- Paramedics must understand and follow medical ethics and laws to avoid civil and criminal liability. They are bound by professional ethics to do no harm, act in good faith, and act in the patient's best interest. EMS research presents ethical issues regarding informed consent. - The legal system includes federal and state laws, with two types of law - civil and criminal. Lawsuits against paramedics usually involve negligence claims. Paramedics are subject to their state's medical practice act and scope of practice. Patient privacy is protected by HIPAA. - Paramedics must obtain consent, honor patient refusals and autonomy when possible, and understand decision-making capacity, especially for minors. They must

1. Chapter 4
Medical, Legal, and
Ethical Issues

2. Medical/Legal and Ethics
• Consent/refusal of care
• Confidentiality
• Advance directives
• Tort and criminal actions
• Evidence preservation
• Statutory responsibilities
National EMS Education
Standard Competencies

3. Medical/Legal and Ethics
• Mandatory reporting
• Health care regulation
• Patient rights/advocacy
• End-of-life issues
• Ethical principles/moral obligations
• Ethical tests and decision making
National EMS Education
Standard Competencies

4. Introduction
• Medical providers
provide care under
a set of laws
affecting how
patients must be
treated.
– Ethics
– Laws
© Brand X Pictures/Creatas

5. Introduction
• Paramedics work within several laws.
– Both federal and state
• You must understand the laws and ethics
related to emergency care.
– Failure to perform your job can result in
civil/criminal liability.

6. Introduction
• Ethics
– Deals with the study of the distinction between
right and wrong
• This text is only a framework.
– Laws and obligations vary between states.

7. Medical Ethics
• Two types
– Personal
– Professional
• In cases where
they conflict, you
must put your
personal ethics
aside.

8. Medical Ethics
• Medical ethics are related to the practice
and delivery of medical care.
– Your understanding of medical ethics must be
consistent with the codes of your profession.

9. Medical Ethics
• The Oath of Geneva
– Drafted by the
World Medical
Association in 1948
– Taken by medical
students after
completion of their
studies
• Code of Ethics for
Emergency Medical
Technicians
– Issued by the
National Association
of Emergency
Medical Technicians
in 1978
– Still in use
– Pledge to a number
of ethical codes

10. Medical Ethics
• Your state, service,
or company may
have its own codes,
policies, and rules.
• The ICARE Program
– Incorporates many of
the finest qualities of
EMS professionals
• All codes stem from
concern for patients.

11. Medical Ethics
• Apply three basic ethical concepts when
making a decision:
– Do no harm.
– Act in good faith.
– Act in the patient’s best interest.

12. Medical Ethics
• Paramedics must be
accountable for their
actions at all times.
– Choose a mentor.
• Professional ethics
are also important.
• Always be respectful
of patients.

13. Medical Ethics
• The ethics of your profession require:
– A total commitment to acting in the best interest
of your patient
– To otherwise conduct yourself in a professional
and ethical manner at all times

14. Medical Ethics
• The most successful and fulfilled
paramedics:
– Are patient advocates
– Engage in training and professional development
– Put the good of the team first
• You are responsible for the future of EMS.

15. Ethics and EMS Research
• EMS practices have largely evolved from
“grass roots” efforts.
– Properly randomized, controlled studies are
uncommon, but are emerging.
• Remember, “do no harm.”
– Seek further education.

16. Ethics and EMS Research
• EMS care still relies on anecdotal
experience.
– Some procedures prove not to be helpful.
• Conducting studies on patients without
informed consent is an ethical dilemma.
– How are researchers handing ethical debates?

17. The Legal System in the United
States
• Federal and state government make,
administer, and interpret laws affecting
paramedics.
– Three branches of government

18. Types of Law
• Two types of law
govern paramedics
in court:
– Civil
• Patient can sue for
perceived injury
– Criminal
• State can
prosecute for
breaking a statute
Courtesy of Oregon State Police.

19. Types of Law
• Civil law
– Concerned with establishing liability
– Civil suit is a legal action of this sort
• Most lawsuits result from vehicle crashes.
• Criminal prosecution
– Action taken by government against someone
prosecutors believe violated a law

20. Types of Law
• Most suits against
EMS involve
negligence.
• Intentional tort
claims may also be
filed:
– Assault
– Battery
– Libel or slander
– False imprisonment
© Dan Myers

21. The Legal Process
• Begins when a complaint is filed
• Process may take several years
– Discovery period
– Motions
– Settlement process or trial

22. The Paramedic and the Medical
Director
• Relationship is complex
• Paramedic must answer to:
– Medical director
– Licensing agency
– Employer
• Despite overlap, distinctions are important.

23. The Paramedic and the Medical
Director
• Legislation may require a medical director.
– Supervises paramedic
– Paramedic is not the medical director’s agent
• Medical director may issue remedial
requirements
– Not responsible for disciplinary actions

24. The Paramedic and the Medical
Director
• Many paramedic activities require orders
from a physician.
– Online or offline
• If conflicts arise, online medical control
should resolve them.
– Not the paramedic

25. Licensure and Certification
• Terms often confused; generally:
– Certification
• Certain levels of credentials
• Criteria met for minimum competency
– Licensure
• Privilege granted by government authority
– Credentialing may also be adopted.

26. Discipline and Due Process
• Licensing action may be taken if an
infraction occurs.
– Paramedic has a right to due process.
• Notice
• Opportunity to be heard

27. Medical Practice Act
• Defines minimum qualifications of health
service providers
• Defines skills practitioners can use
• Establishes means of licensure/certification
– May also include relicensure requirements

28. Scope of Practice
• Care paramedic may perform according to
the state under its license or certification
– Medical director may not permit paramedic to
perform all skills/give all medications.
• Practicing outside scope of practice is
negligence or a criminal offense

29. Health Insurance Portability
and Accountability Act
• HIPAA
– Stringent privacy
requirements
– Provides for
criminal sanctions
and civil penalties
– Information can be
disclosed:
• For treatment
• For payment
• When authorized

30. Health Insurance Portability
and Accountability Act
• Special reporting
situations:
– Mandated reporting
– Authorized data
collection/research
– Subpoenas
• Privacy officer
required
– Ensures PHI is not
released illegally

31. Health Insurance Portability
and Accountability Act
• Some states have patient confidentiality
laws.
– Confidentiality is part of the code of Ethics for
Emergency Medical Technicians.
• You must provide patients with a copy of
your service’s privacy policy.
• HIPAA also regulates electronic information.

32. Emergency Vehicle Laws
• Most states have specific statutes.
– Define emergency vehicle
– Dictate what traffic should do
• Emergency vehicles must be operated
safely.
– Most states have a higher standard for EMS.
– If a crash occurs, EMS is usually at fault.

33. Transportation
• Patients should be transported to hospital of
their choice when possible/reasonable
– Most EMS have protocols that direct transport.
• Paramedics can be liable if patient:
– Is transported to an unequipped facility
– Is not transported and later deteriorates

34. Crime Scene and Emergency
Scene Responsibilities
• Use extreme caution.
– Do not move or touch anything unless absolutely
necessary.
– Patient may carry evidence in rape cases.
– Protect scene from contamination.
– When in doubt, attempt resuscitation.

35. Mandatory Reporting
• Each state has its own requirements.
– Virtually every state has laws for reporting child
and elder abuse.
• Many states have immunity provisions.
• Failure to report is a crime.
– Know reporting requirements in your state.

36. Paramedic–Patient
Relationships
• Always do what is best for the patient.
• Decisions should be based on standards of
good medical care.
– Not possible legal consequences

37. Consent and Refusal
• You must obtain consent before providing
care. To provide consent, a patient must:
– Be of legal age
– Possess decision-making capacity
• Patients can refuse care.

38. Consent and Refusal
• Informed consent
– Must be obtained from every adult with decision
making-capacity
• To obtain informed consent:
– Describe the problem and proposed treatment.
– Discuss risks and alternatives.
– Advise the patient of consequences of refusal.

39. Consent and Refusal
• Expressed consent
– A type of informed consent
• Implied consent
– Consent that is assumed when an adult is
unconscious or too ill/injured to verbally consent
• Involuntary consent is an oxymoron.

40. Decision-Making Capacity
• Refusals must be informed.
• Decision-making capacity is the ability of
the patient to:
– Understand information.
– Process information.
– Make a choice.

41. Decision-Making Capacity
• If a conscious patient with decision-making
capacity refuses treatment:
– Cannot be treated without a court order
– Consult with medical control.
– Use your “people skills.”

42. Decision-Making Capacity
• Patients who refuse treatment are not “bad.”
– May not want to admit there is a problem
– Have patient speak to medical control.
• Maintain a courteous, sympathetic attitude.
• Documentation is critical.

43. Decision-Making Capacity
• Back up refusal forms with action.
– Do everything you can to inform the patient.
– Ultimately, respect his or her rights.
• It may not be clear as to whether or not a
patient has decision-making capacity.

44. Decision-Making Capacity
• Generally, patients with
altered mental status or
unstable vital signs
cannot refuse transport.
– Know the criteria for
establishing mental
competence.
• If the situation is life-
threatening, transport.
The Ascensia Contour Blood Glucose
Meter. Photo courtesy of Bayer
HealthCare LLC. © 2006 Bayer
Healthcare LLC.

45. Decision-Making Capacity
• Some states have emergency transportation
statutes.
– Protect paramedics making good-faith judgments
about decision-making capacity
• Psychiatric emergencies present problems.
– Follow protocols.

46. Minors
• Obtain consent from a legal guardian.
– In loco parentis if guardian is unavailable
• Notify law enforcement and medical control if
a parent refuses necessary treatment.
– State may assume custody

47. Minors
• Emancipated minors
– Treated as legal
adults because of
qualifying
circumstances
• Obtaining consent is
a difficult skill.
– Your expertise will
build over time.

48. Violent Patients and Restraints
• You can only use
force in response to a
patient’s force
against you.
– Do not enter an
unsafe scene.
• Only restrain medical
patients who are a
danger to themselves
or others.
© Jack Dagley Photography/ShutterStock, Inc.

49. Negligence and Protection
Against Negligence Claims
• No protection for gross negligence
• Negligence occurs when:
– There was a legal duty to the patient.
– There was a breach of duty.
– The failure to act was the proximate cause of
injury.
– Harm resulted.

50. Negligence and Protection
Against Negligence Claims
• Behaving according
to established
standards and
procedures is the
best protection.
– Consider insurance
coverage.
• “Foreseeability” is
one aspect of
negligence.
• Negligence is
typically divided
into three
categories:
– Malfeasance
– Misfeasance
– Nonfeasance

51. Elements of Negligence
• Duty
– Prescribed by law
– Do no further harm to patient.
– Obligated to respond to calls while working
• Typically, not while off duty
• Make sure appropriate personnel respond.

52. Elements of Negligence
• Duty (cont’d)
– Must perform within a standard of care when
providing assistance
– Cannot abandon the patient once care begins
– Must maintain licensure or certification and skills
– EMS systems can be held to a legal duty.

53. Elements of Negligence
• Breach of duty
– Standard of care
• What a reasonable paramedic would do in a
similar situation
– Some states distinguish between ordinary and
gross negligence.
– Re ipsa loquitur or negligence per se may apply.

54. Elements of Negligence
• Proximate cause
– Improper action or failure to act caused harm
• Harm
– Usually physical injury
– May also include emotional distress, loss of
income, loss of spousal consortium, etc.

55. Abandonment
• Termination of care without patient’s consent
– Implies continuing need for treatment
• Once you respond, you cannot leave until a
provider with equal or higher training takes
responsibility.

56. Abandonment
• Complete a written report.
• Some situations may not require transport
but are not considered abandonment.
– Medical director will provide protocols.
– Generally, encourage transport.
• Know your service’s protocols.

57. Patient Autonomy
• Patients have the
right to direct their
own care
– Almost every case
– Respect and honor
patient’s rights.
• Regardless of
perceptions of
others
• Even if patient’s
death is result
© UPI/HO/Landov

58. Patient Autonomy
• Resolve ethical
conflicts through
communication.
– If you disagree with a
physician, discuss it.
– Always act as a patient
advocate.
• You may need to treat
a patient against his or
her wishes.

59. DNR Orders
• Describes which
life-sustaining
procedures, if any,
should be
performed
– Laws differ
between states.
– May include a
physician order or
medical jewelry Courtesy of the MedicAlert Foundation ®. © 2006, All
Rights Reserved. MedicAlert ® is a federally registered
trademark and service mark.

60. DNR Orders
• Generally, DNRs must:
– Clearly state medical problem
– Have patient/guardian signature
– Have signature of one or more physicians
• You must still provide supportive measures if
a patient is not in cardiac arrest.

61. Withholding or Withdrawing
Resuscitation
• Relies on common
sense, reasonable
judgment
• Consider:
– Time to reach
definitive care
– Likelihood of survival
• Rare survival cases
should not guide
your decisions.

62. Withholding or Withdrawing
Resuscitation
• Provide 15 minutes of best available
method.
– Stop if no extenuating circumstances exist.
– Follow written protocols.
• State laws vary.
– State laws continue to govern your practice with
deceased patients.

63. Withholding or Withdrawing
Resuscitation
• Halting resuscitation is especially difficult
with pediatric patients.
• Seek training, review literature, and have
open discussions regarding resuscitation.
– Understand consequences of interventions.
– When in doubt, contact medical control.

64. End-of-Life Decisions
• You will often deal with patients at the very
end of their lives.
– Treat with respect and empathy
– Never question why help was called.
• Providing information and support is part of
your job.

65. End-of-Life Decisions
• Avoid imposing your own moral code.
– Respect patient’s wishes, even if you disagree.
• You may encounter confusing scenarios.
– Resuscitate until paperwork is confirmed.
– Avoid hostile encounters with family members
who disagree with the patient’s wishes.

66. End-of-Life Decisions
• Medical orders for life-sustaining treatment
(MOLST)
– Similar to DNR, but more expansive
– May apply with impending pulmonary failure
– Guide use of CPR, intubation, feeding tubes
antibiotics, palliative care

67. End-of-Life Decisions
• Organ donation
– Keeping a patient
alive for an organ
donation is a major
ethical issue.
– Understand state
laws.
– Attend workshops.
– EMS plays a vital
role in securing
transplants.

68. Good Samaritan Legislation
• Provides immunity from liability
– Passed to encourage public to help
– Some protection for EMS personnel
• Does not apply while on duty
– Legal duty applies
• Must do all you can, within your knowledge

69. Ryan White Act
• Provides safeguards and protections for
health care workers exposed or potentially
exposed to certain designated diseases
– Notify your infection control officer if you believe
you may have been exposed.

70. • Paramedics must understand law and
ethics; failure may result in civil and/or
criminal liability.
• Professional ethics bind the paramedic.
• Three primary ethical principles for
paramedics are to do no harm, act in good
faith, and act in the patient’s best interest.
• EMS research presents ethical dilemmas
regarding informed patient consent.
Summary

71. Summary
• The three branches of government are
executive, judicial, and legislative.
• Two types of law: civil and criminal
• Paramedics are susceptible to assault and
battery charges.
• Restraining a patient against his or her will is
false imprisonment.
• Risks to paramedics: defamation, slander,
libel

72. Summary
• The lawsuit process: complaint, defendant
response, discovery, settlement, trial
• Paramedics are subject to multiple legal
jurisdictions.
• Paramedics are held personally responsible
for their actions.
• Directives from the medical director are
binding, unless the paramedic believes they
will cause harm.

73. Summary
• State legislation allows paramedics to
practice in every state.
• Licensure is a privilege.
• Paramedics have a right to due process.
• The Medical Practice Act defines the scope
of practice for the paramedic.
• HIPPA protects patient information.

74. Summary
• EMTALA prevents hospitals from turning
away patients.
• Emergency vehicle operation must be
performed safely.
• Transportation of a patient depends on
preference and medical needs.
• Paramedics must preserve evidence and
document their actions at a crime scene.

75. Summary
• Failure to report particular cases can result
in legal action.
• Some types of deaths must be reported to
local law enforcement personnel.
• Paramedics cannot infringe on the privacy,
consent, and refusal from patients of sound
mind.
• The only protection against a civil suit over
refusal is documentation.

76. Summary
• Informed consent must be obtained prior to
any medical process.
• Expressed consent must be obtained prior to
any treatment.
• Implied consent exists when paramedics
deem treatment is required for patients who
cannot answer for themselves.

77. Summary
• Determining the decision-making capacity of
a patient can be tricky, but tools can provide
factual documentation of patient ability to
make clear decisions regarding his or her
medical care. Thorough documentation and
consultation with medical control will provide
the best protection against lawsuits.
• Minors cannot consent to care or refuse it;
exceptions exist for emancipated minors.

78. Summary
• Patients may be restrained if they are a
danger to themselves or others.
• Protocols and professional ethics take
precedence over the personal feelings of the
paramedic.
• Negligence occurs when duty to act, breach
of duty, proximate cause, and injury-related
processes have occurred.

79. Summary
• Negligence can be acts of commission or
omission.
• Paramedics cannot abandon their patients.
• Documentation prevents the appearance of
abandonment.
• Patients have the right to determine their
own care.

80. Summary
• DNR orders define the care a patient wants
when lifesaving procedures are required.
• Paramedics need to become familiar with
the choices their patients have made related
to medical care and treatment issues.
• Paramedics must address futile resuscitation
efforts prior to an emergency event.
• Good Samaritan laws protect the paramedic
providing care off duty.

81. Summary
• Governmental immunity may protect the
paramedic who is not negligent.
• The statute of limitations and contributory
negligence are two common legal defenses.
• The relationships between paramedics and
their employers are affected by federal and
state laws.

82. Credits
• Chapter opener: © Mark C. Ide
• Backgrounds: Blue—Jones & Bartlett Learning.
Courtesy of MIEMSS; Green—Jones & Bartlett
Learning; Purple—Jones & Bartlett Learning.
Courtesy of MIEMSS; Red—© Margo
Harrison/ShutterStock, Inc.
• Unless otherwise indicated, all photographs and
illustrations are under copyright of Jones & Bartlett
Learning, courtesy of Maryland Institute for
Emergency Medical Services Systems, or have
been provided by the American Academy of
Orthopaedic Surgeons.