Professional Development: Part 3--How to Adhere to a Code of Ethics in EMS

      You are dispatched to a possible "code blue." You arrive on scene and walk up to the front door of a single-family home, and as you get there an elderly man opens the door. He is visibly upset and appears to be crying. He says quietly, "My Agnes is cold, and I don't think she's breathing. Please help her!" He leads you into a first-floor room where a woman is lying in a hospital bed. You can see that Agnes is blue around the lips. You establish that she is unresponsive. You feel her skin as you open her airway—it is warm. She is not breathing. You ventilate her with a BVM and check for a pulse, but find none. You prepare to move Agnes to the floor to start CPR, but just as you begin to pick her up, someone enters the room and yells, "Stop! What are you doing? Mom is DNR!"

   How many of us are prepared to handle the moral and ethical dilemma beginning to play out in the scene above? This is just one of the moral and ethical challenges we face. Can you think of others? How about triage situations? Maybe you witness a coworker steal something on a call. Maybe your partner asks you to lie and say he was with you last night, when he was really who-knows-where. Perhaps you've worked with a paramedic who has regularly misidentified cardiac rhythms on nearly every case presenting with other than normal sinus.

   Back when I was in EMT school, the topic of morals and ethics was not addressed in any detail. I can't remember much discussion of it in medic school, either. We covered issues like duty to act and abandonment, good Samaritan laws and DNR situations. But there is so much more to the topic, so many situations we find ourselves in, that we need a stronger foundation upon which to build our choices and responses to such challenges.

   To begin a our discussion of morals and ethics, we need to have a grasp of the meaning of the concepts. What is moral? What does ethical mean? Here are some common definitions:

   Moral: Concerned with principles of right and wrong or conforming to standards of behavior and character based on those principles;¹ relating to principles of right and wrong;² relating to duty or obligation; pertaining to those intentions and actions of which right and wrong, virtue and vice, are predicated, or to the rules by which such intentions and actions ought to be directed; relating to the practice, manners, or conduct of men as social beings in relation to each other, as respects right and wrong, so far as they are properly subject to rules.²

   Ethical: Of or relating to the philosophical study of ethics, conforming to accepted standards of social or professional behavior;³ being in accordance with the accepted principles of right and wrong that govern the conduct of a profession;⁴ in accordance with principles of conduct that are considered correct, especially those of a given profession or group.⁴

   If we take these detailed definitions and distill them down to something we can apply to our EMS practice, we are left with basic concepts. Moral is related to standards of behavior concerning what is right and wrong. Ethical is related to how we apply those standards of right and wrong to our EMS practice. This ties directly to Dr. Herbert Swick's second professional behavior: "Physicians adhere to high moral and ethical standards."⁵ Swick goes on to say that the principles of beneficence (to do good) and nonmaleficence (to do no harm) are long-standing components of medical ethics. As EMS practitioners, we also have an obligation to do good and do no harm. This is what our patients and communities expect of us.

   That ethical and moral considerations are important to the practice of EMS is demonstrated by the inclusion of ethics in the National EMS Education Standards. The preparatory competency for EMTs, AEMTs and paramedics includes knowledge of "ethical issues." The medical/legal and ethics "elaboration of knowledge" section includes "ethical principles/moral obligations" as a bullet in the EMR, EMT and AEMT levels, and adds "ethical tests and decision making" at the paramedic level.

   Professional groups representing lawyers, accountants, engineers, social workers and a wide variety of others— including healthcare organizations like the American Medical Association and American Nurses Association—often have codes of ethics or conduct. Areas that ethical codes often address, compiled by the NIH's National Institute of Environmental Health Sciences, include:

• Honesty*
• Responsible mentoring*
• Objectivity
• Respect for colleagues*
• Integrity*
• Social responsibility*
• Carefulness*
• Nondiscrimination*
• Openness
• Competence*
• Legality*
• Respect for intellectual property
• Confidentiality*
• Human subjects protection
• Responsible publication.⁶

   The 10 asterisked areas apply directly to the practice of EMS. We could make a case for the others as well. Does EMS have such a code? If I said we do, could you find it? Where are our moral and ethical standards? The National Association of EMTs (NAEMT) adopted a Code of Ethics in 1978 which you can find at www.naemt.org/about_us/emtoath.aspx. Paraphrased, simplified and updated, it includes the following:

   As an EMS practitioner, you contribute to your professional status by choosing to acknowledge an obligation to EMS, to all members of the medical community and to society to adhere to and follow the EMS Code of Ethics.

   EMS practitioners will:

• Strive to do good and alleviate pain and suffering.
• Do no harm and never use EMS knowledge or skill in any way that could be detrimental to public well-being.
• Provide service to anyone based upon need and without regard for race, color, religion, age, disability, social standing or sexual orientation.
• Strive to work in harmony with all members of the healthcare team; to be a good citizen; and to continuously work to ensure delivery of high-quality service and EMS care to all people.
• Demonstrate and continue to maintain competence in the knowledge, skills and attitudes required of an EMS practitioner at the practitioner's level of licensure and hold other EMS practitioners accountable for maintaining similar competence.
• Maintain confidentiality of personal information collected in the course of EMS practice.
• Participate in defining and upholding standards of EMS education and practice.
• Assume responsibility to know the laws, statutes, and rules and regulations that govern EMS practice; participate in the legislative process related to EMS practice; and practice in accordance with the law.
• Delegate care to another EMS practitioner licensed to a lower level only if the care required falls within the scope of practice of the EMS practitioner accepting delegation of care.
• Refuse to participate in unethical practice, and will report unethical or incompetent practice in other EMS practitioners to appropriate authorities in a professional manner.

   If we accept that EMS needs a code of ethics and that we should use such a code as a guide to our behavior as professionals, how can we apply the code to practice?

   What does the code of ethics say that we can use to guide us in a triage situation? The NAEMT code says, "The Emergency Medical Technician shall maintain professional competence..."⁷ Part of an EMS practitioner's competency set should include an understanding of triage theory and its application, and how, when demand outstrips resources, to do the most good for the most people.

   What should we do if we witness our partner stealing? Here is the standard provided by the code: "The Emergency Medical Technician refuses to participate in unethical procedures, and assumes the responsibility to expose incompetence or unethical conduct of others to the appropriate authority in a proper and professional manner."⁷ This same passage addresses how to handle a request to lie or the incompetent coworker.

   What guidance does the code provide when we consider the new education standards? The code says we should participate in defining and upholding EMS education and practice standards. I would interpret this to mean we have an obligation to participate in the implementation process. Do you know what is happening in your state regarding implementation? I'm sure help is needed and there are opportunities to get involved.

Conclusion

   To adhere to high ethical and moral standards, we have to know what those standards are. If we expect EMS practitioners to know and follow a code of ethics, we have to teach them the standards and review them in every EMS program. We have to discuss the meaning of each section and ensure we know how to utilize the code to help us make decisions, and understand the consequences if we don't. Students should practice applying the code in scenarios. We should keep these concepts fresh in our minds and our practice, and we must monitor ourselves and our colleagues to ensure we demonstrate this professional behavior throughout our careers.

   The EMT Code of Ethics is more than 30 years old. Although it may be time (or past time) to review and update it, it still provides guidance and standards we can use to measure our performance. We should turn to the EMT Code of Ethics to help us make good choices and to provide a reference when we need a standard to guide our behavior.

   Next month we will consider the third of Swick's professional behaviors, responding to society's needs and behaving in a manner that reflects a social contract with the community we serve.

References

1.Google search, Define: moral.

2. www.dictionary.net/moral.

3. Google search, Define: ethical.

4. www.thefreedictionary.com/ethical.

5. Swick H. Toward a normative definition of medical professionalism. Acad Med 75(6): 612–616, June 2000.

6. www.yourdictionary.com/dictionary-articles/Define-Ethics.html.

7. Gillespie C. NAEMT Code of Ethics. www.naemt.org/about_us/emtoath.aspx, 1978.

The AMA's Ethics Group

   The American Medical Association's Ethics Group works to improve patient care and the health of the public by examining and promoting physician professionalism. It has three components:

• The Council on Ethical and Judicial Affairs, composed of seven practicing physicians, a resident or fellow, and a medical student, develops ethics policy for the AMA.
• The Ethics Resource Center develops practical solutions for physicians confronted with ethical challenges.
• The Institute for Ethics is an academic research and training center focused on ethics in healthcare.

   For more, see www.ama-assn.org.

Michael Touchstone, BS, EMT-P, is chief of EMS training for the Philadelphia Fire Department. He has participated in EMS leadership, management and educational development initiatives at multiple levels. Contact him at m-touch@comcast.net.