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.