Chapter 1 Ethics PDF

# CH.1 Ethics ## PSL: Yazan Mohammad ### Key Terms * **Autonomy** The principle of self-determination; that is, a person's ability to make moral decisions, including those affecting personal medical care. * **Beneficence** A duty to confer benefits; the practice of good deeds; an obligation to ben...

# CH.1 Ethics ## PSL: Yazan Mohammad ### Key Terms * **Autonomy** The principle of self-determination; that is, a person's ability to make moral decisions, including those affecting personal medical care. * **Beneficence** A duty to confer benefits; the practice of good deeds; an obligation to benefit others or to seek their good. * **Bioethics** The systematic study of moral dimensions, including the moral vision, decisions, conduct, and policies of the life sciences and health care. * **Ethics** The discipline relating to right and wrong, moral duty and obligation, moral principles and values, and moral character; a standard for honorable behavior designed by a group with expected conformity * **moral injury** The psychological impact of witnessing events that conflict with one's personal morals or acting in a way that contradicts one's morals. * **morals** The personal standards that a person uses to distinguish right from wrong. * **unethical** Conduct that fails to conform to moral principles, values, or standards. ### Ethics Overview Paramedics make ethical choices on almost every shift. Issues such as consent, refusal, confidentiality, and end-of-life choices often involve ethical dilemmas. Ethical dilemmas may occur in every phase of an emergency medical services (EMS) call. Ethical decisions are based on an appraisal of moral judgments- a concept that places the responsibility on individuals. ### The Difference Between Morals and Ethics The difference between morals and ethics can seem confusing. The two concepts have similarities, but a basic, subtle difference exists. Morals define personal character. Ethics stresses a social system in which those morals are applied. In other words, ethics points to standards or codes of behavior expected by the group to which a person belongs. This group could be a social group, a religion, a company, a profession, or even a family ### Example Situations * **Example 1:** A defense attorney must defend a man she believes is guilty of murder. The attorney believes that murder is wrong and immoral, and that this person would be a danger to society if found not guilty and released. However, the legal system and the ethics of the profession to which she belongs require that her client be defended as vigorously as possible. Her client also must receive a fair trial. In this case, the attorney's ethics must override her personal morals. * **Example 2:** In most parts of the world, a doctor may not euthanize a patient, even at the patient's request, because it is against the ethical standards for health care professionals. However, the same doctor may personally believe in a patient's right to die; this belief represents his or her own morality. ### The Patient's Right to Self-Determination * All paramedics face ethical issues during their careers. Most issues deal with the patient's right to self-determination and the paramedic's duty to provide patient care. * The concept of the patient's right to self-determination is known as **autonomy**, and the concept of the paramedic's duty to provide patient care that is of benefit to the patient is known as **beneficence**. ### Commonly Accepted Bioethical Values | Ethical Value | Description | |---|---| | Allocation of resources | Consistent access to quality medical services; the distribution of health-related services among various people and uses | | Autonomy | Self-determination; a person's ability to make moral decisions, including those affecting personal medical care. The three components of autonomy are agency (awareness of oneself as having desires and intentions and acting on them); independence (absence of influences that so control what a person does that it cannot be said the person wants to do it); and rationality (rational decision making). | | Beneficence | A duty to act in the interest of the patient's welfare; the practice of good deeds; an obligation to benefit others or seek their good. | | Confidentiality | The presumption that certain information will not be revealed to others without the patient's permission. Confidentiality, like privacy, is valued because it protects individual preferences and rights. | | Non-maleficence | The prevention of harm, from the Hippocratic tradition that established primum non-nocere (“Above all, do no harm”); a prohibition against actions with foreseeable harmful effects. | | Personal integrity | Adherence to a personal set of values and moral standards | ### The Code of Ethics for EMS Practitioners I solemnly pledge myself to the following code of professional ethics: * To conserve life, alleviate suffering, promote health, do no harm, and encourage the quality of emergency medical care. * To provide services based on human need, with compassion and respect for human dignity, unrestricted by consideration of nationality, race, color, or status * To not use professional knowledge and skills in any enterprise detrimental to the public well-being. * To respect and hold in confidence all information of a confidential nature obtained in the course of professional service unless required by law to divulge such information. * To use social media in a responsible and professional manner that does not discredit, dishonor, or embarrass an EMS organization, co-workers, other health care practitioners, patients, individuals or the community at large. * To maintain professional competence, striving always for clinical excellence in the delivery of patient care. * To assume responsibility in upholding standards of professional practice and education. * To assume responsibility for individual professional actions and judgment, both in dependent and independent emergency functions, and to know and uphold the laws which affect the practice of EMS * To work cooperatively with EMS associates and other allied healthcare professionals in the best interest of our patients. * To refuse participation in unethical procedures ### Professional Accountability * As professionals, paramedics conform to a standard set by their level of training and regional practice. Paramedics are accountable to the patient, the medical director, and the EMS system for meeting this standard of care, and they can face legal accountability if the standard is not met. * Duties include commitment to high-quality patient care, continuing education, skill proficiency, and licensure and/or certification. A paramedic who is accountable to the profession is more likely to provide good patient care and make ethical decisions. ### Moral Accountability Moral accountability refers to personal ethics-that is, personal values and beliefs. Combining moral, legal, and professional accountability may be difficult in an emergency. At times, the paramedic must draw on personal ethics to resolve conflicts among these roles and duties. Moreover, the paramedic must decide on a course of action. When dealing with ethical questions, paramedics should remember the following key points * **1. Emotion is not a reliable determinant for ethical decision making.** Rational decision making relies on research and prudence to determine what is right. Remember, however, that in the prehospital setting it may not be possible to make a fully informed decision. All available information should be considered and acted upon according to one's experience and ethical framework. * **2. Global protocols are meant to guide, not dictate.** If paramedics encounter an unfamiliar situation, they are likely to make a poor or even an unethical decision. In these circumstances, paramedics should consult with medical direction, coworkers, a supervisor, or a set of guidelines or other resources. Consultation is better than limiting oneself to one's own knowledge base or principles. * **3. Once the ethical question has been answered, the answer becomes a "rule” to guide behavior, at least in that setting.** Paramedics should follow that rule and use it as an established guideline moving forward. Experience addressing ethical dilemmas in the field will build a foundation for future ethical issues that may be encountered. ### Ethical Tests in Health Care * **1. The most basic question of ethical tests in health care is, “What is in the patient's best interest?"** However, doing what is best, or what one thinks is best, is not enough to justify actions. One must determine what the patient wants. The paramedic can do this using statements by the patient (if the patient has decisional capacity) and written statements. Family input is helpful if the patient shows altered mental status or a lack of decisional capacity. * **2. The role of "good faith” in making ethical decisions should be balanced with the wishes of the patient and the family.** Whether an act is done in good faith can be determined by answering the question, "Am I doing my best to help and not harm my patient?" * **3. The global concept of health care is providing patient benefit and avoiding harm.** It recognizes and respects the patient's autonomy. The concept also recognizes the various legal issues that affect the delivery of health care ### Global Concepts of Ethical Health Care * **1. Help the patient, or at least to do no harm.** * **2. Refrain from interfering if the illness is incurable and inevitably mortal.** * **3. Insofar as possible, attack the cause of the disease therapeutically.** Today, these global concepts of ethical health care can be stated as follows * **1. Provide patient benefit.** * **2. Do no harm.** ### Rapid Approach to Ethical Problems in an Emergency A method of ethical case analysis, or "rules of thumb" process, has been designed as a way to deal rapidly with ethical problems in an emergency. The steps of this process are as follows: * **1. Ask yourself whether you have experienced a similar ethical problem in the past.** If so, use that experience as a precedent for this problem and follow the previously established rule. * **2. If you have not already experienced a similar ethical problem, buy time for deliberation and for consulting with coworkers and medical direction.** * **3. If buying time for deliberation is not an option, use a set of three tests to help you make a decision** * **Test 1 (impartiality test).** Would you accept the action if you were in the patient's place? The impartiality test helps correct partiality or personal bias. * **Test 2 (universalizability test).** Would you feel comfortable having this action performed in all relevantly similar circumstances? The universalizability test helps do away with moral decision difficulty. * **Test 3 (interpersonal justifiability test).** Are you able to provide good reasons to justify and defend your actions to others? The interpersonal justifiability test requires that the paramedic define reasons for proceeding that others would approve. ### Resolving Ethical Dilemmas * **1. At times, ethical dilemmas can be difficult to resolve.** This may be the case when global concepts of health care are in conflict. Resolution of these conflicts can be guided by the health care community and the public. The role of the health care community in resolving these conflicts is to set standards of care, provide research and treatment protocols. * **2. The role of the public in managing ethical conflicts in medicine includes creating laws, setting public policy, and allocating resources to protect the patient's rights.** It also includes participating in the use of advance directives and other self-determination documents to make the patient's wishes known * **3. The paramedic should apply the rapid approach to emergency medical problems and answer the following ethical questions:** * **1. What is in the patient's best interest?** * **2. What are the patient's rights?** * **3. Does the patient understand the issues at hand?** * **4. What is the paramedic's professional, legal, and moral accountability?** ### Allocation of Resources * **1. Fairness in the allocation of resources and obligations is a commonly accepted bioethical value and is incorporated into society-wide health care policies.** This perceived right to universal access to an adequate level of health care is a complex economic issue that is affected by the need to contain health care costs * **2. Two factors affect true parity in the allocation of resources.** * **1. person's access to health insurance.** Even if a person has health insurance, the plan may define which medical services are covered or excluded * **2. treatment decisions made when resources are inadequate to meet patient care needs.** This may occur, for example, during a disaster involving multiple casualties. When rationing of care is required, it should be based on ethically oriented criteria. ### Case Study 1 You have been dispatched to the home of a 74-year-old man. The man complains of chest pain. The patient is in obvious distress and provides a significant cardiac history. He asks to be taken to the Veterans Administration hospital (60 Km away), where he had heart surgery several years ago. Based on the patient's history, the physical examination findings, (ECG), your investigations (in consultation with medical direction) you elect to take the patient to a closer hospital so that his condition can be stabilized. The patient becomes anxious and complains of increasing chest pain. He tells you that he has no medical insurance and demands to be taken to the Veterans Administration hospital. ### Confidentiality * **1. Most people are considered to have a basic right to privacy.** The principle of confidentiality refers to a person's private and personal information. This information should not be disclosed by a health care professional without the patient's consent. Doing so is illegal * **2. In some cases, however, the release of such information may be required by law.** An example of such a case is the disclosure to others involved in the patient's care that a patient has tested positive for infection with the human immunodeficiency virus (HIV). ### Case Study 2 You have been dispatched to MVA. A young man's car struck another car head-on, killing the driver of that car. The young man, who is the patient, is shaken but has only minor injuries. As the patient is prepared for transport, he confides to you that he had used cocaine shortly before the crash. He asks you to keep the information confidential and not to tell the police officers at the scene. ### Consent * **1. This right is a basic element of the relationship between the patient and paramedic.** * **2. This right also can be inferred from the Code of Ethics for EMS Practitioners.** Cases in which patients refuse lifesaving care can produce legal and ethical conflicts, as shown in the following case studies. ### Case Study 3 You have been dispatched to a restaurant where an older adult woman has collapsed. She has suffered cardiac arrest, and a waiter is performing (CPR). The ECG monitor reveals ventricular fibrillation. Defibrillation is delivered, but the rhythm remains unchanged. As resuscitation measures are continued, the woman's husband says to you, "She said she didn't want this. Her living will is at home. Please stop what you're doing and let her go." ### Case Study 4 You have been dispatched to an office building where a 55-year-old woman collapsed at a business meeting. She is alert and oriented, complains of chest pain, and is pale and diaphoretic. You advise the patient of the possibility of MI and the need for immediate care and transport. The patient insists on waiting until after the meeting has concluded to seek medical care on her own and asks the EMS crew to leave. ### Care in Futile Situations * **1. An action is seen as futile if it serves no purpose or is totally ineffective.** When you providing care in a case that may be futile should consult with medical direction. Consultation can help you to decide on a course of action. An example of a futile situation in health care is continuing resuscitation initiated by bystanders when the patient clearly has expired. Another example is providing life support measures for a patient who has fatal injuries. * **2. The definition of futility may pose an ethical dilemma.** Providing CPR to a patient when you believe the patient has irreversible brain damage can cause ethical conflict. Not all futility judgments are controversial. For example, CPR is futile in patients with obvious signs of death, such as decapitation, rigor mortis ### Case Study 5 You arrive at a home where you find a 3-month-old baby who obviously has been dead for several hours. The mother is screaming, “Help her! Help her!" Your partner decides to proceed with advanced life support care even though it is clearly futile. Is this decision ethical? ### Patient Advocacy and Paramedic Accountability While providing care, the paramedic serves as the patient's advocate. This advocacy may conflict at times with the paramedic's accountability to the patient, the physician medical director, and the health care system (protocols). In such a case, the paramedic should discuss all options with medical direction. As a rule, it is prudent and ethical to mistake on the side of providing for the needs of the patient when conflict arises ### Examples of Ways in which a Paramedic Can Serve as the Patient's Advocate * **1. Educating patients about the delivery of health care and the role they can play to help change the nation's health care system** * **2. Intervening when it is in the patient's best interest, particularly when the patient cannot communicate** * **3. Making sure health care decisions are made by patients and their physicians and are based on the patient's medical needs, not financial considerations** * **4. Promoting patient access to reliable information about state-of-the-art medical technologies and treatments** * **5. Promoting fairness and equality in health care system** ### Paramedic's Role as Physician Extender * **1. As a physician extender, the paramedic generally is responsible for following the orders of the medical director or the director's designee.** However, sometimes these orders may not seem suitable. For example, the paramedic may believe that a medication order is contraindicated for the patient. Or a medication may be medically acceptable but may not be in the patient's best interest (eg, an order for an IV drug to treat asthma before the patient's inhaler has been tried). * **2. When a conflict occurs between medical direction and the paramedic, communication is the key to resolving short-term and long-term concerns** ### Ethical Leadership in Paramedicine * **1. Leadership is a key aspect of the paramedic role.** Effective leaders are committed to ethical conduct. Ethical conduct applies to interactions with patients, the community, and other members of the EMS team. The community expects ethical behaviors from public safety professionals, and as leaders within that system, it is imperative that paramedics model those practices. * **2. Reflection on one's own ethical life can begin by asking five questions:** * **1. Did I practice any virtues today?** * **2. Did I do better than harm today?** * **3. Did I treat people with dignity and respect today?** * **4. Was I fair and just today?** ### The End