All healthcare providers, from physicians to nurses’ aides, bear significant responsibility for the ethical treatment of their patients. Emergency physicians, nurses and other healthcare professionals have periodically updated their ethical guidelines to address important new issues and technologies, such as the confidentiality rules implemented under HIPAA.1,2 Emphasis on proper ethics in the ED is important, but ethical treatment of the patient in the prehospital setting is just as significant.
Until recently, however, EMS had been an outlier in addressing bioethical issues. The National Association of Emergency Medical Technicians (NAEMT) Code of Ethics, drafted by Charles Gillespie, MD, and first adopted in 1978, had never been revised until the latest version was adopted by the NAEMT on June 14, 2013.3 This article reviews why an update was necessary, evaluates the current code and recommends further revisions.
Updating the Standard
Tremendous change has occurred in healthcare—and in the broader world—since the original NAEMT Code of Ethics was adopted more than 35 years ago. Accordingly, many of the principles found in the original version were outdated. Some were unclear while others served primarily to promote EMS as a profession, rather than expressing professional responsibilities for the ethical treatment of patients. In its recent update, the NAEMT has shown a renewed commitment to ethical practice.
Considering the unique challenges of EMS, it’s especially important emergency medical providers maintain professional decorum in order to show proper respect and provide appropriate treatment for their patients. Emergency medical personnel face unique challenges, which begin with having a relatively brief training period when compared to other healthcare providers. Additionally, EMS personnel work in environments that are highly variable, often unfamiliar and sometimes dangerous. The EMS practitioner is also usually the first healthcare provider to encounter patients who are suffering from an acute health issue or have altered mental status. During this initial contact, the EMS practitioner must demonstrate a capability to treat a patient correctly and respectfully, as this first interaction can set the tone for the patient’s entire health care experience.
The Revised Code
The revised NAEMT Code of Ethics updates important terms, substituting “emergency medical services practitioner” for “emergency medical technician” and “emergency medical technician–paramedic.” A more substantive change can be found in the second principle, where “to not judge the merits of the patient’s request for service, nor allow the patient’s socioeconomic status to influence our demeanor or the care that we provide” was added to the original. This early addition helps to clarify the intention of the existing principle and also signals a change in the tone of the Code of Ethics from that of the original document.
The updated Code of Ethics is more patient-centered than the original. In the fourth principle, for example, the word “work” has been changed to “service” and the seventh principle has added the phrase, “striving always for clinical excellence in the delivery of patient care.” Much of the original Code of Ethics was about the EMS practitioner; in fact, the terms “patients” and “patient care” were absent. At its core, EMS is about delivering high-quality patient care, and the importance of the changes the NAEMT has made to acknowledge this shouldn’t be understated.
The NAEMT has used more than updated terminology to bring its Code of Ethics into the present day. The fifth principle is entirely new; it addresses the use of social media: “to use social media in a responsible and professional manner that does not discredit, dishonor, or embarrass an EMS organization, co-workers, other health care practitioners, patients, individuals or the community at large.”3
The NAEMT has also chosen to remove an earlier principle that read: “The Emergency Medical Technician, or groups of Emergency Medical Technicians, who advertise professional service, do so in conformity with the dignity of the profession.”4
This deleted principle was similar to a principle in a previous version of the American Medical Association’s (AMA) Principles of Medical Ethics. The AMA removed this principle in the 1980s after the Supreme Court upheld an order from the Federal Trade Commission that the AMA must allow physicians to advertise their services.5
The new principles could create room for interpretation about issues of delegation of care. Photo Art Vandalay
Other notable deletions can be found in the seventh and eighth principles. In the original Code of Ethics, those principles read:
The Emergency Medical Technician shall maintain professional competence and demonstrate concern for the competence of other members of the Emergency Medical Services health care team.4
An Emergency Medical Technician assumes responsibility in defining and upholding standards of professional practice and education.4
The NAEMT has chosen to remove concern for competence of other members of the healthcare team from the seventh principle. This revision reinforces the focus of the EMS practitioner on patients, and the EMS practitioner’s duty to “expose incompetence or unethical conduct of others” is included in the final principle.
The change to the eighth principle is subtler; the word “defining” has been removed. This change is also praiseworthy because most EMS practitioners don’t have direct authority or responsibility to define standards of professional practice and education.
More Work to be Done?
Although the NAEMT’s recent revisions have greatly improved its Code of Ethics, further alterations would prove beneficial. For example, one of the principles removed during the revision process stated:
The Emergency Medical Technician has an obligation to protect the public by not delegating to a person less qualified, any service which requires the professional competence of an Emergency Medical Technician.4
It could be argued that there’s room for interpretation about issues of delegation of care within the existing principles. Delegation of care is an important issue for EMS professionals, however, and for the purpose of clarity, the Code of Ethics could benefit from the inclusion of this or a similar principle.
In the second principle, the merits of the patient’s request for service are mentioned, but the option of the patient to refuse treatment isn’t. Treatment refusal and the issue of abandonment should be addressed in a single principle that states the EMS practitioner has a responsibility to honor patient consent and refusal of treatment, with the caveat that the EMS practitioner shall not leave his or her patient unless required to do so as the result of a mass casualty or triage incident.
The third principle states that an EMS practitioner isn’t to use professional knowledge or skills in any way that may be harmful to the public well-being. This principle is very general and could benefit from further clarification. A specific reference to EMS practitioners adhering to professional knowledge and skills that are within their scope of practice could provide more clarity. This principle could also assert that EMS practitioners shouldn’t use medical equipment in any enterprise that would be detrimental to the public well-being. An ambulance, splint, medication or other intervention could be harmful to the public well-being if used incorrectly.
The revised Code of Ethics includes positive changes in the direction of a more patient-centered Code of Ethics, but the central importance of interpersonal relationships in prehospital care could be emphasized even more strongly. Most EMS calls require communication with either the patient or bystanders, and the Code of Ethics could benefit from a more specific focus on these interactions. The EMS practitioner has a strong moral obligation to be truthful with his or her patients, but honesty is not specifically addressed in any of the existing principles. A principle addressing this concern could read:
The emergency medical services practitioner shall communicate honestly with patients and shall strive to be reassuring without fostering false hope.
Ethics Education in EMT Curricula
The recent changes to the NAEMT’s Code of Ethics and the additional changes proposed above will result in an improved level of patient care. The influence of these changes would be even greater, however, if the certification curricula of EMS personnel included a more substantial ethics education, perhaps with the Code of Ethics as a focal point. The list of United States Department of Transportation National EMS Education Standards is extensive, and certification courses are highly structured to cover all essential topics, making it difficult to include more time for any one subject.6 Addition of the Code of Ethics as a new topic within existing curricula would greatly increase the amount of class time students would devote to ethics education. Instead of lecturing on abstract ethical concepts, EMS instructors could call attention to fundamental professional responsibilities recognized in the Code of Ethics and explore their practical implications for patient care.
Even if more time can’t be devoted to ethics education in the lecture setting, ethics can still become a larger part of the skills components of the curriculum. A substantial portion of class time is spent running through patient treatment scenarios and practicing hands-on skills; this time could serve to further reinforce a student’s ethics education. For example, in a motor vehicle collision scenario, the student’s ability to respond to questions asked by the patient regarding an additional critically injured passenger could be assessed, in addition to the student’s ability to properly extricate his or her patient. In this way, the patient assessment algorithm can remain a focal point, but ethical treatment of patients and additional ethical issues can be included in certification courses without having to make allowances for any additional time. Alternatively, continuing education could also be a means to address time constraints found in the certification curriculum.
EMS is an essential part of our healthcare system, and the role of EMS professionals should not be underestimated. EMS practitioners serve on the frontlines of medicine, where many ethical issues arise that must be dealt with quickly and compassionately. The NAEMT has clearly demonstrated a commitment to ethics with the recent revisions of its Code of Ethics, but more could be done. Additions like those suggested above could help the NAEMT’s Code of Ethics better accomplish its purpose, the ethical treatment of patients.
1. American College of Emergency Physicians. (April 2011.) Code of ethics for emergency physicians. Retrieved Jan. 10, 2013, from www.acep.org/Content.aspx?id=29144.
2. United States Department of Health and Human Services. (1996.) Health insurance portability and accountability act 1996. Retrieved Jan. 10, 2013, from www.hhs.gov/ocr/privacy/hipaa/administrative/statute/hipaastatutepdf.pdf.
3. National Association of Emergency Medical Technicians. (June 2013.) National Association of Emergency Medical Technicians EMT oath and code of ethics. Retrieved Nov. 15, 2013, from www.naemt.org/about_us/emtoath.aspx.
4. National Association of Emergency Medical Technicians. (1978.) National Association of Emergency Medical Technicians EMT oath and code of ethics. Retrieved Jan. 10, 2013, from www.naemt.org/about_us/emtoath.aspx.
5. Pertschuk M, Correia E. The AMA versus competition. American Sociologist. 1983;38(5): 607–610.
6. National Highway Traffic Safety Administration. (January 2009.) National emergency medical services education standards. Retrieved June 2, 2013, from www.ems.gov/pdf/811077a.pdf.