Case Report

By Prof. Halvor Nordby
Corresponding Author Prof. Halvor Nordby
Faculty of medicine, department of health and society, Ekromskogen 46b - Norway 2624
Submitting Author Prof. Halvor Nordby

Medical ethics, Prehospital emergency work, Ethical challenges, Patient communication

Nordby H. Ethics in Prehospital Emergency Medicine: An Ethical Dilemma in Patient Communication. WebmedCentral MEDICAL ETHICS 2013;4(5):WMC004247
doi: 10.9754/journal.wmc.2013.004247

This is an open-access article distributed under the terms of the Creative Commons Attribution License(CC-BY), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Submitted on: 10 May 2013 02:33:02 PM GMT
Published on: 11 May 2013 07:42:32 AM GMT


Abstract: This case report discusses an ethical dilemma about consent and patient autonomy from prehospital emergency services. It is argued that the dilemma involves deep ethical problems, and that these problems have not received sufficient attention in the literature on the ethical dimension of emergency medicine and prehospital provider-patient communication. The discussion illustrates a general point: Focusing on ethics and communication falls under the more general task of elucidating non-technical skills. In recent years it has been widely recognized that non-technical skills are of crucial importance in emergency work and prehospital patient care (1, 2, 3). Knowledge of ethical caring frameworks is an essential element of non-technical skills, and such frameworks should therefore receive more attention in education and practice that aim to prepare emergency personnel for difficult situations.


This article discusses an ethical dilemma experienced by two students in a national further education course for paramedics in Norway  where one of the authors of this case report has been responsible for the module Ethics and communication.  The two paramedics described the dilemma in conversation and, as they were uncertain about their conduct, asked for some comments about the ethical dimension of their actions.

The case appeared to raise interesting questions about paramedics’ entitlement to put psychological pressure on patients.  Consequently, it was recognized that it would be a good idea to analyze the situation as a case study. This was suggested to the paramedics who had experienced the case, and they consented to the project. They said that they believed that there should be more focus on ethics and communication in prehospital work, and that analyzes of dilemmas of the kind they experienced could lead to more focus on this area of emergency medicine.  

On the basis of the paramedics’ oral description of the situation, the case was initially written down. This transcribed description was shown to the paramedics, adjusted in the light of their comments and then rewritten in completely general terms.

The purpose of doing a complete general rewriting was to make sure that the case description could not be traced to any specific location, person or circumstances. Thus, the case described below is not the actual dilemma experienced by the paramedics, but a typical imagined example of the kind of situation they experienced. By describing and analyzing the case on this kind of general type level, it is possible to arrive at substantial conclusions that fit a variety of cases that fall under the general dilemma that we describe.

Case Presentation

An ambulance is called out to an elderly woman with chest pains. She is generally weak and has been nursed in her own home for some time, primarily by her husband. In the last few days her condition has deteriorated rapidly. When the paramedics arrive the patient says that ‘The pain is not so bad as it was’. EKG shows some irregularities, but no definite sign of significant heart disease. The patient is worried and understands that more detailed examinations in hospital are important. However, she does not want to go there unless her husband accompanies her. The husband, however, does not wish to come along in the ambulance. He is very old, emotionally exhausted and tired of nursing his wife. He needs desperately to rest and sleep, and he thinks that professional health workers now can good give his wife adequate treatment and care. He promises her that he will come to the hospital as soon as he regains his strength. This promise, however, is not sufficient for the patient. She wants her husband to come with her in the ambulance there and then. She says that she is not willing to ‘go anywhere’ unless her husband joins her.

In the end the paramedics managed to persuade the husband to come along, but they did this in a very direct way, by saying ‘Your wife might have a serious heart disease. Her health is more important than you right now’. This had an immediate effect; the husband came along in the ambulance. Later on, after the assignment, the paramedics felt uncertain about their choice of words. Had they put too much pressure on the husband? Was it ethically acceptable to use the speech acts that they used?


The ethical dilemma, as experienced by the paramedics, was as follows: In the further education course where they were students, the paramedics had learned about Kant and his idea that morality “provides a rational framework of principles and rules that guides and places obligations on everyone, entirely apart from each individual’s personal goals and interests” (4, p.178). According to Kant’s famous categorical imperative – what he conceives to be the most fundamental ethical rule -  we have a rational duty to act ”only according to that maxim [rule] whereby you can at the same time will that it should become a universal law” (5, p.1013).

As O’Neill (6, p.178) observes, this is “a highly articulated version of a demand for respect for persons”.  Thus, it is widely recognized that Kant’s “imperative insists that one must treat other persons as having their autonomously established goals” (4, p.188). The key implication in patient interaction is that health personnel should defer to patients’ wishes as long as they are autonomous, and as long as their preferences do not have disproportionate negative consequences for other persons (7).


The case is special because it involves five questions that should be distinguished from each other. (A) Was the patient’s wishes autonomous? (B) Was the husband’s wishes autonomous? (C) What was the nature of the patient’s somatic condition? (D) Where the paramedics morally entitled to persuade the husband to defer to his wife’s preferences (as they did)? (E) Alternatively, to what extent should they have attempted to persuade the patient to go to the hospital without the husband?

It was especially the two last questions the paramedics had focused on. These questions raised ethical dilemmas about choices of communicative actions. Was it ethically acceptable to tell the husband that he ‘should think more about the needs of his wife than his own fatigue’? Or should they have respected and conformed to the husband’s point of view, focused on the wife, and told her that transport to hospital was ‘absolutely imperative’?

The paramedics realized that these questions could not be answered independently of the others. For one thing, if the patient was not autonomous, then the paramedics thought they were more entitled to ‘talk to her in a very direct way’ as one said. But they also recognized that this depended on the third question: if they could establish that the patient’s condition was not very serious, they were not entitled to ‘put much pressure on any of them’


The paramedics had an implicit awareness of important ethical concepts. The ideal of dialogue that does not involve communicative pressure corresponds to the idea of informative communication. Communication processes are informative when senders convey true, factual information to audiences (8). It is widely recognizeed that this is the natural ethical starting point in all professional communication (9). But this does not mean that all patient communication should be informative. Sometimes health workers are entitled to set the informative norm aside by using paternalistic communication, communication that is not informative (10). However, this requires a special justification: one should be able to explain why this form of verbal paternalism is in the patient’s best interests.

When a patient is not autonomous and not aware of very negative consequences of his own wishes, such a justification emerges. In order to secure adequate treatment – treatment that the patient was likely to accept if he was autonomous – it is legitimate to communicate paternalistically. The question is whether the above case was a situation of this kind.

The more fundamental question is completely general. To what extent it is ethically correct to put pressure on patients and relatives in situations involving uncertainty about autonomy and somatic conditions? It would fall the limits here to pursue this question in any detail. The more modest aim has been to use the above case to show that the question is important. But it has not received much attention in health care ethics.

Why is this so?  There can be many reasons, but one suggests itself as a plausible explanation: Ethical problems related to philosophical frameworks about the moral significance of consent and freedom have not received much attention in discussions of prehospital challenges. Challenges concerning communication, ethics and autonomy have typically been discussed within institutional frameworks like hospitals or nursing homes. The challenges become different in prehospital work and other medical practices in which decisions and actions have to be made quickly, yet on limited knowledge. In order to develop ethical principles and guidelines that can be of help in these practices, future empirical and theoretical research needs to pay more attention to the contextual nature of ethical challenges in prehospital emergency care.

Furthermore, a thorough focus on ethical dilemmas of the above kind must, in effect, involve a broader focus on non-technical skills in emergency medicine. Ethical dilemmas and communication problems cannot be solved on the basis of technical skills. There are no tools or technical equipments that can be used as instruments for proper ethical decision making. Making good ethical decisions requires a trained sensitivity to the ‘human factor’ of patient interaction. It is necessary to have a well developed awareness of how alternative actions should be valued as ‘good’ and ‘bad’, ‘right’ and wrong’.  

In sum, ethics should be an important focus area in education and practice that aim to prepare emergency personnel for difficult patient situations. Sadly, few training programs for prehospital health workers include ethics and communication as substantial modules. In order to give paramedics and other emergency personnel resources for solving difficult communication problems, ethical dilemmas of the kind we have presented in this case report should receive more systematic attention in basic and further education programs.


1. Reader T, et al. 2006. Non-technical skills in the intensive care unit. British Journal of Anaesthesia 96 (5), 551-9.
2. Flin R, Maran N 2004. Identifying and training non-technical skills for teams in acute medicine. Quality and Safety in Health care 13, 80-84.
3. Fletcher G, et al. 2002. The role of non-technical skills in anaesthesia: A review of current literature.  British Journal of Anaesthesia 88 (3), 418-29
4. Beauchamp T 1982. Philosophical ethics. New York: McGraw-Hill.
5. Kant I 1992. Grounding for the metaphysics of morals. In Classics of moral and political theory, ed. Michael Morgan, 991-1042. Indianapolis: Hackett publishing.
6. O’Neill O 1997. Kantian ethics. In: A companion to ethics, ed Peter Singer. 175-186. Oxford: Blackwell.
7. Kuhse H, Singer P 2004. A companion to bioethics. Oxford: Blackwell.
8. Silverman J, Kurtz S, Draper J 2005. Skills for communicating with patients. Oxford:
9. Løgstrup, K E 1997. The ethical demand. Notre Dame and London: University of Notre Dame press publishing.
10. Wear, S 1993. Informed consent: Patient autonomy and physician beneficence within clinical medicine. Dordrecht: Kluwer.

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2 reviews posted so far

Ethics in Prehospital Emergency Medicine
Posted by Dr. William J Maloney on 05 Feb 2014 08:23:24 PM GMT Reviewed by Interested Peers

Who is the Patient?
Posted by Dr. Russell Searight on 17 Jun 2013 08:50:48 PM GMT

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