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Film: Exposing the EmergencyDepartment

See related article, p. 217.

[Iserson KV. Film: exposing the emergency department. AnnEmerg Med. February 2001;37:220-221.]

As every 2-year-old seems to know, the easiest response toevery question is “No!” So it is with those who profess eth-ically, often giving both the discipline and its disciples ascurrilous reputation.

Television, the mass medium with which our societyhas a love-hate relationship, has dared to peek behind thecurtain into one of the last bastions of true medical mys-tique—the trauma bay. It seems we must respond. Thequestion is how? We must, of course, be sensitive to pre-serving our patients’ confidentiality (actually, both pri-vacy and confidentiality are at issue), so the knee-jerkresponse would be to say, “Of course, we shouldn’t dothis.” However, we may want to take a more reasoned lookat the issues.

As I see it, the issues are: privacy and confidentiality ofboth patients and those accompanying them, consent,and the program’s value and purpose. I will try to addresseach in turn.

P R I V A C Y

Privacy and confidentiality are separate issues—ethicallyand legally. Privacy has 3 elements: the physical sphere inwhich others may not intrude, freedom of choice overimportant decisions, and control over personal informa-tion. Closely related is confidentiality, which governswhat patient information can be revealed without explicitconsent.1 Although related, these are separate issues.

All emergency department patients (and those accom-panying them) lose some privacy because of the nature ofthe ED’s physical layout, medical necessities, and to bene-fit patients in need of close monitoring. This is, perhaps,nowhere more evident than in the trauma or resuscitationbays where patients often lose both physical and informa-tional privacy. Bodies are bared in front of strangers andpersonal data are revealed. Many of those in attendanceare neither physicians nor nurses. In some cases, theymay be police, students of various types, clerks, laboratoryand radiography technicians, department volunteers,chaplains, social workers, housekeepers, medics, andeven private citizens accompanying these individuals (eg,police “ride-alongs,” “community interns”). Such visitors

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may hear and see very private things. This is a part ofemergency medicine, and is most common in teachinghospital EDs.

How is filming without prior consent different thanother common privacy breaches in the ED (or does itdepend on who is doing the filming)? It may be instruc-tive to look at patient responses after Trauma: Life in the ERfilmed at Charity Hospital in New Orleans. Emergencyphysician Larry Weiss, MD, JD, wrote, “The photo-jour-nalists they used conducted themselves in an extremelyprofessional, pleasant, and unobtrusive manner. Wereceived endless compliments from our patient popula-tion when they saw the programs on TV.” (He still thoughtthere was an ethical problem) (personal communication,June 23, 2000).

C O N F I D E N T I A L I T Y

Once anyone becomes privy to patient information, itmust remain confidential. That is, this informationshould not and cannot be released without the patient’s(or surrogate’s) express consent. (How often police vio-late this standard is unclear.) This is stated explicitly aspart of their participation in the ED, is implicit in thebehavior of others involved in the patient’s care, or is sim-ply a professional and legal standard everyone accepts.

In many institutions, resuscitations are routinely video-taped and then shown for educational and research pur-poses without either consent from or the knowledge ofpatients, surrogates, or relatives. Cases are discussed,including sensitive and intimate details, in open confer-ences, albeit without explicitly identifying the patient—although no one ever has difficulty locating the patientname if they desire to do so. How these commonly acceptedelements of emergency medicine differ from videotaping byan outside party under the same constraints is uncertain.

Experience seems to demonstrate that filmmakers,networks, and their lawyers are more stringent about pre-serving patient confidentiality than are hospital person-nel. No one has ever claimed that networks showedpatient-trauma footage without explicit consent. Indeed,in some cases, producers review the video with the con-senter to discuss what parts they may not want shown.Confidentiality, then, is not an issue.

C O N S E N T

The question of consent is interesting. I continue to ques-tion the validity of “informed” consent obtained whenpatients or surrogates are under the stress of critical medi-cal events and in the admittedly bizarre setting of an ED. It

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They said or implied that if it were educational, it wouldbe different. But we know that the best education is goodentertainment. Why do people fall asleep at many medi-cal lectures? Because they are educational (ie, boring) andnot entertaining (ie, interesting).

One of our objectives as physicians is to educate thepublic about health issues. As organized emergencymedicine has noted with alarm, programs such as ER andChicago Hope do not show reality, thus inflating and dis-torting patient expectations. Few media portray the real-ity of violence, its effect on families, the reality of death, orthe dedication and effort expended by the entire medi-cal/emergency medical services team. If they do occasion-ally get it right, viewers see it as “only fiction.” Is educat-ing the public less important than educating medicalprofessionals? Doesn’t the injury prevention education(implied by the pain and suffering, not to mention themedical interventions) that the program shows warrant—if not mandate—its public broadcast?

Reality television is a reality—although some programsare clearly more real than others. Why are people flockingto see these programs? Primarily because the Americanpublic is not stupid—they know the difference betweenreality and soap opera. Trauma: Life in the ER is not faked—and viewers know that.

Perhaps we should ask, who benefits from the show?And who is harmed? Aside from the commercial bene-fits that the media, the hospital, and the communityaccrue, there are true social benefits: trauma preventioneducation. Might I even suggest that the producersmight want to enhance this aspect, and even make theshow a bit more interesting, by including specific edu-cational commentary. These could be visuals about howsome of the “accidents” could have been avoided, howcommon some types of trauma are among certain popu-lation groups, and things people can do to diminishsome serious trauma (eg, safety equipment on cars,power tools).

As long as patient safety is not an issue (it does notseem to be), I believe that not only does the end justifythe means (although it often does not), but also that thereis no harm in filming under these circumstances. Ibelieve that emergency medicine and the health carecommunity should actively support their activities andthose of our members who participate. Unlike the 2-year-old, we should not be afraid to say “yes.” It demon-strates maturity.

Perhaps we want to also remember that, in some ways,television is society’s anesthesia.

1. Iserson KV, Sanders AB, Mathieu D. Ethics in Emergency Medicine. 2nd ed. Tucson, AZ: GalenPress Ltd; 1995:153-154.

is, nevertheless, part and parcel of both standard emer-gency care and emergency/trauma/critical care research—when the “emergency research without immediate con-sent” policy is not being used. In addition, before the newfederal policy governing emergency research was in place,many centers used “deferred consent,” performing theintervention and then asking for surrogate or patient con-sent, such as in many brain resuscitation protocols. In theclinical arena, a number of kidney transplant centers haveclinicians place cooling-perfusion catheters in patients asthey are pronounced heart-lung dead (often in the ED) inthe hope that survivors will then give permission to donatethe organs. Both of these situations involve invasiveactions that rely on deferred consent. Although there aresome ethical questions about both (and I have raised themmyself), many physicians, EDs, medical institutions, andethicists believe that these actions were or are permissible.

How does videotaping before consent differ from theseother accepted activities? It seems to be much less intru-sive than either intrusive research or catheter placement.At least the videotapes can be destroyed. One must won-der if a certain snobbishness is in effect. People seem towant their 15 minutes of fame, whether or not physicians(or the Joint Commission on Accreditation of HealthcareOrganizations—the “Big Brother” who has been asked to“rule” on the issue) think that is appropriate. To denythem this opportunity may be simply an updated form ofpaternalism.

As for consent, I believe one not-so-obvious caveat isin order. While patients who are awake and alert can con-sent or not to the filming, they should also give their after-the-fact consent like other patients. It is not always clearthat patients immediately after trauma have the capacityto consent while in their stressed situation.

The suggestion has been made that, like research with-out prior consent, community acceptance should be ob-tained before such filming commences. If we are seekingpublic approval, it seems that we have gotten it from theresponse of patients, families, and the viewing public.Even though most emergency physicians do not watchthis program (we get enough of it in our daily work), thepublic is fascinated by the behind-the-scenes look atthings that have been traditionally hidden from them.Note that the nonprurient “Behind the Scenes” series hasbecome very popular by showing interesting and previ-ously “hidden” subject matter.

P U R P O S E

Finally, there is the question of the purpose and value offilming. It is “only entertainment,” complained critics.

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R E S P O N S E B Y J O E L M . G E I D E R M A N , M D

[Geiderman JM. Response to film: exposing the emergencydepartment. Ann Emerg Med. February 2001;37:222.]

Rather than examining this issue from the point of view ofthe 2-year-old, I prefer to look at it from the point of viewof the parent. In the United States today, the problem islack of discipline, not lack of permissiveness. As a fatherof 3 small children, I can tell you that it is easiest to say“yes” to their constant stream of requests. But this is howthe child becomes spoiled. The truly hard answer to somepopular trends is “no.”

Dr. Iserson’s statement that all patients who come tothe emergency department lose some privacy is not nec-essarily true. In our 70,000+ patients per year traumacenter, we have made great efforts through proper designto provide privacy. Where this is a problem, it is our dutyto solve it rather than exploit it. Similarly, if valid informedconsent cannot be obtained in the “bizarre setting” of anED, we must change the setting, not abandon the concept.

The quote from Dr. Weiss lacks validity because it isnot a scientific sampling whatsoever. In an equally unsci-entific sampling, I have never spoken to one friend or col-league who has said they would want a camera crew pres-ent if their spouse or children were brought into a traumabay for resuscitation.

The discussion of patients in case conferences is com-pared to videotaping by an outside party with the commentthat the difference between these 2 events is uncertain.This is like saying that attending an autopsy and peekingthrough someone’s window are similar acts because theyboth involve viewing a naked body. As to the issue of edu-cation, telling the public that if they come to an ED theirprivacy may be violated sends exactly the wrong messageabout our specialty.

Finally, there is the matter of paternalism, the blanketrejection of which is unwise. Fathers must protect chil-dren, and physicians must protect vulnerable patients. Isit not paternalistic for physicians to decide when it isallowable to waive the patient’s right to privacy? Beingwilling to say “no” in the face of enormous public and peerpressure is an act of courage, not fear.

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