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VIPs in the ED – Practical and Ethical Issues

November 10, 2018

Written by Clay Smith

Spoon Feed
The authors argue that it is ethical to triage or place some VIP patients differently based on privacy concerns (assuming no harm to other patients), but it is unethical and usually harmful to actually provide different care based on VIP status.

Why does this matter?
Practicing in Nashville, it doesn’t take long to bump into celebrity patients.  I’ve seen music stars from every genre (not just country), not to mention hockey and football stars.  Oh, don’t forget big donors, suit-wearing administrators, political figures, noted scholars, and the entourage of VIP family members, friends, coaches, trainers, or body guards.  How should we handle VIPs in the ED?

Is VIP status right?
The bottom line is stated at the beginning of this article.  It may be the right thing to triage or place some VIP patients differently (assuming no harm to other patients), but it is unethical and usually harmful to actually provide different care based on VIP status.  Several ethical principles are in play.

  • Autonomy – A VIP has the right to make medical decisions that will affect their own bodies.  However, preferential treatment over others is unethical as is providing harmful, unnecessary treatment to a VIP.

  • Beneficence – We are to provide benefit to patients.  In some cases, “doing good” for the patient may mean moving a highly recognizable celebrity to a place of privacy quickly.

  • Nonmaleficence – Do no harm.  Care for a VIP should never jeopardize life or limb-saving care for another patient.

  • Justice – Especially under EMTALA, hospitals must provide the same level of medical treatment during emergencies to all people, regardless of VIP status.

  • Fairness and equality – The authors refer to, “consequentialism [aka ‘doing good for the most people’], which holds that actions can be argued to be right or wrong according to the balance of their good and bad consequences…[Therefore,] expedited VIP triage may be justified in order to benefit patients, the department and the institution all at the same time, without causing harm to anyone, as long as it is done prudently.”  I think this is debatable.  If this is code for, “rich-donors-get-a-bed-before-a-non-VIP-as-long-as-no-one-gets-hurt-because-they-will-continue-to-give-large-donations,” then this is dubious.  Looking forward to your comments!

  • Privacy – They state, “easily identified VIPs may be at greater risk of having their privacy violated,” and may need special provisions in the ED.  I think this is true.

Treatment – They argue that medical treatment must be the same, VIP or not.  For example, President Garfield likely would have survived his assassination attempt but for the domineering and subsequently disgraced lead physician, who recommended “rectal feeding” with his own recipe of, “egg yolks, finely minced meat, cold water, 2 drachams of beef peptonoids, 5 drachams of whiskey, and on some occasions several drops of tincture of opium.”  Yummy!  Compare to Reagan’s assassination attempt in which he was rushed to GW, finely tailored suit cut off, and taken to the OR like any other GSW victim.

Disposition – Under no circumstance should a VIP get a bed before a patient who is sicker and in greater need.  However, the authors argue that all things being equal, getting a celebrity out of the ED may benefit their privacy and relieve some chaos from having them there.

Avoid Harm – Deviation from standard of care treatment can lead to big trouble.  Do the right thing for the VIP and the other patients in your care.

Wrap-Up – The authors argue that prioritizing the care of VIPs, “may be ethically justifiable as long as other patients in need of time sensitive treatment or with other special needs are not harmed.”  But they are clear, “The actual medical care of VIP patients should not vary from one patient to the other.”

The care of VIPs in the emergency department: Triage, treatment and ethics.  Am J Emerg Med. 2018 Oct;36(10):1881-1885. doi: 10.1016/j.ajem.2018.07.009. Epub 2018 Jul 4.

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What are your thoughts?