Hidden Crisis: Ethics Breakdown in Massachusetts

In June 2010, news broke of a recertification scandal involving emergency responders in Massachusetts. By the time the investigation was done, more than 200 EMTs and paramedics had received punishments ranging from suspensions to permanent revocation of credentials.

This case may have represented the single most egregious breakdown of EMS ethics ever—that we know of. It caused a significant uproar not only in Massachusetts, but across the nation and internationally. This article will explore some of the motivations of those involved, as well as possible causes and remedies for such situations.

Ethics Course

As noted above, suspensions were meted out over the scheme, which recertified providers who had not attended the required classes. Involved participants who wanted to become recertified were required to take an ethics course approved by the state Office of Emergency Medical Services (OEMS). This course was designed and presented by an independent contractor (the author) with OEMS approval.¹

It was designed not to review what the individuals had done wrong—they were well aware of that. Rather, the program was intended to overview current concepts and present a number of clinical situations as springboards for discussion of ethical issues. It was designed as an educational program to fill gaps in knowledge, not as a three-hour punishment session. It contained information on concepts of medical ethics, about 30 vignettes, a short section on professionalism, comments from colleagues, Massachusetts regulatory requirements and a review of the EMT Code of Ethics adopted in 1978.² Of that Code of Ethics, about a third of its 13 tenets were violated in this case.

The case vignettes went from simple to complex. The first involved a depressed elderly woman with a UTI telling an EMT she “just wanted to die.” What, participants were asked, would you do with this information if you received it? Another took the statement “I’m glad he/she isn’t my partner” and asked why people would make it and what implications it might have for them, their service and especially their patient.

The course was presented at different hours and locations a total of 17 times over four months. Some attendees registered in advance; others just heard about the class and showed up. The cost was $30, but was optional if students couldn’t afford it. At the end of the program, participants were asked to evaluate their experiences (see Figure 1). Most did.

Before being given to the providers involved here, the course was trialed five times as a continuing education program for different groups of noninvolved EMTs and paramedics. This comprised a control group. These students included three classes of mixed EMTs and paramedics with varying lengths of service who worked for a private ambulance service; a college EMS group consisting of relatively new EMTs; and a group of paramedics with different levels of seniority from different agencies including fire departments, municipalities and private ambulance services.

The program was ultimately given to 161 involved providers. Evaluation results were tabulated and graphed for comparison to the control group. Approximately halfway through the program, we added an additional data point for time of service in the field.

What Did We Find?

The results and conclusions surprised us. The problems we face are significant in both scope and depth.

The involved individuals were not new to the field: Their average time of service was 15 years. Their experience ranged from 4 years to 35, with 70% having been in EMS between 8–22 years. They had done at least two refreshers, and most had done significantly more.

In reference to the ethics course, more than two-thirds of both the control group and the involved group thought it was worth their time. Most could not remember having been taught the EMT Code of Ethics in their initial training or reviewing it since. But while 84% of the control group said it was important for every EMT to take such a class, less than half (48%) of the involved group believed so.