Principlism in paramedicine: an examination of applied healthcare ethics

Autonomy

The principle of autonomy relates to respecting the wishes of the patient, and is literally translated as self-rule (Gillon, 1994: 184; Kerridge et al, 2005: 49). Autonomy recognises the patient as a self-determining individual who is entitled to information about their condition, care and treatment options. The patient is therefore able to make their own decisions, and is entitled to agree to treatment or to refuse it.

Regardless of a patient's background or circumstances, autonomy enshrines the dignity and self-determination of an individual on the basis that they are a human being, and are therefore entitled to the rights of a human being (Gillon, 1994: 185).

Regardless of whether the patient has the capacity to express their wishes, and whether the clinician agrees with those wishes, the known wishes of the patient should be respected (Stoljar, 2007, 11; Breen et al, 2010, 49-68; Parkinson, 2015: 345).

Paramedics must therefore provide both space and safety in the paramedic-patient relationship to allow patients to receive information, ask questions and even to decline treatment that the paramedic would otherwise intend to administer.

At its core, the principle of autonomy is designed to protect the patient and the clinician from the problems of abuse of power and exploitation in the healthcare relationship.

The more the patient trusts the clinician, the easier it is for the clinician to unwittingly (and hopefully never otherwise) abuse their power within their interactions. Such an abuse of power may occur when the patient receives treatment that the clinician thinks is best but that the patient does not want; or it may occur when a patient feels pressured to comply with the wishes of a clinician (for example, to undress for assessment or to receive an invasive intervention), which can cause the patient to feel exposed and degraded.

Regrettably, it is easy for patients to be exploited if they respect a practitioner (or, in the case of children, where the parents do), and the risks are higher when a clinician is working in the privacy of treatment rooms or the patient's home with minimal supervision.

The relevance of the principle of autonomy within paramedic practice is therefore obvious. Paramedics are widely trusted across the community; they operate in urgent environments where a patient may feel unsure about expressing their concerns or uncertainties about treatments being provided; and paramedics often assess and treat patients in the privacy of the home, where there is limited supervision from other practitioners.

Because of these realities, paramedics need to be diligent about upholding the principle of autonomy, especially if the profession wishes to protect the high levels of community trust and respect it currently enjoys.

Beneficence

The second principle is beneficence. Although not a commonly used term, the meaning of beneficence is at the heart of modern health professions (Gillon, 1994: 185; Beauchamp, 2007, 5; Cullity, 2007: 19). Beneficence means to further a patient's welfare (Gillon, 1994: 184; Beauchamp, 2007: 5-6) and ‘to act in the best interests of the patient’ (Breen et al, 2010; 4).

The principle of beneficence—helping patients and acting in their best interests—is not only a principle that clinicians routinely subscribe to, but also something that motivates and unites clinicians across many healthcare settings.

However, there are difficulties around the practical application of beneficence. Paramedics and other clinicians wish to provide care that is in patients' best interests; yet difficulties may arise when there are different views about what constitutes a patient's best interests. For example, are the best interests of a patient determined according to the patient living longer, or living a shorter but happier life, or on the basis of something else entirely? It may also be noted that a clinician's perception of best interests is limited by factors including the knowledge of a clinician, and the existing evidence at that point in time, not to mention social influences.

A second challenge relates to the extent of help that should be provided by clinicians under the principle of beneficence. Paramedics wish to help the patients they are responding to and, sometimes, help provided by paramedics involves filling in the gaps when other healthcare and social services are unavailable (Bowles et al, 2017: 5; Spence, 2017; Proctor, 2019; Eaton et al, 2020).

This raises another practical question of beneficence: how far should a clinician go to help their patients? What are the appropriate limits to the help provided by paramedics and other clinicians?

One way to navigate these potential challenges is to remember that each principle—autonomy, beneficence, non-maleficence and justice—must be considered in conjunction with the other principles.

This approach is demonstrated in the example in Box 1. In this example, the challenges relating to a patient's best interests are addressed when the principle of beneficence is considered in conjunction with the principle of autonomy.

Case study: navigating issues of autonomy and beneficence

A clinician recommends that an older patient—who has just been diagnosed with prostate cancer—should start taking a certain medication and continue to have the condition monitored.

The patient seeks a second opinion and, consequently, another clinician recommends that the patient should instead undergo surgery for the condition.

In both cases, the clinician has formed an opinion which—in their mind—is in the patient's best interests and will further his welfare.

The patient expresses to the clinicians that he does not wish to consider either of the proposed treatment options, because of the deleterious effects that such treatments may have on his sexual function. He advises his clinicians that, once he has met a partner and has fathered a child, he will be happy to undertake any treatment they recommend to him.

As a result of the patient expressing this desire, the clinicians talk to the patient about treatment options that account for both his condition and his desires to maintain sexual functions and father a child.

There are several points to make about the case study in Box 1. First, two clinicians may have different views about what is best for the patient, which is not uncommon in healthcare. Second, the patient's wishes (principle of autonomy) may highlight priorities of which clinicians are not aware.

Third, acting in the best interests of patients involves the clinician using their knowledge and capabilities to help patients achieve the clinical outcomes they seek, which are not necessarily those that the clinician would prefer.

Fourth, assistance provided by a clinician is limited to things that are appropriate and done in the right way (Cullity, 2007: 19). For example, it is absolutely appropriate for clinicians to help this patient achieve his desired outcomes through providing advice on options and treatment but it is out of scope and not appropriate for the clinician to feel obliged to help the patient meet a compatible female partner.

Reflection 5 asks readers to consider the limits of providing help to patients by examining the principles of beneficence and justice. The point made at this stage of the article, however, is that ethical issues can be clarified when practitioners consider the four principles in conjunction with one another, rather than considering only one principle or giving undue weight to one over the others.

Non-maleficence

Non-maleficence is concerned with not doing harm (Beauchamp, 2007; Breen et al, 2010, 4; 5) or at least that the net benefit of treatment outweighs the harms it causes (Gillon, 1994: 185).

The concept of net benefit acknowledges that many beneficial medical procedures involve some form of harm. For example, heart surgery, which benefits the patient, will also inflict the lesser harm of an incision in the chest; or the life-saving medication that a paramedic administers to the patient's benefit will incur the relatively minor harm or discomfort a patient receives from an intravenous needle.

For these reasons, the principle of non-maleficence is often paired with that of beneficence: the harms associated with a treatment should not outweigh the benefits of the treatment (or, at the very least, the reasonably expected benefits).

Non-maleficence, however, is not just a counterbalance to beneficence. Non-maleficence should be viewed in terms of both its relationship to beneficence (by way of net outcomes) and also independently (Gillon, 1994: 185).

For example, non-maleficence as an independent principle may require the clinician to actively guard against iatrogenic harm and avoidable patient harm. The scenario described in Box 2 illustrates this.

Case study: practical application of non-maleficence

A 19-year-old woman sustains a bad fracture to her arm. Paramedics attend to the patient, administer pain relief, immobilise the arm and perform other necessary procedures. In this sense, their treatment is impeccable.

The paramedic treating the patient has had a cough for the past few days and is not particularly attentive to hand hygiene and other standard requirements for infection control.

In the back of the ambulance while he is interacting with the patient, pathogens are exchanged with her. This leads to the patient developing a bacterial chest infection after a few days, which resolves following a course of antibiotics.

The patient's arm was also surgically repaired without complications.

In this scenario, the patient has experienced a net benefit as the harms associated with her care—the discomfort of surgery and the inconvenience of a chest infection—are arguably insignificant compared to the benefit of being able to use her arm again. However, no one would suggest that the paramedic was entirely non-maleficent just because the patient, overall, experienced a net benefit.

In this sense, the principle of non-maleficence requires clinicians to participate in reasonable activities designed to prevent avoidable patient harm. This could include compliance with hand hygiene procedures or pre-administration cross-checks of medication, for example.

Another application of the principle of non-maleficence is the obligation to participate in continuing professional development activities (Gillon, 1994: 185), or ensuring that suitable professional indemnity insurance is in place so that if harm is caused, there is at least a mechanism to remedy it.

Like the other principles, non-maleficence has both complementary and independent applications in paramedic practice.

Justice

The principle of justice concerns fairness and equity. At a basic level, it is about avoiding discrimination between people on the basis of race, creed, political affiliation, sexual orientation and even socioeconomic status (Gillon, 1994; Kerridge et al, 2005: 49; Beauchamp, 2007).

Clinicians often wish to associate themselves with these tenets, which involves providing high-quality care regardless of the patient's noble or humble circumstances.

This is certainly a consideration at the front of paramedics' minds because emergency injury and illness can be experienced by all members of society regardless of social or economic circumstances.

A more difficult yet equally important aspect of the principle of justice is that of distributive justice. Distributive justice relates to the fair distribution of healthcare resources to deliver fair outcomes for the community.

Put simply, in an imaginary world where there are infinite healthcare resources (whether they be staff, facilities or equipment), it is easy to treat patients fairly; all patients would get whatever assistance they may need or desire. However, in the real world where resources are finite, decisions need to be made about the fair distribution and use of healthcare resources.

In Western healthcare systems, resource allocation is usually based on need—that is, those with the greatest need will usually receive a greater allocation of resources.

For example, a patient who has had a cardiac arrest will usually receive more paramedic resources and a higher priority of response than the patient with a minor sports injury; this is because the needs of the former are considered to be greater than the needs of the latter.

While the logic of distributive justice may be easy to accept when we think of priority-based dispatch systems, this concept presents much greater challenges when it is applied to the everyday actions and decision-making of individual clinicians.

This is because distributive justice requires clinicians to consider what is meant by the appropriate (and even efficient) use of finite healthcare resources (Gillon, 1994: 185–187; Kerridge et al, 2005: 47; Beauchamp, 2007; Breen, 2007; Breen et al, 2010, 4–5), a concern from which paramedics are not exempt.

In short, individual paramedics—like other health professionals—make decisions every day about the fair, appropriate and efficient use of finite healthcare resources.

Paramedics engage with the principle of justice when: higher response priorities are allocated to some patients and not others; additional backup resources are requested for some cases and not for others; a decision is made about the urgency with which a patient should be conveyed to hospital; and at the triage desk when a paramedic's handover assists in the allocation of a hospital triage score.

Each of these circumstances is relevant in some way to the appropriate use of finite health resources and therefore to the principle of justice.

Uniquely in the paramedic profession, the challenges of distributive justice are heightened further when paramedics attend a multi-victim or disaster situation, such as where the immediate, life-threatening needs of multiple patients greatly outnumber the available resources. The scenario in Box 3 illustrates such an event.

Scenario: one paramedic at a road traffic accident with multiple victims

A paramedic working in a rural area is the first paramedic on scene at a high-speed bus accident. Owing to the serious nature of the event, multiple ambulances have been dispatched but the closest of these backup resources is 20 minutes away. On arrival, the paramedic finds:

In these circumstances, disaster plans will usually require that those with the greatest need will not receive the greatest resources—at least in the first instance. The first paramedic on scene will have the unenviable, yet absolutely critical, role of providing only basic interventions, and setting in place procedures that will achieve the greatest good for the greatest number of patients.

The practical challenges of operating in these circumstances are immense, not to mention the ethical aspects and the clinician's innate desire to help others (Lindridge, 2017: 160–162).

Distributive justice is concerned with the equitable allocation of healthcare resources, and the equitable allocation of burdens arising from a lack of healthcare resources.