Education| Volume 48, ISSUE 4, P492-498, April 2015

Download started.


Understanding Ethical Dilemmas in the Emergency Department: Views from Medical Students' Essays

Published:December 03, 2014DOI:



      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.


      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.


      During a 4th-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.


      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.


      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.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of Emergency Medicine
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • DuBois J.M.
        • Burkemper J.
        Ethics education in U.S. medical schools: a study of syllabi.
        Acad Med. 2002; 77: 432-437
        • Eckles R.E.
        • Meslin E.M.
        • Gaffney M.
        • Helft P.R.
        Medical ethics education: where are we? Where should we be going? A review.
        Acad Med. 2005; 80: 1143-1152
        • Campbell A.V.
        • Chin J.
        • Voo T.C.
        How can we know that ethics education produces ethical doctors?.
        Med Teach. 2007; 29: 431-436
        • Fryer-Edwards K.
        • Wilkins M.D.
        • Baernstein A.
        • Braddock 3rd, C.H.
        Bringing ethics education to the clinical years: ward ethics sessions at the University of Washington.
        Acad Med. 2006; 81: 626-631
        • Roberts L.W.
        • Warner T.D.
        • Hammond K.A.G.
        • Geppert C.M.A.
        • Heinrich T.
        Becoming a good doctor: perceived need for ethics training focused on practical and professional development topics.
        Acad Psychiatry. 2005; 29: 301-309
        • Hafferty F.W.
        • Franks R.
        The hidden curriculum, ethics teaching, and the structure of medical education.
        Acad Med. 1994; 69: 861-871
        • Iserson K.V.
        Ethical principles—emergency medicine.
        Emerg Med Clin North Am. 2006; 24: 513-545
        • Larkin G.L.
        • Iserson K.
        • Kassutto Z.
        • et al.
        Virtue in emergency medicine.
        Acad Emerg Med. 2009; 16: 51-55
      1. Code of ethics for emergency physicians.
        Ann Emerg Med. 2004; 43: 686-694
        • Cordingley L.
        • Hyde C.
        • Peters S.
        • Vernon B.
        • Bundy C.
        Undergraduate medical students' exposure to clinical ethics: a challenge to the development of professional behaviours?.
        Med Educ. 2007; 41: 1202-1209
        • Nelson M.S.
        • Eliastam M.
        Role-playing for teaching ethics in emergency medicine.
        Am J Emerg Med. 1991; 9: 370-374
        • Shuman A.G.
        • Barnosky A.R.
        • Koopmann C.F.
        Implementation of ethics grand rounds in an otolaryngology department.
        Laryngoscope. 2012; 122: 271-274
        • Levy F.
        • Kelen G.
        Resuscitation attempts in asystolic patients: the legal tail wagging the dog?.
        J Emerg Med. 2006; 30: 223-226
        • Santen S.A.
        • Hemphill R.R.
        A window on professionalism in the emergency department through medical student narratives.
        Ann Emerg Med. 2011; 58: 288-294
        • Corbin J.
        • Strauss A.
        Basics of qualitative research: techniques and procedures for developing grounded theory.
        Sage, Thousand Oaks, CA2008
        • Glaser B.
        • Strauss A.
        The discovery of grounded theory: strategies for qualitative research.
        Aldine, Chicago, IL1967
        • Pellegrino E.D.
        The virtues in medical practice.
        Oxford University Press, New York1993
        • Beauchamp T.L.
        • Childress J.F.
        Principles of biomedical ethics.
        Oxford University Press, New York2001
        • Kaldjian L.C.
        • Rosenbaum M.E.
        • Shinkunas L.A.
        • et al.
        Through students' eyes: ethical and professional issues identified by third-year medical students during clerkships.
        J Med Ethics. 2012; 38: 130-132
        • Bryan C.S.
        • Babelay A.M.
        Building character: a model for reflective practice.
        Acad Med. 2009; 84: 1283-1288
        • Park J.
        • Woodrow S.I.
        • Reznick R.K.
        • Beales J.
        • MacRae H.M.
        Observation, reflection, and reinforcement: surgery faculty members' and residents' perceptions of how they learned professionalism.
        Acad Med. 2010; 85: 134-139
        • Stern D.T.
        • Papadakis M.
        The developing physician—becoming a professional.
        N Engl J Med. 2006; 355: 1794-1799
        • Marco C.A.
        • Lu D.W.
        • Stettner E.
        • Sokolove P.E.
        • Ufberg J.W.
        • Noeller T.P.
        Ethics curriculum for emergency medicine graduate medical education.
        J Emerg Med. 2011; 40: 550-556