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Revised and approved by the ACEP Board of Directors June 2008.
Reaffirmed by the ACEP Board of Directors October 2001.
Approved by the ACEP Board of Directors June 1997 titled, "Code of Ethics for Emergency Physicians" replacing original statement titled, "Ethics Manual" approved by the ACEP Board of Directors January 1991
A Compendium of ACEP Policy Statements on Ethical Issues Revised 2002, 2003, 2004, 2005, 2006, 2007, 2008, 2009, 2011, 2012, 2013, 2014
The basic professional obligation of beneficent service to humanity is expressed in various physicians' oaths and codes of ethics. In addition to this general obligation, emergency physicians accept specific ethical obligations that arise out of the special features of emergency medical practice. The principles listed below express fundamental moral responsibilities of emergency physicians.
Emergency Physicians shall:
Although professional responsibilities have been a concern of physicians since antiquity, recent years have seen dramatic growth of both professional and societal attention to moral issues in health care. This increased interest in medical ethics is a result of multiple factors, including the greater technologic power of contemporary medicine, the medicalization of societal ills, the growing sophistication of patients, efforts to protect the civil rights of disadvantaged groups in our society, and the persistently rising costs of health care. All of these factors contribute to the significance, the complexity, and the urgency of moral questions in contemporary emergency medicine.
In addressing ethical questions, emergency physicians can consult a variety of sources for guidance. Professional oaths and codes of ethics are an important source of guidance, as are general cultural values, social norms embodied in the law, religious and philosophical moral traditions, and professional role models. All of these sources claim moral authority, and together they can inspire physicians to lead rich and committed moral lives. Problems arise, however, when different sources of moral guidance come into conflict in our pluralistic society. Numerous attempts have been made to find an overarching moral theory able to assess and prioritize moral claims from all of their various sources. Lacking agreement on the primacy of any one of these theories, we are left with a pluralism of different sources of moral guidance. The goal of bioethics is to help us understand, interpret, and weigh competing moral values as we see reasoned and defensible solutions to moral problems encountered in health care.
The unique setting and goals of emergency medicine give rise to a number of distinctive ethical concerns. Among the special moral challenges confronted by emergency physicians are the following: First, patients often arrive at the emergency department with acute illnesses or injuries that require immediate care. In these emergent situations, emergency physicians have little time to gather additional data, consult with others, or deliberate about alternative treatments. Instead, there is a presumption for quick action guided by predetermined treatment protocols. Second, patients in the emergency department often are unable to participate in decisions regarding their health care because of acute changes in their mental state. When patients lack decision-making capacity, emergency physicians cannot secure their informed consent to treatment. Third, emergency physicians typically have had no prior relationship with their patients in the emergency department. Patients often arrive in the emergency department unscheduled, in crisis, and sometimes against their own free will. Thus, emergency physicians cannot rely on earned trust or on prior knowledge of the patient's condition, values, or wishes regarding medical treatment. The patient's willingness to seek emergency care and to trust the physician is based on institutional and professional assurances rather than on an established personal relationship. Fourth, emergency physicians practice in an institutional setting, the hospital emergency department, and in close working relationships with other physicians, nurses, emergency medical technicians, and other health care professionals. Thus, emergency physicians must understand and respect institutional regulations and inter-professional norms of conduct. Fifth, in the United States, emergency physicians have been given a unique social role and responsibility to act as health care providers of last resort for many patients who have no other feasible access to care. Sixth, emergency physicians have a societal duty to render emergency aid outside their normal health care setting when such intervention may save life or limb. Finally, by virtue of their broad expertise and training, emergency physicians are expected to be a resource for the community in prehospital care, disaster management, toxicology, cardiopulmonary resuscitation, public health, injury control, and related areas. All of these special circumstances shape the moral dimensions of emergency medical practice.
As noted above, the emergency department is a unique practice environment with distinctive moral challenges. To respond appropriately to these moral challenges, emergency physicians need knowledge of moral concepts and principles, and moral reasoning skills. Just as important for moral action as knowledge and skills, however, are morally valuable attitudes, character traits, and dispositions, identified in ethical theory as virtues. The virtuous person is motivated to act in support of his or her moral beliefs and ideals, and he or she serves as a role model for others. It is, therefore, important to identify and promote the moral virtues needed by emergency physicians. Fostering these virtues can be a kind of moral vaccination against the pitfalls inherent in emergency medical practice. Two timeless virtues of classic Western thought have essential roles in emergency medicine today: courage and justice.
Courage is the ability to carry out one's obligations despite personal risk or danger. The courageous physician advocates for patients against managed care gatekeepers, demanding employers, interrogating police, incompetent trainees, dismissive consultants, self-absorbed families, and inquiring reporters, just to name a few. Emergency physicians exhibit courage when they assume personal risk to provide steadfast care for the violent, psychologically agitated criminal or the infected intravenous drug-user. Justice or fairness is the disposition to give such person what is due to him or her. Justice helps emergency physicians shepherd resources and employ therapeutic parsimony, refusing marginally beneficial care to some while guaranteeing a basic level of care for all others.
Additional virtues important to the practice of emergency medicine are vigilance, impartiality, trustworthiness, and resilience.
Vigilance is perhaps the virtue most emblematic of emergency medicine. In few other specialties are physicians called upon to assist patients and colleagues, immediately, twenty-four hours a day. Emergency physicians must be alert and prepared to meet unpredictable and uncontrollable demands, despite the circadian disharmony that threatens personal wellness.
The virtuous emergency physician practices impartiality by giving emergency patients an unconditional positive regard and treating them in an unbiased, unprejudiced way. Impartiality is most important in emergency medicine, since many emergency patients are poor or intoxicated and have poor hygiene, little education, and value systems at odds with that of the physician. Emergency physicians must treat perpetrators of violent crime with the same regard as victims and must resist the temptation to use disparaging remarks and gallows humor to ridicule psychotic patients or eccentric colleagues. Emergency physicians must be tolerant of people of different races, creeds, customs, habits, and lifestyle preferences.
Another essential virtue of emergency physicians is trustworthiness. Sick and vulnerable emergency patients are in a dependent relationship, forced to trust that emergency physicians will protect their interests through competence, informed consent, truthfulness, and the maintenance of confidentiality. Emergency physician clinical investigators must also be trustworthy, so that patient-subjects can trust they will not be exploited for power, profit, or prestige.
Finally, emergency physicians require the virtue of resilience in order to remain composed, flexible, and competent in the midst of clinical chaos. A tired, overstressed emergency department staff requires elasticity and optimism in order to stave off cynicism, resignation, disillusionment, numbing and professional burnout. Resilience enables emergency physicians to meet the challenges of difficult situations and enables them to encourage others to do so also. Excellence in emergency medicine requires flexibility, adaptability, and cooperative ability, allowing one to work well with patients and team members of all types. Resilience facilitates one's ability to recover undaunted from change of misfortune. It is also manifest in an ability to not take personally every insult hurled by angry patients, bereft families, or disgruntled coworkers. Resilient persons are hardy, curious, purposeful, and adaptable; they trust in their own power to influence the course of events. Maintaining flexibility and coping with the typical circadian disharmony of emergency work is difficult, but the virtue of resilience, an appropriate sense of humor, and an unsinkable optimism can keep team spirit afloat even in the harshest emergency department environment.
The physician-patient relationship is the moral center of medicine and the defining element in biomedical ethics. The unique nature of emergency medical practice and the diversity of emergency patients pose special moral challenges, as noted above. Broad moral principles can nevertheless help to categorize the emergency physician's fundamental ethical duties. This section will rely on a prominent principle-based approach to bioethical theory to describe emergency physician duties of beneficence, nonmaleficence, respect for autonomy, and justice.
Physicians assume a fundamental duty to serve the best interests of their patients by treating or preventing disease or injury and by informing patients about their conditions. Emergency physicians respond promptly to acute illnesses and injuries in order to prevent or minimize pain and suffering, loss of function, and loss of life. In pursuing these goals, emergency physicians serve the principle of beneficence, that is, they act for the benefit of their patients.
To secure the benefits of health care, patients freely disclose sensitive personal information to their physicians and allow physicians access to their bodies for examination and treatment. Patients retain a strong interest, however, in protecting personal information from unauthorized disclosure and in preventing unnecessary intrusions on their physical privacy. Emergency physicians also respect the principle of beneficence, therefore, by protecting the privacy of their patients and the confidentiality of patient information. Personal information may only be disclosed when such disclosure is necessary to carry out a stronger conflicting duty, such as a duty to protect an identifiable third party from serious harm or to comply with a just law.
At least as fundamental as the duty to benefit patients is the corresponding duty to refrain from inflicting harm. This duty, called the duty of nonmaleficence, is central to maintaining the emergency physician's integrity and the patient's trust. In contemporary emergency medical care, the potential for significant patient benefit is often inescapably linked with the potential for significant complications, side effects, or other harms. Emergency physicians cannot, therefore, avoid inflicting harms, but they can respect the principle of nonmaleficence by seeking always to maximize the benefits of treatment and to minimize the risk of harm. Physicians who lack appropriate training and experience in emergency medicine should not misrepresent themselves as emergency physicians. Likewise, in order to avoid unnecessary harm to patients, physicians without adequate training and knowledge should not practice without supervision in the emergency department or prehospital setting.
Adult patients with decision-making capacity have a right to accept or refuse recommended health care, and physicians have a concomitant duty to respect their choices. This right is grounded in the moral principle of respect for patient autonomy and is expressed in the legal doctrine of informed consent. According to this doctrine, physicians must first inform the patient with decision-making capacity about the nature of his or her medical condition, treatment alternatives, and their expected consequences, and then obtain the patient's voluntary consent to treatment. Emergency physicians also should respect decisions about a patient's treatment made by an appropriate surrogate decision maker, if the patient lacks decision-making capacity. Emergency physicians should be expert in the determination of decision-making capacity and the identification of appropriate surrogate decision makers if indicated.
Emergency physicians may treat without securing informed consent when immediate intervention is necessary to prevent death or serious harm to the patient. This is, however, a limited exception to the duty to obtain informed consent. When the initiation of treatment can be delayed without serious harm, informed consent should be obtained. Even if all the information needed for an informed consent cannot be provided, the emergency physician should, to whatever extent time allows, inform the patient (or, if the patient lacks capacity, a surrogate) about the treatment he or she is providing, and should not violate the explicit refusal of treatment, if the patient possesses decision-making capacity. In some cases, for personal and cultural reasons, patients ask that information be given to family or friends and that these third parties be allowed to make treatment choices for the patient. Patients may, if they wish, waive their right to informed consent or delegate decision-making authority for their care to others. Other exceptions to the duty to obtain informed consent apply when treatment is necessary to protect the public health and in a limited number of emergency medicine research protocols where obtaining consent is not feasible, provided that these research protocols are developed in concordance with federal guidelines and are approved by the appropriate review bodies.
To choose and act autonomously, patients must receive accurate information about their medical conditions and treatment options. Emergency physicians should relay sufficient information to patients for them to make an informed choice among various diagnostic and treatment options. Emergency physicians, when speaking to patients and families, must not overstate their experience or abilities, or those of their colleagues or institution. They should not overstate the potential benefits or success rates of the proposed treatment or research.
Significant moral issues may arise in the care of terminally ill patients. Emergency physicians should, for example, be willing to respect a terminally ill patient's wish to forgo life-prolonging treatment, as expressed in a living will or through a health care agent appointed under a durable power of attorney for health care. Emergency physicians should also be willing to honor "Do Not Attempt Resuscitation (DNAR)" orders and other end of life orders, appropriately executed to express the patient's treatment preferences. Emergency physicians should understand established criteria for the determination of death and should be prepared to assist families in decisions regarding the potential donation of a patient's organs for transplantation.
In a broad sense, acting justly can be understood as acting with impartiality or fairness. In this sense, emergency physicians have a duty of justice to provide care to patients regardless of race, color, creed, gender, nationality, or other irrelevant properties. In a more specific sense, justice refers to the equitable distribution of benefits and burdens within a community or society. In the United States, public policy has established a limited right of patients to receive evaluation and stabilizing treatment for emergency medical conditions in hospital emergency departments. This policy indirectly ascribes to emergency physicians a social responsibility to provide necessary emergency care to all patients, regardless of ability to pay. As noted in the Principles of Ethics for Emergency Physicians listed above, emergency physicians also have a duty in justice to act as responsible stewards of the health care resources entrusted to them. In carrying out this duty, emergency physicians must make careful judgments about the appropriate allocation of resources to maximize benefits and minimize burdens.
The practice of emergency medicine requires multidisciplinary cooperation and teamwork. Emergency physicians interact closely with a wide variety of other health care professionals, including emergency nurses, emergency medical technicians, and physicians from other specialties. General ethical rules governing these interactions include honesty, respect, appreciation of other perspectives and needs, and an overriding duty to maximize patient benefit.
Emergency physicians, in keeping patient benefit as a primary goal, must participate with other physicians in the provision of health care. Channels of communication between health care providers must remain open to optimize patient outcomes. However, communication may be interrupted when a sick patient requires immediate and definitive intervention before discussion with other physicians can take place. When practical, emergency physicians should cooperate with the patient's primary care physician to provide continuity of care that satisfies the needs of the patient and minimizes burdens to other providers. Concerns regarding the extent of primary care rendered and referral required should be discussed with the primary physician whenever practical. Emergency physicians should support the development and implementation of systems that facilitate communications with primary care providers, consultants, and others involved in patient care.
On-call physicians, like emergency physicians, are morally obligated to provide timely and appropriate medical care. Emergency physicians should strive to treat consultants fairly and to make care as efficient as possible. The choice of consultant by the emergency physician may be guided by the preference of both the primary care physician and the patient or by institutional protocols. If multiple physicians work in the emergency department, each patient should have a clearly identified physician who is responsible for his or her care. Transfer of this responsibility should be clear to the patient, family, and staff involved, and should be clearly documented in the patient's medical record. When a patient is discharged from the emergency department, there must be a clear transfer of responsibility to the admitting or follow-up physician. This transfer must be clearly communicated to the patient when practical.
Although the emergency physician assumes primary responsibility for patient welfare, emergency medicine is a team effort. For any specific patient, the physician must coordinate the efforts of nurses and support staff. To make the most effective use of the specific skills and expertise of emergency physicians, nurses, and other support staff, all should participate in the design and execution of emergency department care systems and protocols. Neither nurse practitioners nor physician assistants nor doctors in training should be used as emergency physician substitutes without adequate supervision and the consent of patients.
In the prehospital setting, emergency medical technicians of all levels rely on and rightfully expect the cooperation of emergency physicians with whom they work. Base station command physicians and other emergency providers should strive to work harmoniously with prehospital personnel to optimize care for the patient. Patient-centered, nonjudgmental, open communication is an important part of ethical medical command. Hospital and prehospital providers must respect patient confidentiality and the dignity of all personnel involved.
The principle of nonmaleficence dictates that patients be protected from physicians who are incompetent or impaired. Emergency physicians should strive for technical and moral excellence and should refrain from fraud or deception. When any physician is found deficient in competence or character through appropriate peer review process, it is morally imperative to protect patients and to assist that physician in addressing and, if possible, overcoming such deficiencies. Corrective action may include internal discipline or remedial training. To provide adequate protection for their patients, health care institutions should require appropriate remediation before the impaired physician returns to practice.
Emergency physicians should be advocates for emergency medical care as a fundamental right. Cost effective and efficient care is important so that resources can be available to provide care when it is needed. Cooperation with persons whose expertise is in the management and administration of health care systems is essential for provision of efficient care. A central role of physicians is to keep patient interests paramount in administrative and business decisions.
Emergency physicians practicing in academic settings have important moral responsibilities to medical students, residents, prehospital care personnel, and learners of all types. Learners depend on their clinical supervisors and professors to teach them both the moral and technical aspects of emergency medical practice. In addition to providing explicit instruction, practicing emergency physicians should serve as role models for ethical behavior in their relationships with patients, students, research subjects, and other health care professionals.
Emergency medicine residents, medical students, and other health care professionals in training must not be mistreated, abused, or coerced for faculty self-interest. Teaching physicians must fulfill their obligation to teach and provide appropriate levels of supervision for students under their tutelage. Performance evaluations and letters of recommendation require a careful assessment of the learners' strengths and weaknesses. Such evaluations must be accurate and clearly identify those individuals who may jeopardize patient care. Patient interests should not be compromised in the education process, and patients should never be required to participate in teaching activities or research without their consent. Emergency medicine residents must strive to master the discipline of emergency medicine, including understanding and accepting their moral duties to patients, profession, and society.
Expert witnesses are called on to assess the appropriateness of care provided by emergency physicians in matters of alleged medical malpractice and peer review. To assure that unbiased expert witness testimony is available to courts and panels that are trying to determine the applicable standard of care, the American College of Emergency Physicians (ACEP) encourages emergency physicians with sufficient expertise to testify in these venues. ACEP believes that these expert witnesses, at a minimum, should be emergency physicians who are certified in emergency medicine by the American Board of Emergency Medicine (ABEM), the American Osteopathic Board of Emergency Medicine (AOBEM), or, in pediatric emergency medicine, by the American Board of Pediatrics (ABP), and who have been actively practicing clinical emergency medicine for at least three years prior to the date of the incident under review.
As an expert witness, the physician has a clear ethical responsibility to be objective, truthful, and impartial, evaluating cases on the basis of generally accepted practice standards. It is unethical to overstate one's opinions or credentials, to misrepresent maloccurence as malpractice, to provide false testimony, or to use the name of the College as prima facie evidence of expertise.
While reasonable compensation for a physician's time is ethically acceptable, physicians should not provide expert testimony solely for financial gain lest this unduly influence their testimony.
The emergency physician researcher should abide by basic moral and legal principles contained in federal, institutional, and professional guidelines that govern human and animal research. Basic ethical requirements for research studies include appropriate study goals, scientifically valid design, appropriate informed consent, confidentiality of records, and minimization of risks to subjects. Approval from appropriate institutional review boards is required, but it remains the responsibility of the investigator to protect the rights and welfare of patient-subjects. Federal regulations allow institutional review boards to grant a limited waiver of informed consent in specific emergency medicine research studies, where multiple additional protections for patient-subjects are provided. It is imperative that data be collected carefully, interpreted correctly, and reported accurately; research misconduct and fraud are grounds for disciplinary action and loss of funding. Emergency physician investigators should follow responsible authorship practices; for example, all co-authors should actively participate in all parts of the study, including literature review, study design, data collection, data analysis, and manuscript preparation.
The emergency physician owes duties not only to his or her patients, but also to the society in which the physician and patients dwell. Though the emergency physician's duty to the patient is primary, it is not absolute. Emergency physician duties to the general public inform decision-making on a daily basis; for example, the emergency physician has duties to allocate resources justly, oppose violence, and promote the public health that sometimes transcend duties to individual patients. To fulfill demands of equity and justice, society may place limits on the authority of the physician to satisfy an individual patient's interests. Emergency physicians should be active in legislative, regulatory, institutional, and educational pursuits that promote patient safety and quality emergency care.
Both society and individual emergency physicians confront questions of justice in deciding how to distribute the benefits of health care and the burdens of financing that care among the various members of the society. Emergency physicians routinely address these issues when they assign order of priority for treatment and choose appropriate diagnostic and treatment resources. In making these judgments, emergency physicians must attempt to reconcile the goals of equitable access to health care and just allocation of health care with the increasing scarcity of resources and the need for cost containment.
As noted above, US public policy, as articulated in the federal Emergency Medical Treatment and Active Labor Act (EMTALA), has established access to quality emergency care as an individual right that should be available to all who seek it. Recognizing that emergency care makes a substantial contribution to personal well-being, emergency physicians endorse this right and support the universal access to emergency care. Denial of emergency care or delay in providing emergency services on the basis of race, religion, sexual orientation, real or perceived gender identity, ethnic background, social status, type of illness or injury, or ability to pay is unethical. Emergency physicians should act as advocates for the health needs of indigent patients, assisting them in finding appropriate care. Insurers, including managed care organizations, must support insured patients' access to emergency medical care for what a prudent layperson would reasonably perceive as an emergency medical condition. Society, through its political process, must adequately fund emergency care for all who need it.
Decisions to limit access to care may be made only when the resources of the emergency department are depleted. If overcrowding limits access to care, that limit must be applied equitably, unless the hospital has a unique community resource such as a trauma center, in which case the selection of a special category of patient may be acceptable.
Prehospital care is an essential societal good that emergency physicians, in conjunction with government, industry, and insurers must continue to make available to all members of society. All patients seeking assistance of prehospital care providers should undergo assessment by emergency medical technicians or paramedics in a timely fashion. Decisions concerning transport to a medical facility should be made on the basis of medical necessity, patient preference, and the capacity of the facility to deal with the medical problem.
Patients requiring hospitalization for further care should not be denied access to an appropriate medical facility on the basis of financial considerations. Transfer to another appropriate accepting medical facility for financial reasons may be effected if a) the patient provides consent and b) there is no undue risk to the patient. Admission or transfer decisions should be made on the basis of a patient's best interest.
It is unethical for an emergency physician to participate in the transfer of an emergency patient to another medical facility unless the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the risks of the transfer or unless a competent patient, or a legally responsible person acting on the patient's behalf, gives informed consent for the transfer. Emergency physicians should be knowledgeable about applicable federal and state laws regarding the transfer of patients between health care facilities.
Although the care and disposition of the patient are primarily the responsibility of the emergency physician, on-call consultants should share equitably in the care of indigent patients. This may include an on-site evaluation by the consultant if requested by the emergency physician.
Emergency physicians have an obligation to ensure that quality care is provided to all patients presenting to the emergency department for treatment. Participation in quality assurance activities and peer review are important for assuring that patterns of inadequate care are detected. Participation in continuing education activities, including the development of scientifically-based practice guidelines, assists the emergency physician in providing quality care.
Health care resources, including new technologies, should be used on the basis of individual patient needs and the appropriateness of the therapy as documented by medical literature. Diagnostic and therapeutic decisions should be made on the basis of potential risks and benefits of alternative treatments versus no treatment. The emergency physician has an obligation to diagnose and treat patients in a cost-effective manner and must be knowledgeable about cost-effective strategies; but the physician should not allow cost containment to impede proper medical treatment of the patient.
Because of their unique expertise, emergency physicians have an ethical duty to respond to emergencies in the community and offer assistance. This responsibility is buttressed by local Good Samaritan statutes that protect health care professionals from legal liability for good-faith efforts to render first aid. Physicians should not disrupt paramedical personnel who are under base station medical control and direction.
In a situation where the resources of a health care facility are overwhelmed by epidemic illness, mass casualties, or the victims of a natural or manmade disaster, the prudent emergency physician must make important triage decisions to benefit the greatest number of potential survivors. When the numbers of patients and severity of their injuries overpower existing resources, triage decisions should classify patients according to both their need and their likelihood of survival. The overriding principle should be to focus health care resources on those patients most likely to benefit who have a reasonable probability of survival. Those patients with fatal injuries and those with minor injuries should be made as comfortable as possible while they await further medical assistance and treatment.
Serving as a societal resource, emergency physicians have the dual obligation to protect themselves, staff, and patients from violence and to teach EMS personnel under their supervision to do likewise. Hospitals have a duty to provide adequate numbers of trained security personnel to assure a safe environment. Ensuring safety may mean that patients who appear to present a high risk of violence will lose some autonomy as they are restrained physically or chemically. Emergency physicians never should resort to restraints or medication for punitive or vindictive reasons. Restraints are indicated only when there is a reasonable possibility that patients will harm themselves or others. The need for restraint of emergency department patients should frequently be reevaluated.
The emergency physician has an ethical duty to diagnose, treat, and properly refer suspected victims of abuse and neglect, including partners, children and dependent adults, and to report domestic violence to appropriate authorities as permitted or required by law.
Emergency physicians advocate for the public health in many ways, including the provision of basic health care for many uninsured patients. As a safety net both for patients who lack other resources of care and for victims of disaster, emergency departments provide needed care and assistance to many of the most vulnerable members of society. In times of disaster, pandemic, or other public health emergencies, emergency departments serve as a vanguard of preparedness against a constellation of medical and social ills.
Emergency physicians have first-hand knowledge of the grave harms caused by firearms, motor vehicles, alcohol, and other causes of preventable illness and injury. Inspired by this knowledge, emergency physicians should participate in efforts to educate others about the potential of well-designed laws, programs, and policies to improve the overall health and safety of the public.
Serving patients effectively requires both scientific and technical competence, knowledge of what can be done, and moral competence, knowledge of what should be done. The technical emphasis of emergency medicine must be accompanied by a corresponding emphasis on character and careful moral reasoning, as emergency physicians increasingly confront difficult moral questions in clinical practice.
In the face of future uncertainties and challenges, ethics will remain central to the clinical practice of quality emergency medicine. Both technical and moral expertise can and should be nurtured through advanced preparation and training. The time and information constraints inherent in emergency practice make reflection on important ethical principles and values challenging. This Code is offered both for thoughtful consideration and as a resource when issues arise in clinical practice. The principles of emergency medical ethics identified herein may serve as a guide for practitioners and students of this developing art. Through the process of moral reflection and deliberation, emergency physicians can make difficult and time-sensitive decisions based on a sound moral framework that benefits both patients and profession.
The policy statements listed in the Compendium section of the Table of Contents of this policy are available on ACEP's website http://acep.org


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Consolidation: The costly fictionMarch 13,2014Policymakers are declaring it a bad year for Vermont school budgets. Thats because 35 were voted down. The fact that voters approved 217 budgets doesnt seem to matter as much.
Almost all those defeated budgets included just a modest increase or even a decline in actual spending. This means local school boards are doing their job. However, because of varying declines in pupil numbers, some districts per pupil costs arithmetically increased. Per pupil costs are misleading since losing a couple of fifth-graders doesnt make running your fifth-grade class less expensive, but because the states funding formula rests heavily on per pupil costs, state funding to those districts decreased. In short, even where actual school costs went down, school taxes often went up.
Since taxes probably shouldnt increase when school costs decrease, officials plan to revise the formula. They also say schools should cut expenses.
Most teachers could provide a list of unproductive programs and consultants, and redundant, untested assessments by which their schools waste money. These expenditures are commonly tied to state and federal mandates and that miraculous funding source called grants, which we like to pretend dont cost anything, even though they come out of the same wallets that pay school taxes.
Policymakers rarely question these questionable expenses. Many instead argue that small school districts duplicate administrative services, and that we could reduce those costs by consolidating districts under fewer superintendents.
Lurking behind administrative restructuring is the reality that consolidation means not only the elimination of some local administrators, but also the elimination of many local schools. In towns with one school, this means losing your town school altogether.
Despite claims that consolidating districts would save money, thats not how things usually work out. My reading suggests that consolidation eventually costs more, not less, but the best that proponents can reasonably argue is that its fiscally neutral. For every economy of scale in hiring or purchasing, there are at least as many inefficiencies that come with greater distance from the classrooms and schools where actual education is delivered. As for reducing administrators, the first thing most superintendents in larger districts do is hire assistant superintendents.
Proponents also argue that consolidation would somehow better provide education for the 21st century, a tagline policymakers have been tacking on to justify dubious ideas since the 1980s. This false assertion is more insidious and dangerous. Its advocates tout the alleged benefits when schools adopt a shared vision. They claim that consolidating power into larger districts they often hope to lead is for the kids.
In practice shared vision means whatever theory happens to be the current educational flavor of the month. Its commonly shared by cramming it down the throats of local teachers, parents and taxpayers. Policymakers rail against one size fits all education, but thats precisely what results from consolidated supervisory directives. As for the kids, you cant know whats good for students unless you work with them. The problem with public education is that too many decisions are already made by people too far from and ignorant of what happens in a classroom. Consolidation would only exacerbate this pernicious flaw in the way we govern schools.
Critics complain that governance by local boards is messy and inefficient, and sometimes it is. But Winston Churchill was right. Democracy is the worst form of government, except for all the others.
Each of us has little direct influence on our national leaders, but we accept that limitation because the federal government, while distant, is best suited to deal with issues like defense and foreign policy. At the State House we have a slightly enhanced opportunity to affect decisions. But our most direct control over public policy exists in our towns and cities.
Nothing belongs closer to home than control of our public schools. Exporting power over our schools to some governing body across the county or state will weaken our communities and deny parents a meaningful voice in their childrens education.
Proponents claim that maintaining community schools is an outmoded, romanticized custom we can no longer afford. The truth is theirs is the costly fiction that ignores economic and education realities.
Make no mistake. Consolidating school districts wont save money. What it will do is further weaken schools by removing control of public education even farther from the classrooms where education happens.
Peter Berger teaches English at Weathersfield School.MORE IN CommentarySure, you can buy your uncle a necktie that he wont wear, or your niece an Amazon certificate... Full StoryA lot of serious long-term national issues simply werent addressed in the recent national election. Full StoryI have written on the anomaly of the separation of the private and public sectors in our society,... Full Story
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Dartmouth Beats No. 17 Harvard on Dysenchuk's Last-Second Goal
from press release
HANOVER, N.H. — Sophomore Nikki Dysenchuk
(Darien, Conn.) scored in the last second of regulation to push the
Dartmouth men's lacrosse team past 17th-ranked Harvard, 9-8, on
Saturday at Scully-Fahey Field. It was Dysenchuk's only goal of the
contest and his eighth goal on the season. It improved the Big
Green to 4-3 overall and 1-0 in the Ivy League. The Crimson dropped
to 5-2 overall and 1-1 in the conference. The loss also ended
Harvard's four-game winning streak.
Dartmouth held an 8-6 lead with 3:47 remaining in the game, but could not stop the late attack by the Crimson. Harvard cut the lead to one on a goal by Ryan Stevens and then tied the contest on a man-up goal by Jeff Cohen with 1:16 left in the game.
The Big Green maintained possession for the last shot but missed, and the ball went out of play with 2.5 seconds left on the clock. The officials discussed the play and added time to give Dartmouth 4.7 second to try and score. Dysenchuk took the ball from behind the net and attacked from the right side. He blew past the defender, and fired a low line drive that beat the goalie as time expired.
The scoring started quickly in the game with the Big Green netting a goal seven seconds into the first. After winning the opening face off, Dartmouth got the ball to junior John DeChiaro (Port Jefferson Station, N.Y.) who beat Harry Krieger for the first goal. Harvard responded by scoring two goals in the quarter to take a 2-1 lead into the second. In the second quarter, the Big Green outscored the Crimson, 2-1, to push the game to a 3-3 tie heading into halftime. Dartmouth won the third quarter 3-2, and each team scored three goals in the final period.
Junior Fergus Campbell (New Canaan, Conn.) slowed down a Harvard offense that came into the game averaging 12.67 goals per game. Campbell tied a season high by making 17 saves in the victory. Campbell earlier this season had 17 saves in a 9-7 victory at Sacred Heart. Sophomore Chris Costabile (Sykesville, Md.) led the team with three goals to bring his season total to eight. The only other player with more than one point was junior Drew Tunney (Greenwich, Conn.) who had a goal and an assist. In all, seven different Dartmouth players recorded a goal, including the first career goal for senior Adam Boardman (Longmeadow, Mass.).
Harvard went 1-for-4 in man-up situations, while the Big Green went 0-for-1. The Crimson grabbed 37 ground balls compared to 31 for Dartmouth.
The Big Green next play at seventh-ranked Cornell on Sunday, April 3, at 3 p.m.
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April 12, 2012 —
For the past week, I have fallen under the thrall of a mesmerizing event that is being streamed live via two webcams hosted by the Cornell Lab of Ornithology. A pair of herons are tending five beautiful blue eggs in a nest built in a dead white oak in the middle of Sapsucker Woods pond outside the Cornell Lab's Johnson Center for Birds and Biodiversity in the Ithaca, NY region.
The fifth egg was laid on April 6. At month's end, viewers are in for a treat when the eggs hatch, during the final week of April. Thanks to the marvels of modern technology, the dedication of Cornell staff and the pair of herons providing the show, we can all experience the moments when the eggs crack and the chicks, covered in pale gray down, begin to emerge.
According to the website, herons have nested there since 2009, hatching and fledging four young each year. The male and female share incubation duties for 25-30 days and the young hatch at various times over a period of two to five days. They will remain in the nest for seven to eight weeks before taking their first flight.
In summer 2009, the herons began building the nest. Now nearly four feet across and a foot deep, it wraps almost entirely around the trunk of the tree. Herons also form colonies or "heronries," with multiple nests made from sticks placed high in trees.
Accessing the Cornell Lab's webcam also allows viewers to hear the natural sounds emanating from the ten-acre pond and surrounding woods, such as a chorus of spring peepers and occasional honks from Canada geese. As the herons' feathers ruffle in the wind and the clouds drift overhead, the effect can be likened to viewing a living painting. See the not-so-minor miracle underway at www.allaboutbirds.org/page.aspx?pid=2433 [2]. Join in the lively chat that has developed. And consider making a donation to sustain this wonderful resource.


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June 2007
Authorizers Support New School
After an authorizer grants a charter to the individual or group who will run the charter school, the real work of school start-up begins. The majority of the school's and the authorizer's responsibilities start after the charter is granted: The authorizer and the school must define their obligations to one another and the methods by which the authorizer will hold the school accountable. During the first few months—even up to the first year—of a school's operation, these authorizers provide intensive support to help ensure that the school's goals and responsibilities are clear, and that the school has everything in place that will support its success.
Assist schools in developing meaningful measures of student performance
After the charter is granted, but before the school opens, it is important to define the school's student performance goals and how they will be measured. Most of these organizations follow a yearlong process during which they work with the school to develop rigorous performance goals. In some cases, authorizers allow schools one year after opening to develop their accountability plans. These authorizers report that working with schools over an extended period of time allows them to define meaningful performance goals based on students' incoming performance levels.
Each authorizer profiled in this guide includes student performance measures that are the same for all of its schools. This allows each authorizer to compare the performance of its schools to each other and to other schools with similar student populations. While some offices continue to include school-specific performance measures in the accountability plan or contract, others do not encourage schools to include school-specific indicators, largely because it is challenging for schools to develop rigorous assessments to measure these indicators. Those who continue to include schoolspecific indicators argue that such indicators benefit schools because they allow the schools to evaluate their success in meeting unique missions. These authorizers also argue that schoolspecific indicators allow schools to counter the problems associated with using only one statewide standardized test (such as test results reported too late to be useful to teachers). The Massachusetts charter office, for example, has written guidelines that refer to this dilemma by noting, "The solution to the challenge posed by the limitations of one assessment tool is to use assessments strategically and in combination."
The charter school accountability system in Massachusetts requires schools to establish specific five-year performance objectives designed to measure the school's progress in three areas: 1) raising student achievement, 2) establishing a viable organization (e.g., one that has financial stability), and 3) fulfilling the terms of its charter. These objectives are included in each school's accountability plan. Schools are required to submit their initial plan by Aug. 1 after their first year of operation. Every Aug. 1 thereafter, each school submits an annual report that discusses the school's interim progress on each goal and presents evidence to validate its claims.
In order to help schools undertake the daunting task of writing an accountability plan that measures progress in so many different areas, the Massachusetts charter office has developed Guidelines for Writing Charter School Accountability Plans.12 This document provides schools with detailed instructions on developing goals and measures and includes references to many common pitfalls. For example, the guidelines note in the first few pages:
An accountability plan is not designed to describe all of the outcomes a charter school has set for itself. It sets objectives for the most critical areas of performance that will inform a decision about whether to renew the school's charter. Effective measurement and reporting can require a significant commitment of time and resources, and even concise goals can yield a lengthy Annual Report. A more powerful case is made when schools measure fewer things better than many things incompletely or superficially.
Relative to the other authorizers, the SUNY Institute and the Indianapolis mayor's office have fairly prescriptive performance requirements for the schools they authorize. SUNY Institute charter schools are required to develop an accountability plan during the first year of their charter that includes goals that are organized into two sections—"academic" and "unique programmatic areas." Charter schools authorized by the Indianapolis mayor's office also are required to develop an accountability plan during the first year of their charter.
In SUNY Institute-authorized schools, student performance must be measured in absolute terms, using value-added measures (e.g., assessments that measure students' academic growth), and compared to the performance of local district schools or the district school where the charter school's students would have been assigned to attend. SUNY Institute expects at least 75 percent of all its schools' students to score at proficiency levels on state reading and math exams. SUNY Institute staff members offer workshops for schools as well as individual guidance to help them develop meaningful and measurable goals for student performance.
Charter schools authorized by the Indianapolis mayor's office are required to measure students' performance not only using state standardized tests but also using the Northwest Evaluation Association's Measures of Academic Progress reading and math tests in the fall and spring. (See fig. 6 for the Indianapolis mayor's office timeline for accountability plan development, implementation, and oversight, which describes when the schools submit testing data and other performance indicators to the mayor's office.) This consistent year-to-year testing allows the mayor's office to assess the "value-added" by each school—the school's contribution to the learning of its students. The charter schools office at CMU also conducts a value-added analysis of its schools' performance, using a Web-based, realtime assessment system called Scantron's Performance Series, which it makes available to all of its schools. Schools administer the test every fall and spring and use the testing data to track students' learning progress over time. The Indianapolis mayor's office also encourages schools to develop school-specific performance goals, but schools are not required to do so.
Figure 6. Indianapolis Mayor's Office Timeline for Accountability Plan Development, Implementation, and Oversight
|Year 1
|Summer Pre-Opening
|School finalize initial common and school-specific performance indicators and assessments and makes plans for baseline data gathering. A representative from the Mayor's Office visits each school to ensure the school is ready for operation
|School collects baseline data on all initial performance indicators. External team visits school to assess implementation of basic system and processes, and provides feedback to school.
|School submits baseline data on all initial performance indicators to the Mayor's Office.
|School continues gathering data on all initial performance indicators. External team visits school to assess implementation of systems and processes, and provides feedback to school. External organization surveys staff and parents at school.
|Summer (by June 1)
|School submits data reporting annual progress on all initial performance indicators to the Mayor's Office.
|Year 2
|School continues gathering data on all performance indicators. External team may visit school to monitor performance and provide feedback.
|School submits draft school-specific indicators. External team may visit school to monitor performance and provide feedback.
|Mayor's Office and school finalize school-specific indicators.
|External organization surveys staff and parents at school.
|Summer (by June 1)
|School submits data reporting annual progress on all performance indicators to the Mayor's Office.
|Year 3
|School continues gathering data on all performance indicators. External team may visit school to monitor performance and provide feedback.
|School conducts self-evaluation of performance. External organization surveys staff and parents at school.
|Summer (by June 1)
|School submits data reporting annual progress on all performance indicators to the Mayor's Office.
|Year 4
|School continues gathering data on all performance indicators.
|Fall or Spring
|External team visits school for several days to corroborate third-year self-evaluation and provide additional information and detailed report to Mayor's Office. Mayor's Office provides feedback to school on issues that may affect the renewal of the school's charter. External organization surveys staff and parents at school.
|Summer (by June 1)
(to be scheduled)
|School submits data reporting annual progress on all performance indicators to the Mayor's Office.
School leadership meets with Mayor's Office to discuss an action plan for addressing areas needing improvement identified in the previous academic year's site visit report. If necessary, school completes a memorandum of understanding (MOU) with the Mayor's Office regarding this action plan.
|Year 5
|School continues gathering data on all performance indicators. School addresses areas needing improvement identified by third-year self-evaluation and fourth-year external report. External team may visit school to monitor performance and provide feedback.
|External organization surveys staff and parents at school.
|Summer (by June 1)
|School submits data reporting annual progress on all performance indicators to the Mayor's Office.
|Year 6
|School continues gathering data on all performance indicators. School continues addressing areas needing improvement identified by third-year self-evaluation and fourth-year external report, if not yet resolved. External team may visit school to monitor performance and provide feedback.
|External organization surveys staff and parents at school.
|Summer (by June 1)
(by August 1)
|School submits data reporting annual progress on all performance indicators to the Mayor's Office.
School submits charter renewal application by August 1st. The renewal application will be an in-depth analysis of the school's performance over the previous six years.
SUNY Institute-authorized schools may include additional measures of student performance beyond outcomes on state standardized tests. (See fig. 7 for SUNY's guidelines for writing accountability plans that include required and optional accountability measures.) However, SUNY Institute does not encourage schools to do so without demonstrating a clear understanding both of how to develop the measures and the determination of what the measures will contribute to students' success. According to Jennifer Sneed, the senior vice president of the SUNY Institute, she and other institute staff tell schools: "If this will help you in the administration of the school, is part and parcel of your mission, and will be useful to you internally, then by all means include it in your accountability plan. But the fact is, it is a lot of work. You may want to do these things, but not include them in your plan." In the development of schools' accountability plans, the SUNY Institute staff members place primary value on students' learning progress and mastery of core subjects. If schools wish to develop additional, school-specific measures of success that assess unique aspects of their school's program (such as arts performance), they must do so largely on their own.
Support schools during the incubation and planning period
These authorizers have found through experience that the most critical phase of a charter school's development is often in the first few months after it receives a charter, during which it must prepare the school for students and staff. Even the most experienced school leaders have probably not had to prepare a facility, hire an entirely new staff, develop a curriculum, attract students and prepare a budget—all in a relatively short time span. Accordingly, these authorizers provide more intensive support during this period—between the initial grant of a charter and the first day of school opening, and in some cases throughout the school's first year—than they provide after this start-up period.
In Minnesota, one of the tools that the VOA of Mn charter office uses to help schools become established initially is a detailed checklist of actions they need to take before and during the first year the school is open (see fig. 8). This checklist, which has been through several revisions, is organized as a timeline so that school leaders know what they need to do and when. The Massachusetts charter office uses a similar checklist called "Summary of All Action Items," covering what needs to be done by when. This six-page checklist is at the beginning of a handbook produced by the Massachusetts charter office to guide schools through opening. The Opening Procedures Handbook13 also includes guidelines on such issues as governance, enrollment, school safety, and hiring.
In both Chicago and New York City, authorizers use additional strategies to support schools during this critical period. The Chicago Public Schools Office of New Schools has worked with one of its partners, the Renaissance Schools Fund,* to provide each new school with funding for three staff positions, usually including the school leader, to prepare for the school's opening during the eight months leading up to its first day of classes. In addition, CPS provides optional office space and technology support so that new school leaders have adequate work space as they prepare to open. In 2006, at the time of this study, it was too early to evaluate the impact that this incubation support, which began in 2004, would have on the future success of the new schools, but initial reports from participating school leaders were positive. In the future, the CPS Office of New Schools would like to further improve the start-up process by bringing in intermediary organizations that can provide technical assistance to address common challenges, such as board development and student recruitment.
Figure 7. Excerpt From SUNY Institute's Guidelines for Writing Accountability Plans
______Charter (High) School
English Language Arts
Goal: Students will ___________________________
Absolute Proficiency
75% of each high school accountability cohort 26 will score at least 65 on the New York State English Regents exam.
Each year, the school's aggregate Performance Index on the State ELA exam will meet its Annual Measurable Objective set forth in the state's NCLB accountability system.
Operational outcome measure(s) 27
Each year, __________________________
Comparative Proficiency on State Exams
Each year, the percent of students in the high school accountability cohort passing the English Regents Exam with a score of 65 or above will exceed that of the cohort of all students from the local school district.
For each high school cohort, the percentage of students scoring above 65 on the English Regents Exam will place the school in the top quartile of all similar schools as determined by the institute and based on similar school categories as generated by the State Education Department and New York City Department of Education._____________________________
25 The Accountability Plan for a school operating in its first charter period is in effect for four years, up to the time the school would apply for charter renewal.
26 The high school accountability cohort is defined as all students who entered the ninth grade anywhere for the first time four years previously and were enrolled in a school on BEDS day of year four (excluding students no longer in the school after BEDS day for extra-ordinary reasons).
27 The outcome measure includes: an expected level of performance for students to achieve; the assessment tool to determine the performance; who will administer and score the instrument (if it is not a standardized test); when it will be administered, and to which students.
NYC charter schools have the benefit of a similar program that offers even more direct technical assistance. That is, in addition to incubation space (a desk, phone, and computer) at the nonprofit New York City Center for Charter School Excellence (CCSE), leaders of new schools also have access to leadership and management training, school development workshops, facilities planning, and school assessments that highlight students' strengths and weaknesses. (See fig. 9 for CCSE school support plan for development and operational phases.)
Every charter school authorized by the NYC office of Charter Schools also receives a preopening visit from a staff member from the charter office during the summer preceding its first year.
Figure 8. VOA of MN Charter School Start-up Progress Checklist
Figure 9. NYC CCSE individual Charter School Support Plan
Our school support actions are designed to promote quality as a critical friend, impacting new school development and results through open communication, school agreement, strong relationships and effective resources allocation. Our charter school support criteria is driven by a quality charter school model.
Fall 2005
|Planning/Start Up Tools
|Introductory Forums
|Capacity Review/Guidance
|Technical Assistance Reviews
|Web site/Print Materials
|Pipeline of New School Opportunities
|Alternative Tracks for School Ideas
|Strong School Recruitment
|Technical Assistance Needs by School
|Identification of Strong Schools
|Capacity Training and Self Assesmnet-
Quality Charter School Model
|Stimulate School Replications
|Referrals to Allied Organizations
|Application Development Referrals
|Planning Grants
|Application Issue Identification
|Strategic Leadership/Management Training
|Governance Development
|Assessment of strengths and weaknesses
|School Development Workshops (Academics,
Governance, Facilities)
|Incubation Space
|Critical Friends Reviews
|Facilitate School Visits
|Leadership Identification
|Authorizer Information Sharing
|Readiness Reviews
|Back Office Plan/Structures
|Resource Recommendations
|Best Practices Sharing
|Staffing Plan
|Staffing Support
|Facilities Plan
|Facilities Setup
|Facilities Plan
|Facilities Setup
|Funding (Public/Private) Development
|Operations Setup
|Leadership Support/Capacity Building
|School Services
|School Support Tools
|Academics - Guidebooks, Student Assessment
Tool Kit, Training, Coaching, Resources
|School Reviews - Critical Friend School Reviews,Coaching, Authorizer Reviews, Interventions
|Operations - Guidebooks, Training, Coaching,Resources, Staffing, Back Office Systems, Shared Services, Obstacle Remover
|Use of Center Space
|Annual School Reviews and School Needs Assessments
|Facilities - Real Estate Development Consultation, Site Identification Assistance, Facility Management Resources
|Strategic Planning
|Principal Coaching
|Principal Development - Pipeline, Training,Coaching
|Best practice Sharing
|Governance Development
|Teacher Development - Recruiting, Certifications Support, Professional Development Networks
|Shared Space Support
|Weak Spot Action Planning/Strategic Planning
|Communications - Materials, Consultations, External Relations
|Coordinated Communication Platform-Charter Leader News (CLN) email Updates of crucial opportunities for the charter school community
|Renewal Preparations Referrals
|Governance - Guidebooks, Recruiting, Training Resources
|Cross School Leader Networks
|Fundraising - Guidebooks, Training, Brokering
|All Schools Support: Quality Model, Advocacy Authorizer Process/Systems, Knowledge Management
The visit is based on a "school readiness review" protocol and focuses mainly on elements of successful school opening, including staffing, curriculum, facilities, and board governance. This protocol addresses factors regarding whether the school has what it needs to serve students on the first day. during this visit, staff members collect information, such as certificates of occupancy, fiscal policy manuals, job descriptions, operations manuals, and materials regarding insurance. They also make sure that school administrators know how to obtain any such missing documents before the first day of school.
Many charter school boards seek out and contract for services with school management organizations during this early stage. Such contracts are particularly common in Michigan, and CMU's charter office has become a national leader in helping charter leaders negotiate effective contracts with what they call "Educational Service Providers" or ESPs. The CMU Board of Trustees implemented its Educational Service Provider Policies14 in 1999 to help its charter school boards negotiate agreements with ESPs and establish relationships with ESPs that will be beneficial for the schools. (See fig. 10 for an educational service provider agreement included in the CMU policy guide.) The policies require, for example, that the charter school board retain its own legal counsel and demonstrate a responsible and thorough search for an ESP.
* The Renaissance Schools Fund is an independent, nonprofit organization dedicated to raising money to support the mayor's Renaissance 2010 initiative to open 100 new schools in Chicago by the year 2010.


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INGREDIENTS:¼ cup olive oil 1 lb. chorizo sausage, cut into ¼" rings and browned 1 lb. chicken, cooked and diced 1 cup red onion, small dice 4 cups fresh tomatoes, medium dice 2 Tbsp. minced fresh garlic (about 4 medium cloves) 2 Tbsp. tomato paste 1 Tbsp. brown sugar 1 Tbsp. chopped fresh rosemary 1 Tbsp. chopped fresh sage 2 tsp. salt 2 tsp. pepper 1 tsp. saffron threads ¼ tsp. crushed red pepper 1 cup California golden raisins 6 cups chicken stock 1 cup julienne rosted red peppers (about ...
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