A 28-year-old woman is brought to the emergency department by the police after trying to walk across a busy highway. The patient is alert and oriented to self only. She refuses vital signs, glucose testing, and a urine sample. The physician introduces himself; moments later, the patient stands and pushes him backward. The physician is able to exit the room and alert nursing and security staff. The patient continues to be verbally threatening and attempts to lunge at the physician when he returns to the examination room. She is physically restrained by staff and intramuscular lorazepam is administered. Once the patient is no longer agitated, physical restraints are promptly discontinued, and the physician continues the evaluation. Which of the following is the most accurate statement regarding this scenario?
Ethical principles in medicine | |
Principle | Duty |
Beneficence | Promote good & act in the best medical interests of the patient |
Nonmaleficence | Do no harm to the patient |
Autonomy | Protect & facilitate the patient's individual, informed decisions |
Justice | Equally distribute health care resources & provide fair & equitable treatment |
Proportionality | Ensure that methods used to achieve a worthwhile goal are necessary, appropriate & not excessive |
Proportionality is the ethical principle that considers whether an intended goal ("the end") is sufficiently worthwhile and ensures that the methods used ("the means") to achieve it are necessary, reasonable, and not excessive. "The end justifies the means" describes a goal so important that any method, even if harsh, may be used to achieve it. Upholding proportionality means that the benefits of an intervention outweigh the risks and that the degree of intervention is appropriate.
In this scenario, proportionality was upheld in the medical management of a patient without decisional capacity. This patient is alert but delirious (ie, oriented to self only), has refused medical care, and poses an imminent danger to herself and others (eg, lunging at and threatening the physician). The goal is to protect the patient and staff from harm and to facilitate an emergency evaluation for life-threatening causes of her delirium.
Given the importance of these goals, the use of physical restraints and medication is necessary, reasonable, and not excessive because lesser interventions (eg, continuing with verbal de-escalation only) would unreasonably risk greater harm and delay emergency care. In accordance with proportionality, restraints are removed immediately once the acute danger has passed, thereby curbing excessive force.
(Choice A) Capacity is determined by a patient's ability to understand and make informed decisions. This patient's lack of decisional capacity is due to acute delirium; it is not based on her refusal of care or inability to maintain personal safety because a patient with intact decisional capacity can still refuse care at the risk of personal safety.
(Choice B) Respect for autonomy means upholding a patient's informed decision. Patients without capacity are, by definition, incapable of making informed decisions. In this situation, an evaluation is medically necessary and does not violate autonomy in this situation.
(Choice C) Beneficence involves acting in the best medical interests of the patient, which may include restrictive protocols in delirious patients to limit danger and to facilitate emergency evaluation.
(Choice E) Justice refers to the equal distribution of health care resources and the provision of fair and equitable healthcare to all people. This principle was upheld when the patient was brought to the emergency department for medical care.
Educational objective:
Proportionality ensures that sufficiently worthwhile goals are achieved by necessary, reasonable, and nonexcessive methods. An example is the use of physical restraints to maintain patient safety when nonrestrictive options are insufficient, followed by immediate removal of the restraints once danger passes.