It is common for law enforcement agents to be present in the emergency department and to seek evidence or maintain custodial authority of patients after alleged criminal activity. This interaction can be particularly challenging as emergency physicians balance their ethical commitment to maintain patient confidentiality and avoid measures that may put the patient at risk and the concomitant obligation to obey laws that allow police to obtain evidence in a criminal investigation. The ACEP policy statement Law Enforcement Information Gathering in the Emergency Department recognizes this underlying tension and calls for individual emergency physician discernment when making judgments on what is appropriate while prioritizing preserving patient confidentiality, safety, and well-being.

The risk of accidental interaction with law enforcement may also influence undocumented immigrants who seek medical care. Undocumented immigrants often do not have the forms of identification necessary to obtain insurance or regular outpatient medical care. As a result, many preferentially utilize the emergency department. In its policy statement Delivery of Care to Undocumented Persons, ACEP declares its opposition to governmental initiatives to either force health care providers to report such individuals to immigration authorities when seeking care or to otherwise limit their access to care in the emergency department. Emergency physicians, therefore, have comparable obligations to maintain confidentiality for all patients regardless of immigration status. HIPAA may also require maintenance of confidentiality on issues such as immigration status.

Together, the Code of Ethics and related policy statements place a particular emphasis on maintaining the integrity of the doctor-patient relationship by preserving patient confidentiality in providing emergency care. Ethical violations can clearly arise if emergency physicians violate confidentiality directly or by facilitating unauthorized disclosures by others with competing interests. However, the Code of Ethics also envisions competing obligations that may require confidentiality to be set aside after careful discernment of the importance to disclose certain information in very narrowly defined and specific circumstances (eg, patient protection and public interest).

Ethical Obligations in Commercial Relationships and Interactions with Society

A number of ACEP policies address issues of commercial relationships between emergency physicians and outside entities. These include relationships in practice management, financial influence on clinical decision making, and conflicts of interest. With rapid changes in the health care system and the delivery of emergency care, these areas are evolving as are the ethical challenges they pose.

ACEP policy supports contractual relationships that protect the right of the emergency physician to have a fair, equitable, and supportive environment. This environment is one in which the emergency physician should be informed of any provisions in an employment arrangement that concern termination, as well as the ability to review those components of the groups’ contract with the hospital dealing with termination of the individual physician’s contract. Additionally, the emergency physician should receive early notification if performance problems arise, have the opportunity to address the relevant issues, and have adequate access to a fair evaluation and investigatory process prior to termination. ACEP policy also supports the physician’s right to review the activities of entities that manage billing and collections.