Film: Exposing the Emergency Department - Annals of Emergency ...

EDITORIALS

Film: Exposing the Emergency Department See related article, p. 217. [Iserson KV. Film: exposing the emergency department. Ann Emerg Med. February 2001;37:220-221.] As every 2-year-old seems to know, the easiest response to every question is “No!” So it is with those who profess ethically, often giving both the discipline and its disciples a scurrilous reputation. Television, the mass medium with which our society has a love-hate relationship, has dared to peek behind the curtain into one of the last bastions of true medical mystique—the trauma bay. It seems we must respond. The question is how? We must, of course, be sensitive to preserving our patients’ confidentiality (actually, both privacy and confidentiality are at issue), so the knee-jerk response would be to say, “Of course, we shouldn’t do this.” However, we may want to take a more reasoned look at the issues. As I see it, the issues are: privacy and confidentiality of both patients and those accompanying them, consent, and the program’s value and purpose. I will try to address each in turn. PRIVACY

Privacy and confidentiality are separate issues—ethically and legally. Privacy has 3 elements: the physical sphere in which others may not intrude, freedom of choice over important decisions, and control over personal information. Closely related is confidentiality, which governs what patient information can be revealed without explicit consent.1 Although related, these are separate issues. All emergency department patients (and those accompanying them) lose some privacy because of the nature of the ED’s physical layout, medical necessities, and to benefit patients in need of close monitoring. This is, perhaps, nowhere more evident than in the trauma or resuscitation bays where patients often lose both physical and informational privacy. Bodies are bared in front of strangers and personal data are revealed. Many of those in attendance are neither physicians nor nurses. In some cases, they may be police, students of various types, clerks, laboratory and radiography technicians, department volunteers, chaplains, social workers, housekeepers, medics, and even private citizens accompanying these individuals (eg, police “ride-alongs,” “community interns”). Such visitors

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may hear and see very private things. This is a part of emergency medicine, and is most common in teaching hospital EDs. How is filming without prior consent different than other common privacy breaches in the ED (or does it depend on who is doing the filming)? It may be instructive to look at patient responses after Trauma: Life in the ER filmed at Charity Hospital in New Orleans. Emergency physician Larry Weiss, MD, JD, wrote, “The photo-journalists they used conducted themselves in an extremely professional, pleasant, and unobtrusive manner. We received endless compliments from our patient population when they saw the programs on TV.” (He still thought there was an ethical problem) (personal communication, June 23, 2000). CONFIDENTIALITY

Once anyone becomes privy to patient information, it must remain confidential. That is, this information should not and cannot be released without the patient’s (or surrogate’s) express consent. (How often police violate this standard is unclear.) This is stated explicitly as part of their participation in the ED, is implicit in the behavior of others involved in the patient’s care, or is simply a professional and legal standard everyone accepts. In many institutions, resuscitations are routinely videotaped and then shown for educational and research purposes without either consent from or the knowledge of patients, surrogates, or relatives. Cases are discussed, including sensitive and intimate details, in open conferences, albeit without explicitly identifying the patient— although no one ever has difficulty locating the patient name if they desire to do so. How these commonly accepted elements of emergency medicine differ from videotaping by an outside party under the same constraints is uncertain. Experience seems to demonstrate that filmmakers, networks, and their lawyers are more stringent about preserving patient confidentiality than are hospital personnel. No one has ever claimed that networks showed patient-trauma footage without explicit consent. Indeed, in some cases, producers review the video with the consenter to discuss what parts they may not want shown. Confidentiality, then, is not an issue. CONSENT

The question of consent is interesting. I continue to question the validity of “informed” consent obtained when patients or surrogates are under the stress of critical medical events and in the admittedly bizarre setting of an ED. It

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EDITORIALS

is, nevertheless, part and parcel of both standard emergency care and emergency/trauma/critical care research— when the “emergency research without immediate consent” policy is not being used. In addition, before the new federal policy governing emergency research was in place, many centers used “deferred consent,” performing the intervention and then asking for surrogate or patient consent, such as in many brain resuscitation protocols. In the clinical arena, a number of kidney transplant centers have clinicians place cooling-perfusion catheters in patients as they are pronounced heart-lung dead (often in the ED) in the hope that survivors will then give permission to donate the organs. Both of these situations involve invasive actions that rely on deferred consent. Although there are some ethical questions about both (and I have raised them myself), many physicians, EDs, medical institutions, and ethicists believe that these actions were or are permissible. How does videotaping before consent differ from these other accepted activities? It seems to be much less intrusive than either intrusive research or catheter placement. At least the videotapes can be destroyed. One must wonder if a certain snobbishness is in effect. People seem to want their 15 minutes of fame, whether or not physicians (or the Joint Commission on Accreditation of Healthcare Organizations—the “Big Brother” who has been asked to “rule” on the issue) think that is appropriate. To deny them this opportunity may be simply an updated form of paternalism. As for consent, I believe one not-so-obvious caveat is in order. While patients who are awake and alert can consent or not to the filming, they should also give their afterthe-fact consent like other patients. It is not always clear that patients immediately after trauma have the capacity to consent while in their stressed situation. The suggestion has been made that, like research without prior consent, community acceptance should be obtained before such filming commences. If we are seeking public approval, it seems that we have gotten it from the response of patients, families, and the viewing public. Even though most emergency physicians do not watch this program (we get enough of it in our daily work), the public is fascinated by the behind-the-scenes look at things that have been traditionally hidden from them. Note that the nonprurient “Behind the Scenes” series has become very popular by showing interesting and previously “hidden” subject matter. PURPOSE

Finally, there is the question of the purpose and value of filming. It is “only entertainment,” complained critics.

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They said or implied that if it were educational, it would be different. But we know that the best education is good entertainment. Why do people fall asleep at many medical lectures? Because they are educational (ie, boring) and not entertaining (ie, interesting). One of our objectives as physicians is to educate the public about health issues. As organized emergency medicine has noted with alarm, programs such as ER and Chicago Hope do not show reality, thus inflating and distorting patient expectations. Few media portray the reality of violence, its effect on families, the reality of death, or the dedication and effort expended by the entire medical/emergency medical services team. If they do occasionally get it right, viewers see it as “only fiction.” Is educating the public less important than educating medical professionals? Doesn’t the injury prevention education (implied by the pain and suffering, not to mention the medical interventions) that the program shows warrant— if not mandate—its public broadcast? Reality television is a reality—although some programs are clearly more real than others. Why are people flocking to see these programs? Primarily because the American public is not stupid—they know the difference between reality and soap opera. Trauma: Life in the ER is not faked— and viewers know that. Perhaps we should ask, who benefits from the show? And who is harmed? Aside from the commercial benefits that the media, the hospital, and the community accrue, there are true social benefits: trauma prevention education. Might I even suggest that the producers might want to enhance this aspect, and even make the show a bit more interesting, by including specific educational commentary. These could be visuals about how some of the “accidents” could have been avoided, how common some types of trauma are among certain population groups, and things people can do to diminish some serious trauma (eg, safety equipment on cars, power tools). As long as patient safety is not an issue (it does not seem to be), I believe that not only does the end justify the means (although it often does not), but also that there is no harm in filming under these circumstances. I believe that emergency medicine and the health care community should actively support their activities and those of our members who participate. Unlike the 2year-old, we should not be afraid to say “yes.” It demonstrates maturity. Perhaps we want to also remember that, in some ways, television is society’s anesthesia. 1. Iserson KV, Sanders AB, Mathieu D. Ethics in Emergency Medicine. 2nd ed. Tucson, AZ: Galen Press Ltd; 1995:153-154.

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EDITORIALS

RESPONSE BY JOEL M. GEIDERMAN, MD

[Geiderman JM. Response to film: exposing the emergency department. Ann Emerg Med. February 2001;37:222.] Rather than examining this issue from the point of view of the 2-year-old, I prefer to look at it from the point of view of the parent. In the United States today, the problem is lack of discipline, not lack of permissiveness. As a father of 3 small children, I can tell you that it is easiest to say “yes” to their constant stream of requests. But this is how the child becomes spoiled. The truly hard answer to some popular trends is “no.” Dr. Iserson’s statement that all patients who come to the emergency department lose some privacy is not necessarily true. In our 70,000+ patients per year trauma center, we have made great efforts through proper design to provide privacy. Where this is a problem, it is our duty to solve it rather than exploit it. Similarly, if valid informed consent cannot be obtained in the “bizarre setting” of an ED, we must change the setting, not abandon the concept. The quote from Dr. Weiss lacks validity because it is not a scientific sampling whatsoever. In an equally unscientific sampling, I have never spoken to one friend or colleague who has said they would want a camera crew present if their spouse or children were brought into a trauma bay for resuscitation. The discussion of patients in case conferences is compared to videotaping by an outside party with the comment that the difference between these 2 events is uncertain. This is like saying that attending an autopsy and peeking through someone’s window are similar acts because they both involve viewing a naked body. As to the issue of education, telling the public that if they come to an ED their privacy may be violated sends exactly the wrong message about our specialty. Finally, there is the matter of paternalism, the blanket rejection of which is unwise. Fathers must protect children, and physicians must protect vulnerable patients. Is it not paternalistic for physicians to decide when it is allowable to waive the patient’s right to privacy? Being willing to say “no” in the face of enormous public and peer pressure is an act of courage, not fear.

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