medical field is one that is populated with professionals whom non-medical individuals do not think about every day; yet these professionals profoundly affect the care received and in many cases the life or death of an individual being treated by the medical community. Individuals such as a radiology technician, a dietician, or even the assistant who carries medications to patients can be an integral part of a patient's treatment and survival. Emergency Medical Technicians are often the first responders to a trauma or sudden illness and, as such, may be a patient's only interaction with the medical community. In emergency situations, these individuals become especially important and, as a result, have more complex roles to play.
The role of the Emergency Medical Technician, or EMT, is highly involved and constantly evolving. What is considered proper procedure on one day may change in the next, with advances and discoveries in medical science. One example of this would be the renewed emphasis on protecting medical personnel from body fluids after the discovery of how HIV and similar fluid-borne diseases can be passed via mouth-to-mouth resuscitation or accidental blood contact. Almost overnight, the job description and elements of the EMTs was radically changed; protocols regarding gloves and mucous membrane protections were added to protect medical professionals from contracting the newly-discovered blood-borne diseases. In order to address specific issues in this atmosphere, the EMT Code of Ethics was written by Charles Gillespie in 1978 and subsequently approved to help deal with the ethical dilemmas of emergency treatment (Gillespie 1978).
This shift in emphasis on fluid contact is only one example of the ever-changing world of EMTs; the nature of the field requires that its members constantly be aware of their behaviors, and keep their decision-making and problem solving skills sharp. This paper will examine how these factors play into the ethics of the emergency medical technicians' field, the situations and persons involved in the implementation of the Emergency Medical Technician Code of Ethics, and the overall effect on EMTs that the Code has had. Specifically, this paper will examine the ethics surrounding informed consent to treatment and to certain research participation by an injured or ill individual, who is unable to consent, in disaster situations
The first part of an inquiry into the ethics involved in the professional behavior of EMTs today involves their decision-making and problem-solving duties. These decisions and ideas, naturally, dictate the behavior of an EMT. An early portion of the Code of Ethics assures that a fundamental responsibility of the Emergency Medical Technician is to conserve life, to alleviate suffering, to promote health, to do no harm, and to encourage the quality and equal availability of emergency medical care (Gillette 1978).
It is significant that this tenet of ethical behavior in the Code does not state for whom the EMT is to perform these actions. In today's world of medical advances, to "promote health and alleviate suffering" could be interpreted as performing an action that would benefit research in terminally ill or mortally wounded patients; to "conserve life" might mean donating one patient's organs to another patient in need of a transplant when it became obvious that the trauma victim whom they are treating would not survive. All of these interpretations are feasible; it is up to the individual decision-making and other judgement skills of the EMT to make the lightning-fast choices required.
Another aspect of the decision making and problem solving skills needed by EMTs is with regard to informed consent. Informed consent requires that a patient understand and consent to the medical procedures being performed; in cases of trauma or other emergency were the patient is unable to respond, the AHA Patients' Bill of Rights exempts this requirement:
Except in emergencies when the patient lacks decision-making capacity and the need for treatment is urgent, the patient is entitled to the opportunity to discuss and request information related to the specific procedures and/or treatments, the risks involved, the possible length of recuperation, and the medically reasonable alternatives and their accompanying risks and benefits (emphasis added, AHA 1998).
The principle of informed consent is a vital one to performing the role of an EMT; without it, a technician would not be required to determine treatment options such as if the patient has an allergic or other reaction to certain medications which would disallow their use, as well as in a case where the patient has a religious objection to certain procedures, such as a blood transfusion.
Informed consent requires that these areas be explained and approved by the patient before medical procedures take place; however, in an emergency this is not always feasible or even possible. An unconscious patient obviously cannot convey his or her wishes regarding certain medical treatments. The ethics of treating such patients becomes foggy most often in life-or-death situations where experimental procedures could be the only possible way of saving the patient; such procedures require informed consent, but in the even that consent is impossible to obtain, how does the individual EMT go about making the decision to either go ahead with or deny the treatment? In evaluating this decision, recall the EMT Code of Ethics which requires that emergency medical personnel have a "fundamental responsibility" to "conserve life" (AHA 1978).
This ethical juxtaposition facing EMTs, between conserving life in every manner possible, and in carrying out the proper methods of informed consent, has become one specific dilemma in the field today. This question faces not just EMTs, but all medical personnel involved in treating emergency patients and disaster victims; standard procedure allows EMTs to make the decision individually and at the time of treatment (Richardson 2005). Congress has legislated that emergency medical treatment is a special situation where informed consent is not a requisite to performing medical research or experimental procedures to save the life of a patient (ibid.).
This legal precedent, however, has no bearing on the medical ethics of performing treatment in an emergency situation. It sets a binding law and protects emergency personnel from being accused of illegal behavior in a situation where research or experimental treatments are performed, but legality is a far cry from ethics. Establishing ethical definitions of proper treatment, however, toes a fine line in between the issues discussed above between the patient's right to informed consent and the EMT's duty to conserving life, which may not necessarily refer to the immediate patient's life.
Adding to the conflict and to the high demand of decision-making on the part of an EMT is the fact that "emergency" is not clearly defined in the medical literature; one person's emergency for which informed consent would be waived might be another person's mild to moderate pain (Annas 2004, p. 51). Immediate decisions must be made, sometimes without all relevant information, regarding a patient's ability to consent; this becomes especially wrought with pitfalls when the patient is unable to consent not because of physical limitations, i.e. unconsciousness, but because of mental ones, such as intoxication, mental illness, or other obstacles to mental clarity.
In these cases, decisions must be made as to the necessity or humanity of performing certain procedures by the emergency personnel on hand; it is important to remember that the definition of greater good to be achieved via the medical procedure might not be for the immediate treatment but as research for other patients. At times, these decision lie solely in the hands of the emergency medical technicians who respond to the patient's or their proxy's request for medical attention. In making these types of decisions and in considering potential alternatives and compromises to certain treatments, EMTs perform high-level selections between choices that are oftentimes matters of life and death. The specific incidence of this ethical dilemma examined here was the case of performing certain procedures that normally require a patient's informed consent without such a consent if the situation is dire enough that the patient being treated cannot medically give such consent, such as cases of extreme trauma or of altered states of mind.
The need for a formal system of inquiry regarding the ethics in situations such as this one, which is faced by emergency medical responders daily, is immediate (Collogen, Tuma, Dolen-Sewell, Borja and Fleischman 2004). EMTs, as first responders, must not only be well-versed in the legality and procedure associated with such situations but also must have a self established set of ethics regarding individual cases such as the ones discussed above. In a field where EMTs have such discretion in an area of such varied and wide-ranging distinctions, a well-defined individual or collective system of inquiry and examination is requisite for ethical behavior by the personnel.
Currently, these decisions are made on a case-by-case basis by the individual emergency personnel in each situation. Opinion is split among EMTs regarding if this system is best for managing ethical concerns that might arise, or if a more standardized system such as an entire code, like that of the Code of Ethics for EMTs would be…