Introduction

Emergency medical services providers make ethical decisions on a daily basis [1]. They frequently deal with issues of patient refusal, confidentiality, the treatment of minors, and other challenging ethical dilemmas. The fast-paced prehospital work environment compounds the complexity because difficult decisions often need to be made without having all the necessary information and without sufficient time for extended consideration and debate. An understanding of the principles of medical ethics, however, can help guide EMS providers on the front lines when faced with ethical questions.

Emergency medical services medical directors, physicians, and personnel should be familiar with the prevailing statutes of their respective state and local governments because ethical debate may be moot if the law renders a ready decision. However, because individual cases vary widely, the law leaves many ethical questions unanswered. There are important differences between ethics and the law. The law attempts to ensure order by establishing rules that are derived from social values. The law, however, does not attempt to enforce every moral value. Following legal rules alone, therefore, may be ethically insufficient. For example, EMS providers not infrequently encounter patients who refuse care. Although the minimal legal standard requires a signature of release by the informed patient, the signature alone may be ethically insufficient. From an ethical and professional standpoint, it is important to explore the patient’s understanding, concerns, and perhaps alternative options for treatment in order to ensure that the patient is appropriately cared for. It is important to remember that the law establishes rules and regulations based on societal values but it does not mandate the full display of the highest ethical behaviors.

This chapter will introduce core medical ethics principles and demonstrate how they can be applied to common ethical dilemmas encountered in the prehospital setting.

Refusal of treatment and transport

Case #1: EMS responds to a 45-year-old unhelmeted man who was struck by a car while riding his bicycle with his two young sons. The patient is found thrashing about on the ground, with signs of head trauma. When EMS providers attempt to transport the patient to the ambulance, the patient repeatedly refuses care, instead only asking about the whereabouts of his children, who are unharmed and remain at his side. The patient is clearly disoriented and unable to engage the paramedics in any sustained manner. One of the EMS providers asks if the patient can be treated and transferred against his will.

Case#2: EMS is dispatched to the home of a 90-year-old woman with known end-stage lung cancer who is complaining of shortness of breath. Upon their arrival, EMS intervention is refused by a cachectic but lucid patient who is very aware of her medical condition. She explains that she has been recently discharged from the hospital after extensive discussions with her oncologist regarding her preference to spend her remaining days at home. She understands that her progressive shortness of breath is a result of her end-stage lung cancer and that she will likely die from the disease in the near future. The patient’s sons and daughters admit that they had initiated the 9-1-1 call because they felt their mother appeared extremely uncomfortable. The patient adamantly refuses any transfer to the hospital, while her family demands that EMS providers “do something” to help her.

Autonomy is a core principle of medical ethics [2]. Individuals are assumed to have the right to self-determination, even if their decisions result in harm to themselves. Patient refusal of care may apply to a specific course of treatment (e.g. insertion of a peripheral IV) or plan for further care (e.g. patient refusing transportation to the closest hospital in favor of a different facility). For EMS providers, patients have capacity to make their own medical decisions when the following criteria are fulfilled [3,4].

1. The patient must have sufficient information about his or her medical condition.
   
2. The patient must understand the risks and benefits of available options, including the option not to act.
   
3. The patient must have the ability to use the above information to make a decision in keeping with his or her personal values.
   
4. The patient must be able to communicate his or her choices.
   
5. The patient must have the freedom to act without undue influence from other parties, including family and friends.

If any of the above criteria are not met, EMS providers should balance their respect for the patient’s limited decision-making capacity with their obligation to act in the patient’s best interest. A great challenge for EMS providers is to expertly assess decision-making capacity in order to understand when a refusal is informed and when it is an impulsive gesture of a person who lacks capacity due to severe psychiatric disease, intoxication, or overwhelming medical illness [5]. For example, medical conditions such as hypoglycemia, head trauma, and sepsis can make patients impulsive, restless, angry, and antagonistic such that there may be confusion regarding their ability to reason. If EMS providers believe a patient lacks decision-making capacity (as opposed to competence, which is a legal determination), actions should be taken to ensure the patient’s safety and best interest. In this regard, EMS personnel must operate under the rubric of beneficence, another core principle of medical ethics [2].

In situations of refusal of care, providing unwanted treatment over the objection of a patient with sufficient decision-making capacity may render the EMS provider guilty of battery [6]. Conversely, an impulsive or incompletely informed refusal leading to lack of treatment and transport leaves the provider liable for negligence. It is therefore strongly recommended that whenever EMS providers defer transport or treatment due to a patient’s refusal of care, the patient’s decision-making capacity should be explicitly documented in the medical record, with special attention to the information that was specifically communicated and understood by the patient. Similarly, when EMS providers act in the patient’s best interest and treat or transport a patient who refuses care but who is deemed to have insufficient decision-making capacity, the conditions leading to this determination should be carefully documented. EMS providers must remember that it is not the responsibility of patients to prove they have decisional capacity; it is the responsibility of the provider to identify any impairment of such capacity.

The patient in case #1 clearly did not exhibit signs of decision-making capacity, likely secondary to the head trauma he sustained. EMS providers would be acting ethically to deny his refusal of care and instead act in his best interest by treating and transporting him to a hospital for definitive care.

The patient in case #2, though critically ill, still possessed full decision-making capacity when questioned by EMS personnel. She demonstrated that she sufficiently understood her medical condition, the risks and benefits of refusing further medical care, and how these decisions were in keeping with her personal values of wishing to die at home surrounded by her family and friends. For this patient, her decision to refuse further care is compatible with the EMS provider’s ethical obligation to respect a patient’s autonomy. Although the patient’s family may disagree with the patient’s decision, EMS responders would be acting ethically by respecting her wishes not to be transported to a hospital.