One of the biggest issues facing EMS is that we re not sure what we really are. Is EMS health care? Is EMS public safety? Is EMS public health? In its recent publication, the National Institutes of Health determined that EMS actually has components of each of these (see Figure 1). The responsibilities of each of these three disciplines are diverse. Can we do all three well? This question makes me reflect on my days as a medical student, learning about medical ethics.
When I was interviewing for medical school in the early 1980s, several of the medical schools posed a hypothetical question as a part of the interview process. The question went as follows:
Heinz s wife has a rare form of cancer that cannot be cured with currently available drugs and therapies. But there is one drug that physicians think might save Heinz s wife. It is a form of radium that a druggist in the same town had recently discovered. The drug is expensive to make, but the druggist is charging 10 times what the drug cost him to make it. He pays $200 for the radium and charges $2,000 for a small dose of the drug. Heinz goes to everyone he knew to borrow the money, but he could raise only $1,000, which is half the amount asked by the druggist. Heinz goes to the druggist and tells him that his wife is dying and asks him to sell the drug cheaper or let him pay later. But the druggist says, No, I discovered the drug and I m going to make money from it. What should Heinz do?
This is a classic moral problem attributed to noted psychologist Lawrence Kohlberg. What Kohlberg (and the medical school admissions committee) was looking for was not so much the answer, but the reasoning used to formulate the answer. Medical schools look for students who function with a high level of moral reasoning because health care providers must always put the needs of the patient above virtually all other needs.
Kohlberg followed the work of Swiss psychologist Jean Piaget and believed that people pass through different cognitive and moral developmental stages as we age. Kohlberg identified the following stages of moral reasoning:
LEVEL 1: PRE-CONVENTIONAL MORALITY
Stage 1 Obedience and Punishment
The earliest stage of moral development is seen in young children, although adults are capable of expressing this type of reasoning. At this stage, children see rules as fixed and absolute. Obeying the rules is important because it s a means to avoid punishment (see Figure 2).
Stage 2 Individualism and Exchange
At this stage, children account for individual points of view and judge actions based on how they serve the individual needs. In the Heinz dilemma, children argue that the best course of action is whichever best served Heinz s needs.
LEVEL 2: CONVENTIONAL MORALITY
Stage 3 Interpersonal Relationships
This stage, often called the good boy/good girl orientation, focuses on living up to social expectations and roles. There s an emphasis on conformity, being nice and considering how choices influence relationships.
Stage 4 Maintaining Social Order
In this stage of moral development, people begin to consider society as a whole when making judgments. The focus is on maintaining law and order by following the rules, always doing one s duty and respecting authority.
LEVEL 3: POST-CONVENTIONAL MORALITY
Stage 5 Social Contract and Individual Rights
At this stage, people begin to account for the differing values, opinions and beliefs of other people. Rules of law are important for maintaining a society, but members of the society should agree upon these standards.
Stage 6 Universal Principles
Kolhberg s top level of moral reasoning is based upon universal ethical principles and abstract reasoning. At this stage, people follow these internalized principles of justice, even if they conflict with laws and rules.
Medical schools tend to want students who function in Stages 5 and 6. That is, they want people to become physicians who will place the care of patient s first sometimes when it conflicts with the law.
Thus, we have a conundrum. Public safety, especially law enforcement, requires employees to adhere to Kohlberg s Maintaining Social Order stage (Stage 4) for much of their work. In fact, this reasoning is reinforced in law enforcement academies. In this stage of moral reasoning, adhering to the letter of the law trumps all other concerns. An example of this, of which I m acutely aware, is a local Texas Highway Patrolman who wrote his wife a ticket for speeding. His moral reasoning was she broke the law and the law must be enforced no matter who the offender.
Such a priority can conflict with the role of EMS. In our textbooks, and in education classes, we teach that the patient always comes first (after scene and personal safety). We emphasize that EMS personnel are advocates for the patient. Thus, in EMS education, we ask that EMTs and paramedics function, at a minimum, in Kohlberg s Social Contracts and Individual Rights stage (Stage 5).
This then presents a moral dilemma. For example:
- You respond to an auto versus tree collision. En route to the hospital, the patient admits to having a crack cocaine addiction and dropped his crack pipe while driving and hit the tree. He tells you he s on probation for possession of a controlled substance and being arrested again will ensure that he ll be incarcerated. He says, Please don t tell the cops. Do you keep what he tells you in confidence or do you report it to authorities?
- You re transporting a 27-year-old male to a hospital after he was found beaten in a hotel room. En route, he tells you he was having an extramarital homosexual relationship with a man with whom he works. He asks you not tell his wife what happened and asks you to lie and say he was beaten outside the elevator of his office. His wife meets you at the hospital and begins to question you, tearfully, about what happened to her husband? What do you tell her?
- You pick up an EMT who works for a neighboring ambulance service. While off-duty and in his private vehicle, he was struck from the rear by a drunk driver. En route to the hospital, the EMT pulls a small baggy of marijuana out of his pants and asks you to throw it out of the ambulance. Do you throw it out? Do you tell the police?
- An elderly patient has end-stage COPD. She has been on oxygen for 6years and weighs 80 pounds. She has been intubated and placed on a ventilator seven times. The last time, she was on the ventilator for 17 weeks. She s in respiratory failure and pleads with you not to intubate her. Your service does not have CPAP. The nursing home staff seemed to indicate that everything possible should be done. Should you honor her requests and let her die? Should you intubate her as the rules say ?
In EMS, we have to make decisions in the best interest of our patients. Thus, there may not be any rules or laws to guide us only moral and ethical principles. Sometimes, the rules and laws may actually conflict with what s best for the patient. Law enforcement officers can always cite the law as the moral determinant of what to do. But I would maintain that the best law enforcement officers are those who enforce the laws through moral reasoning. Thus, instead of writing a public intoxication citation for a chronic inebriate (Stage 4 reasoning), they give the person a ride to a detox center or shelter (Stage 5 6 reasoning).
I realize that this is an extremely complex issue. But before we determine what EMS truly is, we have to look at the ethical and moral decisions EMS personnel have to make for that s truly who we are. In the overall scheme of things, EMS personnel are much more like physicians than public safety officers. Thus, I think that EMS should be more health care and less public safety (see Figure 3).
The best EMS systems I ve seen are those where EMS is a part of the healthcare system (e.g., Australia, United Kingdom). I think fire departments do a very good job of bridging this moral gap. While fire departments enforce laws (e.g., building codes and fire-lane violations), they primarily serve to protect individuals and their property. In my opinion, they do a great job. Fire departments, although considered public safety, have less trouble straddling moral EMS issues than do police departments. This is why the concept of EMS as part of a public safety department (fire, police, EMS) has failed in most communities. In summary, before we can address EMS s identity issue, we must first critically examine our moral and ethical thinking and constraints.
By the way, I told the medical school interviewers that Heinz should steal the drug and leave what financial compensation he could. It must have been the right answer because I got in.
- National Academies of Science, Institute of Science: Emergency Medical Services: At the Crossroads. The National Academies Press: Washington, D.C., 2006.
- Kohlberg L: “The claim to moral adequacy of a highest stage of moral judgment.” Journal of Philosophy. 70:630 646, 1973.