Paramedicine is evolving in Australia, and has transitioned from providing rudimentary care and transport to delivering advanced prehospital and out-of-hospital care by highly trained professionals (O'Meara and Grbich, 2009). As this evolution continues, paramedics have to address increasingly complex situations that require not only astute clinical and operational knowledge but also a deep understanding of how to apply judgement in what are often ethically complex cases.
An expert practitioner involved in the intricacies of complex clinical care requires a range of capabilities in addition to clinical knowledge and well-honed skills (Tyreman, 2000). The development of expertise occurs via several stages; all of these must be progressed through but some can occur concomitantly. The Dreyfus model of development, which is often adopted in health education, encompasses the novice, advanced beginner, competent, proficient and expert stages (Persky and Robinson, 2017: 73). These stages involve progressive problem-solving so individuals must engage in increasingly complex problems consciously aligned with their stage of development (Persky and Robinson, 2017: 72).
McKie et al (2012: 253) acknowledge the merit in rational, technical and evidence-based approaches to practice, but feel that they may not always be sufficient to address the complexity, unpredictability and ambiguity inherent in clinical practice. This is where phronesis, or practical wisdom, has a role to play. Phronesis is a form of practical knowing or practical reasoning relating to human action that allows judgement to be applied to a specific situation. Phronesis assimilates theoretical and practical knowledge and competence with appropriate experience, judgement and situational understanding (Chiavaroli and Trumble, 2018).
Paramedicine is a pragmatic, dynamic profession. While understanding ethical principles is necessary, it is possessing the practical wisdom of when to apply those principles that appears to be key. Haggerty and Grace (2008: 239) note that clinical wisdom can be ‘cultivated but not taught’. Cultivation of clinical wisdom occurs through practice, with the ultimate aim being the assimilation of clinical judgement, a patient's goals of care and ethical reasoning. It takes years of practice in the company of experienced clinicians who demonstrate practical wisdom by example to develop wise clinical judgement (Kaldjian, 2010).
What situations involving ethical dilemmas are paramedics likely to be exposed to in practice? A simple keyword search of the literature to identify relevant studies reveals that there has been a sporadic exploration of the ethical dilemmas faced by paramedics internationally.
In the early 1990s, a prospective study involving an urban advanced life support prehospital emergency service in the United States (US) was undertaken to assess the variety of ethical dilemmas that confronted paramedics. This study was one of the first looking specifically at this topic and found that a range of ethical dilemmas arose in approximately 15% of all cases attended (Adams et al, 1992).
Following this, Heilicser et al (1996) extended the descriptive process of categorising ethical dilemmas faced by emergency medical technicians, focusing on one US emergency medical service (EMS) system.
Both of these studies identified ethical problems in paramedicine, including issues of informed consent (such as the refusal of treatment or transport), requests for limitation of resuscitation, conflicts of hospital destination and dilemmas involving advance directives (Adams et al, 1992; Heilicser et al, 1996).
Further international research has continued the general exploration of ethical dilemmas experienced by paramedics, with similar findings (Sandman and Nordmark, 2006), while other researchers have sharpened their focus to explore more specific issues, with the ethics of resuscitation (Nordby and Nøhr, 2012; Anderson et al, 2017) and ambulance diversion (Adkins and Werman 2015; Geiderman et al, 2015) as examples.
The question arises of whether Australian paramedics face similar ethical dilemmas that present as problematic in their professional experience. The keyword search yielded very few studies exploring ethical problems encountered by Australian paramedics. Therefore, the current study used the survey designed by Heilicser et al (1996) as a foundation, and sought to identify, categorise and describe the ethical problems faced by paramedics in Australia.
For this research, an ethical issue was defined as ‘any incident that posed a question of what the prehospital medical provider [a paramedic] “ought to do”’, which was taken from Adams et al (1992: 1260), one of the original studies exploring ethical dilemmas in the prehospital setting.
This study explores paramedics' experience of situations that present an ethical issue from their own perspectives. While one paramedic may view a situation as clear cut, another may perceive it as presenting an ethical dilemma. The term ‘perception’ is used to represent paramedics' differing experiences of ethical dilemmas.
Methods
Participants
All paramedics working for state-based ambulance services in Australia were eligible to take part in the survey. Eligibility was limited to this cohort as there would be congruency between employment, education and exposure to similar patient populations.
Strategies used to promote the survey included social media and an article in an industry journal (Shearer, 2019). In total, there were 84 respondents; of these, 19 (22.6%) were excluded following the initial qualification question establishing whether they were paramedics who worked for an Australian state-based ambulance service, resulting in a total sample of 65 respondents. Participants were not required to answer all questions.
Procedure
The survey instrument was developed and administered online using SurveyMonkey, made accessible through a hyperlink or QR code provided through the aforementioned promotional strategies. Participants could complete it at their convenience.
The survey had been piloted to test the acceptability of the questions among a small group of paramedic colleagues over 2 weeks in September and October 2018. There were six responses to the pilot instrument. Feedback received was discussed with the supervisory team and led to clarification of some wording, correction of typographical errors, and indicated how long the survey would take to complete. The instrument was adjusted accordingly.
Materials and measures
The survey design was based on an instrument developed by Heilicser et al (1996) to examine ethical dilemmas in emergency medical services from the perspective of the emergency medical technician. Further closed and open questions were added to contextualise the survey for this research, such as demographic questions adapted to the Australian context, and grouping and expansion of ethical issue examples. The overarching purpose of the survey was to explore Australian paramedics' experience of ethical dilemmas in their prehospital work.
Before starting the survey, participants were given a brief introduction, and told about the rationale and purpose of the investigation, with the consent process outlined.
An initial eligibility question identified participants from Australian state-based ambulance services, and this was followed by the other questions. Part 1 covered participants' background, including the state where they worked, clinical operational level, and years of experience as examples, and part 2 asked about their education.
Part 3 contained questions regarding ethical dilemmas. Participants were asked to indicate whether each of the areas listed had presented ethical dilemmas in their clinical judgement or decision-making during their prehospital work. Examples include ‘issues of informed consent and minors’, ‘questions of patient competence’ and ‘confidentiality’ to name a few. Participants were asked to rate their experience of ethical dilemmas in a given situation on a five-point Likert scale, ranging from never (1) to every time (5).
The definition of an ethical dilemma was set out on each page of the survey for reference. The terminology ‘prehospital medical provider’ within the definition was changed with ‘paramedic’ to reflect the Australian context.
Part 4 explored participants' management of ethical dilemmas; part 5 surveyed participants' education in ethics; and, finally, part 6 obtained demographic information.
Completion of the survey assumed consent. All responses were treated anonymously and all data stored securely.
The original survey instrument by Heilicser et al (1996) had been assessed for validity. For the purposes of this research, the adapted survey was piloted to ensure face validity and construct validity remained given the original survey had been designed 25 years ago.
Ethical approval to undertake the survey was obtained through the CQUniversity Australia Human Research Ethics Committee, approval number 0000021166.
Data analysis
The online SurveyMonkey platform collated the responses, with the quantitative data transferred into the Statistical Package for Social Sciences (SPSS) (SPSS, v. 26 Chicago (IL), USA) for analysis using descriptive statistics.
Responses on key demographic variables were subjected to one-way ANOVA to examine the effects of clinical level, educational background, location, gender and years in the profession on paramedics' experience of ethical dilemmas. Qualitative data underwent thematic analysis.
The lead author was responsible for the overall design, conduct and analysis of the research, and was assisted by the other authors in their capacity as higher degree research supervisors.
Results
Results were drawn from questions that participants had responded to; they were not required to answer all questions. A broad cross-section of the profession was captured in terms of age, work location and years of experience (Table 1). There were more men than women, and more than 75% of the respondents worked full-time.
| Variable | Descriptor | n | Percentage (%) |
|---|---|---|---|
| Gender | Male | 26 | 63.41 |
| Female | 15 | 36.59 | |
| Age (years) | <20 | 0 | 0 |
| 20–24 | 2 | 5 | |
| 25–29 | 2 | 5 | |
| 30–34 | 8 | 20 | |
| 35–39 | 4 | 10 | |
| 40–44 | 2 | 5 | |
| 45–49 | 9 | 22.5 | |
| 50–54 | 9 | 22.5 | |
| 55–59 | 1 | 2.5 | |
| 60–64 | 2 | 5 | |
| >65 | 1 | 2.5 | |
| State of service | Northern Territory | 0 | 0 |
| Australian Capital Territory | 3 | 5 | |
| Queensland | 18 | 30 | |
| New South Wales | 18 | 30 | |
| Victoria | 10 | 16.66 | |
| Tasmania | 1 | 1.67 | |
| South Australia | 9 | 15 | |
| Western Australia | 1 | 1.67 | |
| Work location | Metropolitan area | 29 | 49.15 |
| Large regional location | 21 | 35.59 | |
| Small regional location | 7 | 11.86 | |
| Remote location | 2 | 3.4 | |
| Years of experience | <10 | 21 | 36.21 |
| 10–20 | 18 | 31.03 | |
| >20 | 19 | 32.76 | |
| Clinical level | Paramedics | 33 | 55 |
| Specialist paramedics | 21 | 35 | |
| Extended/community | 6 | 10 | |
| Full-time or part-time | Full-time | 46 | 79.31 |
| Part-time | 12 | 20.69 |
Areas presenting ethical dilemmas for paramedics are shown in Table 2. While clinical level, educational background, work location and gender have some influence on the experience and perception of ethical dilemmas by paramedics in Australia, the results demonstrate it is a paramedic's length of time in the profession that is consistently associated with significant differences (P<0.05) in their perception of ethical matters. The dilemmas experienced in each area according to demographic and professional factors are detailed below.
| Clinical level | Educational background | Work location | Gender | Years of experience | |
|---|---|---|---|---|---|
| Issues of informed consent and minors | |||||
| Refusal of service (treatment) | ns | ns | ns | ns | ns |
| Refusal of service (transport) | F(2, 45) =3.30; P=0.046 | ns | ns | ns | F(2, 45) =4.00; P=0.025 |
| Conflict of hospital destination | ns | ns | F(2, 45)= 4.96; P=0.011 | ns | F(2, 45) =5.16; P=0.010 |
| Issues surrounding consent for research | ns | ns | ns | ns | ns |
| Issues surrounding consent in general | ns | ns | ns | ns | ns |
| Patients with advanced directives (living wills, DNRs) | ns | ns | ns | ns | F(2, 45) =4.94; P=0.012 |
| Patients without advanced directives | ns | ns | ns | ns | ns |
| Nursing home awareness of advanced directives | ns | ns | ns | t(35.162) =2.659; P=0.012 | F(2, 45) =4.97; P=0.011 |
| Treatment of minors | ns | ns | ns | ns | ns |
| Questions of patient competence | |||||
| Decisional capacity | F(2, 42) =6.14; P=0.005 | ns | ns | t(24.462) =2.089; P=0.047 | ns |
| Request for limitation of resuscitation | |||||
| A formal document request, e.g. advance directive, DNR order | ns | ns | ns | ns | F(2, 42) =7.45; P=0.002 |
| Verbal assertion formal document exists but unable to be produced at the time | ns | ns | ns | ns | ns |
| An informal request, e.g. verbal request | ns | ns | ns | ns | ns |
| Conflicting requests i.e. one or more family members present who disagree | ns | ns | ns | ns | ns |
| Issues of duty of paramedics | |||||
| Duty of care | ns | ns | ns | ns | ns |
| Identifying possible child abuse or neglect in the field | ns | F(2, 40) =4.08; P=0.024 | ns | ns | ns |
| Threatening circumstance/undue personal risk (dangerous situation) | ns | ns | ns | ns | ns |
| Threatening circumstance/undue personal risk (dangerous patient) | ns | ns | ns | ns | ns |
| Conflict between value judgement of paramedic and patient (what ought to be done) | ns | ns | ns | ns | ns |
| Conflict between value judgement of relatives, patient and paramedic (what ought to be done) | ns | ns | ns | ns | ns |
| DNR: do not resuscitate order; ns: not significant | |||||
| Conflict between value judgement of paramedics on same case (what ought to be done) | ns | ns | ns | ns | ns |
| Conflict regarding treatment options and/or organisational guidelines (what ought to be done) | ns | ns | ns | ns | ns |
| Intervention versus not | ns | ns | ns | ns | ns |
| Raising an issue of clinical misadventure | ns | ns | ns | ns | F(2, 41) =3.49; P=0.040 |
| Resource allocation | |||||
| Limited resources/job tasking allocation | ns | ns | ns | ns | ns |
| Triaging of multiple patient scenes | ns | ns | ns | ns | ns |
| Conflict of hospital destination | ns | ns | F(2, 40)= 5.36); P=0.009 | ns | F(2, 40) =3.93; P=0.028 |
| Competing claims to care – stated case versus actual case (e.g. shortness of breath turning out to be a runny nose) | ns | ns | ns | ns | ns |
| Confidentiality | |||||
| Conflict with legal, operational or public concerns, e.g. being asked patient information by police or media | ns | ns | ns | ns | ns |
| Truth telling | |||||
| Conflict between what paramedics believe to be the truth versus what they thought was in the patient's best interests, e.g. patient's family indicating the patient is unaware they have a life-limiting illness | ns | ns | ns | ns | ns |
| Training | |||||
| Clinical skills teaching/practising clinical skills on live patients | ns | ns | ns | ns | ns |
| Clinical skills teaching/practising clinical skills on failed resuscitation attempt (deceased patients) | ns | ns | ns | ns | ns |
DNR: do not resuscitate order; ns: not significant
Clinical level
The various clinical levels were grouped according to common clinical roles and likely clinical tasks.
The first group, ‘paramedics’, covers clinical levels offering standard prehospital care, including paramedics, ambulance officers, paramedic interns, and advanced care paramedics.
The second group, ‘specialist paramedics’, comprises paramedics holding advanced clinical roles, such as intensive or critical care paramedics or members of special operations teams or similar.
The third group of ‘extended/community care paramedics’ unites paramedics whose roles focus on extended, community or low-acuity care paramedicine.
Of the 32 ethical dilemmas explored, only two areas showed any significant difference when it came to clinical level.
There was a significant difference in perceiving refusal of service (transport) as an ethical dilemma as a function of clinical level [F(2, 45)=3.30; P=0.046). Post-hoc comparisons revealed that extended/community care paramedics more frequently (mean=4.00; SD=0.00) identified refusal of service (transport) as an area of ethical dilemma than specialist paramedics (mean=2.74; SD=1.05).
Additionally, decisional capacity was perceived as an ethical dilemma as a function of clinical level [F(2, 42)=6.14; P=0.005]. Post-hoc comparisons revealed that extended/community care paramedics more frequently (mean=4.00; SD=0.82) identified decisional capacity as an area of ethical dilemma than paramedics (mean=3.09; SD=0.53) or specialist paramedics (mean=3.05; SD=0.40).
Educational background
The one area in educational background presenting with a significant difference was the identification of possible child abuse or neglect in the field [F(2, 40)=4.08, P=0.024], with the difference being those paramedics with a Bachelor (university) degree qualification more frequently (mean=3.00; SD=0.54) identified this as an ethical dilemma than those with a diploma (vocational) qualification (mean=2.33; SD=0.65).
Work location
Regarding work location, conflict of hospital destination (e.g. where a patient or someone making a decision for them wants to go to a certain hospital, but the paramedic believes a different one such as specialist cardiac centre would be more appropriate) was significant in two of the broad areas of ethical dilemma investigated.
The first was ‘issues of informed consent and minors’ [F(2, 45)=4.96; P=0.011], with post-hoc comparisons revealing that paramedics in metropolitan locations more frequently (mean=2.95; SD=0.98) identified conflict of hospital destination as an area of ethical dilemma than their colleagues in small regional or remote locations (mean=1.75; SD=0.71). The second was ‘resource allocation’ (F(2, 40)=5.36; P=0.009), where post-hoc comparisons again revealed that paramedics in metropolitan locations more frequently (mean=2.80; SD=0.83) identified conflict of hospital destination as an area of ethical dilemma than their colleagues in small regional or remote locations (mean=1.75; SD=0.89). Therefore, paramedics in metropolitan locations more frequently and consistently identified conflict of hospital destination as an ethical dilemma than their counterparts in small regional and remote areas.
Paramedic gender
An independent-samples t-test was conducted to compare whether gender affects a paramedic's experience and perception of ethical dilemmas.
There were two areas in which gender was found to be significant. Female paramedics more frequently identified nursing home awareness of advance directives (t(35.162)=2.659; P=0.012; ƞ2=0.177) as an ethical concern (mean=3.73; SD=0.46) than their male counterparts (mean=3.08; SD=1.08). Similarly, women (mean=3.40; SD=0.63) on average identified more ethical dilemmas around decisional capacity (t(24.462)=2.089; P=0.047; ƞ2=0.118] than men (mean=3.00; SD=0.50).
Years of experience
The length of experience in the profession was consistently associated with significant differences in paramedics' perception of ethical dilemmas (Table 2). For ease of interpretation of findings, years of experience were grouped to reflect paramedics with <10 years of experience; those with moderate levels of experience (10–20 years), and those with >20 years of experience in the profession.
Areas with a significant difference between these groups include refusal of service (transport), conflict of hospital destination, raising an issue of clinical misadventure, and advance directives.
There was a significant difference in perceiving refusal of service (transport) as an ethical dilemma as a function of experience (F(2,45)=4.00; P=0.025). Post-hoc comparisons revealed that paramedics with moderate levels of experience more frequently (mean=3.29; SD=0.92) identified this as an area of ethical concern than the most experienced paramedics (mean=2.40; SD=1.06).
Conflict of hospital destination presented ethical concerns in two broad areas, including ‘issues of informed consent and minors’ and ‘resource allocation’.
Regarding issues of informed consent and minors, there was a significant difference around perceiving conflict of hospital destination as an ethical dilemma as a function of experience (F(2, 45)=5.16; P=0.010). Post-hoc comparisons revealed that paramedics with moderate levels of experience more frequently (mean=3.18; SD=0.88) identified this as an ethical dilemma than the most experienced paramedics (mean=2.27; SD=0.80) or less experienced paramedics (mean=2.25; SD=1.13).
Regarding resource allocation, there was a significant difference in perceiving conflict of hospital destination as an ethical dilemma as a function of experience (F(2,40)=3.93; P=0.028). Post-hoc comparisons revealed that paramedics with moderate levels of experience more frequently (mean=2.87; SD=0.92) identified this as an ethical dilemma than less experienced paramedics (mean=2.00; SD=1.00).
There was a significant difference in perceiving raising clinical misadventure as an ethical dilemma as a function of experience (F(2,41)=3.49; P=0.040]. Post-hoc comparisons revealed that the less-experienced paramedics more frequently (mean=2.64; SD=0.63) identified this as an ethical dilemma than the most experienced paramedics (mean=2.00; SD=0.65).
Advance directives caused ethical concerns for paramedics as a function of experience in a few key areas, each with particular nuances. Under the general area ‘issues of informed consent and minors’, there was a significant difference in perceiving both patients with advance directives (living wills or do not resuscitate orders) (F(2,45)=4.94; P=0.012) and nursing home awareness of advance directives (F(2,45)=4.97; P=0.011) as ethical dilemmas as a function of experience. Post-hoc comparisons revealed that both lesser (mean=3.19; SD=0.75) and moderately (mean=3.24; SD=0.83) experienced paramedics more frequently identified patients with advance directives as an area of ethical dilemma than the most experienced paramedics (mean=2.4; SD=0.91). The difference when it came to nursing home awareness of advance directives was that paramedics with moderate levels of experience more frequently (mean=3.71; SD=0.69) identified this as an area of ethical dilemma than the most experienced paramedics (mean=2.80; SD=1.08).
Under the general area ‘request for limitation of resuscitation’, there was a significant difference in perceiving a formal document request (e.g. advance directive, DNR order) as an ethical dilemma as a function of experience [F(2,42)=7.45; P=0.002]. Post-hoc comparisons revealed that paramedics with moderate levels of experience more frequently (mean=3.25; SD=0.68) identified this as an area of ethical dilemma than the most experienced paramedics (mean=2.53; SD=0.64) or less experienced paramedics (mean=2.29; SD=0.83).
Findings from open questions
Within the survey, paramedics were asked via an open-ended question if there were any other areas of prehospital care that they felt presented ethical dilemmas.
Analysis of responses to identify common themes revealed that a range of organisational issues pose ethical concerns for paramedics, ranging from clinical supervision, discordance in the interpretation of guidelines, policies or legislation between peers and other health professionals, and taking goods and resources for personal use.
Other areas presenting ethical challenges in patient care include assessing patient capacity and refusal of service, with alcohol and drug use affecting patient capacity featuring here as well. Other broad areas identified include sociocultural matters, and issues around clinical supervision and palliative care patients.
The survey asked paramedics how they managed ethical dilemmas they faced, and 78% of respondents indicated they used their experience to make a judgement, with only 27% relying upon their education to resolve them.
In a subsequent question, paramedics listed what could be implemented to remedy any or all of the issues identified. Strong themes emerged with increased education and engaged discussion featuring prominently. Paramedics said that changes in legislation and, more importantly, organisational policy were required to make it clear in a structured and supportive manner where individual responsibilities lay. They also highlighted communication as a strategy for improvement, both organisationally and with the community, with several respondents also calling for an ‘ethics officer’ or advice line to be arranged for paramedics to access and discuss ethical dilemmas when they arose.
Discussion
Results of this study highlight that Australian paramedics do experience ethical dilemmas; however, how the perceive them varies depending on personal characteristics and the types of ethical dilemma encountered. This discussion considers those ethical dilemmas, grouped according to type.
Refusal of service (transport)
Elements of consent including informed refusal can prove difficult for paramedics, adding pressure when determining what ought to be done. When a patient meets the tests for informed consent (informed, understood, voluntary and made by a person with legal capacity), and refuses treatment and/or transport, this presents paramedics with a conflict between respecting the patient's autonomy and the duty to protect life (Steer, 2015).
In this study, the authors have explicitly differentiated between refusal of treatment and refusal of transport, as some patients may accept treatment then refuse transport, which may be a separate source of ethical dilemma.
Refusal of service (transport) was perceived more frequently as an ethical issue for moderately experienced paramedics than those with more experience. Here again, Steer (2015) offers some insight, suggesting that the most experienced clinicians have likely developed greater sensitivity of judgement in determining whether a situation is a true emergency and, as a result, are more likely to respect a refusal. In contrast, less experienced clinicians are somewhat less secure in accepting a refusal and are more likely to err on the side of caution. Moderately experienced paramedics sit somewhere in the middle, where a tension in expectations arises. These paramedics are transitioning from anticipating that a patient will accept treatment and transport to a position, gained with experience, where the paramedic is more comfortable with a patient refusing transport. This transition is perhaps what highlights problems for moderately experienced paramedics, as they may lack the exposure required to develop practical wisdom compared to more experienced colleagues.
Additionally, extended/community care paramedics more frequently identified refusal of service (transport) as an area of ethical dilemma than specialist paramedics, such as intensive or critical care paramedics. This may well be a function of role expectation and the types of cases they are called to. Extended and community care paramedics are relatively new roles in Australian paramedicine. These paramedics are often engaged in cases where the intent is to assess and treat patients comprehensively within their home, then refer patients directly to another service provider for follow-up care, rather than assess, treat and transport patients to a hospital (SA Ambulance Service, 2020). Therefore, it is not surprising that refusal of service (transport) might prove ethically challenging, particularly in cases where there is a conflict between a patient's expectation that they are treated at home, versus the paramedic's assessment of the need for more immediate definitive care.
A larger sample size would offer the opportunity to conduct in-depth analysis to establish any potential interaction effect between clinical level and experience regarding refusal of service.
Conflict of hospital destination
Conflict of hospital destination was raised as an ethical dilemma in relation to location and experience.
From a location perspective, this dilemma was more evident for metropolitan-based paramedics compared with regionally or remotely located colleagues. This may be a function of choice: the more hospitals that are available to you, the more complex the decision-making, and vice versa.
From an experience perspective, conflict of hospital destination was more of an issue for moderately experienced paramedics compared with the most or least experienced paramedics. This may reflect the progression of clinical decision-making from novice to expert. A novice clinician follows the rules and may have limited discriminatory judgement; a moderately experienced clinician can see what is relevant and irrelevant and can perceive appropriate deviations from standard rules; however, is not quite at the level of expert, who thinks intuitively and no longer relies on rules (Wainwright et al, 2011; Persky and Robinson, 2017).
Advance directives
Advance directives present ethical dilemmas for paramedics across a few areas within this research, with gender and different levels of experience offering the main variations.
Contemporary paramedics manage a broad range of complex health needs in the community, with their involvement in palliative and end-of-life care cases increasing (Kirk et al, 2017). Despite this increase in case attendance, international studies have found that paramedics feel ill-prepared and lack confidence in attending to this aspect of their clinical practice. Kirk et al (2017) found that the majority of participants rated their end-of-life training as poor and identified validity of documentation as a concern when attending cases involving end-of-life care. Similarly, in a study involving German paramedics, Taghavi et al (2012) found that paramedics did not feel sufficiently trained in advance directives, and that discussion of the legal facets of these documents should be included in paramedic curricula.
Advance directive legislation is relatively recent in Australia and differs between states. In the 1980s, the Natural Death Act legislation was introduced in the Northern Territory and South Australia, which enabled the documentation of end-of-life medical preferences in a living will (Australian Government Department of Health and Ageing, 2011). Subsequently, a few states have legislated for advance care directives that accurately record healthcare and treatment preferences, while others rely upon common law (Australian Government Department of Health and Ageing, 2011). Several state and national reviews have been undertaken in attempts to establish congruence between legislation but the situation remains complex.
This complexity is evidenced in this research by the range of ethical dilemmas that advance directives present to Australian paramedics who engage in cases where the presence or absence of such documents poses a problem. This is an area for further consideration concerning both legal guidance and paramedic education.
Decisional capacity
Extended/community care paramedics found that decisional capacity posed ethical concerns more than other paramedics. Again, this finding may well reflect their different scope of practice in Australia with its focus on hospital avoidance.
A patient demonstrating decisional capacity can be involved in more sophisticated decisions about their care in an out-of-hospital context than one who may lack decisional capacity. It is therefore reasonable that extended/community paramedics may experience more complexities about what they ought to do where there is a question of a patient's decisional capacity compared with their colleagues in more traditional paramedic roles.
Furthermore, female paramedics reported situations presenting decisional capacity as an ethical dilemma slightly more frequently than their male counterparts. An exploration of the literature to seek evidence relevant to this finding identified that while this topic has been studied extensively in other disciplines such as business, there is limited research involving clinical ethics. This gap in the literature pertaining to gender differences regarding the experience of clinical ethical dilemmas shows an opening for future research.
Raising an issue of clinical misadventure
Less experienced paramedics identified raising an issue of clinical misadventure as an ethical dilemma more than the most experienced paramedic cohort.
Speaking up is a form of assertive communication used by health professionals, using questions, shared information or opinions in team situations where concerns arise regarding the safety and quality of patient care to prevent harm (Schwappach et al, 2019). While speaking up is increasingly acknowledged as an essential aspect of reducing risk, withholding one's voice is common, with health professionals rendered silent in critical situations. Schwappach et al (2019) articulate that silence or withholding voice may occur for many reasons, with the existence of hierarchies in health professions being a prominent cause.
It is therefore not surprising to find that less experienced paramedics would be troubled by speaking up, especially concerning a situation involving clinical misadventure.
It is anticipated that recent advocacy for training paramedics in human factors and crew resource management, as discussed by Summers and Willis (2020), will reduce the experience of this ethical problem.
Identification of possible child abuse or neglect in the field
The only domain where educational background made a difference was the identification of possible child abuse or neglect in the field, with paramedics with a Bachelor (university) degree education more frequently identifying this as an ethical dilemma than those with a diploma (vocational) qualification.
Educational background, therefore, has limited impact on broader paramedic perception of ethical dilemmas in the field, which may be a function of the lack of education at all levels regarding potential ethical dilemma identification, engagement and resolution.
International comparison
In their original study exploring ethical dilemmas in EMS in the US, Heilicser et al (1996) identified patient refusal of care, conflict of hospital destination, patients without advance directives and doctors dictating where a patient should be transported as the most frequent ethical dilemmas experienced by emergency medical technicians.
Patient refusal of care—the most frequent ethical dilemma in the study by Heilicser et al (1996)—was identified more in the Australian context as an issue of refusing transport to hospital. In the present study, paramedics were asked to differentiate between the refusal of service (treatment) and refusal of service (transport).
Conflict of hospital destination was also found to be an issue in common. Ethical dilemmas around the presence or absence of advance directives were identified as significant and multifaceted in both contexts, which again highlights the need for greater guidance and education both for paramedics and for health professionals in general.
Improved ethics education for paramedics was recommended in the US research by Heilicser et al (1996) and is reflected in these Australian findings. Interestingly, it was evident in both contexts that this education should not be targeted solely at paramedics. Respondents advocated education to encompass health professional colleagues and the community, with engaged discussion highlighted as a strategy. The need for clarification and circulation of policies was a finding of both previous international research and the present study, with the US results suggesting that this may offer improved understanding via a ‘defined approach to many potential conflicts’ (Heilicser et al, 1996: 241). Australian paramedics, similarly, articulated the need for changes in legislation and organisational policy to make it clear in a structured and supportive manner where individual responsibilities lie.
Limitations
The current study had several limitations. As it is part of a broader research project, by design the eligibility criteria were limited to state-based paramedics in Australia. This study has presented what might be only a subset of a broader range of ethical dilemmas, and certain ethical dilemmas might be common across different clinical contexts; it does, however, offer a foundation for future, more integrated studies and contribute to the emerging global picture of ethical dilemmas faced by paramedics.
Distribution of the survey was limited to social media and a promotional piece in an industry journal. A greater sample size and participants answering all questions may have enabled further statistical analysis of the relationship between variables.
This research replicates previous international research, with the survey instrument contextualised to the contemporary Australian context.
The ethical dilemmas presented within the survey instrument may lead to a possible bias in responses. There may be other demographic variables that influence paramedics' perception or experience of ethical dilemmas. Given the findings of this study, further research could explore these issues further.
A second stage of research is under way using a qualitative methodology to explore ethical dilemmas experienced by paramedics more broadly.
Recommendations
Australian paramedics face a range of ethical dilemmas. It was evident that experience is a critical factor in many areas within the broader survey. The fact that experience features heavily and is relied upon more than education suggests that educational approaches need to be reconsidered. This implies a greater focus is required on ethics education for paramedics including phronesis, the fostering of practical wisdom, and applied ethics. Educational approaches involving a range of learning strategies such as guided reflective practice, engaged discussion, modelling and case-based learning (Holland, 1999) should be considered.
Improved ethics education in paramedicine will offer greater insight and understanding, enabling professional and community engagement, enhanced communication and advocacy for improvements in legislation and organisational policy. As noted earlier, research into the differences between gender in the experience of clinical ethical dilemmas is also recommended.
Conclusion
Australian paramedics report being presented with several complex ethical dilemmas in the course of their work. The concerns identified in this study reflect those found in the profession internationally. While there is great value in paramedics gaining experience to support the development of practical wisdom to address ethical dilemmas, educational approaches designed to support the development of phronesis require greater emphasis.