Prehospital Ethics

[Kevin L]

Hi Guys:

I haven't worked in EMS for almost 20 years due to a duty-related injury . . . and now that medicine has advanced, we have reached a place where my injury can be fixed and I can get back on the truck and work in EMS again.

Yet I know a lot of things have changed in the field, and I wonder how certain ethical conflicts are handled.

So, here is a scenario . . . it really happened to me, and involved a certain religious conflict and I had sanctions levied against me.

I was a field training officer, and our medical director was involved with a lot of educational programs, including being on the faculty at a local school with an osteopath school (our medical director was a D.O., not an M.D.) and a program for advanced nursing degrees.

So, I had a student assigned to me who was studying for his advance practice nurse practitioner. He had several years experience working in a pediatric intensive care unit, and he had forgotten more about pediatrics than I have ever learned.

So, we ran on a very, very sick kid who was fighting a kind of pediatric cancer (leukemia), and was a type 1 diabetic at the same time.

I felt like I was missing something, so I put my student in charge, and he did an excellent job and saved the kid's life.

Here's the problem: The family was deeply conservative and religious, and my student had a lot of effeminate mannerisms that would cause people to assume (correctly, but it doesn't make a difference to me) that he's gay.

The parents wrote us up and complained because I "exposed their child to homosexualist influences", and if their kid turned out gay, then it would be my fault. After all, homosexuals are "usually child molestors", and their child was at a "delicate stage in his masculine development."

Evidentally, there was an older son who turned out gay, so they disowned him, and their pastor and congregation blamed the family for the older kid's upbringing.

So, I get censured and have to go through a peer review committee because by delegating my effeminate student to take over patient care, I violated the family's religious beliefs. In their minds, it was like forcing a blood transfusion on a Jehova's Witness.

Yet this student was assigned to me to work, and I was encouraged beforehand to give him as much autonomy and "hands-on" EMS tasks as could be managed.

Also, we had no specific protocols for handling this type of religious conflict.

With the understanding that this nurse helped this kid stay alive, how would such a thing be handled now?

Would you guys mind weighing in pro and con?

Thank you in advance.

 

[Peak]

I don’t see any ethical problem.

You had a family with an irrational and unfounded complaint. There is no academic literature to support that there is any more CSA by heterosexual versus homosexual individuals, nor any evidence that simple exposure to homosexual people increases the rate of homosexuality. There is some mediocre case study literature that suggests that there was a higher rate of CSA history amongst gay and lesbian individuals, however that is clearly not relevant to the situation.

Frustratingly this is a complaint that I have to deal with several times a year when families are unhappy with their gay appearing nurse or physician. In reality caring and nurturing is traditionally a fairly effeminate trait, and we have a large number of effeminate seeming (with a huge variety of how much or little) male staff. Many of our effeminate acting male staff are in fact straight, many of our ‘straight acting’ are gay. Unfortunately it is a complaint that is usually just easier for me to have the charge nurses assign a female staff member rather that fight that battle, regardless of the inappropriateness of the complaint.

 

[Aprz]

Usually you just do things in front of the parents, and if they tell you to stop, you stop. If it is something invasive like giving a drug or starting a drug, if time permits, ask first.

Doesn't sound like you did anything wrong. I don't show up to calls and tell people I celebrate holidays or that I am an athiest. I don't think it is reasonable to expect someone to tell people that they are a gay before assessment or treatment.

Sounds like this happened awhile ago. Thankfully times are different and I think it is just something people are regularly exposed to. I remember I used to be shocked when a guy says his husband or when someone says "his husband". I'd be like waaaaat??? Now, I hear it all the time, and it's not so shocking anymore.

 

[Kevin L]

Usually you just do things in front of the parents, and if they tell you to stop, you stop. If it is something invasive like giving a drug or starting a drug, if time permits, ask first.

Doesn't sound like you did anything wrong. I don't show up to calls and tell people I celebrate holidays or that I am an athiest. I don't think it is reasonable to expect someone to tell people that they are a gay before assessment or treatment.

Sounds like this happened awhile ago. Thankfully times are different and I think it is just something people are regularly exposed to. I remember I used to be shocked when a guy says his husband or when someone says "his husband". I'd be like waaaaat??? Now, I hear it all the time, and it's not so shocking anymore.

Thank you. And yes, it was a while ago. At the time, we were moving quickly because the kid was in really rough shape . . . and I may have not been paying as much attention to the parents as I should have been (an example of tunnel vison on my part). The kid had non-ketotic hyperosmolar crisis and complications from chemotherapy at the same time, and we had our hands full and needed to move quickly.

 

[Kevin L]

I don’t see any ethical problem.

You had a family with an irrational and unfounded complaint. There is no academic literature to support that there is any more CSA by heterosexual versus homosexual individuals, nor any evidence that simple exposure to homosexual people increases the rate of homosexuality. There is some mediocre case study literature that suggests that there was a higher rate of CSA history amongst gay and lesbian individuals, however that is clearly not relevant to the situation.

Frustratingly this is a complaint that I have to deal with several times a year when families are unhappy with their gay appearing nurse or physician. In reality caring and nurturing is traditionally a fairly effeminate trait, and we have a large number of effeminate seeming (with a huge variety of how much or little) male staff. Many of our effeminate acting male staff are in fact straight, many of our ‘straight acting’ are gay. Unfortunately it is a complaint that is usually just easier for me to have the charge nurses assign a female staff member rather that fight that battle, regardless of the inappropriateness of the complaint.

Thank you, and I appreciate you weighing in.

As a paramedic, we were expected to be pragmatic and practical. We were definitely concerned with ethical considerations . . . but we were also expected to do what we had to do to save peoples' lives.

In this instance, I put my student in charge because that was what would save the kid's life. I pointed this out afterward to the parents, and they said: "The ends don't justify the means . . . ", and they would consider their kid just as dead from homosexuality as from cancer combined with diabetes.

 

[silver]

So much bait in here

 

[ffemt8978]

Duplicate threads merged

 

[DrParasite]

Here's the problem: The family was deeply conservative and religious, and my student had a lot of effeminate mannerisms that would cause people to assume (correctly, but it doesn't make a difference to me) that he's gay.

The parents wrote us up and complained because I "exposed their child to homosexualist influences", and if their kid turned out gay, then it would be my fault. After all, homosexuals are "usually child molestors", and their child was at a "delicate stage in his masculine development."
...
So, I get censured and have to go through a peer review committee because by delegating my effeminate student to take over patient care, I violated the family's religious beliefs. In their minds, it was like forcing a blood transfusion on a Jehova's Witness.

Let's modify the story a bit... instead of being effeminate, your student is black, and the family doesn't want to expose Junior, because it will turn Junior into (insert racial stereotype here), and that violates their cultural beliefs. or your student is white, and the family doesn't want Junior to be treated by the white devil (or another equally ignorant and offensive term). Or the family is gay, and doesn't want your straightness to expose the child to heterosexualist influences. How much weight and validity do you think any of these complaints will have? What if your student was a cleared medic, and was working with an openly gay stereotypical woman, what would the family's response be then? Forbid the ambulance crew from treating their dying son?

The only time I would say the patient (or patient's family) gets a choice is when they request a provider of the same sex due to religious beliefs or due to the patient's situation, and that's only a best-effort, not a guarantee, especially when the patient is in a life or death situation.

If I had been your supervisor, I would have listened to the family's complaint, tried to explain that while we try to accommodate, that isn't always the best course of action during an emergency, and had them put their complaint in writing. Then I would thank them for bringing it to my attention, and advise them I would investigate and handle this appropriately. I would have then called you into my office, asked for your side of the story, advise you that you did nothing wrong, and then I would close the case. I might even call the family back and tell them appropriate action was taken regarding their concern. This way all parties are heard and left satisfied.

 

[Kevin L]

Let's modify the story a bit... instead of being effeminate, your student is black, and the family doesn't want to expose Junior, because it will turn Junior into (insert racial stereotype here), and that violates their cultural beliefs. or your student is white, and the family doesn't want Junior to be treated by the white devil (or another equally ignorant and offensive term). Or the family is gay, and doesn't want your straightness to expose the child to heterosexualist influences. How much weight and validity do you think any of these complaints will have? What if your student was a cleared medic, and was working with an openly gay stereotypical woman, what would the family's response be then? Forbid the ambulance crew from treating their dying son?

The only time I would say the patient (or patient's family) gets a choice is when they request a provider of the same sex due to religious beliefs or due to the patient's situation, and that's only a best-effort, not a guarantee, especially when the patient is in a life or death situation.

If I had been your supervisor, I would have listened to the family's complaint, tried to explain that while we try to accommodate, that isn't always the best course of action during an emergency, and had them put their complaint in writing. Then I would thank them for bringing it to my attention, and advise them I would investigate and handle this appropriately. I would have then called you into my office, asked for your side of the story, advise you that you did nothing wrong, and then I would close the case. I might even call the family back and tell them appropriate action was taken regarding their concern. This way all parties are heard and left satisfied.

Thank you.

I worked for a private ambulance company (we had "first response" areas where we were cheaper than a locally supported EMS system), and--because of political and business reasons, and because the fire-rescue agencies resented us, as we were non-union--we were held to unrealistic perfectionistic standards when it came to complaints and/or making the people in our area "happy." We were expected to respect religious and cultural priorities, so complaints were taken very seriously.

In any case, thank you very much for weighing in, and I appreciate the validation.

 

[Summit]

Let's be realistic about how this would be handled now vs in 2000. Now if you guys had been written up there would be a huge social media blowup over this and the ambulance service would have been subjected to the full wringer of indignation of such flagrant pandering to unacceptable biases. And rightfully so.

 

[Kevin L]

Let's be realistic about how this would be handled now vs in 2000. Now if you guys had been written up there would be a huge social media blowup over this and the ambulance service would have been subjected to the full wringer of indignation of such flagrant pandering to unacceptable biases. And rightfully so.

Thank you. I'm glad that things have changed.

 

[DrParasite]

we were held to unrealistic perfectionistic standards when it came to complaints and/or making the people in our area "happy." We were expected to respect religious and cultural priorities, so complaints were taken very seriously.

In any case, thank you very much for weighing in, and I appreciate the validation.

There is nothing wrong with having high standards, and/or making the people in your area happy; in fact, I would argue that it is generally a good practice to do what you can to make the customer happy. And I would say that you should be expected to respect religious and cultural priorities whenever possible. However, that doesn't mean the customer gets to choose their ambulance crew, or who the provider is. They should be treated appropriately from a clinical perspective, and, if possible, respect cultural priorities.

For example, if you were dealing with a female patient on an OB call, and their culture says no one but the husband gets to see the wife's genitals, what should the two male providers do? I don't want someone to die over a cultural belief, but at the end of the day, we have a job to do, and we should be working with the family, not creating an adversarial experience. But if we need to do something that is in the best interests of the patient, then I would do my job, and let my supervisor smooth things over (using the example I provided earlier).

Complaints should be taken seriously and fully investigated; however, that doesn't mean the complaint has merit, nor is the customer always right in what they expected the provider to do.

 

[Kevin L]

There is nothing wrong with having high standards, and/or making the people in your area happy; in fact, I would argue that it is generally a good practice to do what you can to make the customer happy. And I would say that you should be expected to respect religious and cultural priorities whenever possible. However, that doesn't mean the customer gets to choose their ambulance crew, or who the provider is. They should be treated appropriately from a clinical perspective, and, if possible, respect cultural priorities.

For example, if you were dealing with a female patient on an OB call, and their culture says no one but the husband gets to see the wife's genitals, what should the two male providers do? I don't want someone to die over a cultural belief, but at the end of the day, we have a job to do, and we should be working with the family, not creating an adversarial experience. But if we need to do something that is in the best interests of the patient, then I would do my job, and let my supervisor smooth things over (using the example I provided earlier).

Complaints should be taken seriously and fully investigated; however, that doesn't mean the complaint has merit, nor is the customer always right in what they expected the provider to do.

Thank you again.

 

[Knuckles]

I’ve always been taught to ask myself, “What is in the best interest of the patient?”. That applied to every aspect of EMS, whether it be a procedure, medication (or in some cases I.e. interaction, withholding said med), etc. That being said, it was in the child’s best interest to have the student perform, however the parents should have made their decision/beliefs clear AT THE TIME OF THE CALL or no one would have known.

I am the EMS Chief for my department and have 2 effeminate men on my squad (one straight, one gay) and would back either of them in a case like this. Luckily, times have changed quite a bit, people of an alternative lifestyle are more accepted and parents speak up more, but if they waited until after the call, it’s on them. Just my opinion, but I would have explained , if they didn’t speak up at the time, neither of you would have known. But I digress.

Times have changed and it’s not as hard anymore.

 

[Kevin L]

Thank you very much.