The Kohlberg Protocol

That sounds like a title for a great spy novel, doesn’t it?

My partner and I were called to a mall for an elderly fall. We found an octogenarian male patient who got his walker tangled in the escalator steps and fallen forward onto his knees. He had some skin tears and abrasions to his right knee and right hand. He was accompanied by his daughter, who explained that the patient had baseline Alzheimer’s dementia. His current level of confusion was more than his average level of confusion, but within the bounds of how his mentation normally waxes and wanes. 

I chatted with the gent while I cleaned him up and bandaged him as well as I could. The man knew his name and that his daughter was with him. He didn’t know where he was or anything time-related. He understood what had happened with the fall on the escalator, but once I began to discuss how dirty escalators were he kind of checked out. 

Because the patient obviously lacked decision-making capacity, I explained (mostly to his daughter) that I would be happy to take her father to the hospital, but what was most needed was soap and water. She understood the limitations of my exam and cleaning, and agreed that a hospital was unnecessary. I asked about a durable medical power of attorney, and the patient’s daughter said that nobody held POA for the patient. She also explained that they had an important appointment about an hour from that time which they absolutely couldn’t miss. (I asked if it was a meeting with a lawyer to get DMPOA paperwork written with a smile.  The daughter did not think me funny.)

What would you do? Would you take the patient to the hospital, after explaining that there was nobody present on scene with legal decision-making authority? That is what the protocol calls for. Would you let the obviously confused patient refuse further care and transport? Would you let the daughter refuse for the patient, even though she had no legal authority to do so?

My instinct was to work around the protocol. I understood the legal, moral, and ethical foundations of the refusal of care protocol, but I also understood that the protocol authors did not have this specific situation in mind when they wrote the rules. My preferred plan was to make base contact, explain the situation, and work out a way to leave the patient in care of his daughter. My partner felt the opposite. He explained to me that the protocols were clear and that I had to take the patient in the absence of decision-making authority. I told him that I would rather do what I thought was right. “Protocols are protocols, and they are written for a reason,” he told me.

What would you do?

Lawrence Kohlberg was an American psychologist who developed a theory explaining stages of moral development. Being that psychologists are crazy imaginative people, his theory is called “Kohlberg’s Stages of Moral Development.” The theory dates from about 1958 or so, but was expanded and developed since. There are three levels, each with two stages.

The first level is called the Preconventional Level. At this level, which is usually seen in children up until middle school, the morality of an action is based upon the consequences to the actor. 

• Stage 1 is the punishment avoidance stage. Children in this stage obey rules established by more powerful people. Rules will be broken if getting caught and punished is unlikely. Wrong behaviors are those behaviors that are punished. “Last time I did that, I got spanked. So I won’t do that again.”
• Stage 2 is the favor exchange level. Children in this stage will satisfy the needs of others if their needs are also handled. Right and wrong is still consequence based, but the consequence in this stage is a positive one.  “What’s in it for me?”

Kohlberg’s second level is the Conventional Level. Moral choice in this level is compared to societal expectations, with the actor accepting societal mores and morality. This level of morality usually appears in high school-aged children.

• Stage 3 is the “good boy” stage.  Actions are chosen based on which ones will please authority or high-status figures.  This stage of morality is based on the sharing, trust, and loyalty inherent in relationship maintenance.  “Being good makes people like me.”
• Stage 4 is the law and order stage.  A large part of society exists at this stage of moral decision-making.  Decision makers at this stage look to society for moral/ethical guidance.  Each member of the society has a duty to obey the rules – and the rules are inflexible and shouldn’t change.  “What if everybody did that?”

The final level of Kohlberg’s theory is the Post-Conventional Level. At this level of morality, principles take precedence over laws. It is rare to see this level used before college.

• Stage 5 is the social contract stage of moral thinking. In this stage, rules represent agreements and are a useful mechanism to maintain order. But rules are not absolute dictates; they are flexible and should be changed or abandoned as need requires.
• Stage 6 is thought to be a purely theoretical stage. It is rare to see an individual operating at this stage. In this stage, universal ethical principles transcend specific norms and rules. Individuals here have a strong inner conscience. That conscience is obeyed, rather than rules and laws. These individuals willingly disobey laws that violate their own ethical principles.

Why do you follow EMS protocols? It is kind of a weird question, I know. Is it to avoid getting into trouble? Is it because your boss gave you the protocols and they must be followed? Is it that protocols are guidelines, but you will do what you think best? 

I would argue that you shouldn’t follow protocols blindly. Do what you would be proud to defend. But to do that, one must have all the necessary information to make good decisions, including didactic and specific situational knowledge. Follow the protocols because you agree with them, not necessarily because you have to.

I’m not saying that a better person operates in the Post-Conventional level at all times. I constantly bounce back and forth between Stage 4 and Stage 5. I will run red left turn arrows constantly because I think they are an insultingly stupid waste of my time. But I show up to work on time because it is one of the work rules. I even operate at a Pre-Conventional level when I go the speed limit solely in order to avoid a ticket. 

In the case above, was being Post-Conventional and my partner was operating at a Conventional level. Like him, I considered the protocol requirements for transport. I thought they didn’t fit the situation well, though. Instead I decided to do what I thought best – release the patient to his daughter. As a backstop to my decision-making, I contacted the base physician. The doctor agreed and the patient was left at the scene. I don’t think that transporting the patient would have been wrong, however. It just depends on your own comfort level in a given situation, along with which of Kohlberg's stages you happen to be operating within at that time.

I find it interesting to think about those kinds of things, though. Isn’t it cool that a discussion of protocols can get into psychological theories and morality?