The University of Oslo, Faculty of Medicine, Department of Health and Society, Norway
Received date: August 06, 2013; Accepted date: january 28, 2014; Published date: February 09, 2014
Citation: Nordby H (2014) Ethics in Paramedic Services: Patients’ Right to Make Their Own Choices in a Pre-hospital Setting. J Clin Res Bioeth 5:171. doi: 10.4172/2155-9627.1000171
Copyright: © 2014 Nordby H. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
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This case report discusses an ethical dilemma in pre hospital ambulance work, involving a patient who was reported to have an ailment in a public place. When paramedics arrived, the patient said that he felt fine, and that he did not want to be transported for further examinations. He told the paramedics that he had to catch an important appointment, and he promised that he would seek medical advice later that day if the paramedics thought it was imperative.
Analysis: An initial assessment of vital parameters indicated no sign of serious illness, but the paramedics could not exclude the possibility of underlying brain or heart disease. They therefore faced a dilemma: was it correct to act in accordance with the patient’s expressed wishes, or should they insist that he should undergo further medical assessment? The patient was given detailed explanations about the possibility of illness, but he did not change his mind. Eventually, the paramedics and their supervising doctor concluded that the best option was to let the patient go, as they regarded the patient as capable of making informed decisions.
Discussion: The article uses concepts from ethical theory to argue that this conclusion was justified. As a general rule, if patients are not autonomous, and if letting them decide can have severe negative consequences for them, then ethical paternalism is justified. However, in this case it was not reasonable to assume that any of these conditions were met. The patient seemed sufficiently autonomous, and the probability of serious disease was very low.
Conclusion: The paramedics could not have absolutely certain knowledge that the patient was fully autonomous and not suffering from serious illness, but requiring absolute knowledge would be to require too much. Overruling patient preferences in all situations involving nothing more than a minimal risk of serious disease, contradicts a reasonable interpretation of the principle that patients who are reasonably well informed about their situation should be allowed to make informed choices about their health care.
Pre-hospital medical work; Ethical dilemmas; Paramedicpatient interaction; Autonomy; Paternalism
The case is typical of what paramedics sometimes call ‘stress situations’: it is not uncommon that ambulance services are summoned to patients who experience symptoms of illness or disease due to exhaustion and fatigue. Such psychological factors can be the extra element that triggers ailment and possible underlying heart or brain disease. This case involved a situation of this kind.
A middle aged man had collapsed on a train station, and by passers contacted medical emergency telephone. When paramedics arrived, the patient was sitting on a bench. He said that he had experienced a ‘light dizziness’ but this was now gone and he felt ‘better and better’. Preliminary investigations could not document, or even indicate, a serious underlying condition. However, in the light of the reported ailment and the by passers’ report of how they found the patient, the paramedics told the patient that they wanted to transport him to causality department for further assessment. This, however, did not correspond to the patient’s wishes. He said that he ‘was fine’, that he had an important appointment it was imperative that he did not miss, and that he needed to catch the next train, which was leaving very soon. The patient promised that he would seek medical advice after his appointment - later that day - if the paramedics thought it was necessary. The paramedics tried to change the patient’s mind by communicating explanations of possible risks and procedures of assessment. The patient seemed to understand all these explanations - he seemed to be well aware of his own situation, possible causes of his symptoms and consequences of his preferences - but he still wanted to go on with his journey.
The context of the patient encounter put extra pressure on the paramedics. They were in the middle of a busy public setting with many people hurrying in and out of trains, observing what was going on. The patient was impatient and eager to leave. He could not understand why it was problematic for the paramedics to let him go on to his destination as long as this was his own wish. The patient said that the ailment was probably caused by too much work and general tiredness. Initial assessment could not document serious illness, so this was probably right. Nevertheless, the paramedics had to consider the possibility of an underlying condition. The patient could have a serious heart or brain disease, and if so, instant support to avoid possible dramatic consequences could be crucial.
The paramedics faced a dilemma that did not have an obvious answer: was it ethically acceptable to let the patient go on with his journey, or was it morally justified to insist that he should come with them in the ambulance? The latter course of action would involve ethical paternalism  – a decision to influence another person’s preferences by claiming that he should not act in accordance with his own wishes [1-3].
None of these two options seemed initially to constitute a good ethical solution to the dilemma. If the paramedics let the patient go, he could develop a serious disease that might have been prevented if the patient received treatment. But forcing the patient to have an examination and refuse to let him act in accordance with his own preferences fell outside the paramedics’ formal authorization and power of attorney. They were not entitled to exercise physical power by stopping the patient from going on the next train to his destination.
The paramedic tried to solve the dilemma by pursuing a third option – by giving more detailed explanations to the patient of why further assessment was important. They explained why he might have a significant problem and why this problem could be very serious. They also informed him about the procedures for uncovering underlying illness and the importance of early treatment if that was necessary.
However, this did not help. No matter how the paramedics communicated facts and information about possible causes of the patient’s symptoms, the patient insisted that he ‘wanted to go’. As one of the paramedics said: ‘We tried everything, but he was stubborn. It was impossible to persuade him, and he was fully aware of the information we had given him. In fact, he said explicitly that he had understood everything we had told him.’
At this stage one of the paramedics reported that he tried to put a mild form of communicative pressure on the patient, by saying ‘If I had been you, I would have thought more about my health than this appointment. I definitely think you should come with us.’ But this did not help, and now the patient started to become irritated. He responded, ‘I am not you, and you are not me. I want to choose my own actions and I understand what I choose.’
Further discussion seemed fruitless, and the patient’s train was coming very soon. The paramedics threw in the towel. Letting the patient go on with his journey was not conceived to be a very good solution, but it was conceived to be the best option, all things considered. The paramedics consulted with their supervising doctor on the phone. He asked them if the patient had understood all relevant information – if there was no significant doubt about this. The paramedics replied that they had no genuine reason to believe that the patient’s was not reasonably well informed. The doctor said that as long as the patient was well informed, forcing the patient to undergo further assessment against his own free will was ethically and juridically wrong. The doctor also believed, like the paramedics, that there was no good justification for putting more communicative pressure on the patient. The doctor and the paramedics agreed that the patient should be discharged from the services, and this was done.
It is a basic ethical and juridical principle in health care that patients have a fundamental right to decide how they want to live their own lives . However, it is standardly recognized that these decisions must be informed: patients need to be aware of the consequences of their preferences [5,6].
This condition seemed to be met in the above case. The patient had listened carefully to what the paramedics said. The explanations had reached his attention and they had used a language that he understood; they had clarified, controlled and checked that he had grasped the information they had given him. The patient seemed to be well informed and capable of making rational choices. In short, even though the patient was eager to not miss his appointment - and starting to become somewhat stressed about this - there was no reason to believe that he did not make an informed decision.
The two paramedics who encountered the patient were students in a national further education program for paramedics working in ambulance services in Norway1. They described the dilemma in conversation with the author of this case report (being one of their lecturers) and, as they were uncertain about their conduct, asked for some comments about the ethical dimension of the dilemma and their actions.
The case appeared to raise interesting questions about patients’ right to make decisions in prehospital settings. These settings, characterized by uncertainty, acuteness and difficult health work in public contexts have not, unfortunately, received much attention in the literature on health care ethics. Analyses of how health personnel should solve ethical dilemmas have typically been designed to fit controlled institutional contexts - contexts in which there is time and resources to clarify somatic and psychological states (like the state of being well informed). These analyses are of limited value in stressful and hectic prehospital work, situations where decisions have to be made quickly on the basis of limited knowledge, time and resources. Nevertheless, this is a large and very important sector of our public health services.
In order to bring more attention to these pre hospital dilemmas, an initiative was made to analyze the paramedics’ encounter as a case report. This was suggested to the paramedics, and they consented to the project. They said that they believed that there should be more focus on ethics and communication in prehospital work, and that they hoped that analyzes of dilemmas of the kind they experienced could lead to more focus on this area of emergency medicine.
On the basis of the paramedics’ oral description of the situation, the case was initially written down. The transcribed description was shown to the paramedics who had been in the patient encounter, adjusted in the light of their comments and then rewritten in completely general terms. The main purpose of doing a complete rewriting was to make sure that the case description could not be traced to any specific location, person or circumstances. As presented above it cannot be connected, and cannot be traced, to any specific person, place or circumstances.
The generalization also served another purpose. By describing and analyzing a case on a type level, it is possible to arrive at substantial conclusions that fit a variety of cases that fall under the general dilemma . In short, it is easier to elucidate its general significance. This means that the analyses below apply to a variety of cases that are more or less similar to situations of the kind described above. It should be easy for the reader to understand how the man points generalize.
Initially, the case seemed to involve a choice between two courses of action: letting the patient decide or insist that he needed further assessment. Both alternatives were conceived to be problematic.
As experienced by the paramedics, the dilemma can be theoretically explained as follows. In the further education course where they were students, they had learned about ethics and the hugely influential philosopher Kant who argued that morality “provides a rational framework of principles and rules that guides and places obligations on everyone, entirely apart from each individual’s personal goals and interests” . According to Kant’s famous categorical imperative - what he conceives to be the most fundamental ethical rule - we have a rational duty to act ”only according to that maxim [rule] whereby you can at the same time will that it should become a universal law” .
O’Neill  points out that this is “a highly articulated version of a demand for respect for persons”. Thus, it is widely recognized that Kant’s “imperative insists that one must treat other persons as having their autonomously established goals” . The key implication in patient interaction is that health personnel should defer to patients’ wishes as long as their preferences do not have disproportionate negative consequences for other persons and as long as the patients are autonomous [11,12]. As Young  notes, the condition of autonomy means that the patient “must be competent, must understand the information disclosed to her and must give (or withhold) her consent freely”. Furthermore, for a patient to give informed consent (or informed refusal of treatment), the patient must be able to make independent and free choices:
…When a patient exercises her autonomy she decides which of the options for dealing with her health-care problem (including having no treatment at all) will be best for her, given her particular values, concerns and goals. A patient who makes autonomous choices about her health care is able to opt for what she considers will be best for her, all things considered .
The paramedics saw this when they tried to develop the patient’s knowledge: they used communication to make him capable of making decisions that were as autonomous as realistically possible. In general, such communication should initially be neutral. When challenging a patient’s preferences, health workers should always start out by attempting to give a balanced and informative account of their medical perspective on the patient’s symptoms and possible causes [12-14]. By communicating professional knowledge it is often possible to give patients a new perspective on their experienced symptoms - a perspective that can lead them to revise their wishes [5,15]. The paramedics clearly acknowledged this when they started out by giving the patient explanations about the possible causes of his symptoms. The problem was that the patient continued to refuse to defer after having heard these explanations.
The paramedics set aside the principle of neutrality when they started to put pressure on the patient by using sentences like ‘If I were you, I would definitely come with us’. However, when this did not help, they did not feel entitled to put more heavy pressure on him. This corresponds to the idea that the legitimacy of patient pressure must be grounded in considerations about acuteness, uncertainty about serious conditions, and patients’ abilities to understand what is in their best overall interests .
The above case illustrates that there are many ways patients might appear to lose their autonomy. As Young  notes, “The effects of injury, illness or medication can increase the probability that a patient will make choices that appear unbalanced and so call into question her competence to make decisions about her health care”. But knowing that states of ill-health can increase the probability of unbalanced decisions is not the same that knowing that they actually do so in a given case. In ordinary clinical practice it is often difficult to determine how autonomous patients’ wishes are, and prehospital ambulance work is definitely such an area.
In many situations there is sufficient doubt for overruling patient preferences. However, this was not the case above. It could be that the patient had a serious illness; this could not be ruled out. But how defensive should health workers be? More or less forcing all patients to act contrary to their preferences on the basis of very small probabilities, would lead to a comprehensive form of patient paternalism that is inconsistent with modern ideals of patient involvement and individual freedom to make choices that are reasonably well informed.
It should, as a final methodological point, be emphasized that doubt about autonomy in itself is insufficient as an ethical justification for putting communicative pressure on patients. If letting patients decide clearly has no substantial negative consequences for them or others, then health workers should stick to neutral communication, even when the patients’ preferences are not fully autonomous. In the above case there was a small probability of a serious condition, and this made the paramedics entitled to put some pressure on the patient. But the probability was so small, and the patient seemed to be so autonomous, that more intense pressure was not justified.
Written informed consent was obtained from the health workers for publication of this case report. The case has been described as a general dilemma and cannot be traced to any actual patients, place or event. All names and descriptions of the health workers who experienced the case have been formulated in anonymous terms.
HN received a D. Phil in philosophy of mind and language at the University of Oxford in 2001, and is now working as a professor at the University of Oslo, Faculty of medicine, and at the University college of Lillehammer, Faculty of health and social sciences. His main research interests include health management, provider patient communication and ethics in health care. In his research he has focused extensively on communicative challenges and ethical dilemmas in pre hospital emergency medicine, and he has for many years worked closely with medical rescue teams and the national ambulance services in Norway. He has written many books and more than 100 theoretical and empirical research articles on issues related to health management, ethics and communication in health care.