Archives of Academic Emergency Medicine. 2022; 10(1): e1 OR I G I N A L RE S E A RC H Proposing an Emergency Medicine Ethical Guideline; a Qualitative Study Leili Asadabadi1, Kamran Soltani Nejad2, Atefeh Zolfagharnasab3, Mina Mobasher4∗ 1. Clinical Research Unit, Shahid bahonar Academic Center, Kerman University of Medical Sciences, Kerman, Iran. 2. Afzalipour Faculty of Medicine, Kerman University of Medical Sciences, Kerman, Iran. 3. Department of Library and Medical Information, Faculty of Management and Medical Information Sciences, Kerman University of Medical Sciences, Kerman, Iran. 4. Department of Medical Ethics and History of Medicine, Faculty of Iranian Traditional Medicine, Kerman University of Medical Sciences, Kerman, Iran. Received: November 2021; Accepted: November 2021; Published online: 1 January 2022 Abstract: Introduction: Emergency medicine physicians face major ethical challenges in their practices. Furthermore, they need to be aware of the principles of ethical analysis and clinical decision-making in order to provide quality care. This study aimed to propose professional ethics codes in the emergency medicine department. Methods: This is a qualitative study, which was performed using narrative review and expert panel, and was conducted in three steps, including: literature review and preparation of the initial draft of the ethical con- cepts, obtaining expert opinions on this initial draft and its validation, and finalizing main ethical components in emergency medicine. In this study, we received the opinions of an expert panel including 10 medical ethicists and 12 emergency medicine specialists using a survey form. Results: The ethical guide to emergency medicine can be formulated in 34 key ethical concepts, 6 sub-components, and 5 main components including emergency physician-patient relationship, and emergency physicians’ relationships with other professionals, students, re- searchers, and community. Conclusion: Emergency care providers need to be familiar with ethical guidelines in order to improve quality of care in emergency departments. The findings of this study suggest that a guideline on patient-physician relationship as well as the emergency physicians’ ethical obligations for other professionals, students, researchers, and community should be developed in line with ethical norms. Keywords: Codes of ethics; emergency medicine; practice guideline; physician-patient relations Cite this article as: Asadabadi L, Soltani Nejad K, Zolfagharnasab A, Mobasher M. Proposing an Emergency Medicine Ethical Guideline; a Qualitative Study. Arch Acad Emerg Med. 2022; 10(1): e1. https://doi.org/10.22037/aaem.v10i1.1391. 1. Introduction Emergency medicine physicians face major ethical chal- lenges in their practices due to criticality of situations in the emergency department as well as the advances of knowl- edge and technology in health care services. Consequently, they need individual knowledge and group discussions to make decisions. There is a consensus that moral sensitivity is one of the requirements of physicians’ practice in emer- gency medicine settings (1). The ethical responsibilities of emergency physicians in patient care require that they be ∗Corresponding Author: Mina Mobasher; Afzalipour Faculty of Medicine, Kerman University of Medical Sciences, 22nd Bahman Blvd., Kerman, Iran. Tel: 0098-34-33257660-4. Fax: 0098-34-33257671. Email: m.mobasher@kmu.ac.ir, ORCID: http://orcid.org/0000-0002-7115-861X. aware of their professional values, and the principles of eth- ical analysis. Furthermore, ethical codes are a systematic guide for shaping the ethical behaviors of people (2). Emer- gency physicians should be aware that there may be contro- versial ethical challenges in each of the medical procedures (3). The principles, rules, and ethical standards have been developed at the organizational, national, and even global levels and introduced as professional ethical guidelines for many professions, and professionals are obliged to abide by it (4). According to the American Emergency Medicine Association (AEMA) recommendations, emergency medicine practition- ers must be actively engaged in professional ethics in order to ensure the provision of optimal care in the process of clin- ical decision-making. The performance quality of emergency medicine physicians This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem L. Asadabadi et al. 2 can improve and contribute to the integration of morality- based practices in different situations provided that there are professional ethics standards and they are practiced (5). Moreover, if medical students and residents work accord- ing to ethical principles taught to them during their training in emergency medicine, these principles improve their pro- fessional behaviors and moral decision-making, and this is critically important in their professional practice in the fu- ture. Emergency physicians should engage in educational programs related to ethical reasoning in order to be able to resolve ethical challenges in complicated situations of emer- gency departments (6). Teaching the emergency staff about ethical dilemmas in emergency medicine and developing or providing access to appropriate resources such as ethical guidelines can be very helpful in managing difficult emer- gency situations and some aggressive patients and their fam- ilies, as well as complex emergency situations (7). Further- more, a moral guide can also be a reliable tool to evaluate the performance of physicians as well as leading to unity of prac- tice and strengthening the sense of responsibility and pro- fessional commitment in physicians. This study aimed to re- view resources, narratively, and clarify key ethical concepts and main components of the ethical issues in the emergency medicine department. 2. Methods 2.1. Study design and setting The present study is a qualitative study that was conducted in three main steps. The first step consisted of drafting the early version of the codes of emergency medicine that in- cluded three parts: 1) review of texts using content analysis and extraction of ethical concepts, 2) translating ethical con- cepts into codes and 3) completion of the code list by adding ethical codes of the other countries. 2.2. Data gathering In order to extract ethical concepts, a search in the three in- ternational databases Web of Science, PubMed and Scopus was conducted using the keywords ethics, code of ethics, emergency and EMS in the title and abstract fields without any time limit until the end of 2020. Also, a search was con- ducted in the Persian language databases including magiran and SID with the keywords including emergency medicine, ethics, medical etiquette, education. In addition, the phrase code of ethics for emergency was used in the Google search engine and the websites of the Ministries of Health in differ- ent countries in order to access relevant documents to pro- vide codes of ethics related to emergency medicine in these countries. These documents are important sources of infor- mation that can make important contributions to a review, may reduce publication bias, and increase reviews’ compre- hensiveness. Figure 1 shows the process of extracting rele- vant articles (Figure 1). Two members of the research team checked on the credibility of the data source and its usability for our study using com- mon sense and valid search engines. We studied the articles to identify the ethical concepts that are mentioned in a form of behavior (so as to indicate the engamenet in or abandon- ment of a specific behavior) related to the emergency depart- ment. The ethical concepts were merged and categorized. After achieving data saturation and the literature review was stopped. Following this step, ethical concepts became a code of ethics. Otherwise, it would have been written in form of do’s and dont’s that emergency medicine specialists should oblige. Furthermore, to ensure the comprehensiveness of the obtained codes, the ethical codes related to the emer- gency medicine profession were collected from four coun- tries based on availability and ease of access. Finally, the first draft of the code of ethics was ready to enter the next step. In the second step of this qualitative study, we used expert sampling, a purposive sampling technique, to include only those with expertise in a certain area (emergency medicine and medical ethics). In fact, these experts are purposefully as different from each other as possible to help in identification and selection of information related to the ethical issues in emergency medicine practices. We try to reduce the biases in this study as much as possible by using this sampling. Our ex- perts were emergency medicine specialists and medical ethi- cists with different backgrounds from different universities of medical sciences in Iran (Kerman, Qom, Tehran, Rafsanjan, Mashhad). They announced that they did not have any con- flict of interest. In this step of the study, we conducted a survey of experts by emailing them a survey form. The compiled text was sent to ten medical ethicists. According to five of their comments, the necessary modifications were carried out in the initial text by the medical ethicist in our research team. The sec- ond text was reread with members of the research group and the required modifications were made. The third version of the compiled text was sent to twelve emergency medicine ex- perts through email and 6 of them sent their comments back. Verbal and written explanation was given to these experts. Also, in the survey step, in order to complete the validation of the obtained codes, experts on the subject were asked to express their views on the compiled text in terms of the clar- ity of the content of each code and its feasibility. The agree- ment of medical ethicists in the first stage and the agreement of emergency medicine specialties in the second stage pro- duced data saturation. Therefore, the depth and volume of data was suitable. In each step, the completed forms were reviewed, and based on the received suggestions, the necessary changes were made in the forms and writing styles of some codes. There- This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem 3 Archives of Academic Emergency Medicine. 2022; 10(1): e1 fore, some codes were combined, adjusted, or deleted, and the opinions of the above-mentioned expert groups were summarized. 2.3. Statistical analysis Finally, we could clarify the main components by placing similar ethical concepts into one subcomponent by apply- ing the technique introduced in Sandolowski study (8). In this way, the final set of proposed ethical codes in emergency medicine was formulated as the final edition and prepared to be presented to relevant authorities. In this study, we in- troduced key ethical concepts and main components of the ethical guidelines developed in emergency medicine. 2.4. Ethical consideration This study was approved by Kerman University of Medical Sciences in 2019 with the ethics code (IR.KMU.AH.REC.1398.015) obtained from the National Ethics Committee in Biomedical Research. 3. Results We extracted 9750 documents to review their titles and ab- stracts and selected 221 documents for the final review. Of the selected ones, 30 documents were used to compile the codes (Figure 1), most of which were related to the United States (12 documents) and Iran (5 documents), respec- tively. There were two documents related to the Philippines. Articles (one for each country) were from New Zealand, the United Kingdom, Turkey, Saudi Arabia, Pakistan, and Canada. Also, five documents were co-written (Table 1). Eth- ical codes of the countries showed that the general respon- sibilities of emergency physicians all over the world were considered the responsibility of emergency physicians to- ward patients’ rights in terms of obtaining informed consent, maintaining privacy and patients’ best interests as well as the social responsibility of emergency physicians and their re- sponsibility toward their colleagues and the community. The ethical concepts are mentioned in a form of behavior (so as to indicate the engamenet in or abandonment of a specific behavior) related to the emergency department Furthermore, results of the first and second step of our study showed 34 key ethical concepts in the scope of emergency medicine physicians’ practice (Table 2). According to the results, guidelines that generally ap- ply to ethical compliance in emergency medicine include the principles of respect for autonomy, beneficence, non- maleficence, and justice in medicine. Furthermore, the im- portance of strengthening ethical virtues in the performance and flexibility of emergency physicians should be empha- sized in triage and in the complex challenges and situa- tions of emergency medicine. Therefore, paying attention to the prevailing values in emergency medicine such as adher- ence to the six professional behaviors including altruism, re- sponsibility, honesty and integrity, respect for others, excel- lence, and justice was very important. In addition, work con- science, discipline, good mood, attention to the patient and her/his wishes, making trust, adherence to rules and regula- tions, and acceptance of responsibility for error were impor- tant values in emergency medicine. Finally, the ethical con- cepts were categorized in five main components and 6 sub- components in this area (Table 2). 4. Discussion In this study, the general structure of the necessary ethi- cal concepts in Iranian emergency medicine were proposed based on the opinions of experts on the subject and the con- cepts in the articles and the structure of codes in other fields of medical sciences in Iran as well as other countries. Accord- ing to the results of this study, the general structure of the proposed ethical guideline of emergency medicine included five main components, the relationship between the emer- gency physician and the patient, other professionals, stu- dents, research group, and the community. One of the important concepts of the present study for emer- gency physicians was considering the interests of emergency patients, which is in the results of other studies and codes from other countries (9-16) as well as the guide provided by the American Emergency Medicine Association (5). The emergency physicians need to pay more professional atten- tion to their patients’ interests in emergency departments. This principle can indicate paying attention to the patient’s pain, and physical and mental sufferings that should be re- duced by physicians as much as possible. Another suggestion of the present study for emergency physicians is to observe non-maleficence to patients, which was also reported in the results of similar studies (6, 13, 15- 18) and the other codes (5, 14). There are degrees of risk or side effects in many emergency cases due to the exces- sive overcrowding and complex conditions prevailing in the emergency department; therefore, emergency physicians are obliged to assess the condition and the possibility of harming patients and make a suitable decision. Trying to enhance the knowledge and skills of emergency physicians was one of the ethical codes, which can also be identified in the other studies (9, 12, 19, 20). Improving physicians’ knowledge and skills can be classified as one of the codes that significantly affect other concepts in this study, such as benefit for patients, non-maleficence, improv- ing the quality care, and attention to students’ education. When the emergency specialist increases his/her scientific and practical knowledge, he/she can certainly provide bet- ter and more effective care for patients. Hence, emergency This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem L. Asadabadi et al. 4 Table 1: Bibliographic profile of final included studies First Author Year Country Type Language Study design Subjects Data gathering New Zealand Medical As- sociation 2020 New Zealand Statement English - - - Qusai Talat Alwaznah 2019 Saudi Arabia Review article English Qualitative - Literature review Keith A Colaco 2018 Canada Article English Quantitative Staff nurses and physicians Questionnaire Helen Askitopoulou 2018 - Book English - - - Diane Gurney 2017 USA Practice Guideline English - - - American College of Emergency Physicians 2017 USA Statement English - - - Philippine Medical Asso- ciation 2017 Philippine Statement English - - - Philippine Medical Asso- ciation 2017 Philippine Statement English - - - Waleed Zafar 2015 Pakistan Article English Qualitative ED physicians In-depth interview Maria F Jime´nez- Herrera 2014 - Article English Qualitative Nurses Interview; focus group Müesser Özcan 2014 Turkey Article English Quantitative emergency care providers Questionnaire Anders Bremer 2014 - Article English Quantitative Ambulance professionals - Torben K. Becker 2013 USA Guideline English - - - John Jesus 2012 - Book English - - - Catherine A. Marco 2012 USA Review article English Qualitative - Review of Affordable Care Act 2010 Catherine A. Marco 2012 USA Review article English Qualitative - Review of Affordable Care Act 2010 Gregory Luke Larkin 2009 - Review article English Qualitative - Review Khim Horton 2007 UK Review article English Qualitative - Literature review Rita Sommers-Flanagan 2007 USA Review article English Qualitative - Review Bagher Larijani 2007 Iran Review article English Qualitative - Review Kenneth V. Iserson 2006 USA Review article English Qualitative - Review Bagher Larijani 2005 Iran Review article English Qualitative - Review Canadian Medical Associ- ation 2018 Canada Statement English - - - John Brown 1999 USA Review article English Qualitative - Review James Adams 1998 USA Review article English Qualitative - Review Bernard Heilicser 1996 USA Article English Qualitative Emergency medical technicians Questionnaire Kenneth V. Iserson 1991 USA Article English Qualitative - Review ACEP Ethics Committee 1991 USA Statement English - - - Akram Izadikhah 2013 Iran Article English Qualitative - Review; focus group Mohsen Shahriari 2011 Iran Thesis Persian Mix method Nursing professionals Review; interview; focus group Amir Ahmad Shojaee 2011 Iran Article Persian Qualitative - Review Sodabeh Jolaee 2010 Iran Article Persian Qualitative Nursing professionals Review; focus group ED: emergency department. specialists should pay special attention to this issue. The results of similar studies (10, 11, 16, 19, 21, 22) and the ethical guideline provided by the American Society of Emer- gency Medicine (5) emphasized the impartial performance This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem 5 Archives of Academic Emergency Medicine. 2022; 10(1): e1 Table 2: The relationships of participants’ characteristics with return of spontaneous circulation (ROSC) Main Component Sub-component Key ethical concepts The relationship between the emer- gency physician and the patient Patient’s rights • attention to the protection of the patient’s interests and privacy according to laws and regulations • benefits or risks of treatments • patient’s decision-making capacity and consent • patient’s transfer to other departments in accordance to laws and regula- tions • paying attention to the patients when they refuse treatment • attention to the rights of vulnerable patients and minorities • attention to the correct principles of resource allocation The relationship of emergency physicians with other professionals -Rights of col- legues -Individual rights • paying attention to mutual communication and facilitating these relations in terms of protecting patients’ interests • not having prejudices • choosing counselors • correct transfer of patients’ care responsibilities • paying attention to patients’ disabilities • proper use of care protocols • coordination with personnel and maintaining dignity and personality • preventing deception and fraud and fighting against these problems • access to whose right to be supported in emergency challenges • non-acceptance of gifts Relationships with students, in- terns, and other learners -Patient’s rights - Student rights • the emergency physician is a role model for learners • closely monitoring the moral performance of learners • providing feedback to them • paying attention to the interests of patients in educational centers and ob- taining their consent Relations with research groups -Patient’s rights - Research Ethics • following the ethical guidelines in general and specific research • observing the main ethical requirements for research studies • taking responsibility for the protection of participants’ rights • gaining knowledge of the law and regulations on prevention of scientific fraud • active participation and supervision in research The relationship between the emer- gency physician and the community -Patient’s rights - Community rights • being active in relation to legal, regulatory, organizational, and educational measures • non-discrimination and providing emergency services for all members of society • participating in continuous education activities and trainings necessary for the community • being aware of strategies for saving resources • proper cooperation with pre-hospital staff • making the right triage decisions • correct action against domestic violence and abuse • training to improve the health and safety of the community and fair behaviour of emergency physicians. Furthermore, emergency physicians must deal with issues related to the distribution of scarce health care resources and decide which treatments the patients should receive and what facilities they should use in the emergency room due to the special conditions of the emergency department and the hospital- ization of patients with unstable vital signs and lowered level of consciousness. So, it is necessary to practice with justice and fairness in the emergency department. Respect for Patient Autonomy was another code of this study, which is a concept found in many studies (9-14, 16, 18-20, 23) and a guide provided by the American Society of Emergency Medicine, and was also pointed out in the other studies from the United States, New Zealand, and Canada (5, 13, 15). Of course, observing this code for emergency physicians is a lit- tle more difficult than physicians in other departments and requires more effort due to the emergency conditions of pa- tients, the risk of patients’ mortality and morbidity, and time This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem L. Asadabadi et al. 6 Figure 1: The flowchart of the extracted articles. constraints in this department. Emergency specialists should try to provide patients with complete information and help their family members decide about the treatment as much as possible. Improving the quality of patients’ care was selected as one of the ethical concepts in the codes of ethics in emergency medicine. This finding has been noted in other researches (9, 12, 19) and other ethical guidelines (5, 13, 15). In fact, im- proving the quality of patients’ care in this ward will reduce the patients’ mortality and morbidity more than other wards due to the nature of the emergency department. Another ethical concept in this research was paying atten- tion to students ’ training, which is a code of ethics present in the other ethical guidelines of emergency medicine (9, 19, 20). It is necessary that the clinical staff members of emer- gency departments, in addition to their comprehensive ef- forts to save patients’ lives, not neglect the educational is- sues related to all groups of students. Because, the training process for interns and students of other related fields such as nursing and emergency medicine assistants is performed in the emergency department of public hospitals. Eventually, these trainees will serve independently in some remote and This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem 7 Archives of Academic Emergency Medicine. 2022; 10(1): e1 sometimes deprived areas as the first line of treatment, so, if they receive the more practical and comprehensive training during their studies, they will definitely provide better ser- vices, which can certainly lead to reduced medical malprac- tice and patient mortality and morbidity. Control of violence in emergency departments was another ethical concept of this research, which is also present in the results of similar researches (11, 12, 18, 20). This issue is important for emergency specialists due to the stressful and complex situations in the emergency departments and the low tolerance of the patients and their companions due to the occurrence of various accidents. The emergency medicine professionals should have more patience against verbal vi- olence of patients and their companions and facilitate the treatment process through appropriate behavior with pa- tients and other colleagues. Resource allocation consideration and giving enough knowl- edge about this issue was another research concept that was present in the results of other researches (5, 11, 19, 24). Con- sidering the limited resources in the emergency department, especially in hospitals in developing countries, it is neces- sary for emergency specialists to have a good relationship with staff and university officials to meet their demands eas- ily. Also, when they are restricted or under adverse condi- tions, they should request for assistance in order to protect patients’ lives. Protecting the life of every human being in any position and situation is the duty of the emergency medicine physician. The ethical responsibilities of emergency medicine physi- cians in their practice and care requires them to be aware of their beliefs, as well as the basis and principles of ethical analysis and decision-making. Ethical rituals (or codes) are systematic guidelines to form moral behaviors. Emergency medical professionals have the responsibility to decide and operate based on professional values in their career. Since emergency medical practitioners are one of the most important groups of service providers who have a significant impact on the quality of healthcare provision, their compli- ance with professional ethics will also be an effective factor in improving the quality of care. In addition, a codified ethi- cal guideline can provide a reliable tool for evaluating physi- cians’ performance for regulatory organizations. 5. Limitations In the present study, the code of ethics published by the Emergency Medicine Association of some countries such as the United States has been considered, which has been cited in many articles and studies of the other countries. But there was limited access to medical codes of emergency medicine in other countries. Comparative research between public and private hospitals is also proposed to take place in the future so that the results can be used for making policies in this area. Moreover, it is better to assess the views of a larger group of experts to finalize the general structure of the ethical codes of emergency medicine in Iran. 6. Conclusion Moral sensitivity is one of the requirements of professional practice in emergency medicine settings. Thus, a codified ethical guideline can establish an applicable policy for these specialists to increase their practical abilities and provide better, and more effective care for patients. In this regard, the findings of this study sheds light on a more rational solu- tion to the ethical issues in emergency medicine physicians’ relationship with patients, other professionals, students, re- searchers, and communities. 7. Declarations 7.1. Acknowledgments This article is the result of a part of the dissertation by Kam- ran Soltaninejad in the emergency medicine specialty course in Kerman University of Medical Sciences in 2020, approved by Kerman University of Medical Sciences in 2019 with ethics code (IR.KMU.AH.REC.1398.015) obtained from the National Ethics Committee in Biomedical Research. The authors wish to express their deepest gratitude and warmest appreciation to all the medical ethicists and emergency medicine special- ists who in any way have contributed and inspired the re- searchers. 7.2. Author contribution Study concept and design was performed by Mina Mobasher. Searching the articles and other documents was performed by Atefeh Zolfagharnasab. Considering the documents, ex- tracting the articles were done by Mina Mobasher, Leli sad- abadi and Kamran Soltani Nejad. Content analysis, extract- ing the ethical concepts, and drafting of the ethical codes were done by Mina Mobasher, Leli sadabadi, Kamran Soltani Nejad and Atefeh Zolfagharnasab. All authors reviewed the final draft of this article. Study supervision was performed by Mina Mobasher. 7.3. Funding None. 7.4. Conflict of Interest The authors stated that there was no conflict of interest. This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem L. Asadabadi et al. 8 References 1. Askitopoulou H, Singler K, Frühwald T, Weissenberger- Leduc M. Ethical Issues of Emergency Medical Care for Older Patients. In: Nickel C, Bellou A, Conroy S, editors. Geriatric Emergency Medicine. Cham: Springer Interna- tional Publishing; 2018. p. 369-95. 2. Moskop JC, Mitchell JM, Ray VG. An ethics curriculum for teaching emergency medicine residents. Annals of emer- gency medicine. 1990;19(2):187-92. 3. Alwaznah QT, Alabdrabalrasol EA, Alshaikhnasser RA, Shaikh AA, Alharbi AS, Alqahtani EZ. Ethics in emergency medicine. Indo American Journal of Pharmaceutical Sci- ences. 2019;6(2):3279-84. 4. Horton K, Tschudin V, Forget A. The Value of Nursing: a Literature Review. Nursing Ethics. 2007;14(6):716-40. 5. American College of Emergency Physicians. Code of ethics for emergency physicians. Annals of Emergency Medicine. 2017;70(1):1-14. 6. Özcan M, Akpinar A, Birgili F, Beydilli H. Ethical chal- lenges in emergency medical services and ethical rea- soning among emergency care providers. Acta Medica Mediterranea. 2014;30(2014):241-7. 7. Colaco KA, Courtright A, Andreychuk S, Frolic A, Cheng J, Kam AJ. Ethics consultation in paediatric and adult emergency departments: an assessment of clinical, eth- ical, learning and resource needs. Journal of medical ethics. 2018;44(1):13-20. 8. Sandelowski M, Barroso J, Voils CI. Using qualitative metasummary to synthesize qualitative and quantita- tive descriptive findings. Research in nursing & health. 2007;30(1):99-111. 9. Marco CA, Moskop JC, Schears RM, Stankus JL, Book- man KJ, Padela AI, et al. The ethics of health care re- form: impact on emergency medicine. Academic emer- gency medicine : official journal of the Society for Aca- demic Emergency Medicine. 2012;19(4):461-8. 10. Shojaee AA, Abolhassani Niyaraki F. Medical ethics and disasters. Medical Ethics and History of Medicine. 2011;4(6):27-38. [In Persian]. 11. Aacharya RP, Gastmans C, Denier Y. Emergency de- partment triage: an ethical analysis. BMC emergency medicine. 2011;11(2011):16-29. 12. Iserson KV. Ethical principles–emergency medicine. Emergency medicine clinics of North America. 2006;24(3):513-45. 13. Association CM. CMA Code of Ethics and Professionalism Canada: Canadian Med- ical Association; 2018 [Available from: https://policybase.cma.ca/documents/PolicyPDF/PD19- 03.pdf. 14. Association PM. Code of Ethics of the Philip- pine Medical Profession Philippine: Philip- pine Medical Association; [Available from: https://www.philippinemedicalassociation.org/wp- content/uploads/2017/10/FINAL-PMA- CODEOFETHICS2008.pdf. 15. Association NZM. Code of Ethics for The New Zealand Medical Profession New Zealand: New Zealand Medical Association; 2020 [Available from: https://www.nzma.org.nz/assets/Uploads/Documents/Code- of-Ethics-Redesign-2020-Version-4.pdf. 16. Sommers-Flanagan R. Ethical considerations in cri- sis and humanitarian interventions. Ethics & Behavior. 2007;17(2):187-202. 17. Jiménez-Herrera MF, Axelsson C. Some ethical conflicts in emergency care. Nursing Ethics. 2015;22(5):548-60. 18. Gurney D, Gillespie GL, McMahon MP, Kolbuk ME. Nurs- ing Code of Ethics: Provisions and Interpretative State- ments for Emergency Nurses. Journal of Emergency Nursing. 2017;43(6):497-503. 19. Jolaee S, Bakhshandeh B, Mohammadebrahim M, As- garzadeh M, Vasheghanifarahani A, Shariat E, et al. Nurs- ing code of ethics in Iran: the report of an action research. Medical Ethics and History of Medicine. 2010;3(2):45-53. [In Persian]. 20. Izadikhah A, Changiz, Yamani N, Mirshahjafarey I. De- veloping codes of ethics for clinical medicine educators. Medical Ethics and History of Medicine. 2013;6(1):37-52. [In Persian]. 21. Zafar W. Moral experience and ethical challenges in an emergency department in Pakistan: emergency physi- cians’ perspectives. Emergency medicine journal : EMJ. 2015;32(4):263-8. 22. Larkin GL, Iserson K, Kassutto Z, Freas G, Delaney K, Krimm J, et al. Virtue in emergency medicine. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine. 2009;16(1):51-5. 23. Association AM. Code of Medical Ethics Opinion 2.1.1 America: American Medical Association; [Avail- able from: https://www.ama-assn.org/delivering- care/ethics/informed-consent. 24. Jafari manesh H, Ranjbaran M, Vakilian K, Tajik R, Almasi-Hashiani A. Nursing’s code of ethics: a survey of respecting the code among nursing students. Medical Ethics and History of Medicine. 2014;6(6):45-55. [In Per- sian]. This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem Introduction Methods Results Discussion Limitations Conclusion Declarations References