Exploring Ethical Dilemmas: An Analysis of Moral Challenges in Paramedic Education

By Dr. Peter Mangles

Abstract

Paramedic educators play a critical role in shaping the future of practitioners and clinicians, ensuring their competence and ethical standards. On the back off a world-wide pandemic, technological advances, global health initiatives, expanded scopes of practice, increased focus on education and professionalism and pharmaceutical advancements the ethical challenges encountered by educators in their workplace continue to be realized across the paramedicine discipline.

These challenges arise from the intersection of increasing complex healthcare systems, evolving ethical norms, and a diverse paramedic, medical, nursing and allied health workforce. Key ethical dilemmas in paramedic education incorporate a multitude of issues such as fostering professionalism, managing conflicts of interest, addressing cultural and diversity-related concerns, maintaining student well-being, and ensuring academic integrity.

Paramedic educators must navigate these and other challenges while upholding the highest ethical standards, balancing competing interests, and fostering a culture of ethical excellence in paramedic education. This paper explores the importance of recognizing and addressing these ethical challenges, providing insight into the multifaceted role of academics and educators and the broader implications for paramedic practice and patient care.

Additionally, it emphasizes the need for ongoing training, support, and resources to help paramedic educators effectively navigate these ethical complexities in their demanding workplace environments.

Key Words: ethical, ethics, education, paramedicine,  out-of-hospital

Introduction

Educators play a crucial role in shaping the future of paramedics and other  out-of-hospital practitioners (e.g. Emergency Medical Technicians, Patient Transport Officers). As the  out-of-hospital sector evolves and develops, it will continue to face numerous challenges, and paramedic educators and academics will encounter a range of ethical issues in their workplace.

The ethical dilemmas faced by paramedics and educators, will affect and influence practitioners, clinicians, students, and the broader healthcare system. Education plays a pivotal role in shaping the well-being of individuals and communities and educators must strive to impart knowledge and foster resilient behaviors, whilst encountering and managing a myriad of ethical challenges.

Ethical issues that arise in the field of paramedic education, include complexities such as informed consent, cultural sensitivity, autonomy, and the dissemination of accurate information. This paper explores the extant literature and identifies the current ethical dilemmas faced by paramedic educators and the contemporary strategies in place to address them, ultimately promoting more ethical and effective health education practices.

Paramedic education is a vital component of public and private health initiatives worldwide, aiming to empower individuals and communities to make informed decisions about their health. While the overarching goal of education is to improve the well-being of individuals and society, it is not without ethical challenges.

The evolving  out-of-hospital environment continues to generate novel ethical issues that arise in paramedic education, emphasizing the need for educators to navigate complex terrain with sensitivity and a commitment to ethical principles. Paramedics, medical officers, allied health personnel and nurses often find themselves facing decisions that demand moral discernment, shaped by ethical principles.¹

These professionals and practitioners bear the responsibility of providing care while simultaneously striving to maximize benefit and minimize harm, all while prioritizing the well-being of their patients. In complex scenarios, it is not unusual to question the relevance of additional ethical deliberation before taking any definitive action or making care decisions.²

Fundamental Principles of Ethics

In the realm of paramedic education and training, the fundamental principles of ethics (autonomy, beneficence, non-maleficence and justice), play a pivotal role in shaping the professional conduct and decision-making processes of future paramedics.

Gillon³ proposes that the “four principles plus scope” approach offers a straightforward, accessible, and culturally neutral method for considering ethical issues in healthcare. It provides a shared, fundamental moral analytical framework and a common, foundational moral vocabulary. Autonomy emphasizes the importance of respecting patients’ rights to make informed decisions about their own care.

This principle is foundational in the paramedic’s duty to provide comprehensive information, enabling patients to understand their options and the implications of their choices. Thor⁴ suggest, fostering autonomy in health practitioners and paramedic training involves cultivating communication skills that empower patients, ensuring that they can participate actively in their care decisions.

Beneficence and non-maleficence are intertwined principles that focus on the paramedic’s obligation to act in the best interest of the patient while avoiding harm. Beneficence requires paramedics to provide interventions that maximize patient well-being, which includes the judicious use of medical knowledge and skills to promote health outcomes.

Conversely, non-maleficence, often encapsulated in the maxim “do no harm,” necessitates a careful consideration of the risks and benefits associated with any intervention. In their exploration of these principles, Beauchamp and Childress⁵ highlighted the necessity for paramedic and practitioner education programs to instil a thorough understanding of these ethical considerations, particularly in high-stress situations where rapid decision-making is required.

Justice, the final cornerstone of medical ethics, ensures that paramedics provide fair and equitable care to all patients, regardless of their background or circumstances. This principle is especially crucial in prehospital settings, where paramedics often encounter diverse populations with varying levels of access to healthcare resources.

Braveman, Fielding, Laveist, et al.⁶, suggest that integrating the principle of justice into paramedic training involves educating students about social determinants of health and encouraging cultural competence, which are vital for delivering unbiased and equitable care.

By embedding these ethical principles into the core curriculum, paramedic education can produce practitioners who are not only technically skilled but also ethically conscious and committed to equitable patient care.

Paramedic academics and educators are continually faced with a complex set of moral and ethical issues that range from issues of pedagogy and training to the impact of healthcare decisions on patient lives.

One significant ethical dilemma is the question of curricular emphasis; specifically, whether to focus on traditional biomedical knowledge or to include broader ethical, social, and cultural contexts that influence patient care.⁷ Producing the right balance is crucial for the student, the educator, and the wider community in which they serve.

A purely technical focus may produce clinicians skilled in procedures but lacking in holistic, empathetic care. On the other hand, an overt emphasis on the ethical or social aspects can potentially detract from the critical technical proficiency required in paramedical practice. Clarke^8(p533) suggests that health education “aims to promote the fullest notion of health in people. Health in this context incorporates not just physical health but health in all its holistic dimensions, including psychological, spiritual, physiological, and sociological aspects.”

Another issue is the inherent power dynamic between educators and students, which can be problematic from both a moral and ethical standpoint. Role modelling makes the most of a powerful teaching strategy.⁹

Students are typically evaluated by the same educators who teach them, which can raise concerns about objectivity. The situation is further complicated by the sensitive nature of paramedical education, where critical skills must be imparted effectively but without undermining the confidence or emotional well-being of the student.

One of the most salient moral issues involves preparing students for the ethical challenges they will face in healthcare settings, such as issues of patient autonomy, informed consent, and end-of-life decisions.¹⁰

While it is important to provide a strong ethical foundation, there is also a risk of instilling a specific moral viewpoint, thus infringing on the autonomy of students to develop their own ethical perspectives. This is especially pertinent in diverse educational environments where cultural, religious, or philosophical differences can significantly impact ethical considerations.

Adding to this complexity is the advancement of technology, including simulation-based education, which comes with its own set of ethical challenges.¹¹ While simulation provides a safe environment for practice, it also raises questions about informed consent for those who play the role of patients, the use of data gathered during simulations, and the fidelity of simulations to real-life situations.¹²

The ethical responsibilities of paramedic educators also extend beyond the classroom and extends into research, scholarship, and the broader health ecosystem.¹³ There are moral imperatives to produce and disseminate evidence-based approaches to teaching and to contribute to policies and practices that promote equity, justice and excellence in  out-of-hospital care.

This involves navigating conflicts of interest, ensuring intellectual honesty, and advocating for the most vulnerable in the healthcare system. Overall, paramedic educators must continually navigate a complex moral and ethical landscape that requires a thoughtful and nuanced approach.

Ethical Theories

Ethical theories provide frameworks for evaluating what is morally right or wrong, guiding our decisions and actions in various contexts. Two prominent ethical theories are utilitarianism and deontology, each offering distinct perspectives on healthcare ethics.

Dual-process theories of moral judgment propose that our responses to moral dilemmas are influenced by two fundamental moral principles: deontology and utilitarianism. Greene,^14(p1) suggests that “people cannot make compromise judgments when deontological and utilitarian considerations conflict.”

Deontology asserts that the moral worth of an action is primarily contingent upon the intrinsic nature of the action itself, regardless of its outcomes.¹⁴ For instance, it maintains that harming others is inherently wrong, irrespective of any potential positive consequences that may result.

In contrast, utilitarianism posits that the morality of an action is principally determined by its consequences, emphasizing that causing harm may be justified if it ultimately leads to the greater well-being of a larger number of individuals.¹⁵

These two moral principles often coexist within our moral reasoning, and their interplay can shape our ethical judgments in complex and nuanced ways, highlighting the intricate nature of human moral decision-making.

In the out-of-hospital setting, utilitarianism and deontology are theories that are often tested in the most stressful and traumatic circumstances. Ethical utilitarianism in healthcare focuses on making decisions that result in the greatest overall benefit or happiness for the largest number of people, such as prioritizing treatments based on population health outcomes.

In contrast, deontology emphasizes the importance of following moral rules and principles, suggesting that certain actions, like respecting patient autonomy, are inherently right regardless of their outcomes.¹⁶ While utilitarianism might prioritize interventions that benefit the majority, deontology underscores the ethical duty of care to each individual patient, often creating complex ethical dilemmas in healthcare settings.¹⁰

Utilitarianism is a consequentialist ethical theory that posits that the right action is the one that maximizes overall happiness or pleasure and minimizes suffering. In other words, it evaluates the morality of actions based on their outcomes.

This approach prioritizes the greatest good for the greatest number and often involves weighing the consequences of actions to determine their ethical value^17,18,19.

Deontology, on the other hand, is a non-consequentialist ethical theory that emphasizes the inherent nature of actions themselves as the basis for determining their moral worth. Deontologists believe that certain actions are intrinsically right or wrong, regardless of their consequences.^20,21 A central tenet of deontology asserts that individuals must act in a way that their actions could be a universal moral law.

Conway and Gawronski,^15(p216) posit:

The principle of deontology states that the morality of an action depends on the intrinsic nature of the action e.g., harming others is wrong regardless of its consequences; the principle of utilitarianism implies that the morality of an action is determined by its consequences e.g., harming others is acceptable if it increases the well-being of a greater number of people.

A key contrast between utilitarianism and deontology lies in their evaluation of actions. Utilitarianism focuses on the consequences of actions, whereas deontology emphasizes the inherent morality of the actions themselves. For example, in a moral dilemma where lying might save lives, a utilitarian might advocate lying if it maximizes overall happiness, while a deontologist would argue against lying because it is inherently wrong.

Criticisms of utilitarianism^22,233 often centre on concerns related to its potential for sacrificing the rights and well-being of minorities or individuals for the greater good. Opponents argue that this approach may justify morally reprehensible actions if they lead to overall happiness.

Additionally, measuring and comparing happiness can be challenging, making utilitarian calculations subjective and prone to manipulation.

Deontology, too, faces criticism for its rigid application of moral rules without considering the context or consequences. Critics argue that this approach can lead to moral absolutism and fail to address situations where flexibility and consideration of consequences may be necessary. In some cases, following strict moral rules may lead to morally undesirable outcomes.²⁴

Utilitarianism and deontology offer distinct ethical frameworks with different foundations for evaluating actions. Utilitarianism emphasizes consequences and overall happiness, while deontology prioritizes the intrinsic morality of actions. Critiques of these theories highlight the potential for moral dilemmas and shortcomings in their respective approaches.

Ultimately, the choice between these ethical models depends on one’s philosophical stance and the specific ethical challenges at hand. Chukwuneke and Ezenwugo,^16(p19) argue that “in medicine, deontology is patient centred, whereas utilitarianism is society centred.”

These two ethical perspectives appear to be at odds, yet each offers unique pros and cons that might occasionally converge in crucial circumstances. In environments with sufficient resources, the deontological perspective on healthcare tends to be more feasible than the utilitarian one, as it emphasizes individual care over broader societal concerns.¹⁶

Key Ethical Issues in Paramedic Education

Ethical issues in professional education within the  out-of-hospital sector are complex and a critical aspect of ensuring the delivery of high-quality patient care and maintaining the integrity of healthcare professionals. Macpherson, Roqué, and Segarra^25(p1239) argue that “students and new practitioners have seldom addressed ethical conflicts during their training”.

In the  out-of-hospital sector, there are ethical considerations that arise in the education of paramedics, that need to be considered from both an educator and learner perspective.

One prominent ethical issue in paramedic education is the need for transparency and honesty in the dissemination of information. Paramedics must receive accurate and up-to-date information to make informed decisions about patient care.

Ethical concerns arise when educational programs are influenced by financial interests or industry biases, potentially leading to the dissemination of biased or incomplete information.²⁶ Educators must navigate the balance between the need for funding and the ethical responsibility to prioritize the best interests of patients and the profession.

Another critical ethical consideration is the assessment of competency and the maintenance of professional standards. Education programs must establish rigorous assessment processes to ensure that learners are adequately prepared to provide safe and effective care.

Buléon, Mattatia, Minehart et al^27(p42) state that “healthcare curricula need summative assessments relevant to and representative of clinical situations to best select and train learners.”.

Ethical issues arise when programs lower their standards to pass more students or when educators are reluctant to fail learners due to concerns about their future careers. Balancing the duty to protect patients with the responsibility to support learners’ professional development is an ongoing challenge.

Paramedics frequently encounter situations that call for moral judgment, guided by the ethical standards upheld by their profession. They are entrusted with the obligation of delivering care, with the primary goal of promoting well-being and mitigating harm, all while acting in the best interests of their patients. In intricate circumstances, it is not uncommon to ponder whether further ethical consideration is warranted before proceeding with a decision or course of action.²

Additionally, issues of diversity, equity, and inclusion are becoming increasingly important in paramedic education. Ethical considerations related to access to education, representation in the curriculum, and the provision of a safe and inclusive learning environment are paramount. Educators must actively address disparities in paramedic education and work to create an inclusive and culturally competent workforce to meet the diverse needs of patients.

Furthermore, the ethical use of technology in paramedic education is a growing concern. As digital tools and online learning platforms become more prevalent, educators must ensure that the privacy and security of learner data are protected. Ethical issues surrounding the use of artificial intelligence, telemedicine, and electronic health records in education must be carefully addressed to maintain the trust and confidentiality of patient information.^28,29

It has been suggested that the widespread use of Healthcare AI (HCAI) technologies is inescapable and unavoidable, “however, implementation of HCAI may exacerbate certain harms in healthcare.”^{28(p. 5)}

While patients and the public are expected to bear the brunt of any adverse effects stemming from health care artificial intelligence, engaging practitioners, clinicians and patients and their families in acceptance of AI ethics remains a daunting task.²⁶

The synthesis of ethical issues in adult, continuing, and professional education in the  out-of-hospital and paramedic sector is a multifaceted endeavour that requires constant attention and vigilance.

Paramedic educators must balance the need for financial support with their ethical duty to prioritize patient safety and integrity. They must also address issues of transparency, competency assessment, diversity, equity, and the responsible use of technology.

By actively addressing these ethical considerations, paramedic education programs can ensure that future clinicians and professionals are well-prepared to provide the highest standard of care while upholding the principles of ethics and integrity in their practice.

Conclusion

Paramedic education is a vital component of public health, but it is not without ethical challenges. Educators must navigate a complex terrain that includes providing evidence-based information, addressing sensitive topics with cultural sensitivity, obtaining informed consent and promoting health equity.

By upholding these ethical principles, paramedic educators can contribute to improved health outcomes and a more just and equitable society. Paramedic education plays a crucial role in the development of neophyte practitioners, primarily because it lays the foundation for their entire professional journey in a field where every decision can have profound consequences.

The comprehensive training that paramedic students receive is not just about mastering medical procedures and techniques; it is also about developing critical thinking skills, emotional resilience, and a deep understanding of ethical considerations.

These ethical issues are numerous and complex, encompassing dilemmas like patient autonomy, informed consent and the allocation of limited resources. Academics in this field face the challenge of not only imparting theoretical knowledge and practical skills but also instilling a strong ethical framework.

This is essential because, in emergency medical services, practitioners often encounter situations that are not black and white and require a nuanced approach to ethics. The education process thus becomes not just about saving lives, but also about nurturing responsible, reflective, and ethically minded professionals who can make sound judgments in the heat of the moment.

This holistic approach to paramedic education is vital for preparing practitioners to face the myriad challenges of this demanding yet rewarding profession.

While this paper provides an overview of the ethical issues facing paramedic educators, further research is needed to explore specific aspects in greater depth. Researchers can investigate the effectiveness of different strategies for addressing ethical challenges in paramedic education, the long-term impact of mistreatment on students, and the role of diversity and inclusion in ethical education.

Additionally, ongoing research can help identify emerging ethical issues in the rapidly changing  out-of-hospital landscape. Anderson and Fox^31(p223) suggest that “standards of ethical conduct are important in all disciplines and health is no exception.”

In summary, ethical issues in paramedic education are multifaceted and require careful consideration. As the field continues to evolve, educators and policymakers must remain committed to upholding ethical standards that prioritize the well-being and autonomy of individuals and communities. Only through ethical practice can paramedic education fulfill its potential as a force for positive change in public health.

About the Author

Dr. Peter Mangles is a Registered Intensive Care Paramedic and Registered Nurse from Australia who has worked across the world in a clinical, educational and administrative capacity in prehospital, remote and austere emergency care. He received no financial support for the research, authorship and/or publication of this article.

References

1. Gardiner P. A Virtue Ethics Approach to Moral Dilemmas in Medicine. J Med Ethics 2003; 29.5:297–302.
2. Kennedy W. Beneficence and Autonomy in Nursing a Moral Dilemma. Br J Perioper Nurs: 2004; 14.11:500–506.
3. Gillon R. Medical Ethics: Four Principles plus Attention to Scope. BMJ 309.6948 (1994): 184–188. Web.
4. Thor, DC. Ethics in Emergency Medical Services: A Contextual Analysis (2019). (Order No. 22584698). ProQuest One Academic.
5. Beauchamp TL, and Childress JF. Principles of Biomedical Ethics. 7th ed. New York: Oxford University Press, 2013. Print.
6. Braveman PA., S., Fielding, J., Laveist T., Borrell, LN., Manderscheid R, and Troutman A. Health disparities and health equity: the issue is justice. Am J Public Health. 2011 Dec;101 Suppl 1(Suppl 1): S149-55.
7. Emanuel LL and Emanuel EJ. The Economics of Dying – The Illusion of Cost Savings at the End of Life. NEJM 1994; 330.8:540–544. Web.
8. Clarke J. Ethical Issues in Health Education. Br J Nurs, 1993; 2.10:533–538.
9. Cruess SR, Cruess RL and Steinert Y. Role Modelling – Making the Most of a Powerful Teaching Strategy. BMJ 2008; 336.7646:718–721. Web.
10. Beauchamp T & Childress J. Principles of biomedical ethics. Eighth Edition. Oxford University Press: Oxford; 2019.
11. Cook DA, Hatala R, Brydges R, Zendejas B, Szostek JH, Wang AT, Erwin PJ and Hamstra SJ. Technology-enhanced simulation for health professions education: a systematic review and meta-analysis. JAMA, 2011; 306(9); 978-988.
12. Zendejas B, Hamstra SJ, Brydges R, Szostek JH, Cook DA, Hatala R, Erwin PJ, Wang AT. Technology-Enhanced Simulation for Health Professions Education. JAMA, 2011; 306.9:978 Print.
13. Miles SH, Lane L.W, Bickel J, Walker RM and Cassel CK. Medical ethics education: coming of age. Acad Med, 1989; 64(12):705-714.
14. Greene JD. The Dual-Process Theory of Moral Judgment Does Not Deny That People Can Make Compromise Judgments. PNAS 2023; 120.6: e2220396120–e2220396120.
15. Conway P and Gawronski B. Deontological and utilitarian inclinations in moral decision making: A process dissociation approach. Pers Soc Psychol Rev, 2013; 104(2):216-235. doi:https://doi.org/10.1037/a0031021
16. Chukwuneke FN and Ezenwugo AC. Deontology Vs. Utilitarianism: Understanding the Basis for the Moral Theories in Medicine. Int J Med Health Dev 2022; 27.1:19–23.
17. Baron J. Against bioethics. Cambridge, MA: The MIT Press, 2006.
18. Piazza J and Landy JF. Lean Not on Your Own Understanding: Belief That Morality Is Founded on Divine Authority and Non-Utilitarian Moral Judgments. Judgm Decis Mak 2013; 8.6:639–661.
19. Rosen F. Classical utilitarianism from Hume to Mill. New York, NY: Routledge 2003.
20. Tanner C, Medin DL and Iliev R. Influence of deontological and consequentialist orientations on act choices and framing effects: When principles are more important than consequences. Eur J Soc Psychol, 2008; 38:757–769. doi:10.1002/ejsp.493
21. Wang S and Jinghui S. Ethical Dilemmas in the Dermatology Outpatient Department in China. Clin Cosmet Investig Dermatol, 2023; 16:1303–1308.
22. Chadwick R and Gallagher A. Ethics and Nursing Practice. 2nd Ed. Palgrave, London, 2016.
23. Hendricks J. Law and Ethics: Foundations in Nursing and Health Care, Cheltenham 2004.
24. Rodger D and Blackshaw B. An Introduction to Ethical Theory for Healthcare Assistants. Br J Healthc Assist, 2017; 11.11:556–561.
25. Macpherson I, Roqué MV and Segarra I. Moral Dilemmas Involving Anthropological and Ethical Dimensions in Healthcare Curriculum. Nurs Ethics, 2020; 27.5:1238–1249.
26. Kyoiku I. Impact of Financial Conflicts of Interest between Pharmaceutical Companies and Health Care Professionals on Clinical Practice and Educational Programs to Mitigate the Issues. Med Ed (Japan), 2022; 53.2:177–182.
27. Buléon C, Mattatia L, Minehart RD, et al. Simulation-Based Summative Assessment in Healthcare: An Overview of Key Principles for Practice. Adv Simul (Lond), 2022; 7.1: 42–63.
28. Frost EK, Bosward R, Aquino YJ, Braunack-Mayer A and Carter SM. Public Views on Ethical Issues in Healthcare Artificial Intelligence: Protocol for a Scoping Review. System Rev 2022; 11.1: 1–142.
29. Guan J. Artificial intelligence in healthcare and medicine: promises, ethical challenges, and governance. Chin Med Sci J. 2019; 30(34): m76–83.
30. Young AT, Amara D, Bhattacharya A, and Wei ML. Patient and general public attitudes towards clinical artificial intelligence: a mixed methods systematic review. Lancet Digit Health; 2021; 3(9): 599 -611.
31. Anderson RC and Fox R. Ethical issues in health promotion and health education. AAOHN J, 1987; Vol. 35, No. 5: 220 – 223.