When did ethics and morality enter the world of paramedicine? Has it always been there? Is it something we have to consider daily? These and many other questions are what first came to mind on reading The Professional Ethics Toolkit by Christopher Meyers.
I love books and have a terrible habit of flicking through the books I review as soon as they arrive, often forming a totally undeserved and inaccurate opinion of the book depending on which pages I have landed on.
This was the case with this particular book. I immediately picked up on two things—a very philosophical undertone and reference to professions other than paramedicine. This generated a further question… is this book really going to be relevant? However, despite my initial misgivings, the answer was in fact a yes—but with some caveats.
Before delving into the book, it may be helpful to give a frame to the review, relating to those initial questions I asked myself.
History of ethics in paramedicine
It could be argued that ethics and morality have always been a part of prehospital care in as much as, one would hope, prehospital practitioners would always try to act in the best interest of their patients while upholding their wishes as closely as possible.
Move to the early 90s and, as pointed out by Clarke et al (2012), with the advent of the ‘paramedic’ came a development of professionalism that was later enshrined in the protection of title and registration with a professional body. This body prescribed ethical standards, thus putting it clearly on the map. They go on to describe ethics as being ‘…a moral code’ and which ‘can be very subjective’; they also make the distinction that our arena of work is now the ‘front line of out-of-hospital care rather than pre-hospital care’; and that this means we are increasingly faced with ethical decisions. In making these points, they also highlight how many texts on medical ethics are not helpful for paramedics as the cases they highlight are ones that never occur within our scope of practice so do not adequately explore the dilemmas.
Verdict on the book
If medical texts cannot adequately cover the subject, and given what I have said about this book additionally focusing on other professions, how can it possibly help? Surprisingly it does because of the other point I highlighted; that being, the philosophical nature of the book. What this book aims to do is expand on the underlying philosophical reasoning to enable these concepts to be applied to any situation in a pragmatic way.
The author, Christopher Meyers is well placed to offer such guidance. He is a Professor Emeritus of Philosophy, alongside holding various teaching and consultant positions in the field of ethics linked to healthcare.
The book itself is split into two parts: part one deals with ‘Theory, Concepts and Ethics Reasoning’, and part two is given over to working through these concepts and principles, placing them into practical workplace scenarios.
The book is very well structured and provides a familiar layout throughout, whereby concepts and theories are discussed and (most) chapters are rounded off with some case studies to illustrate these and stimulate thought. What is interesting is that they do just that: rather than provide answers (it is an area, as we discover throughout the book, where definitive answers are often not to be found), they stimulate thought. I certainly had some of my own views challenged on more than one occasion.
Professional ethics
The introduction that immediately gets readers mulling over concepts relating to ‘professionalism’ and what this means. As soon as we start part one, the author stresses again the distinction between ‘professional’ ethics as opposed to practical and theoretical ethics. At the root of this is the relationship between a professional and their client, and the trust it entails. Meyers gives a history of how the ‘professional’ developed and its implications, listing what he considers a profession before defining the types of theoretical client relationship.
Ethics reasoning
In chapter two of part one, he then works, philosophically, towards a model of ethics reasoning, first covering the accepted models across the spectrum before combining these into a dynamic model. He finishes part one with a list of moral principles. These principles then form the chapters of part two.
Anyone who has studied this area as part of a paramedic or nursing qualification will already have started to see echoes of the work by Beauchamp and Childress (1979) and Meyers builds nicely on this in a practical and accessible way.
Autonomy and respect
Part two kicks off with the principles of ‘Autonomy & Respect’, with Meyers drawing upon the words and works of Aristotle and Immanuel Kant to help formulate his point: that autonomy is hard work. He describes it as an acquired skill developed from practical wisdom and habituated dedication. In our context, as paramedics, this makes interesting reading given that Meyers convincingly shows that ethical decision making is integral to autonomous decision making and therefore a necessary skill.
Beneficence and non-maleficence
Beneficence and non-maleficence are covered next, which are perhaps more familiar to us all. Again Meyers gives us a philosophical work through of both concepts. Interesting inclusions are those regarding paternalistic beneficence and how incompetence can be a form of maleficence. What shines through is Meyers' ability to crystallise these concepts using simple factual examples.
Competency and confidentiality
He does the same in the next two chapters on competency and then confidentiality with some interesting case studies for each. He also shows how and when a breach of confidentiality may well be ethical.
Conflicts of interest
The following chapter covers conflicts of interest and is enlightening in how it covers the different forms of this. I felt this chapter was one of the most thought-provoking, especially when bias was introduced as a basis for conflicts of interest. Here, of course, bias is being considered in the form of prejudicial bias as opposed to the more familiar cognitive biases.
Fidelity and honesty
The next principle scrutinised is fidelity and honesty. This is possibly one of the more obvious and understood principles. However, Meyers still manages to coax some intriguing thoughts; for example, in the section on a professional's ‘duty to be informed’—is it unethical to not stay ‘up to date’?
Formal justice, bias and allocation
The final chapter covers off the principles of formal justice, bias and allocation; again familiar to those who have ever looked at biomedical ethics. Bias in this chapter, as before, is looked at from the prejudicial perspective, and can make for uncomfortable reading. After all, is there a paramedic who can honestly say that their heart hasn't sunk on hearing of a job in a certain area of town or to a certain patient? These, as Meyers shows, are all forms of bias.
Interestingly, the suggested solution is one of self-reflection, which immediately resonated with me as it is defined by so many as essential on the journey to becoming an expert practitioner, perhaps most notably by Benner (1984). On covering formal justice, there are interesting theories regarding discrimination and how this must be arbitrary to be unethical at a professional level. This argument is developed to then support the concept of equality, dignity and respect for all.
Finishing with just distribution—and in the world of ambulance services, this really could be a hot topic—Meyers presents Rawls's theory, which he summarises perfectly. This is also a thought-provoking read as it talks of resource as ‘social goods’ and how distribution must be focused to the least well off.
Progress, not perfection
The epilogue completes the book with a general message that no one can always ‘get it right’ in ethics and that it is more a journey of progress not perfection.
Overall this book is one that covers its subject in depth in a way that allows the reader to develop principles for application in any situation, as opposed to giving solutions to certain situations. In this way, I believe it fits in with current learning ambitions for our profession in working towards ever increasing autonomy.
The caveats? Well, the depth it goes to may not be what everyone is looking for, and it is certainly no ‘ready reference’. I believe it is a book that can really enrich one's decision making process, especially in the advanced or practitioner setting where managing complex situations may be a more frequent encounter.