EMS, as with other health and non-health entities are confronted with ethical dilemmas on a daily basis --and-- how we respond is of the utmost importance to our profession. As public servants we are (and should be) held to a higher standard. Although provider judgment plays a large role in the resolution of conflicts at the scene, it is important to establish protocols and policies, when possible, to address these high-risk and complex situations.
Medical ethics at its core stands on FOUR (4) distinct pillars.
Beneficence: (doing good) - whatever is done or said must be for the good of the patient. This can include something as being honest. As a provider, always act in their best interest.
Non-Maleficence: (doing no harm) - this harm could be intentional or unintentional. Usually, the patient is the one who determines or interprets what is harmful to them.
Autonomy: (giving the patient the ability to choose freely* - when they are able) - this could mean getting a second opinion, this could also mean refusing ambulance transport to the ED.
Justice: (ensuring fairness) - this can be challenging especially when determining who gets medical treatment when medical resources are scarce.... think MCI and triage scenarios. Ideally, you should treat all patients impartially regardless of race, sex, religion etc... many EMS centric research articles have been published around disparities in care. Pain management amongst minorities comes to mind.
Frequently, the lines between these pillars can blur... (level with me here): Sometimes doing good - like performing a risky treatment, can stand a high chance of causing harm. In this case, what wins? Many times, health systems have ethics committees and/or boards with diverse representation to help sort out and review complex cases.
Some common scenarios that you may encounter are here: Does your agency have established safeguards to combat these? Can they be ethically justified?
+ Denying transportation for a patient not experiencing an emergent medical condition.
+ Denying transportation to a specific hospital - even if it's not the closest, medically appropriate.
+ Initiating or not initiating CPR (scene not safe / obvious signs of death / DNR dilemmas)
+ Off duty responses or calls to action if you're in another jurisdiction (maybe you're on vacation). Do you roll up your sleeves to help?
+ Child abuse cases - where both the victim and the perpetrator need medical attention. How do you prioritize who gets treated first?
+ Sharing sensitive protected health information with folks who may not necessarily need to know.
EMS professionals have a responsibility to themselves, their profession, and their patients to maintain the highest ethical principles. It is important to always err on the side of caution while simultaneously advocating for patient care, patient rights, and ethical consideration of practice. Meaningful discussions around ethics inclusion should begin during your initial education and continue as long as you are practicing. Feel free to utilize the cases above to stimulate conversation at your local agency. You may be surprised where these talks end up. You will find that a consensus opinion from the group may be hard to come by and that's OK.
September 25, 2023
Author: Joshua Ishmael, MBA, MLS(ASCP)CM, NRP
Pass with PASS, LLC.