Paramedic science and practice make up a rapidly developing field that has long since gone beyond the traditional realm of responding to life-threatening emergency calls in an ambulance. Indeed, patients request an ambulance for a diverse range of conditions, including non-urgent, low-acuity illnesses as a result of patient misperception of either their condition or the appropriate use of an ambulance (Brooker et al, 2019). Further, there is pressure for ambulance services to reduce inappropriate conveyance (Carter, 2018) and meet ever-increasing demand (National Audit Office, 2017). Paramedics, therefore, act as clinical gatekeepers that can initiate prehospital treatment, refer for further care (e.g. to a general practitioner (GP) or specialist team), or discharge at home with advice.
Likewise, in the UK, the utility of paramedics has extended into patient-facing services including primary and urgent care, secondary care such as palliative care, urology, paediatrics, and emergency departments, as well as integrated care, responding as part of a multidisciplinary team to the community from hospitals. As such, paramedic scope and role are becoming highly variable. As a result, paramedic care delivery is changing, no longer being a single linear encounter; it may well be a longitudinal, multifactorial relationship, whereby the main point of contact for a patient, is a paramedic.
It can be argued that the underlying foundation of paramedic practice, irrespective of setting, is the desire to care for patients, motivated by making good and right decisions. These are emphasised by the regulatory body, the Health and Care Professions Council (HCPC) (2014) standards of paramedic proficiency (Table 1).
| 2.1 understand the need to act in the best interests of service users at all times |
| 2.3 understand the need to respect and uphold the rights, dignity, values, and autonomy of service users including their role in the diagnostic and therapeutic process and in maintaining health and wellbeing |
| 2.8 be able to exercise a professional duty of care |
| 4.1 be able to assess a professional situation, determine the nature and severity of the problem and call upon the required knowledge and experience to deal with the problem |
| 4.2 be able to make reasoned decisions to initiate, continue, modify or cease treatment or the use of techniques or procedures, and record the decisions and reasoning appropriately |
| 4.4 recognise that they are personally responsible for and must be able to justify their decisions |
| 4.8 be able to make a decision about the most appropriate care pathway for a patient and refer patients appropriately |
Source: HCPC, 2014
What though, is meant by ‘appropriate’ care? What difference is between good and right? And what is duty of care?
The current article series explores paramedic ethics, by way of a discourse of underpinning ethical theories and evidence from research and case law, aiming to draw out a thought-provoking argument that explores the boundaries of paramedic practice. The primary underpinning perspective will be that of justice: the appropriate treatment of persons that is thought to be fair and reasonable (Daniels, 2012). This first article discusses the dutiful obligations paramedics owe their patients.
Duty of care
In 2013, a paramedic refused to attend a 999 call near the end of their shift, when no further resources were apparently available. It gained media attention, and following a 2-year suspension, the paramedic was struck off the register in 2017 (Health and Care Professions Tribunal Service, 2017). The reasons given in part were due to not acting in the interests of the service user, and therefore being in breach of the duty of care. The ethical question here is as follows: is a paramedic obliged to respond to a patient in need?
Established by Donoghue v Stevenson ([1932] AC 562), the principle of duty of care was identified by Lord Atkin as a duty to take reasonable care to avoid foreseeable harm to a neighbour. In law, a breach of duty is best identified when a person is owed a duty of care, and evidence of harm or negligence has subsequently occurred (Bryden and Storey, 2011).
Legally, then, the answer to the ethical question above is yes, since the ambulance service owes a duty to respond without unreasonable delay as exemplified in the landmark case Kent vs Griffith ([2001], QB 36). As paramedics are part of that institution, in the absence of other resources, it is a contractual obligation to respond. Ethically, however, we need to understand the meaning behind duty of care, much of which, can be explained by Kant’s Deontological perspective.
Kant (2017) argues for a principle of universalisability, which can be described as follows: an action has merit if it is replicable in similar situations, by others, and cannot form a contradiction or be reasonably rejected. The premise that all paramedics could refuse to respond to a patient in need is refutable and therefore fails the principle of universalisability. What though, if the premise changed so that paramedics had a right to refuse to respond to a patient if a patient elsewhere was in greater need? This argument is more difficult to refute since we could justify that it would be wrong and harmful to knowingly neglect a rapidly deteriorating patient in favour of one who is more stable. Expanding further, if a paramedic was with one stable patient and say another collapsed in front of them, is it dutiful to neglect and breach duty to the initial patient? To increasingly complicate this issue, what if the unstable patient intends harm to the initial patient upon recovery? Universalisability is therefore too restrictive and ambiguous, requiring automaton-like decisions that do not factor in emotions or real-world complications.
Contractualism
Referring back to contractual obligation, it can be argued that by being a paramedic, there is a social responsibility to help those in need due to the elevated status a paramedic holds (acquired knowledge and expertise) over others vulnerable to this authority such as patients. Scanlon’s (1998) Contractualism largely established in his seminal book, What we owe to each other (which inspired this article’s title), highlights the importance of why knowledge of social position can affect circumstance; action ought to be considered reasonable, so long as it can be justified and mutually agreed upon by others. For instance, in the event of a witnessed patient cardiac arrest, a non-clinical bystander’s obligation would be to get help, whereas a paramedic’s obligation would be greater, even if off-duty. This was exemplified in 2016, when a paramedic failed their duty to treat a patient in cardiac arrest, resulting in a jail sentence and suspension (Professional standards authority for health and social care v HCPC Matthew Geary [2016] EWHC 2210).
There are two key factors in Scanlon’s Contractualism: first, the action cannot be made in self-interest. A paramedic should not justify a decision that favours the paramedic; for instance, conveying a patient in order to finish the shift on time, or paramedic wellbeing at the point of a decision, such as feeling tired, low mood, stressed, moral injury—which ought to be enacted prior to becoming available for duty. The only exception to wellbeing would be if an unforeseen circumstance became apparent, such as an immediate risk of harm to self, or becoming aware that the patient is a family member, causing emotional distress.
The second refers to who the ‘others’ are. Here, others can mean everyone, including paramedics other health professionals, and the patients themselves. Who then, ought to consider a paramedic’s actions justifiable? Historically, professional standards have been measured by peers in the form of the ‘Bolam test’ (Bolam v Friern Hospital Trust, [1957] 1WLR 582). Critically, such a test favours expert evidence which can create conflict between profession and defendant. Unfortunately, paramedics are vulnerable to this conflict. Although dated, the landmark case Taaffe v East of England ([2012] EWCH 1335) saw the medical expert opinion favour that paramedics failed to take a complete history (family history excluded) and rule out a cardiac event, despite a GP consultation the following day. The judge concluded: ‘On the basis of such findings, can a Bolam argument be sustained? I think it cannot.’ (Taaffe v East of England ([2012] EWCH 1335: para 68), citing that expert opinion was insufficient in the support of paramedics. Had an expert paramedic been requested, the judgement may have drawn a more robust conclusion.
Recently, the College of Paramedics (2022) expressed concern relating to HCPC investigations, which have notably lacked a balanced line of enquiry despite having access to patients (witnesses as well as lay members) and experts. This may be due to uncertainty of who the ‘others’ are, and needs urgently addressing if it is to better adhere to the notion of Contractualism and not place paramedics or patients at risk. One solution is for the HCPC to use a broader cohort of expert paramedics and specific patient groups that better represent the circumstance.
In addition, if others are not aware of what the paramedic profession does, actions that are considered reasonable become difficult to define. For instance, paramedics working beyond the ambulance operate in settings that change the clarity of the profession. Is a paramedic who practises private aesthetics serving the interests of the patient more than self-interest of financial gain? Is this reasonable or is it dutiful? If a patient consults with a paramedic regarding a dermatological complaint in primary care, how can the patient be confident that appropriate management is established given the level of diagnostic uncertainty? Paramedics therefore owe it to patients to assure them that they are the appropriate clinician for the circumstance, and are capable of executing their professional duty in the interest of others. Means to achieve this are to adhere to appropriate training and education frameworks, justify (and document) decisions, as well as engage with professional bodies and the wider community.
Conclusion
Scanlon’s Contractualism is a convincing theory in determining whether an action is reasonably dutiful, as long as it is justified in the interest of others. However, with professional diversification, I would advocate that paramedics owe patients an explanation of their role, justifying why their expertise is applicable to the circumstance. Although only touched upon here, the next article will delve further into the ethics of rightness and wrongness.