There can be no greater calling or higher standard for ethical behavior than that assumed by the physician. Our obligation to our patients is paramount and society expects that we conduct ourselves within this standard. We enjoy great privilege as part of our maintenance of these standards and likewise we are held emphatically to these expectations as well. There is little room for lenience among us when these standards are compromised. This is appropriate as the effect on patients, colleagues, and entire organizations can be profound. Public trust and decades of ethical investment may be compromised by the actions of a single transgressor.

The importance of these standards cannot be overstated. This is reflected in the innumerable organizational codes of ethical behavior as well as in federal, state, and local statutes. As physicians the most generally applicable reference is the American Medical Association’s Code of Medical Ethics.¹ In keeping with the focused nature of this text we will constrain our discussion to how these principles affect the ethical management and oversight of EMS organizations.

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  Discuss principles of ethical management and medical oversight (honesty, responsible mentoring, maintaining objectivity, respect for colleagues, integrity, social responsibility, carefulness, nondiscrimination, openness, competence, legality, respect for intellectual property, confidentiality, human subjects’ protection, responsible publication).

  
  
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  Define fiduciary responsibility, and discuss how this relates to EMS administrators and medical directors.

  
  
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  Describe work place harassment and how it affects individuals and an agency as a whole.

  
  
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  Describe the duty to report, as it relates to illegal acts, unethical conduct, and impaired providers.

EMS physicians have the same ethical obligations as other health care providers. These are applied in a wide variety of circumstances, including during individual patient encounters, mass casualty incidences, and in management of medical oversight of an EMS system. Adhering to the expected medical code of conduct requires personal attention and a keen attention to EMS provider education. The protocol-driven nature of much of prehospital medical care can lead to unintentional violations of ethical standards.

Nonmaleficence: (Primum non nocere) “first do no harm.” Acting in a way as to minimize risk to the patient rather than focusing on therapeutic interventions. It is important to emphasize this concept when considering protocol and procedure development. Some protocols and dogmatic approaches to clinical situations may lead to unnecessary interventions if too general of an approach is advocated or prescribed in the protocol. Routine placement of IV catheters may be an example of a potentially harmful intervention that could be overly prescribed based on wording of a protocol.

Beneficence: acting in a manner that in one’s best judgment will benefit the patient. This concept is core to all areas of health care and must be constantly reinforced as the driving principle behind every act by every physician and EMS provider in the system.

Autonomy: the right to make one’s own decisions, using one’s own value system, and act on those decisions, without undue coercion from other people or influences. This is an important ethical concern that is sometimes difficult to instill in emergency responders who have been trained to act and respond to certain emergencies by protocol. It is important for medical directors to actively review policies and procedures relating to respecting patient autonomy and provide education on an ongoing basis relative to refusal of care and transport in the field.

Justice: attempting to maintain a fair distribution of resources, while assessing competing needs, rights and obligations, and potential conflicts with established legislation. It is important to ensure that emergency resources are appropriately distributed based on medical needs of the system. An EMS medical director should avoid advocating for positioning of EMS assets based on real or perceived financial or political gain.

Medical ethics and codes of conduct commonly refer to a set of guiding ethical principles. One specific set of principles is shown in Table 28-1.

HONESTY

Honesty is a cornerstone in all relationships. It is endemic to any good work environment.¹ The consistent prioritization of honesty in the workplace is the foundation by which we meet many of our ethical responsibilities. Honesty demands accurate evaluation of employee performance and leads to responsible mentoring. It also fosters constructive employee feedback to their supervisors.² It supports openness of communication and the unfettered ability to maintain objective two-way communication. An environment that prioritizes honesty allows all members of the community to be heard without fear of reprisal and is absolutely indispensible to effect needed change as it allows for the objective identification of areas for improvement.

Honesty, including being honest with one’s self, allows for the maintenance of objectivity. Objectivity is crucial when supervising others and leads to productive supervisory interventions rather than ones undermined by the showing of emotion or lapses that reveal more visceral responses. The constant application of objectivity demonstrates respect for your colleagues and peers and will only lead to enhanced effectiveness on your part. In your role as an EMS medical director, it is hoped that you will support scholarly pursuits for the advancement of the field at large and the professional advancement of your employees, your peers, and yourself. Honesty again plays an important role here with the respect of others’ intellectual property. This includes the highest ethical standards in citing the work of others. Whether this is appropriate citation of other indexed works or balanced representation of authorship of scholarly works the same principles apply.

Honesty again guides us when we are confronted with our colleagues’ lapses in professional behavior. We have an ethical and often legal responsibility to report certain acts.³ While we are expected to report illegal and unethical behavior, this is not always the case.⁴ By not reporting such behavior you become an accessory to it and open yourself to significant consequences. We should always remember that when our colleagues act outside the rules, and do so in a way that we have become aware of it, they have selfishly jeopardized us and, in the author’s view, enjoy no obligation from us to protect them. This, of course, includes the reporting of impaired providers as covered in detail in Chapter 8.