Consent for treatment, confidentiality, and appropriate treatment for psychiatric problems, substance issues, pregnancy, and sexually transmitted diseases are just some of the ethical challenges involving minor patients in the ED setting. “The ethical and timely treatment of minors is an important component of emergency medical treatment,” says Catherine A. Marco, MD, FACEP, professor in the department of emergency medicine at Wright State University in Dayton, OH.

Ethical challenges in pediatric EDs are more prevalent than in adult EDs, found a recent study.1 Researchers also found that nurses voice specific moral distress issues that are different than adult EDs. Of 123 nurses and physicians surveyed:

• most participants (69%) reported encountering daily or weekly ethical challenges;

• participants wanted more support for moral distress (16%), conflict management with patients or families (16%), and resource issues (15%);

• of 23 reported occurrences of moral distress, 61% were associated with pediatric mental health cases;

• education was the most common intervention clinicians wanted from the ethics consultation service.

“Working in the ED is often associated with being fast-paced and efficient,” says April Kam, MD, MScPH, FRCPC, one of the study’s authors. In contrast, an ethical consultation is viewed as a slow process of careful deliberation that happens on inpatient wards.

As a pediatric emergency physician at McMaster Children’s Hospital in Ontario, Canada, Kam has personally encountered many ethical dilemmas: “I was interested in what the needs were in the ED and how we could address it.” Not surprisingly, nearly two-thirds of respondents reported encountering ethical issues daily or weekly

“The ED is the point of entry for the most vulnerable patients during a stressful time in their lives,” says Kam. Clinicians are making decisions with incomplete information and limited resources. The survey responses reflected keen awareness of these ethical challenges. “The qualitative comments were so rich,” says Kam. “They reflect the challenging environment that all ED healthcare providers work in and the moral distress that they inevitably experience.”

EDs would clearly benefit from more ethics education and ethics-based decision-making tools. “But perhaps equally importantly, there needs to be an outlet for the concerns of ED healthcare providers to be addressed,” says Kam.

At McMaster Children’s Hospital, ED providers do this by documenting any concerns, which are discussed during daily meetings. “We are also in the early stages of implementing a uniform way to debrief after resuscitations,” adds Kam.


1. Colaco KA, Courtright A, Andreychuk S, et al. Ethics consultation in paediatric and adult emergency departments: an assessment of clinical, ethical, learning, and resource needs. J Med Ethics 2018; 44(1):13-20.


• April Kam, MD, MScPH, FRCPC, Associate Professor, Pediatric Emergency Medicine, McMaster University, Ontario, Canada. Phone: (905) 521-2100 ext. 73983. Email:

• Catherine A. Marco, MD, FACEP, Professor, Department of Emergency Medicine, Wright State University, Dayton, OH. Phone: (937) 395-8839. E-mail: