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A woman admitted to the emergency room of a hospital died because no surgeon could be found to stop the bleeding from injuries she sustained in a farming accident. The case points to ethical shortcomings both institutionally and professionally. The call system is inadequate, and physician fears of being sued or insufficiently compensated contribute to the overall problem. Potential responses include the institutional equivalent of a root cause analysis and an understanding of the pressures brought to bear on physicians to treat emergencies.


Emergency Call, Institutional Ethics, John Glaser, Organizational Ethics, Root Cause Analysis


This case came to me sometime after the patient had died, so, in the usual way we think about cases, it was over. But this is not a case mainly about a patient. Rather, it illustrates a number of unresolved issues brought about by the organization of the American health care system; insofar as those issues persist, the case is unresolved.

Before I tell the story, let me rough out a frame of ethical reference. John Glaser, theologian and ethicist, describes three realms of ethics using a model of concentric circles (Glaser, 1994). Within the innermost circle is the individual. This realm is concerned with the rights and duties of individuals as well as with the rights and duties that exist between separate individuals. It is often the subject of our reflection in bioethics cases. That individual, Glaser argues, is always located within an institution—the middle circle of the three. This realm of ethics attends to the key systems and structures of the hospital institution, such as the credentialing process or the on–call system. Finally, institutions themselves are located within the largest circle, the societal realm of ethics. This realm deals with the common good, attending to systems and structures of society—political, educational, economic, legal, etc.—so that individuals within it may be born, grow, labor, love, flourish, age, and die as humanely as possible. Although the consequences of this case landed most terribly and permanently on the individual and her family, I suggest that the ethical issues can only be properly understood by viewing them within the context of the institutional and societal realms.

But first, a word about me. I provide ethics and justice education and consultation to a large not–for–profit health care system comprising 39 hospitals. Each hospital has on its executive management team a Mission Integration leader, parallel in status and responsibilities to the Human Resources executive or the Chief Financial Officer. [End Page 271] It is the responsibility of this executive to monitor and oversee implementation of our health system’s standards for mission integration in four categories, one of which is ethics. It was the Mission Integration leader in this hospital who brought the case to me, not the ethics committee chair, the Chief Medical Officer, or the hospital president. Although the case had begun some weeks before, she called me because she had a sense that the issues unresolved in the case were ethical in nature, not just administrative or financial. Her primary reason for that belief was that there was so much grief, moral distress, and emotional and psychological misery still surrounding discussion of the case by the participants as well as others who had heard about it. Here is the story.

Case Narrative

A farming accident on the day before Thanksgiving brought a 36–year–old woman into the emergency room of this midsized hospital in a midsized urban/rural Midwestern community. The woman had gotten caught in a hay baler. The baler’s blades had amputated her right arm above the elbow and sliced her back to front through her right side. The Emergency Medical Team arrived at the scene immediately, stopped the bleeding, and transported her to the hospital. On the way, the fireman who held her promised that she’d make it.

When the ambulance arrived at the hospital, the emergency department staff acted quickly to pack the woman’s wounds to slow the internal bleeding and set about securing a surgeon. Although the injury was gruesome, the ED physicians agreed with the paramedics that the woman would not die of her wounds, and that it was a matter of stopping the bleeding by surgery. The amputation was clean and the bleeding was stanched. The slice wound missed major organs but not major blood vessels. Estimates were that the patient had about an hour before exsanguination caused irreversible shock and death.

There was a general surgeon in the house, but he was in the middle of a complicated pelvic surgery and could not leave. The staff called the on–call surgeon, who was simultaneously on call for another hospital and in the middle of surgery. He suggested that the hospital call his back–up. The back–up surgeon was called, but refused to come to the hospital unless an orthopedist was in attendance; she said that the last time she came in solo, because she was the only one to touch the patient it was she who had been sued. She had no intention of risking that again. Then the hospital called the Chief of Surgery, and asked him to help get someone in. The Chief responded that he did not think it was appropriate to use his position to persuade a physician to come to the hospital for emergency cases.

A total of seven different physicians refused, for various reasons, to perform the surgery. When the original surgeon finished the operation he was performing, he took the woman to the OR to do what he could. However, so much time had elapsed that there was simply an insufficient volume of blood left in the patient. An hour and a half after her arrival in the ED, she died, leaving a husband, to whom she’d said goodbye before she lost consciousness, and four school–aged children.

A month after the incident, the root cause analysis was undertaken, as it is whenever there is an unanticipated event with a serious adverse outcome. A call system that forbids a physician from being on call in two places at once was implemented. The seven physicians have never been asked how or why the system failed. Two of them underwent peer review, which resulted in no disciplinary action.

Professional and Ethical Issues

Using Glaser’s concentric realms of ethics, our attention focuses first on the individual—the woman and her family. Understandably, such a devastating injury causes emotional shock and neither the husband nor the patient (who was quickly unconscious) exhibited the anger that the hospital executives and emergency department staff experienced at not being able to locate a surgeon. This was no doubt in part because they were spared the actual conversations with the surgeons and so never [End Page 272] heard concerns about lawsuits, payment, or other hurtful comments. As most patients might, they believed that either the surgeons were not in the area (the husband pointed it out that it was the start of a holiday weekend) or were engaged in something just as important. They were kept apprised of the status of the search situation throughout its duration and seemed simply to believe that it was probably her time to die.

Under the traditional categories often used to analyze bioethics cases, this one was unremarkable. We obviously failed to act beneficently for this woman, although our goal and her goal for treatment were the same. Her self–determination was not violated. In terms of justice, examining whether like cases are treated alike, there is no reason to think that any other person presenting with those injuries in the emergency department that morning would have been treated any better or any worse. Clearly, the usual categories used to analyze bioethics cases do not address the deep and persistent moral distress experienced by those who participated in the case. This is where Glaser’s additional realms of ethics may be helpful.

As explained earlier, Glaser’s second tier of ethical analysis is what he calls the institutional level. As I have described elsewhere (Bayley, 2007), the institution of a hospital is an organization with policies, procedures, practices, reporting relationships, quality systems, and ways of doing things. There are also political alliances, power struggles, favors done and owed, and the culture that grows up around these systems and relationships.

In terms of the ethics consultation, it is all too plain that one consultant for 39 hospitals has little chance of helpfully addressing all cases in real time. It is for this reason that all of the system’s hospitals have ethics committees that can respond while the case is unfolding. But, interestingly, no one on the ethics committee of this hospital was called, as they would have been if there had been an urgent need for a consultation over a question of mechanical ventilation, an advance directive, or pain medication. Indeed, if they had been called, what could they have offered? As I have already mentioned, none of the traditional categories of ethical conflict seemed to be helpful in analyzing what happened in this case. The neon sign blazing FAILURE OF BENEFICENCE was recognized only when it was over.

The obviously disturbing aspect of the case was that not one of the physicians believed that it was his or her duty to come to the aid of the patient. The two surgeons on call who were then performing surgery on other patients could legitimately say that those patients already had a moral claim on them. In their case, “first come, first served” is an adequate ethical guide, as it might not be under other circumstances. On an ordinary day in the emergency department, for example, the first patient in might have to be the last patient treated if her emergency is minor compared to those of the others. But when a therapeutic relationship has already been established, and a physician is in the middle of caring for another patient, he or she has no professional or ethical duty to put the first patient at risk for the sake of a new one. However, the other five surgeons—who were overwhelmed by the ghastly nature of the case, who didn’t want to risk a lawsuit, who without seeing her had decided that the patient was already doomed, who were afraid they might not get paid—these physicians could be seen as having shirked their professional responsibility.

The American Medical Association has no generally accepted code of conduct governing such situations, although its Council on Ethical and Judicial Affairs contemplated developing guidelines and even sought oral testimony at a meeting of the House of Delegates. Still, the Director of Ethics Policy at the AMA, when hearing of the case, indicated that the AMA Principles of Medical Ethics, which are the foundation of its Code of Ethics, state unambiguously that physicians are free to choose their patients except in emergencies, and that in her opinion, the physicians who refused to attend to the patient violated one of the most fundamental and long–held tenets of American medical ethics. She added that their actions should be severely condemned (Karine Morin, personal email communication, 2009). [End Page 273]

The call system is an odd hybrid of emergency preparedness and business as usual. On the one hand, a hospital needs to be prepared for the unexpected—a local disaster, family emergencies of regularly scheduled physicians, illnesses or injuries that require the skills of specialists. On the other hand, a hospital cannot afford to pay specialists to sit around and wait for the unexpected. Under ordinary circumstances, physicians with special skills agree to serve on call rotation as part of their privileges to practice at a hospital. But as physicians have perceived a change for the worse in many conditions of practice, from lack of reimbursement by insurance companies to the likelihood of a dissatisfied patient suing, some of them have decided that the one aspect of their quality of life over which they do have some control is whether or not to take call. As they see it, rather than be awakened in the middle of the night, or take time from their families or their hobbies, they would prefer not to be on the call rotation. A further reason to decline call is that many Americans who still have no health insurance use the emergency room as their main source of health care. Emergency departments see patients who, because they have not had primary care, come to the hospital very sick. Physicians rightly suspect that, in many cases, those people who become their patients through the emergency room will be unable to pay their bills.1

In order to address this perplexing situation, some hospitals have begun to pay physicians for being on call. This is a difficult solution that brings up justice issues of its own. Typically, a hospital will pay some specialists to be on call when there are not enough of them. If there are enough physicians in a certain specialty—say, pulmonologists—to cover the rotation adequately, these specialists will not be paid. But if there is a scarcity of a particular specialty—such as orthopedists or pediatricians—these physicians, on the same staff as the pulmonologists, will be paid. If the hospital just decided to be generous and pay them all, the bill would run into the millions.2 The inequity of paying some physicians for call duty but not others raises concerns about justice.

At the institutional level of ethical analysis, then, we can see several conflicts of values. First, there is the conflict between individual physicians’ autonomy and the values of their profession. According to the AMA, their code of ethics requires physicians to attend a patient in an emergency if they are not already attending another patient, something five of the physicians did not do. Second, there is the conflict between physicians and the hospital. Physicians want to be compensated fairly for their work but hospitals cannot afford to compensate them all without putting their own finances at risk. This understandably stresses the stewardship duty of the hospital to conserve resources wherever possible in order to offer fair pay to providers, such as nurses; to provide uncompensated care for patients who are not insured; and to sponsor programs that benefit the community. This conflict is directly influenced by the unaligned interests of physicians and hospitals in general. In the United States, most doctors are independent contractors, not hospital employees. In this delicate relationship, physicians can simply admit patients elsewhere if the conditions at a particular hospital (including expectation of call duty, attitudes of management, peer relationships) are not to their liking.

One of the main insights of Glaser’s three realms model is that the pressure that molds each realm comes from the outside in. An individual can only be marginally more ethical or just than the institution in which she finds herself; an institution can only be marginally more ethical or just than the society in which it operates. Among the ethicists I have talked to across the country with jobs like mine, all have indicated that the issue of call [End Page 274] coverage has presented as both a business issue and an ethical one. Clearly, this is yet another aspect of the American organization of medicine that is not working well across the board.

Can an Ethics Consultation Help?

Sometimes cases that I learn about retrospectively bother me because I worry that the patient or clinician suffered unnecessarily during the time it took the ethics committee to call me (or for me to return the call). But this case is different. If the hospital had requested my services during the hour and a half it took the woman to die, I could have done nothing to change the outcome.

When I was first consulted on this case, two months after it happened, it socked me in the stomach: a young mother died because no one would help her. Probably naïvely, I imagined that if a young intern, having watched one tracheotomy in his short career, had been out in the wilderness with a buddy who ate a berry and went into anaphylactic shock, the intern would not likely tell himself, “I have neither scalpel nor sterile conditions. I’d better not try it.” He would have said, “My friend will die if I don’t do something. This jackknife is not a surgical instrument, but I’m using it anyhow.” I imagined that with the consent of the husband, an emergency room physician could have “become” a surgeon temporarily. The woman, if death were to be her fate, would have died while someone was trying to save her, rather than while we were all waiting and wringing our hands.

I have learned more about the realities of the situation, but one thing that haunts me about this case is that I am unable to learn why my naïve scenario could not have happened. It is the difficulty of asking a genuine question that might have a judgment attached to the answer (or presumes a judgment attached to the question). “What were you thinking?” can be either an inquiry or a reprimand, and in the context of this case (about which many people still feel terrible) and when asked by the ethicist at the system level, reprimand comes through whether intentionally or not. In an effort to really learn the answer, I have asked it of physicians not affected by the case, those in other hospitals or who are personal friends. Their answers have not been satisfying. Part of what lingers organizationally about the case is our inability to understand in detail why it happened.


Our health system utilizes a structured reflection process when executives, board members, managers, or others experience a conflict between or among the organization’s core values. After the root cause analysis on this case was complete, the two physicians had undergone peer review, and the Chief of Surgery’s role was clarified, there was still a sense that the case was unresolved. Because of this, the ethics committee chair, the Chief of Staff, and the Mission Integration leader convened a group that used the structured reflection process to uncover what other ethical issues might remain unaddressed. That process, because the participants were from both within and outside of the hospital, contributed to a growing realization that the geographic area was in need of a trauma center, something that nine years later is now in place.

Unresolved Issues

It would be tempting to conclude that “what can be learned from this case” is that physicians should cultivate the virtue of courage or otherwise act in such a way that this sort of situation would not arise. I prefer to call out three further problems that a case like this illustrates.

First, imagine that a patient with a rupturing aortic aneurism presented to the ER. According to the ER physician, the man was a poor surgical risk and would certainly have died in surgery. The ER staff called the on–call cardiac surgeon, who, on the basis of the man’s surgical risk, declined to come in. The case was referred to another cardiac surgeon, who came to the hospital, met with the family, and broke the bad news that there was nothing surgery could do to help the man. We as a profession need to identify what might ground the ethical obligation of a physician to act in the manner of the second [End Page 275] doctor rather than that of the first, and perhaps physicians in their professional development ought to be encouraged to do this as well.

Another issue is that of physicians who are willing to do a limited amount of on–call rotation but who, depending on their geographic location, may still collectively be unable to completely cover all the necessary call days in a given month at the hospital where they practice. It may not be just the quality of their family lives, money, etc., that is relevant but their personal commitment to doing what is necessary for their own patients. We need to help physicians think through their ethical obligation to “strangers” or “society” versus their ethical obligations to their current patients.

Finally, this case had a grave impact on everyone involved—ED physicians and nurses, the chaplain, the social worker, administrators—in addition to the patient and her family. Despite the clear assessment of the extent and prognosis of the woman’s condition when she arrived in the ED, both by ED physicians and the first responders, physicians who were not involved in the case are opining that with such a devastating accident, the woman surely would have died of her injuries no matter what. The appeal of revisionism is strong in this case, and in cases like it. An honest assessment of the many failures in a case such as this, preserved at least in notes from the case or the records and minutes of groups convened to discuss it, is essential in order to combat the lure of the all–too–human temptation to dispense ourselves from wrongdoing.


  1. 1. Do you think a physician has an ethical obligation to try to help a patient who will otherwise die, even when the patient’s problem is not within the physician’s specialty? If so, how do you ground this obligation? If not, why not?

  2. 2. If physicians have such an obligation, what ought they to do when they face barriers to fulfilling it?

  3. 3. People often see themselves in the best light; it’s very human to see one’s self favorably, and to try to explain away one’s own responsibility when an error occurs. In light of this natural tendency, what structures could be set into place to help physicians and other stakeholders take responsibility in these types of situations?

Carol Bayley
Dignity Health
Correspondence concerning this article should be addressed to Carol Bayley, 185 Berry Street, San Francisco, CA 94117. E–mail:

Conflicts of Interest. The author reports no conflicts of interest.


Bayley, C. (2007). Medical mistakes and institutional culture. In V. A. Sharpe (Ed.), Accountability: Patient Safety and Policy Reform (pp. 99–118). Washington, DC: Georgetown University Press.
Glaser, J. (1994). Three Realms of Ethics. Kansas City, MO: Sheed and Ward. [End Page 276]


1. Such was not the case here. The woman who bled to death was well insured.

2. For example, at the level of payment for the hospital where this case happened ($600 per 24–hour period; 120% of Medicaid for indigent patients), the bill would be between $3.5 million and $4 million per year.

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