Post on 22-Jan-2018
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Bryan E. BledsoeRichard A. Cherry Robert S. Porter
Paramedic Care: Principles & PracticeVolume 1, 5e
Chapter 8Ethics in Paramedicine
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Bryan E. BledsoeRichard A. Cherry Robert S. Porter
Standard
• Preparatory (Medical-Legal and Ethics)
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Bryan E. BledsoeRichard A. Cherry Robert S. Porter
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.
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Bryan E. BledsoeRichard A. Cherry Robert S. Porter
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.
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Bryan E. BledsoeRichard A. Cherry Robert S. Porter
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
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Bryan E. BledsoeRichard A. Cherry Robert S. Porter
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.
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Bryan E. BledsoeRichard A. Cherry Robert S. Porter
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.
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Bryan E. BledsoeRichard A. Cherry Robert S. Porter
Figure 8-1 The relationship of ethical and legal issues and medicine.
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Bryan E. BledsoeRichard A. Cherry Robert S. Porter
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.
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Bryan E. BledsoeRichard A. Cherry Robert S. Porter
Overview of Ethics
• Making Ethical Decisions
– Reason and logic used; emotion excluded as much as
possible from decision-making process.
– Deontological method: people should just fulfill their
duties.
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Bryan E. BledsoeRichard A. Cherry Robert S. Porter
Overview of Ethics
• Making Ethical Decisions
– Consequentialism: actions can be judged as good or
bad only after we know consequences of those actions.
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Bryan E. BledsoeRichard A. Cherry Robert S. Porter
Overview of Ethics
• Codes of Ethics
– Honesty
– Objectivity
– Integrity
– Carefulness
– Openness
– Legality
– Confidentiality
– Responsible publication
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Bryan E. BledsoeRichard A. Cherry Robert S. Porter
Overview of Ethics
• Codes of Ethics
– Responsible mentoring
– Respect for colleagues
– Social responsibility
– Nondiscrimination
– Competence
– Respect for intellectual property
– Human subjects protection
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Bryan E. BledsoeRichard A. Cherry Robert S. Porter
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.
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Bryan E. BledsoeRichard A. Cherry Robert S. Porter
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
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Bryan E. BledsoeRichard A. Cherry Robert S. Porter
Overview of Ethics
• The Fundamental Questions
– Be cautious in accepting family's description of what
patient desires.
– State and local laws
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Bryan E. BledsoeRichard A. Cherry Robert S. Porter
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.
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Bryan E. BledsoeRichard A. Cherry Robert S. Porter
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.
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Bryan E. BledsoeRichard A. Cherry Robert S. Porter
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.
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Bryan E. BledsoeRichard A. Cherry Robert S. Porter
Overview of Ethics
• Resolving Ethical Conflicts
– 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.
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Bryan E. BledsoeRichard A. Cherry Robert S. Porter
Overview of Ethics
• Resolving Ethical Conflicts
– 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?
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Bryan E. BledsoeRichard A. Cherry Robert S. Porter
Figure 8-3 A quick approach to new ethical problems.
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Bryan E. BledsoeRichard A. Cherry Robert S. Porter
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.
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Bryan E. BledsoeRichard A. Cherry Robert S. Porter
Ethical Issues in Contemporary
Paramedic Practice
• Resuscitation Attempts
– 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.
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Bryan E. BledsoeRichard A. Cherry Robert S. Porter
Ethical Issues in Contemporary
Paramedic Practice
• Resuscitation Attempts
– 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.
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Bryan E. BledsoeRichard A. Cherry Robert S. Porter
Ethical Issues in Contemporary
Paramedic Practice
• Resuscitation Attempts
– 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.
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Bryan E. BledsoeRichard A. Cherry Robert S. Porter
Ethical Issues in Contemporary
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
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Bryan E. BledsoeRichard A. Cherry Robert S. Porter
Ethical Issues in Contemporary
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
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Bryan E. BledsoeRichard A. Cherry Robert S. Porter
Ethical Issues in Contemporary
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.
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Bryan E. BledsoeRichard A. Cherry Robert S. Porter
Ethical Issues in Contemporary
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.
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Bryan E. BledsoeRichard A. Cherry Robert S. Porter
Ethical Issues in Contemporary
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.
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Bryan E. BledsoeRichard A. Cherry Robert S. Porter
Ethical Issues in Contemporary
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
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Bryan E. BledsoeRichard A. Cherry Robert S. Porter
Ethical Issues in Contemporary
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.
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Bryan E. BledsoeRichard A. Cherry Robert S. Porter
Ethical Issues in Contemporary
Paramedic Practice
• Professional Relations
– Physician orders something paramedic believes
contraindicated.
– Physician orders something paramedic believes
medically acceptable but not in patient's best interests.
– Physician orders something paramedic believes
medically acceptable, but morally wrong.
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Bryan E. BledsoeRichard A. Cherry Robert S. Porter
Ethical Issues in Contemporary
Paramedic Practice
• Professional Relations
– 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.
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Bryan E. BledsoeRichard A. Cherry Robert S. Porter
Ethical Issues in Contemporary
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
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Bryan E. BledsoeRichard A. Cherry Robert S. Porter
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.
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Bryan E. BledsoeRichard A. Cherry Robert S. Porter
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.
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Bryan E. BledsoeRichard A. Cherry Robert S. Porter
Summary
• Your actions should be:
– Legal and within your scope of practice (justice)
– Helpful (beneficence)
– Not harmful (nonmaleficence)
– Direct wishes of patient (autonomy)