Apr 5, 2019 in Research

RR Final Project

Abstract

Over the last two decades, the field of emergency and pre-hospital medical attention has undergone significant growth with a lot of fundamental changes taking place. As the body of knowledge in the field keeps growing, as technology keeps coming in, and as research keeps defining as well as refining the essentiality and uniqueness of emergency medicine, challenges keeps getting deeper and more complex. In response, efficiency, safe and expeditious transport as well as appropriate care are the fundamental elements of concern in pre-hospital care. This field is known to be fast and undetermined; thus, a lot of challenges and dilemmas are hindering the delivery of service with some instances leading to the death of the victims in the process. According to the guidelines governing emergency medicine, professionalism is crucial and prerequisite for every action coupled with the dire need for ethical decisions and conducts.  Thus, it makes this field more complex and fundamental within the medical industry. 

Ethical Challenges in Emergency Medical Services

Introduction

Emergency medical services are any actions taken to arrest a situation whereby somebody is in a need for attention before they can get to health facility. These services are often extended to the hospital and only aborted when the condition is confirmed stable for any further examination. The services are often referred to as first aid. However, this is where ethics and morality crush due to the untimely nature of the demand and the uncoordinated nature of the emergencies. Some challenges are brought by the compound nature of the emergency, while others come as a result of moral pluralism in terms of reference. In medical service industry, different guidelines demand attention together, hence making the attendants confused and not sure of what should be applied and where. This is called moral pluralism, and it is one of many causes of ethical dilemmas in the EMS. This paper will cover the ethical foundations of emergency medicine practice, define the challenges that come with law and ethics, explain the EMS ethical obligations, discuss some fundamental ethical challenges, and, finally, offer an alternative solution to some of them. Thesis: Emergency medicine code of ethics is a significant driver in the course of service delivery and patient’s confidentiality regardless of any critical situation.

Ethical Foundation of EMS

In EMS, there are usually three fundamental principles guiding the practice of pre-hospital medicine. The first one is the principle of fairness and justice which implies that every action should be equitable and fair to all the involved victims without any kind of discrimination. This calls the physicians for being equitable and fair to all the patients requiring emergency services without giving priority to some of them according to their social or financial status. The second is the principle of beneficence which means that all actions were taken and decisions were made for the sake of benefiting the patient only. This also implies that anything undertaken during the delivery of EMS should be expected to benefit the patient only but not any other party involved. Thus, there is a need for making sure that nothing is done contrary to the interest of the patient. The third paramount principle is the patient’s autonomy. This principle calls for respect and absolute adherence to the patient’s requests and demands since they are the main issues in the actions. In this case, the patient is allowed to request or reject a procedure if he/she feels that it is not performed according to his/her interest. Thus, it demands for patient’s informed consent throughout the process. 

Medical ethics are taught in the institutions of learning but do not adhere to the standards required in the fields, thus calling for regular corporate training and seminars in order to enlighten the practitioners on the market demands and trends. However, some medical institutions do not find it necessary to update their physicians in terms of the code of ethics and trends. Consequently, this causes a lot of problems when an emergency situation occurs and the individual decision-making is fundamental. The foundation of emergency medical service ethics exists within the guidelines provided by the code of conduct that every physician is made to sign when joining the institution, but morality in decision-making is solely dependent on the reasoning and experience in handling complex issues. This is where the conflict comes in since one person may think differently from others about an issue and successfully back it up with the guidelines offered. Translation of rules and directives depends on individual moral thinking and ethical understanding of the script. 

The Relationship between Ethics and Law

Like any other activity, EMS is guided by laws of the states and institutional regulations governing the delivery of services. However, this industry requires more ethical standards than any other field since most of the times individuals have to decide on their own about the course of action. Ethical reasoning and decision-making are fundamental in the activities of the emergency physicians. EMS must look carefully at the laws for guidelines whenever there is the development of methods for saving particular situation. There is an underlying predominant conflict between law and ethics where situations demand attention that is not considered lawful whether in the treatment of the patients or in transporting them to the health facilities. A good example of such conflicts is driving on the wrong side of the road which takes place almost all the time whenever an ambulance has a critically ill or injured patient. Such things call for reasoning and understanding of the laws, and then deciding on the best course of action for saving life of that patient. 

Legal guidance fails to provide all the basic answers in unfolding the dilemmas facing emergency physicians, thus calling the practitioners for taking measures they deem necessary for every particular situation. For instance, a crime scene should not be tampered with before the police are taking their information. However, if life is at stake, emergency services are the most significant action to be taken first. This is where the relationship between law and ethics gets sour because ethics will tell you to pick up the casualty and take victims to the hospital as soon as possible. Nevertheless, the law demands that you leave the scene in order to take fingerprints as well as other vital details. As a medical practitioner offering emergency services, you are left to decide on what you think is ethical and appropriate. Just by the availability of this window of individualized decisions, a lot of conflicts emanate, leading to ethical questions about the standards guiding the industry. 

There are several issues related to EMS that are not sufficiently covered in the law statutes, thus causing conflicts between law and ethics. This is because ethics, but not rules, primarily drives EMS, and, consequently, there are different sources of ethical guidelines, for example, moral pluralism. The universality of law leaves a lot of details unattended for specific practices, and that is the cause why there exist moral dilemmas in EMS when the law is placed ahead of ethical reasoning. For instance, the moral obligation for a physician is to attend to patients, but the law does not provide them with guidelines on how to protect themselves while doing their jobs. If a person was drowning and the emergency service attendant comes to the rescue, the law expects the person to save the victim at all costs, but it disregards the fact that both of them have lives to be secured. The law is one-sided, and this is the genesis of the conflict with ethics. 

The EMS Ethical Obligation

In every contemporary society, there are certain people who assume the role of giving EMS, whether they are from a hospital or from an organization being only registered for emergency responses. Thus, whenever such people move into the case, they assume the obligation of arresting the situation and bringing sanity to it with or without the help of the community. The responsibility of the EMS personnel is to offer medical services with all the available resources without compromising any ethical or legal standards. Financial issues are not meant to hinder delivery of services once a person takes up the responsibility, but they often determine the availability of resources and, eventually, the overall success of the procedure. Unlike any other business venture, EMS is supposed to be equitable and fair to all the victims regardless of their social of financial status, because it places the worth of life ahead of personality. 

Ethically, no person possesses a life that is more significant or expensive than the others’ lives. Thus, the obligation of EMS personnel is to offer service and not to judge people or group them by personality. Explaining this, it is good to look at a scenario where the ethical obligation is placed ahead of financial benefits when delivering services. For example, a member of the Congress is giving a speech in a conference hall when the wall collapses and a stampede occurs. The ethical obligation of the EMS team responding to the situation is to take everybody out and transport the injured to the hospital without looking first at the member of the Congress who was speaking. Attention should be distributed equally without looking at the status of the victims in terms of financial status since life is financially unmeasurable.

 In such a hall, there could have been drinks service girls, security officers, delegates, diplomats, and other high-ranking individuals, but emergency service team should disregard all of that and attend to casualties only. This is the ethical obligation that is guided by the principle of fairness and justice. It would not be fair to leave a person crying for help and search for wealthier individual or a leader who was trapped together with others. In classifying situations and allocating priority, the condition of the emergency should be the only guideline despite financial or social status of somebody evident in the scene. The priority should be given to those who have conditions that are life-threatening and not to the ability of an individual or a family to cater for specialized services. 

Pre-Hospital Ethical Issues

  1. Resuscitation Efforts Limitations. EMS should be useful to all the people in need, regardless of their conditions. This means that no step should be skipped just because somebody appears to be terminally ill or injured beyond healing. There are some fundamental steps in the delivery of EMS, which determine the overall success of the procedure. Among them, there is the resuscitation of the critically ill patients. Cardiopulmonary resuscitation (CPR) is a mechanism applied to help the patients in breathing process when they are on their way to the hospital and during the first few hours of their admission. However, some families make requests to have the mechanism unavailable to their ill relative, maybe because they feel it is not necessary for him of her based on the condition of the illness or perhaps because the patient had warned them not to do it the next time he or she falls sick. In such a case, the family has to sign a written Do-Not-Resuscitate (DNR) request for the medical practitioners to honor it. This is a painful decision that the EMS have to make in accepting the letter since sometimes they evaluate the situation and conclude that what the family is asking is simply to have their relative dead. Based on the principle of beneficence, the EMS personnel are only supposed to act in a manner that respects the wishes and interests of the patient. Backed by the principle autonomy of the patient, such requests have to be legally binding and create a lot of ethical questions. It is not easy to watch a patient’s struggling with death in the last minutes, but the letter has to be respected. Verbal requests are not honored, and the patient has to be treated according to medical standards. 
  2. Informed Consent. In the field of medical services, patients are usually at the center of the procedure, and they are supposed to be aware of everything that is meant to take place. This is done for giving them room to approve or reject procedures or drugs recommended. For this to happen, informed consent has to be applied. Consent is the approval of a procedure or activity through thorough consideration and of one’s own free will. This can only happen if the patient is informed of everything that is taking place. Moreover, if illness does not permit him/her to have consultations, the family is supposed to be consulted on his or her behalf. The challenge comes when the family rejects the procedure when the doctor is sure that nothing more can be done without it, or it is the only way to solve the situation. For instance, an accident happens, one person is seriously injured in one leg, and there is no medical treatment for it. The family or the patient has to approve its amputation, and if they do not agree to the procedure, there is absolutely nothing the EMS personnel can do. The challenge comes because the patient has to live with a risk to die since the law does not allow coercion. Informed consent helps when the patients have conditions that do not permit them to go through certain procedures or take certain medicines.  In such a case, they can tell the EMS personnel to avoid the rejected procedures, thus not triggering other medical issues that can be fatal.
  3. Duty to Provide Care. Among medical environments, EMS is unique in its approach, since it involves situations that can be risky to the victim as well as to the caregiver. This is where the ethical decisions have to be made before taking steps, since the obligation of the EMS personnel is to provide care and, in the process, not to compromise their health or safety. There are some instances where offering service is risky, and the physicians have to make ethical choices before they can venture into the arena. For example, a hostage situation where a gun fight is involved can be risky for the victims, security officers, criminals, and EMS personnel. This is where the evaluation of risk comes before the duty to offer medical assistance. The obligation is sole in providing help to people in a manner that no more damage is done to them, and it extends to the care without compromising the safety of the caregivers. There are some situations where EMS are confirmed impossible, and it is not the duty of the physicians to risk their lives for the victims. 
  4. Confidentiality. The matters of health are personal and should be kept between the patient and the caregiver. This is where EMS stand strongly for fighting for confidentiality of the issues related to the health of the patients under care. In some points, the issues get public, but it is the ethical obligation of the personnel in charge to limit the access to details. Some cases bring ethical challenges in the EMS when the public is involved in the first steps of the service delivery, and some crucial information gets leaked. For example, in a terrorist attack, the members of the public take important roles in helping the EMS and the security agencies to get the victims out of the mess with some of them offering their private cars to work as emergency means of transport to the hospital. In such cases, the privacy of the victims is compromised, but the EMS personnel have an obligation to ensure that more information about the victims is not leaked out once they get to the hospital. Disease outbreak also offers the same challenge, because the people who are not supposed to know the details about the victims are taking a primary role in arresting the situation at the time. The medical guidelines do not allow any physician to conduct secret tests on the patients because this is a breach of their confidentiality. 

Alternative Solution Model

Since some of these challenges manifested in EMS practice are recurrent, some things can be done to ensure the dilemmas are solved. First, there is a need for a general alternative guideline that covers all aspects of medical care in order to eliminate the challenges of moral pluralism. Doctors and EMS personnel should have a central point of reference which takes care of all medical practices. Secondly, the laws should be expanded to cover the challenges that the EMS practitioners face in their practice. Some things requiring expedited decisions can be challenging when the law does not define the course of action. Thirdly, there should be a mechanism for weighing decisions made by the patients in terms of informed consent. Some patients will act out of pain or desperation and complicate the process of their recovery. There should be instances where EMS personnel are allowed to ignore some requests that they deem irrelevant to the current situation. The work of emergency medicine is to save lives and assist in other procedures during recovery making it more crucial than any other medical practice. There should be laws defining the practice and enforcing procedures where informed consent does not seem forthcoming. Patients are not professionals, and some things cannot be easy for them to understand. Thus, getting approval will take hours of explaining in layman terms that can be to the detriment of the recovery process. There should be medical regulations that allow a window period after which informed consent should be avoided for the sake of the patient’s life or health.

Conclusion

Emergency medicine code of ethics is a fundamental driver in the course of service delivery and patient’s confidentiality regardless of the underlying situations. Patient autonomy, justice, and beneficence are the essential ethical principles governing EMS. Ethical conflicts are present throughout the practice due to the complexity of the service as well as the individualism in decision-making. These conflicts often surround vital issues of futile therapy, consent, duty to care, resuscitation, refusal of care, and confidentiality of the patient. EMS must be made fair and equally available to everybody in need, regardless of their social, political, or financial status. Training of EMS personnel on ethical decision-making is fundamental, since it helps them in eliminating chances of ethical dilemmas when they are offering service to victims. The type of training that is offered in schools is more of an abstract thing than a practical affair in the field, and this is what brings conflicts between the practice and ethical foundations. Moral pluralism is a problem brought by having different reference points in the medical practice. Various entities and agencies have their rules that often collide with each other, thus creating a state of controversy in the field.  Finally, the law does not sufficiently cover the challenges of offering EMS, since legal issues are universal for all the fields in the country and fails to point out fundamental questions regarding emergency care. There should be a statute extension of the law, where legal issues surrounding EMS can be sufficiently addressed.  

Related essays