Bledsoe v1 ch08_lecture

Copyright © 2017, 2013, 2009 Pearson Education, Inc. All Rights Reserved.

Bryan E. BledsoeRichard A. Cherry Robert S. Porter

Paramedic Care: Principles & PracticeVolume 1, 5e

Chapter 8Ethics in Paramedicine



Standard

• Preparatory (Medical-Legal and Ethics)



Competency

• Integrates comprehensive knowledge of EMS

systems, the safety and well-being of the

paramedic, and medical–legal and ethical issues,

which is intended to improve the health of EMS

personnel, patients, and the community.



Introduction

• Although ethical problems often have legal aspect,

most are solved in field and not in a courtroom.

• Ethical issues often begin with specific

circumstances; lead to broad general rules or

principles for behavior.



Overview of Ethics

• Morals: social, religious, or personal standards of

right and wrong.

• Ethics (moral philosophy): branch of philosophy;

addresses questions about morality.

– Rules or standards that govern conduct of members of

particular group or profession; how institutions should

function



Overview of Ethics

• Relationship of Ethics to Law and Religion

– Ethics not the same as law.

– Laws much narrower focus than ethics.

– Law frequently has little or nothing to say about ethical

problems.



Overview of Ethics

• Relationship of Ethics to Law and Religion

– Law: impartiality, consistent procedures, methods to

identify and balance conflicting interests.

– Ethics cannot derive from single religion.

– Religion can enhance and enrich one's ethical

principles and values.



Figure 8-1 The relationship of ethical and legal issues and medicine.



Overview of Ethics

• Making Ethical Decisions

– Ethical relativism: each person must decide how to

behave and whatever decision that person makes is

okay.

– Ethics and morality overlap.

– Professional ethics go beyond what one individual

thinks is right or wrong.



Overview of Ethics


– Reason and logic used; emotion excluded as much as

possible from decision-making process.

– Deontological method: people should just fulfill their

duties.



Overview of Ethics


– Consequentialism: actions can be judged as good or

bad only after we know consequences of those actions.



Overview of Ethics

• Codes of Ethics

– Honesty

– Objectivity

– Integrity

– Carefulness

– Openness

– Legality

– Confidentiality

– Responsible publication



Overview of Ethics

• Codes of Ethics

– Responsible mentoring

– Respect for colleagues

– Social responsibility

– Nondiscrimination

– Competence

– Respect for intellectual property

– Human subjects protection



Overview of Ethics

• Impact of Ethics on Individual Practice

– Paramedics exemplify principles and values of

profession.

– Understand and agree to abide by responsibilities

(implicit and explicit) of profession.

– Common sense helps in resolving conflicts.



Overview of Ethics

• The Fundamental Questions

– What is in patient's best interest?

Reassurance, relief from pain, prompt and safe transport

Written statement of patient's desires

Paramedic obligated to respect patient's desires



Overview of Ethics

• The Fundamental Questions

– Be cautious in accepting family's description of what

patient desires.

– State and local laws



Overview of Ethics

• Fundamental Principles

– Beneficence: doing good.

Paramedic's obligation to patient

– Maleficence: doing harm

– Nonmaleficence: not doing harm.

Paramedic obligated to minimize risk as much as possible.



Overview of Ethics

• Fundamental Principles

– Autonomy: competent adult patient's right to determine

what happens to his own body.

Treatment for medical illnesses and injuries

– Justice: paramedic's obligation to treat all patients

fairly.



Overview of Ethics

• Resolving Ethical Conflicts

– Institutional review boards (IRBs): protect rights of

subjects in research projects.

– To reason out ethical problem:

State action in universal form.

List implications or consequences of action.

Compare them to relevant values.



Overview of Ethics


– Is current problem similar to other problems for which

you have already formulated rule?

– If yes, follow rule.

– If no, determine if you can buy time.



Overview of Ethics


– Impartiality test: would you be willing to undergo

procedure or action if in patient's place?

– Universalizability test: would you want action

performed in all similar circumstances?

– Interpersonal justifiability test: can you defend or justify

your actions to others?



Figure 8-3 A quick approach to new ethical problems.



Ethical Issues in Contemporary

Paramedic Practice

• Resuscitation Attempts

– Every state that has laws or rules regarding Do Not

Resuscitate (DNR) orders requires you to see order

and verify legitimacy.

– If patient alive, valid DNR order would not prevent you

from assessing patient and administering basic care.




Paramedic Practice


– Nonmaleficence says do no harm.

– Beneficence and nonmaleficence urge you to help

patient.

– DNR order must meet state and local requirements

regarding wording and witnesses.




Paramedic Practice


– Description of which interventions to be withheld, under

which circumstances

– Every patient entitled to reasonable measures intended

to make patient more comfortable (comfort care).

– Family and loved ones entitled to emotional support

from EMS providers.




Paramedic Practice


– When in doubt, resuscitate.

– Once you have verified validity of order and identity of

patient, you are obligated ethically (perhaps legally) to

cease resuscitation efforts.

– Follow your local protocols.




Paramedic Practice

• Confidentiality

– Obligation to patient to maintain confidential

information

– Every state has laws requiring reporting of certain

health facts.

Births, deaths, particular infectious diseases, child neglect and

abuse, elder neglect and abuse




Paramedic Practice

• Confidentiality

– Valid court order justification for breaching

confidentiality

– Clear threat by patient to specific person

– Probability of harm, magnitude of expected harm,

alternative methods of avoiding harm




Paramedic Practice

• Consent

– Competent patient of legal age has fundamental right

to decide what health care he will receive and will not

receive.

– Doctrine of implied consent: patient unable to give

consent.




Paramedic Practice

• Allocation of Resources

– Civilian triage: most seriously injured receive most care

based on need.

– Military triage: help least seriously injured; produces

greatest number of soldiers who can return to duty.

– Resolving issue of allocation of scarce resources:

examine competing theories in light of circumstances

at hand.




Paramedic Practice

• Obligation to Provide Care

– Those who provide emergency care have special

obligation to help all those in need without regard to

ability to pay.

– Act in patient's best interest, even when against HMO's

economic interests.

– Good Samaritan statutes in every state in U.S.




Paramedic Practice

• Teaching

– Many paramedics act as preceptors or mentors in EMS

systems.

– Inform patients of presence of student.

– Request patient's consent before student performs

procedure.

– Student's skill level; difficulty of procedure; importance

of procedure




Paramedic Practice

• Professional Relations

– As health care professional, paramedic answers to

patient.

– As physician extender, paramedic answers to physician

medical director.

– As employee (or volunteer), paramedic answers to

EMS system.




Paramedic Practice


– Physician orders something paramedic believes

contraindicated.


medically acceptable but not in patient's best interests.


medically acceptable, but morally wrong.




Paramedic Practice


– Ultimately, paramedic must determine how patient's

interests best served.

– Important for paramedic to understand that no matter

what decision he makes, he will have to defend it.

– Disagreements with physician orders happen rarely.




Paramedic Practice

• Research

– Paramedics implement research protocols and gather

data.

– Goal of research: to help future patients by gaining

knowledge about specific intervention.

– Gain patient's expressed consent



Summary

• As paramedic, you must learn to make ethical

decisions that will have an effect on you, your

patient, or others.

• Decision-making process should always be based

on patient's best interest.

• Patient's best interest includes more than

lifesaving procedures.

• Cultural sensitivity included in decision.



Summary

• Patient has autonomy; right to determine what

happens to his own body, and can legally dictate

that.

• Clear distinction between ethics, religion, law even

though common ground between them.



Summary

• Your actions should be:

– Legal and within your scope of practice (justice)

– Helpful (beneficence)

– Not harmful (nonmaleficence)

– Direct wishes of patient (autonomy)