Medical ethics and codes of conduct commonly refer to a set of guiding ethical principles. One specific set of principles is shown in Table 28-1.
Ethical Principles in Medicine
Honesty is a cornerstone in all relationships. It is endemic to any good work environment.1 The consistent prioritization of honesty in the workplace is the foundation by which we meet many of our ethical responsibilities. Honesty demands accurate evaluation of employee performance and leads to responsible mentoring. It also fosters constructive employee feedback to their supervisors.2 It supports openness of communication and the unfettered ability to maintain objective two-way communication. An environment that prioritizes honesty allows all members of the community to be heard without fear of reprisal and is absolutely indispensible to effect needed change as it allows for the objective identification of areas for improvement.
Honesty, including being honest with one’s self, allows for the maintenance of objectivity. Objectivity is crucial when supervising others and leads to productive supervisory interventions rather than ones undermined by the showing of emotion or lapses that reveal more visceral responses. The constant application of objectivity demonstrates respect for your colleagues and peers and will only lead to enhanced effectiveness on your part. In your role as an EMS medical director, it is hoped that you will support scholarly pursuits for the advancement of the field at large and the professional advancement of your employees, your peers, and yourself. Honesty again plays an important role here with the respect of others’ intellectual property. This includes the highest ethical standards in citing the work of others. Whether this is appropriate citation of other indexed works or balanced representation of authorship of scholarly works the same principles apply.
Honesty again guides us when we are confronted with our colleagues’ lapses in professional behavior. We have an ethical and often legal responsibility to report certain acts.3 While we are expected to report illegal and unethical behavior, this is not always the case.4 By not reporting such behavior you become an accessory to it and open yourself to significant consequences. We should always remember that when our colleagues act outside the rules, and do so in a way that we have become aware of it, they have selfishly jeopardized us and, in the author’s view, enjoy no obligation from us to protect them. This, of course, includes the reporting of impaired providers as covered in detail in Chapter 8.
One of the most important roles of the EMS physician is mentorship. Ensuring success of colleagues (other physicians, EMS providers, agency/system administrators, community partners) leads to greater safety for patients and the public. Because of the public nature of emergency services, there can be temptation to withhold advice, support, and/or other forms of mentorship when political or financial gain may be considered at stake. Academic advancement may also influence EMS physicians in university-based systems and lead to concerns over credit for publications, research, and service or citizenship at the institution. Responsible and honest mentorship is key to contemporary and future success of an EMS system and therefore EMS physicians should seek and provide mentorship where appropriate.
Ensuring objectivity can be difficult when evaluating resource allocation, system and provider performance, and personal effectiveness. All these areas are crucial for success of the system. Maintaining objectiveness may require external review and utilization of multisource evaluations and national performance benchmarks. Maintaining objectivity is sometime threatened by concerns over poor performance evaluations and subsequent financial and/or professional consequences. Setting goals and reviewing benchmarks and trends may aid in maintaining objectivity while limiting the risk to individuals within the agency/system.
In order for patient care and safety to remain the primary concern of all providers throughout the phases of care, all members of the health care team must show respect for each other at all times. Prehospital providers, physicians, nurses, technicians, clerks, and other staff must all share this important philosophy. One of the key components of ensuring cohesiveness is for all members of the team to acknowledge to roles, responsibilities, skills, and contributions of all the other members. Unnecessary criticism, negative comments, and unprofessional behavior all endanger this component of ethical medical practice.
The concept maintaining professional integrity is linked to all aspects of care and carer development. Ensuring accuracy in reporting medical information, clinical interventions, outcomes, and research data are examples of integrity. Conflicts of interest arise frequently when considering medical errors and coding and billing practices, but they may also arise in industry relationships. Choosing a particular medical device (eg, monitor/defibrillator) due to familiarity or friendship with the sales representative may even be considered a lack of integrity on the part of the decision maker because the foremost consideration should be patient care and provider and patient safety. Altering or manipulating system outcome data or research data is also a significant threat to professional integrity, even when the manipulation is not altering the information, but rather simply presenting it in a more favorable way.
Social responsibility can be framed to incorporate any practice that contributes to the betterment of the community. Although the general focus of EMS is health, some of the activities of EMS systems, agencies, and providers impact other areas, such as happiness and prosperity. When a member of the community is sick or injured and the EMS system is activated there is a significant potential for that individual to not only be suffering a health problem, but inflated cost of health care delivery will impact the patient’s bill, potentially to the detriment to their perceived prosperity and happiness. When significant costs are passed on to the community in the form of taxes designed to support emergency services, this can also have a negative impact. In addition to ensuring that provision of emergency care and preventative health initiatives are properly implemented, costs should be considered and efforts made to provide care and services at the most efficient level.
Supporting the practicing carefulness in medical care does not that defensive medical practice should be instituted. Rather, carefulness here means that the provider will exhibit prudence and attention to detail in the assessment and management of their patients. This goes beyond the concept of simply adhering to the standard of care, but rather implies that the duty of the provider extends to also being literally careful in all aspects of caring for their patients. The risks of failure to adhere to this principle include all potential causes of provider fatigue, inattentiveness, and complacency.
Discrimination or profiling of patients, or even other providers, can lead to significant medical errors and emotional harm and cannot be tolerated in the EMS arena. Withholding comfort measures, including pain medication, from patients based on their sex, race, ethnicity, religion, or socioeconomic status can lead to major injustices and poor medical care overall. Discrimination also leads to a hostile work environment that may lead to impairment of a provider. The impact on the individual, the agency, and the system can be significant.
Openness in health care is typically thought of as a principle necessary to ensure continued trust in a health care provider and the health care system in general. Although it is uncommon for a patient to suffer a poor outcome as a result of a medical error or series of errors, it is important to consider how to effectively, and openly, communicate these facts to the patient and/or family. The perception of a patient or family member later discovering that a provider was not open and potentially withholding this type of information would likely be that there was an intentional deception taking place. This may lead to mistrust of the provider and the system. It is also equally important to communicate realistic expectations to patient and families and to not ignore the need to discuss medical futility when appropriate.
In this context competence refers to the skill and correctness of the care provided by a health care provider. In order to ensure competence, initial and continuing education must be adequate, medical knowledge and procedural skills must be tested and verified, and providers must ascribe to up-to-date medical practices. A failure to maintain current medical knowledge and skills or a failure to enhance or adapt one’s medical practice to meet current standards of care and medical advances can constitute incompetence. EMS providers and physicians must be dedicated lifelong learners to ensure competence.
Laws represent societal standards and norms and health care providers are bound to honor these standards as members of society. It is the responsibility of EMS providers and physicians to seek changes to the laws and regulations that may stand in the way of best practices, access to care, and changes or enhancements required to improve the delivery of patient care. Improvements and changes to the system should always be sought through legal means.
RESPECT FOR INTELLECTUAL PROPERTY
During the usual practice of an EMS physician, a significant volume of what can be referred to as intellectual property is utilized. All original documents, presentations, techniques, devices, and business strategies could be considered intellectual property of the individual, group, or corporation that developed or contracted for their development. The medical and scientific communities have been trained on the value of sharing information and technology to advance health care. Although this seems to imply that the most ethical course of action would be to share all these materials and ideas in order to help others improve their system and care of patients, this would ignore another ethical concern. Intellectual property issues relative to medical practice in era of globalization have created a more complex view of this area of ethics.5 The intellectual labor of individuals, groups, and corporations should be protected as their property. If this were not the case, then there would be a disincentive to invest in advancement and development of new health care strategies. These two seemingly opposed ethical concerns must be carefully respected. In accordance with respect for colleagues it is also important to consider that misrepresenting the origin of materials created by other EMS providers, physicians, and other colleagues violates both ethical principles: respect for colleagues and respect for intellectual property. When protocols, procedures, presentation materials, and other materials developed by others are used by the EMS physician, it should be done with appropriate citation and in some cases express permission should be obtained.
While we are all very familiar with HIPAA there is also widespread misunderstanding of what this means for practice improvement.12 It was never the intent of HIPPA to constrain quality improvement initiatives. In fact the law specifically allows for “health care operations” as a permitted disclosure.11,12 Patient’s personal data must always be protected but review of that data for the express purpose of call review and quality improvement is absolutely legal. Organizations must have continuous quality improvement initiatives if they are to move forward. Wherever possible patient identification should be protected whenever the situation allows. For example, if a call report is to be reviewed with a group of providers for examples of documentation the name and address should be removed as they do not further the discussion unless that is specifically where the original error occurred. A high-profile call under review should not be hampered by the fact that everyone happens to know who the patient was but all care should be used to keep the discussion among the professionals who can learn from the events and no others. HIPPA compliance allows for sharing of protected health information for the purposes of continuous quality improvement and this right to review outcome data and pertinent medical records is expressly allowed for all “covered entities” which covers almost every EMS agency, provided they transmit any health care information electronically for certain transactions.
PROTECTION OF HUMAN SUBJECTS
As physicians we are always bound to our first duty which is “competent medical care with compassion and respect for human dignity and rights.”1 This fundamental principle is our fallback litmus test for clinical investigations and their impact on human subjects. We must always follow the highest ethical and professional standards when engaging in clinical research. The public trust is at stake and the mere appearance of conflict of interest here can be devastating to an organization. Institutional review boards are an indispensible part of ethical clinical research whose approval is generally required to get any such research published. The US Department of Health and Human Services has a specific Office for Human Research Protections to underscore the extent to which this is a regulated enterprise.
Publication of new methods, research findings, and observations is one of the important contributions that can be made by an EMS physician. Maintaining a high standard for medical publication and ensuring the accuracy and validity of published works is a high priority in maintaining an ethical medical practice because inaccurate information published in the medical literature could have a negative impact on patient care. A great deal of trust is involved in the system of peer review for publication and skewing or manipulating findings threatens that system. In addition to ensuring accuracy of data and conclusions included in manuscripts, it is also important to submit unpopular or unexpected findings for publication, even if they are not favorable to the investigator in some way, as withholding this information may also negatively impact the care of future patients.
In sum, if we are always honest and act on behalf of our patient’s best interests we will be acting like the physicians we all hope to be. “A physician shall, while caring for a patient, regard responsibility to the patient as paramount.”1