Basic Ethical Frameworks

You respond to a cardiac arrest, to find a generally healthy (historically, not so much currently) 65 year old male pulseless and apneic.  There are six or eight of his family members around, too.  A first responder hands you a valid DNR, but the other first responders are performing CPR.  Whiskey tango foxtrot.  When you ask about that, the patient’s entire family agrees when his daughter says, “You have to save him.  That DNR thing was a mistake.  Do everything.  Save his life.”  Do you work the patient or pronounce the patient?

Ethical decision making has been all worked out and described by philosophers and other folks who study such things - the branches of ethical frameworks are called normative ethical systems.  There are two main divisions of ethical frameworks: teleological and deontological.  

Teleologic ethics are concerned with consequences of actions.  If an action has positive consequences, it was an ethical decision.  When a choice we make has negative effects, we were acting immorally.  Teleologic ethics are further divided into a whole bunch of subsets.  We are concerned about two: utilitarianism and eudaemonist ethics.  Utilitarianism is easy - you’ve heard of the “greatest good for the greatest number,” right?  How about Spock’s quote in The Wrath of Khan: “Logic clearly dictates that the needs of the many outweigh the needs of the few.”  Spock’s talking about utilitarianism.  Eudaemonism, on the other hand, is concerned with how actions relate to classical virtues like justice, temperance, courage, and such.  There is a limb of this that extends into medical principles: autonomy (people get to make their own decisions), beneficence (do good/help people), justice (spread the good evenly throughout society), and nonmalfesience (don’t do bad things to people).  

On the other hand, deontologic ethics are concerned with rules, completely separate from the decision’s outcomes.  When confronted with a situation, select the appropriate rule and follow it.  If the rule was selected and applied appropriately, we were acting ethically.  If a rule was ignored, we were immoral.  Legal systems are set up on deontological principles - if a law is broken you get prosecuted.  Many religious ethical frameworks are deontological in nature - one doesn’t eat meat on Fridays not because of the consequence but because there is a rule about that.  Protocols are kind of deontologic decision making tools, too, in a way.  

Immanuel Kant (1724-1804) was a Prussian philosopher who wrote theories of ethics that are considered to be the foundation of deontologic morality.  Kant focused on the duty of a decision maker and the motivations behind the action. (Public domain via Wikimedia Commons)

(By the way, there is a third main branch of ethics - virtue based ethics.  This branch is concerned with who the decision maker is as a person, as well as the development of good moral character.  Think of the elimination of vices.  It doesn’t really help you decide whether to pronounce a dead dude or not.)

Go back to the scenario.  Dead guy, DNR, family is begging you to ignore the (mistaken?) DNR.  Deontologic ethics would advocate pronouncement - the valid DNR was presented to you.  Teleologic ethics is more complicated.  Consider whether the patient will walk out of the hospital.    We should probably also consider the fact that death is kind of irreversible.  Utilitarianism says to work him - make a bunch of family members happy.  But on the other utilitarianist side of the coin, think of the cost of the ICU.  Eudaemonist ethics are more messy - balance autonomy (the patient filed a DNR) with beneficence (we want to do good).

It is a big damn mess, especially if you think about teleology/outcomes too much.  Hospitals have ethics committees to assist providers with making decisions like this.  An ethics committee can’t help you in the field quickly, however.  I think that is why most EMS providers lean toward the deontologic/rules-based ethical framework.  Especially in this case, I think the pronouncement is the way to go.  There is a certain comfort in being able to wrap yourself in the security of a clear rule.  

That bothers me to no end.  As I have explained before, I hate if-then situations.  If chest pain then oxygen.  If drunk then transport.  I hate to abdicate decision making responsibility, including "if DNR then pronounce."  But most rules are actually decision making shortcuts.  Someone smarter than me (probably a committee) has weighed the patient’s ability to make a decision about their future medical care against the family’s wishes and come down on the side of the DNR.  I’m sure it required extensive discussions.  The good news is that I don’t have to have extensive discussions - I can pronounce the patient without weighing the odds of every potential outcome.  

Deontologic ethics and the dependent decision making process doesn’t revolve around blind submission to authority - it is dependent on selecting the correct rule to follow.  Should you be on the chest pain protocol or the dyspnea protocol?  Is this situation what the X protocol was written to cover, or should I go to another?  So I can intellectually work out that rule-based decisions aren’t all that bad.  I’m not abdicating responsibility and authority.  Knowing that still doesn’t make the if-then statement any easier to swallow for me.  

Another scenario: You are an EMS supervisor.  EMT Jones has just called in sick for the seventh time this year - your agency allows for six sick calls per year.  Discipline is thus mandated.  EMT Jones, though, has already worked her way through step-wise discipline and will be fired for this sick call.  You are aware, though, that EMT Jones’ sick calls are due to her son just being diagnosed with leukemia.  Fire her?  Let it slide?

The deontologic answer is to fire EMT Jones.  The line was crossed and so a consequence must occur.  Teleologic ethics work in decisions about your estimate of Jones’ future potential as an employee, her ability to continue medical insurance after being fired, the severity of the previous disciplinary steps, and whatever else you think would go into that decision.  What is the best answer?

If you fire Jones, you are clearly an asshole.  If you don’t fire her, you are playing favorites and could get sued by the next person you do fire.  You may as well throw out the policy manual.  Don’t you hate it when there is no answer that feels right?

I could go on like this for a while.  The point is that neither deontologic nor teleologic frameworks will work 100% of the time.  It is a mistake to only rely on one or the other.  Try your best to do what is right and be able to defend your decision.  You may have been wrong, especially in hindsight, but it will feel better explaining a decision in which you were trying to do the best thing for everyone involved.  Do what you would be proud to defend.