The Ethics of PPE and EMS in the COVID-19 Era

These are trying times for emergency medical services (EMS) personnel on the front lines of the COVID-19 pandemic. In this article we discuss two critical areas of concern. First, we articulate the ethical challenges EMS personnel face in the absence of having proper personal protective equipment (PPE) and offer some guidance on how to frame their decisions.

Second, we give voice to the urgent need for a national dialogue to address the needs of EMS clinicians and leaders. We present key questions that must be answered to improve the future structure of the profession and the safety of all personnel.

These are times that are putting EMS to the test. These are times that will define the future of EMS.

Background

On April 1, 2020, a headline in the New York Times announced: “The federal government’s supply of masks, gloves, and gowns is nearly gone.”¹ During the first few days of April 2020, social media posts from some EMS agencies in the U.S., reported that the agencies already had dangerously low levels of PPE. Headlines from the United Kingdom echoed the concerns “doctors and staff not having access to adequate PPE.”²

Based on these reports, it seems likely that there will be a time period, perhaps weeks, between the use of the last piece of PPE and the arrival of replacements. During that time there may be no proper PPE available for many clinicians including paramedics and emergency medical technicians (EMTs), collectively referred to in this article as EMS clinicians. 

Although many other clinicians are facing challenges during this time, the challenges for EMS clinicians may be particularly difficult because they may be one of the groups with the least ability to protect themselves from the virus and simultaneously be one of the groups with the highest chances of spreading the virus.

In the absence of having proper PPE, individual clinicians are struggling with ethical decisions about how to protect themselves, their families, their patients and their communities. They should not have to make these difficult decisions in isolation at the same time as they try to deal with rapidly growing numbers of patients.

Practical Considerations for Ethical Decision Making

In these extraordinary times when ethical decision-making is being confounded by a highly contagious virus and a potential shortage of PPE, we must remember that EMS personnel make ethical decisions every day as to what they should and should not do when caring for patients and themselves.

EMS clinicians adhere to many solid ethical principles. Beauchamp and Childress³ articulate four core principles of biomedical ethics that are used to guide decision-making in healthcare: respect for autonomy, beneficence, non-maleficence, and justice. Ethics in EMS has also focused on virtue and teamwork.⁴

How can EMS personnel apply and balance these principles during a time that is not only unprecedented but that was, up until just a few weeks ago, largely unimaginable?

To be clear, a pandemic was not only imaginable, but has been expected.^5,6 What was unimaginable is that clinicians would be facing the pandemic with the prospect of not having proper PPE.

Thus, some of the primary ethical questions EMS clinicians are facing now include:

• What is my ethical duty to care for patients during the pandemic and in the absence of having proper PPE?
• If I am in a high-risk group due to age or medical history, should I continue to care for patients in the absence of having proper PPE?
• If I live with family members who are in a high-risk group due to age or medical history, should I continue to care for patients in the absence of having proper PPE?
• If I believe that I might be spreading the virus to patients, patient family members, colleagues and/or community members, should I continue to care for patients in the absence of having proper PPE?

The Need for PPE

What is the need for PPE? Given what is currently known about COVID-19, the only reasonable course of action for EMS clinicians is to work under three assumptions: everything they touch is contaminated, everyone they meet is contagious, and they are contagious.⁷

The current guidance from the U.S. Occupational Safety and Health Administration (OSHA), an agency of the United States Department of Labor, states: “Healthcare workers must use proper PPE when exposed to a patient with confirmed/suspected COVID-19 or other sources of COVID-19;” the OSHA list of required PPE includes “disposable N95 or better respirators.”⁸

The purposes of PPE are to:

• Protect our patients. We practice beneficence and non-maleficence, for example, when we wear PPE during the time we interact with immune-compromised or other high-risk patients
• Protect the provider. We wear PPE when we suspect the patient may have a communicable disease that we might contract during our interaction with the patient
• Protect the community. We apply the PPE to contagious patients, and wear PPE ourselves, to prevent further transmission of a communicable disease to others including to subsequent patients, colleagues, community members and members of our family.

Not having proper PPE may:

• Put patients at risk
• Put EMS clinicians at risk
• Put the community at risk
• Open the chance that the EMS clinician community itself could be devastated by the disease thereby putting future patients at risk
• Cause emotional and moral distress among EMS clinicians.

Duty of Care

EMS clinicians typically think of duty to care to include concepts such as duty to respond and duty to care for patients.⁹ Torda asserts that duty of care presents complexity when it comes to pandemics, again highlighting the conflict between a health professional’s duties and demands of their work and the need to protect themselves, their other patients, their families, and peers.¹⁰

In their review of the severe acute respiratory syndrome (SARS) pandemic of 2003, Singer et al. in their paper “˜Ethics and SARS: lessons from Toronto’ detail the outcomes of a working group formed to identify the key ethical issues and values crucial to analyzing the ethical dimensions arising from the SARS epidemic.

Concerning duty of care, these authors relate that many healthcare workers found themselves in the position of weighing their duty of care to the sick against imminent risks to themselves and their loved ones. It was articulated that this becomes more the concern of professional ethics, however, the working group conceded that even professional duties have limits. Interestingly, the issue of duty of care was one area where the working group could not achieve consensus, particularly regarding the extent to which health professionals are obliged to risk their lives in the delivery of care.¹¹

Professional codes of conduct may offer some direction. For example, in June 2018, the Paramedicine Board of Australia published an interim Code of Conduct to support registered paramedics in Australia to deliver healthcare within an ethical framework.

In the overview the Board states that “˜”¦it is paramount that paramedics ensure their own personal safety and the safety of others when delivering clinical care’. Section 6 of the Code relates to minimizing risk, with the Board recognizing that good practice involves the minimization of risk, encouraging paramedics to take “˜”¦all reasonable steps to address the issue if there is a reason to think that the safety of patients or clients may be compromised’.¹²

In considering duty of care, Torda (2006, p. s74) muses that codes of ethics offering guidance for the conduct of professional duties in the provision of healthcare become complicated when these requirements are balanced against other responsibilities, identifying that these codes are relatively silent when it comes to the issue of duty of care when faced with significant personal risk.

Other Ethical Considerations

Returning to Beauchamp and Childress’s principles (respect for autonomy, beneficence, non-maleficence, and justice) the principles of non-maleficence and justice, in particular, become problematic here and may trigger moral distress for EMS clinicians. No clinician wants to “˜do harm’ to their patients, themselves, peers or loved ones.

The potential scarcity of PPE challenges clinicians in their ability to respect this principle. As for justice, here we are referring more so to material principles of justice, and, the principle of need, which “”¦declares that social resources including health care, should be distributed according to need. To say that a person needs something is to say that, without it, the person will be harmed, or at least detrimentally affected.”¹³ Proper PPE would be considered fundamental to the protection of EMS clinicians, their patients, peers and loved ones in a pandemic such that we are experiencing now.

Mental Health Impacts

Murray discusses moral injury in paramedic practice, suggesting moral injury, “˜”¦encompasses witnessing human suffering, or failing to prevent outcomes which transgress deeply-held beliefs.¹⁴

Symptoms of moral injury, Murray suggests, are strongly linked to feelings of guilt and shame, resulting in emotional numbing and social isolation. Torda (2006, p. s73) adds that anxiety, depression and post-traumatic stress disorder may also result. Thus, these are some of the problems that EMS personnel may face as a consequence to the decisions they are forced to make in the midst of the COVID-19 pandemic.

Current Practices and Perspectives from other Professions

Torda identifies that the SARS pandemic has offered valuable insights, and possible solutions, noting that “˜”¦the most effective approach to management of health care workers required strong leadership, with leading by example, open discussion with workers, adequate information, protection, and voluntariness in terms of allowing health care workers to decide the level of risk that is acceptable to them and reallocating workers as necessary’ (2006, p. s74).

Further, to support this management approach, Torda advocates the engagement of key stakeholders in developing an ethical framework to support decision-making processes involved in pandemic situations. Torda argues that without such a framework, not only is there a risk that health professionals and community members may challenge the acceptance of decisions, but there may be wide-ranging mental health impacts (2006, p. s73).

A physician group in the UK have argued that: “As well as having a duty to protect the public from harm, doctors have a right to protect themselves so that they can continue to care effectively, and it would be ethical for those who would be harmed by contracting COVID-19, including doctors aged over 70 or with underlying health conditions — as per the government’s guidance — to refrain from treating patients with (or suspected to have) the virus. They should instead take on duties away from high risk areas.”¹⁵

At one point in time in the Marine Corps, corpsmen were running into live combat zones to save their squad mates who were shot and injured. Many brave medics were killed doing the job they were trained to do. Then, the Marine Corps changed the standard operating procedure (SOP), trained Marines to do first aid on the battlefield and told the corpsmen to proceed with life-saving treatment when the situation is contained, or momentarily secure. ¹⁶

Before the SOP, the corpsman would have been disciplined for not providing care even in an uncontained environment. After the SOP, the same medic would be disciplined for providing care in an uncontained environment.

Today there are no SOPs for EMS clinicians asked to care for patients during this pandemic. So, when the pandemic is over, will the EMS clinicians be disciplined for not going on a call, or for going on a call without proper PPE and thereby potentially endangering themselves, people on the scene and their future patients?

The American Nurses Association (ANA), an organization representing nurses in the United States, recognizes the perils of this pandemic and suggests that nurses may choose not to work if:

• they are in a vulnerable group
• the nurse feels physically unsafe in the response situation due to a lack of personalprotective equipment or inadequate testing
• there is inadequate support for meeting the nurse’s personal and family needs, or
• the nurse is concerned about professional, ethical, and legal protection for providing nursing care in the COVID-19 pandemic.

The Association goes on to assert that “employers have the responsibility to create, maintain, and provide practice environments that help meet the medical needs of the community within a system that protects nurses and other employees or volunteers. This should include the provision of sufficient, appropriate personal protective equipment.”¦”¹⁷

One emergency medicine physician wrote: “physicians and nurses have an ethical duty to provide care. The perspective of medical ethicists is pretty straightforward–health-care providers, especially physicians, should continue to care for the sick even if it puts their life at risk.

We have an obligation to treat all patients because we chose our profession and are well rewarded by society with money and respect. Nurses have a similar professional duty but have specific exemptions. But there are few, if any, obligations for all the support staff that make my work possible–the techs, clerks, registrars, environmental staff. They don’t take an oath. Some are paid minimum wage, have few benefits, and get none of the societal accolades reserved for doctors and nurses. Why should they die for a $25,000-a-year job and $10,000 worth of life insurance? Who’s going to feed their kids when they’re gone?”¹⁸

Prof. Schuklenk makes two points: “There is no reason why doctors and nurses should be seen to be professionally obliged to risk their well-being today, because we chose governments that starved them of the necessary resources to do their job safely.” “We should be grateful to any health care professional willing to care for COVID19 patients, in the absence of PPE, but we have no reason to take for granted that there will be one when we need them.”¹⁹

The Mayo Clinic is allowing staff to apply for accommodation if the staff member believes that they should avoid all COVID-19 exposure.²⁰

Legal Considerations

As well as the ethical dilemmas presented by lack of proper PPE and infection control in a pandemic, there may also be legal and disciplinary ramifications for breaching proper infection control standards, including the potential for civil liability.²¹

This was case in the aftermath of Hurricane Katrina, a disaster that killed 1,833 persons when it struck the Gulf Coast of the United States in 2005. After the event, clinicians were prosecuted for decisions they made based on having a lack of equipment and resources to treat patients. After this pandemic, will EMS personnel be prosecuted for not treating patients or for putting patients at risk by approaching without PPE?

In the Katrina case, the Good Samaritan laws were found to be inapplicable because the laws apply only to volunteers. In the EMS situation is would seem to be immaterial whether you were paid or not and Good Samaritan would seem to be inapplicable to decisions related to treating or not treating based on the absence of PPE. Laws enacted to apply for caring for patients during a disaster also seem inapplicable.²²

As an example, the Health Emergency Powers Act that was in effect in Louisiana in 2003 stated during a state of public health emergency, any health care providers shall not be civilly liable for causing the death of, or injury to, any person”¦except in the event of gross negligence or willful misconduct” yet healthcare providers were brought to trial. Thus, it will be important for EMS clinicians to review state statutes regarding their liability in disasters to understand if any legal ramifications may apply.

Ethical Decision-making Frameworks

Decision making frameworks can be used to help make decisions under difficult circumstances. The following two frameworks may be helpful in the current context.

First, Thompson et al. provide a framework for ethical decision making that was written in 2006 to assist for pandemic influenza planning in the wake of the SARS pandemic.²³ The framework notes some fundamental values such as:

• Accountability — establishing and maintaining an ethical decision-making system that is in place for the duration of the disaster;
• Inclusiveness and Transparency — ensuring that the decisions should be publicly defensible;
• Reasonableness — that the decisions should be based on reasons (i.e., evidence, principles, values) that employers and employees agree are relevant.;
• Responsiveness — ensuring that there are opportunities to revisit and revise decisions as conditions change.

Second, a white paper prepared out of the work of an Ethics Subcommittee of the Advisory Committee to the Director of the Centers for Disease Control and Prevention (CDC) in 2008 included a framework to consider in public health emergency preparedness and response. The following summary of the points made relate to the current discussion:²⁴

• Harm reduction and benefit promotion: activities should protect public safety, health, and well-being. They should minimize the extent of death, injury, disease, disability, and suffering during and after an emergency;
• Distributive justice: activities should be conducted to ensure that the benefits and burdens imposed on the population are shared equitably and fairly;
• Community resiliency and empowerment: activities should strive towards the long-term goal of developing community resources that will make them more hazard-resistant and allow them to recover appropriately and effectively after emergencies;
• Responsible civic response: activities should promote a sense of personal responsibility and citizenship.

An Urgent Need for a Larger Conversation

The moral, legal and ethical ramifications of individual decisions related to caring for COVID-19 patients without proper PPE leads us to the next to objective of this article: To suggest content for an urgent dialogue the EMS profession must have about continued operation during a time when proper personal protective equipment (PPE) may not be available.

Some of the questions and issues that must be addressed include:

1. Whose obligation is it to take on the risk of exposure in the absence of proper PPE?
2. Should EMS leaders, or the communities they serve, expect EMS clinicians to perform their role if inadequately protected?
3. If most of our providers become ill now, who will care for patients next week?
4. Should a portion of the workforce be told to stay home and self-isolate for a period of time so that they might be available later?
5. Is it appropriate to insist that an employee come to work if that employee is living with ill or high-risk family members? Is it appropriate to allow an employee to come to work if that employee is living with ill or high-risk family members? Can employers be trusted to make these decisions when they have conflicting objectives?
6. What can agencies do to support the mental health of the workforce who may face emotional and moral distress in the wake of their decisions?
7. If a police officer, firefighter or soldier would not be deployed without proper protective equipment, is it reasonable to ask the EMS clinician to face undeniable dangers without proper protective equipment?
8. Do we want to teach EMS clinicians to be risk-averse or do we want them to help and fight for their patients and to demonstrate self-initiative, but use PPE?

Failing to provide clinicians with PPE will likely result in clinicians becoming infected and may subsequently put them out of work for an extended time period, with a percentage of them dying as a result of complications.

We have seen this before in recent times. In the aftermath of 9/11, many EMS clinicians have subsequently died from 9/11 exposures after then EPA Administrator Secretary Christie Whitman erroneously told New York City that that the “air was safe to breathe” when it was not As a result of this erroneous report, many providers worked without respiratory protection.²⁵

Is asking EMS clinicians to function without the well-considered standards for personal protective equipment amoral because it puts the EMS system at risk, puts the individual EMS clinicians at risk, and forestalls the real systemic changes that needs to happen for the underlying problems to be corrected. Should neither citizens nor EMS clinicians be forced to bear this burden for failures of political, health systems, disaster preparedness and EMS leaders?

In Of the Epidemics, Hippocrates tells us that we “have two special objects in view with regard to disease, namely, to do good or to do no harm.” What do we do if we cannot ensure either objective?

• With an absence of proper PPE, is in the best interest of public safety, going on the EMS call or not going on the call?

• Will the EMS profession commit to developing an ethical guide for EMS providers in pandemics?

• Can we develop an ethical guide while simultaneously correcting the EMS system deficiencies that contributed to the current problems?

Conclusions

The points made in this article are meant to assist EMS clinicians and leaders in making ethical decisions during the COVID-19 pandemic, and during the time of insufficient supplies of proper PPE.

To answer these questions the EMS profession should urgently make a firm commitment to engage with key professionals such as lawyers, philosophers, academics, public health professionals, health systems leaders and community representatives. The key outcomes of those discussions should be the development of an EMS-focused ethical framework to guide and support transparent ethical decision-making, and to improve preparedness, in anticipation of future pandemics.

One thing we know for sure — history shows us that this will happen again. The COVID-19 pandemic has shown us that, in addition to a need for sufficient PPE and the need for sufficient on-going support for the EMS clinicians and the system, the U.S. EMS System needs a team that can respond to a multitude of critical ethical questions during times of disaster.

Our heartfelt thoughts go out to our colleagues who are on the front lines making challenging decisions multiple times a day.

This is an unprecedented time with unprecedented challenges. We hope this paper helps you with your decisions. We also hope the paper helps to foster an immediate discussion on a larger level and ultimately leads to much needed improvements in the EMS system.

Disclaimers

The authors claim no conflicts of interest.

The views expressed in this paper reflect the results of research conducted by the authors and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, nor the U.S. Government.

The authors, as experienced professionals with different perspectives, did not agree on every element in this article, but did unanimously agree that the discussion needs to take place among each community of clinicians so that local guidance and standards can be created. This is a collaborative effort that each clinician needs to have a voice in, and these decisions cannot be left solely to administrators or physician medical directors. 

There was no funding for this work.

References

1. New York Times. The federal government’s supply of masks, gloves, and gowns is nearly gone. Available from: https://www.nytimes.com/2020/04/01/world/coronavirus-live-news-updates.html?searchResultPosition=2#link-d414cf4. Accessed 3 Apr 20.

2. Iacobucci G. Covid-19: Doctors still at “considerable risk” from lack of PPE, BMA warns. BMJ. 31 March 2020. Available at:   https://www.bmj.com/content/368/bmj.m1316. Accessed 4 Apr 20.

3. Beauchamp TL, Childress JF. Principles of biomedical ethics (6th ed). 2009. Oxford University Press, New York.

4. Larkin GL, Fowler RL. Essential ethics for EMS: cardinal virtues and core principles. Emergency Medicine Clinics of North America, 2002; 20(4):887-911. Available at: https://europepmc.org/article/med/12476886. Accessed 4 Apr 20.

5. Holmes EC, Rambaut A, Andersen KG. Pandemics: spend on surveillance, not prediction. Nature. 07 Jun 2018, Available at: https://www.nature.com/articles/d41586-018-05373-w. Accessed 4 Apr 20.

6. Larnaud N. Bill Gates warned of a deadly pandemic for years – and said we wouldn’t be ready to handle it. CBS News. March 19, 2020. Available at: https://www.cbsnews.com/news/coronavirus-bill-gates-epidemic-warning-readiness/  Accessed 5 Apr 20.

7. Maguire BJ. COVID-19: Urgent EMS Issues. March 23, 2020. Available at: https://www.jems.com/2020/03/23/covid-19-urgent-ems-issues/. Accessed 4 Apr 20.

8. CDC. COVID-19. Healthcare workers and employers. Available at: https://www.osha.gov/SLTC/covid-19/controlprevention.html#healthcare. Accessed 4 Apr 20.

9. Givot D. Duty to act, assess, treat and transport: A legal refresher for EMS providers. EMS1.com. Available at: https://www.ems1.com/ems-products/consulting-management-and-legal-services/articles/duty-to-act-assess-treat-and-transport-a-legal-refresher-for-ems-providers-ioTzu8rfkGeu7BhH/. Accessed 7 Apr 20.

10. Torda A. Ethical issues in pandemic planning. Medical Journal of Australia. 2006; 185(10): 73-6.

11. Singer PA, Benatar SR, Bernstein M, Daar AS, Dickens BM, MacRae SK, Upshur REG, Wright L, Shaul RZ. Ethics and SARS: lessons from Toronto. BMJ. 2003; 327: 1342 — 4.

12. Paramedicine Board of Australia. Code of Conduct (interim). 2018

13. Beauchamp TL, Childress JF. Principles of biomedical ethics (6th edn), Oxford University Press, New York. 2009.

14. Murray E. Moral injury and paramedic practice. Journal of Paramedic Practice, 2019; 11(10). Available at: https://doi.org/10.12968/jpar.2019.11.10.424. Accessed 3 Ap 20.

15. Royal College of Physicians. Ethical guidance published for frontline staff dealing with pandemic. 31 Mar 20. Available at: https://www.rcplondon.ac.uk/news/ethical-guidance-published-frontline-staff-dealing-pandemic. Accessed 4 Apr 20

16. Tactical Combat Casualty Care for Medical Personnel. Instructor Guide. August 2018. Available at:   https://www.jsomonline.org/TCCC/TCCC-MP%20Curriculum%201708/04%20Instructor%20Guides/2%20Care%20Under%20Fire%20IG%20.pdf. Accessed 5 Apr 20

17. The American Nurses Association. Nurses, Ethics and the Response to the Covid—19 Pandemic. Available at:   https://www.nursingworld.org/~495c6c/globalassets/practiceandpolicy/work-environment/health–safety/coronavirus/nurses-ethics-and-the-response-to-the-covid-19-pandemic.pdf. Accessed 4 Apr 20.

18. Kirsch T. What Happens If Health-Care Workers Stop Showing Up?  The Atlantic. 24 Mar 20. Available at: https://www.theatlantic.com/ideas/archive/2020/03/were-failing-doctors/608662/. Accessed 4 Apr 20

19. Schuklenk U. Health Care Professionals Are Under No Ethical Obligation to Treat COVID-19 Patients. Journal of Medical Ethics. April 1, 2020. Available at: https://blogs.bmj.com/medical-ethics/2020/04/01/health-care-professionals-are-under-no-ethical-obligation-to-treat-covid-19-patients/.  Accessed 10 Apr 20

20. College of Medicine & Science. The Mayo Clinic. Available at: https://college.mayo.edu/covid19/  Accessed 8 Apr 20.

21. Kerridge I, Lowe M, Stewart C. Ethics and law for the health professions (4th ed). 2013. The Federation Press, Sydney.

22. Bailey R. The Case of Dr. Anna Pou: Physician Liability in Emergency Situations. Health Law. Sep 2010. Available at: https://journalofethics.ama-assn.org/article/case-dr-anna-pou-physician-liability-emergency-situations/2010-09. Accessed 4 Apr 20.

23. Thompson AK. et al. Pandemic influenza preparedness: an ethical framework to guide decision-making. BMC Medical Ethics. 2006. Available at: https://bmcmedethics.biomedcentral.com/track/pdf/10.1186/1472-6939-7-12. Accessed 5 Apr 20

24. Jennings B, Arras J. Ethical Guidance for Public Health Emergency Preparedness and Response: Highlighting Ethics and Values in a Vital Public Health Service. Centers for Disease Control and Prevention. Oct 30, 2008. Available at: https://www.cdc.gov/od/science/integrity/phethics/docs/White_Paper_Final_for_Website_2012_4_6_12_final_for_web_508_compliant.pdf. Accessed: 5 Apr 20.

25. DePalma A. Ex-E.P.A. Chief Defends Role in 9/11 Response. NY Times. June 26, 2007. Available at: https://www.nytimes.com/2007/06/26/nyregion/26whitman.html.  Accessed: 5 Apr 20.