Medical students encounter patients with numerous ethically based issues. Frequently, they note conflicts between ethical principles. Such essays constitute an important resource for faculty, resident, and student ethics training.