Pre Hospital Ethics and Legal Issues

The role of a paramedic is challenging, they are constantly first on the scene, make life and death decisions, and must treat people without judgement or prejudice. They are one of the most trusted professions, surely this respect is due to their ethical and respectful treatment of patients, onlookers, family and the general public. To ensure this trust continues it is vitally important that current and future paramedics operate both professionally, legally and ethically.

Paramedics are affected by both case law and statute Law. There is at least fifteen Acts of Law that paramedics work under, they range from acts that refer to the treatment of the mentally unwell – the Mental Health Act 1986 to the use of drugs and restricted substances – the Drugs, Poisons and Controlled substances Act 1981 and regulations 1995, and many others. If found to be negligent paramedics may be sued civilly for damages or face charges such as assault under the Crimes Act 1958.

Negligence relates to all areas of legal and ethical issues for a paramedic, if a paramedic breaches their duty of care, treats without consent, or doesn’t treat patient information with the confidentiality that they deserve then they may be deemed negligent, and therefore face legal action. They are liable for assault if they treat a person who is validly refusing treatment, but liable for negligence if they do not provide treatment and later legal action finds that the patient was not competent to refuse treatment (Steer 2009).

Every action that a paramedic makes will be in line with the ethical principle of beneficence, paramedics are called when people are at a time a need, everything that a paramedic does in their treatment is done to improve their situation, their conduct is constantly aimed at the good and to improve the well being of their patient, and the people around their patient.

Autonomy and consent are tightly linked. There is a requirement that patients consent to treatment, provided they are competent to do so (Cameron, Jelinek, Kelly, Murray, Brown, 2009). This means that paramedics must gain consent from the patient before they treat. For a person to not consent to treatment, the person must be deemed to be autonomous to make that decision. Whether a patient is in fact autonomous or not will be a decision that paramedics will be constantly challenged with.

There are different types of consent, consent may be implied, i.e. by putting out your arm to receive a needle it may be assumed that you consent to that treatment. There is also verbal and written consent. For consent to treatment to be valid, the choices must be informed, understood, voluntary and made by a person of legal capacity (Steer 2007). To be informed means that information specific to the procedure that is significant to the patient is required to be told to the patient, understood means that this information and their choices must be understood by the patient, voluntary means the patient shouldn’t be threatened or pressured into a choice, and a person of legal capacity means that they must be autonomous to make that decision. (Steer 2007). Rogers v Whitaker is a case where relevant information about the risks wasn’t supplied to the patient, meaning the patient wasn’t properly informed of the risks, and therefore didn’t understand the complications that could occur after a medical procedure. When complications occurred the surgeon was found to be negligent because he hadn’t explained the risks to the patient regardless of her questioning (Freckelton 1999).

Of course there will be times when the patient doesn’t have the capability to give consent, for example if the patient is unconscious, incapacitated, very young or suffering from the effects of drugs. In these cases the doctrine of necessity will apply (Eburn 2010). In these cases treatment that is necessary to save the patient’s life, to prevent serious damage to their health or to stop the patient from continuing to suffer from significant pain may be given without consent (Townsend, Luck, 2009). The principle of Beneficence, to do good to others, supports the doctrine of necessity (Steer, 2007). Of course if the wishes of the patient are known, for example through the presence of a do not resuscitate order or information suggesting that they do not wish to receive a blood transfusion, these wishes should be respected. An ethical decision may need to be made if the condition that they are currently being treated for is different to the one that the do not resuscitate order exists for. For example if a terminal cancer patient is in a car accident and has a do not resuscitate order regarding the cancer, should attempts be made to save their lives by treating the injuries caused by the accident, does the do not resuscitate order cover this?

With every patient that a paramedic treats they will be trusted with personal information regarding the patient. In an emergency setting, where patients are more vulnerable because of illness or injury, staff are often provided with confidential family and legal information (Cameron et al, 2009). This information must be treated with confidentiality, meaning that only information relevant to the patient’s condition is given to only the relevant people who need to know, i.e. people that will also be treating that patient. It would not be just or fair on the patient if their private information was discussed with people who had nothing to do with the treatment of them.

This does create in itself ethical dilemmas, in some situations confidentiality of the patient will have to be weighed up against his legal and moral obligations to that of society (Frampton 2004). On one hand if a paramedic or treating professional breaks the confidentiality of a patient, then it may discourage the patient or others from seeking medical assistance in the future, and may result in negative patient outcomes or even death, but if a medical professional doesn’t pass on a warning about a violent patient who carries on offending they must live with the consequences of this action (Frampton 2004). It is now accepted that confidentiality ends where public peril begins, this is brought about by the case Tarasoff where a psychiatrist was found negligent after he was told that a patient intended on killing a friend and he failed to warn, and the patient followed through with his threats. It was found that the psychiatrist, and his department had a duty to warn the third party (Buckner, Firestone 2000). Disclosures can be made in the public interest, usually where it is essential to protect the patient or client or someone else from the risk of significant harm (Conner, 2007)

Being a paid professional paramedics have a duty of care to their patients, that is to provide the best possible care with regards to their training and the injuries of the patient. Obviously paramedics have a higher duty of care to their patients than the general public or volunteer first aider. It is important to remember that when the actions of a paramedic are called into question, the standard of care is that of the reasonable paramedic, not the reasonable expert in emergency medicine, and just because a paramedic isn’t negligent, it doesn’t mean that the service that employs them isn’t if they haven’t trained their paramedics to an acceptable standard (Eburn 2007). The ethical principle of non-maleficence relates to this, paramedics should not cause any more harm to the patient, the patient should be better off after the arrival and treatment of the patient than before.

There is no doubt, as the role of the paramedic continues to expand, the legal and ethical challenges in decision making will increase (Townsend et al., 2009). It is important that as paramedics are faced with ethical and legal issues in the future they deal with them in a professional, educated and understanding manner where the patients best interests are their first priority.

Buckner, F. (2000). Where the Public Peril Begins: 25 Years After TARASOFF. The Journal of Legal Medicine, 21(2).

Cameron, P. Jelinek, G. Kelly, A. Murray, L. Brown, A. (2009). Textbook of Adult Emergency Medicine. Sydney, Churchill Livingstone.

Conner, J. (2007). Practice Makes Perfect – Disclosure of patient records. Emergency Nurse 15(6), 18-19.

Eburn, M. (2007) Ambulance Service of NSW v Worley; further legal lessons for the emergency services. Journal of Emergency Primary Health Care, 5(2).

Eburn, M. (2010). Emergency Law. Sydney, Australia: The Federation Press.

Frampton, A. (2005). Reporting of gunshot wounds by doctors in emergency departments: A duty or a right? Some legal and ethical issues surrounding breaking patient confidentiality. Emergency Medicine Journal, 22, 84-86

Freckelton, I. (1999). The new duty to warn – Medical negligence law: the stakes for the consumer are higher in the medical context than in almost any other. Alternative Law Journal, 24(1), 1-9.

Luck, M. Townsend, R. (2009). Protective jurisdiction, patient autonomy and paramedics: the challenges of applying the NSW Mental Health Act. Journal of Emergency Primary Health Care 7(4).

Steer, B. (2007) Paramedics, consent and refusal – are we competent? Journal of Emergency Primary Health care, 5(1), 1-10.