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Too drunk to care?Ethanol, emergencies, and ethical dilemmasCommentary: Guidelines could never be developedCommentary: Balance the risk as best you canCommentary: Doctors can never have a moral holiday

BMJ 1998; 316 doi: https://doi.org/10.1136/bmj.316.7143.1515 (Published 16 May 1998) Cite this as: BMJ 1998;316:1515

Too drunk to care?

What should doctors do if they are faced with a medical emergency after they have had a few alcoholic drinks? Dr David Cressey describes how, although not entirely sober, he felt compelled to help an unconscious person at a sports event, and two medical ethicists, a psychologist, and another doctor give their views.

Ethanol, emergencies, and ethical dilemmas

  1. David M Cressey, registrar (D.M.Cressey{at}Sheffield.ac.uk)
  1. Anaesthetic DepartmentRoyal Hallamshire Hospital, Sheffield S10 2JF
  2. aTrimbos Institute, PO Box 725, 3500 AS Utrecht, Netherlands
  3. bDepartment of Medical Ethics, Erasmus University Rotterdam, Netherlands
  4. cBristol Oncology Centre, Bristol BS2 8ED
  5. Bristol Oncology Centre, Bristol BS2 8ED
  6. Centre of Medical Law and Ethics, King's College, London WC2R 2LS

    While attending a recent sports event as a spectator, I was faced with a dilemma. I saw an incident in which a spectator was left unconscious and could have injured his neck. The injured man had been placed in the recovery position but was not moving. As the official crowd doctor was not immediately on hand, I felt I should at least offer my services. However, I had had an alcoholic drink. I told the attending ground steward that I was an anaesthetist, and warned him of the risks of a possible neck injury. The steward then asked for my help. I quickly assessed the patient; he had a clear airway, was breathing adequately, had a strong pulse, was pink and well perfused. None the less he had a coma score of 3, and I had seen him drinking and eating moments before the accident.

    When the paramedics and official crowd doctor arrived, the patient was fitted with a hard collar and was placed on a scoop stretcher. Having introduced myself to the crowd doctor and briefed him on the patient's state, I told him that I had had a drink. I then had to decide whether I should participate further in the patient's care. Here was a young man with a possible neck injury and in a hard collar. He had a full stomach, a coma score of 3, and although currently maintaining his own airway, the protective reflexes were obtunded.

    Immediate intubation had been considered but deferred. If intubation became essential it could well have proved technically demanding. While acknowledging the quality of training and skills in airway management of paramedical and medical staff from other specialties, my contribution as an experienced anaesthetic specialist registrar with daily practice of intubation could have proved crucial here. I therefore chose to accompany the patient and the crowd doctor in the ambulance on the grounds that if the young man failed to maintain his airway during transit I could assist. In fact, the transfer was uneventful and the patient was beginning to wake on arrival at the hospital.

    The problem

    The question remains: at what level of intoxication do doctors become too drunk to care for a patient? Under their terms of service (paragraph 4), general practitioners are obliged to give treatment needed immediately because of an emergency at any place in their practice area when they are asked to do so. Caveats attached to this include the fact that they must be available and be physically capable of attending the emergency.

    Figure

    For doctors attending victims of mishaps that are neither part of their professional remit nor part of their terms of service, the case is rather different. There does not seem to be any legal requirement for a doctor to assist in an emergency where no duty of care or professional relationship exist between the victim and the doctor. However, the General Medical Council, in its booklet Good Medical Practice, states that: “In an emergency, you must offer anyone at risk the treatment you could reasonably be expected to provide.” It seems therefore that even if doctors have no legal obligationto assist in an emergency, they have an ethical one. Indeed, does failure to help in an emergency leave the doctor open to allegations of professional misconduct?

    A matter of degree

    In an emergency, when no alternative help is available, it seems clear that aid should be given. When it becomes a matter of the degree of experience of the carer versus clarity of judgment, it is no longer black and white. What effect does drinking alcohol have on the “treatment you could reasonably be expected to provide”? If you have taken any alcohol at all, should you refrain from offering help if alternative trained assistance is available, regardless of your relevant specialist skills? When does it become more appropriate for a less experienced but perhaps more mentally alert carer to be responsible for a patient? What are the legal implications if you assist and something goes wrong? When are you too drunk to care?

    Commentary: Guidelines could never be developed

    1. Henk Rigter, director (hrigter{at}trimbos.nl)a,
    2. Inez de Beaufort, professorb
    1. Anaesthetic DepartmentRoyal Hallamshire Hospital, Sheffield S10 2JF
    2. aTrimbos Institute, PO Box 725, 3500 AS Utrecht, Netherlands
    3. bDepartment of Medical Ethics, Erasmus University Rotterdam, Netherlands
    4. cBristol Oncology Centre, Bristol BS2 8ED
    5. Bristol Oncology Centre, Bristol BS2 8ED
    6. Centre of Medical Law and Ethics, King's College, London WC2R 2LS
    1. Correspondence to: Professor Rigter

      Part of our work is to encourage doctors to reflect on their actions and to adhere to morally appropriate rules of conduct. However, not everything can or should be codified. We expect off duty doctors to act as good—or decent—Samaritans when they are confronted with someone needing medical help. It would be too much to expect them to be flawless in that capacity or to programme their private actions so that the benefit-risk ratio for those who might need their services would always be optimal.

      Dr Cressey's dilemma is not as special as it seems on first sight. True, alcohol may impair mental functions, but it is not unique in that respect. Dr Cressey might just as easily have been affected by a 20 hour shift at work or a baby son who had kept him awake all night. The real issue is that there is something special about alcohol. Doctors may feel embarrassed for having drunk alcohol, even if this was done in moderation and when off duty.

      To act or not to act

      Dr Cressey's case was not extreme. There was a fellow doctor on hand, who was made an accomplice—so to speak—in the moral dilemma, and who took the decision for Cressey to go ahead. Take a more exceptional case. Imagine you are an obstetrician, the only person on a plane with (para)medical training, and you have been drinking champagne. A steward calls for help as a woman is giving birth. She or her child is sure to die if not given proper attention. Do you offer your assistance? It is clear that you are qualified, but the alcohol may have affected your competence. On the other hand, a clumsy lay person might put them in greater jeopardy. To act or not to act, that is the question in medicine.

      Make the decision even more difficult. It is not a life or death situation as the woman may be able to hold on until landing; or she is unconscious and not able to give informed consent. You are an orthopaedic surgeon and you smoked cannabis before boarding. No guideline could deal with all these variations. You must make up your own mind, however clouded it is.

      Even if we wanted to draw up a guideline on alcohol use, it would be virtually impossible. Because of individual differences in sensitivity, there is no clear cut relation between the concentration of alcohol in the blood and mental performance. Moreover, the minimum concentration would have to be related to the complexity of the medical skills required and also to the risk and the severity of the possible consequences of acting or not acting.

      However, there is also a legal side—doctors may be sued for making the wrong choices. We do not welcome this development, which might prompt doctors to save their own skin at the expense of people needing treatment. We prefer to look at physicians as good Samaritans rather than as liability risks.

      A few rules of thumb may be offered to doctors. If you have drunk alcohol, ask a sober qualified colleague to treat the patient. If such a colleague is not at hand, treat patients who would be at risk of dying if treatment is withheld. Do not overestimate your skills—your judgment may be impaired. Therefore, ask bystanders, if present, for feedback on your behaviour.

      Commentary: Balance the risk as best you can

      1. Gareth Rees, consultant
      1. Anaesthetic DepartmentRoyal Hallamshire Hospital, Sheffield S10 2JF
      2. aTrimbos Institute, PO Box 725, 3500 AS Utrecht, Netherlands
      3. bDepartment of Medical Ethics, Erasmus University Rotterdam, Netherlands
      4. cBristol Oncology Centre, Bristol BS2 8ED
      5. Bristol Oncology Centre, Bristol BS2 8ED
      6. Centre of Medical Law and Ethics, King's College, London WC2R 2LS

        You are at a dinner party. You are a pathologist who last had skill training in resuscitation 30 years ago. A businessman in his 60s develops chest pain and collapses. He stops breathing and you are unable to feel his pulse or hear a heartbeat. None of the other guests knows what to do. Because you have had several drinks you become concerned about the advisability of further involvement and decide against trying external cardiac massage and mouth to mouth ventilation. Everyone else would feel that your decision was illogical and preposterous.

        In other circumstances what is right may be much less clear. There are no easy answers to Dr Cressey's questions. At a certain level of alcohol intake, a given doctor's performance will deteriorate to a point where the risk-benefit ratio from a particular intervention in a particular emergency becomes unfavourable. Influencing factors include the amount of alcohol drunk, tolerance to it, the clinical problem, the nature of any appropriate intervention, the doctor's relevant expertise, the availability and nature of alternative assistance, and the risk attached to doing nothing. One potential difficulty is that although doctors are theoretically best placed to evaluate the various factors, their judgment may be impaired.

        No easy answers

        Dr Cressey's expertise could have been life saving. In most situations where doctors are confronted with an emergency outside hospital, whether or not they have been drinking, appropriate and better care from paramedical staff and other doctors is already present or imminent. However, situations similar to that described by Dr Cressey occur from time to time.

        For most doctors a single drink is unlikely to impair judgment and performance to an extent that would justify withholding a clinically important intervention. At this level of consumption most doctors are allowed by law to drive at 70 miles per hour. While the potential for dilemma will usually arise at higher levels, many patients have doubtless had cause to be grateful for the ministrations of doctors who would have failed breathalyser testing.

        Act in good faith

        Many hospital patients have doubtless had cause to be grateful to junior doctors who have been busy on call for such long periods that they would be unsafe to drive. Doctors who have had more than one or two drinks and find themselves unexpectedly in a “clinical” situation must make every effort to recognise the potential for misjudgment and to guard against inappropriate enthusiasm for intervention. They should evaluate the relative risks from intervention and non-intervention. Occasionally, well meaning doctors will get it wrong. However, it is rightly expected that doctors should behave intelligently and responsibly and act in good faith whenever there is such a call on their services.

        Commentary: Doctors can never have a moral holiday

        1. Pat Walsh, lecturer in medical ethics (patricia.walsh{at}kcl.ac.uk)
        1. Anaesthetic DepartmentRoyal Hallamshire Hospital, Sheffield S10 2JF
        2. aTrimbos Institute, PO Box 725, 3500 AS Utrecht, Netherlands
        3. bDepartment of Medical Ethics, Erasmus University Rotterdam, Netherlands
        4. cBristol Oncology Centre, Bristol BS2 8ED
        5. Bristol Oncology Centre, Bristol BS2 8ED
        6. Centre of Medical Law and Ethics, King's College, London WC2R 2LS

          From a moral point of view, Dr Cressey acted properly, and probably wisely, in informing others that he had been drinking. He thus shared responsibility with them for any decision taken. Indeed, one might take this as evidence that he was not, in that nicely ambiguous phrase, “too drunk to care.” Several interesting moral issues are raised by circumstances in which doctors who are not entirely sober find themselves unexpectedly called on to act. But perhaps the question at the heart of Dr Cressey's unease is this one: could the scope of the moral duty of care be such that no doctor should ever be less than totally sober? Or, to put it another way, are doctors ever morally off duty?

          Ideal versus ordinary standards

          Perhaps none of us is entitled to a moral holiday, in the sense that we can ever justifiably claim there are circumstances in which no moral demand can rightly be made of us. In moral theory it is usual to distinguish two levels of moral standards—the ordinary and the ideal. Ordinary moral standards are the minimal standards for moral decency that are required of everyone. Ideal moral standards, however, may be regarded as aspirational in character, and, because they express the individual's personal sense of obligation, are not to be expected of everyone.

          The person who acts in accordance with some ideal typically acts in a way that goes beyond the demands of duty. It is argued by some that these so called supererogatory actions are wrongly conceived as such because our best is what is morally required of us at every moment. Nevertheless, most of us acknowledge the possibility of heroic actions which, perhaps regrettably, are not to be expected of the majority.

          No need for moral heroes

          Dr Cressey's worry, however, is not about whether doctors must be moral heroes. He asks whether the ordinary moral standards required of doctors preclude social drinking. It does seem that some people have a more demanding moral minimum than others, largely because of a role they have voluntarily assumed. Doctors, teachers, and parents are paradigm examples of this. But while teachers are allowed to go off duty, morally speaking, at the end of the working day, parents and doctors cannot. However, even parents can take time off as long as they have made adequate provision for the care of their offspring.

          It seems that doctors can never renounce their duty to assist should the need arise, and therefore that they are never morally off duty in this sense. On the other hand, while we can ask of doctors what we ask of all people in positions of responsibility for others—that they are not drunk on the job—it is unfair to expect doctors never to drink socially just in case a medical emergency should arise. In fact, I do not think this is required. If society were to demand that doctors hold themselves in a constant state of preparedness to provide an optimal level of care, we would also require of them the sort of lifestyle that would ensure peak physical and mental fitness. And, perhaps more tellingly, we would not impose on them the sort of working hours and conditions that lead to errors of judgment caused, not by alcohol perhaps, but by exhaustion.

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