Patients without choices: the ethics of decision-making in emergency medicine.

Patients who use emergency department services generally have no choice of facilities or medical personnel. This fact affects the nature of the physician-patient relationship and the moral rules that govern it. Because a long-term relationship has not been developed, a more formal, legalistic relationship seems inevitable and appropriate. Moreover, the emotional stress of the emergency situation on the patient and the fact that the baseline mental status is unknown to the medical personnel often make it difficult to determine competency for decision-making, especially in cases of refusal of treatment. Although standards of informed consent apply in emergency care, there seem to be discrepancies between theory and practice, and emergency physicians may be more guilty than others of unjustified paternalism. Ways must be found to ensure patients the greatest degree possible of autonomy and informed consent analogous to what they would have in a nonemergency doctor-patient relationship.