depth understandings of the ethical and legal issues that underpin and govern paramedic patient care are critical to safe practice, as they aid in decision-making that promotes patient welfare (Hodgson, 2016). The aim of this essay is to discuss the ethical and legal issues pertaining to a case study from practice involving restraint use and where a paramedic prescription only medication (POM) was administered. Firstly, the ethical issues will be analysed using two ethical theories, followed by a discussion of the legal considerations involved. Third the legal limits surrounding POM’s will be addressed. Finally, the influence of policies on paramedic practice will be explored. While on placement within an ambulance trust, a crew was called to a 60-year old male assaulted on the street. The patient was sitting on the ground, alert but appeared confused, agitated and had no recollection of events. He had a Glasgow Coma Score (GCS) of 14 and had a large hematoma on his occiput. Bystanders informed the crew that the patient had previously lost consciousness. The patient also had a large body mass index. The potential severity of the head injury, the life-threatening risks associated and the necessity to do a full assessment were explained multiple times. The patient appeared not to understand or retain the information and repeatedly asked what had happened and why the back of his head hurt as much. The crew undertook a mental capacity test and the patient was considered to lack capacity as per the Mental Capacity Act (MCA) (2005). Despite attempts to reason with him the patient kept on trying to walk away stating he was fine. It was deemed necessary and, in the patient’s best interest to restrain him. The patient was not combative and was consequently immobilized on the trolley bed without any force, with constant reassurance and explanation. A full trauma assessment was undertaken and the patient was treated for a
Page 3 of 8traumatic brain injury (TBI) with a suspected depressed skull fracture. After careful consideration IV paracetamol was given and as per local trust guidelines the patient was taken to the nearest major trauma centre. In ethics, a moral dilemma is defined as a situation where two or more moral obligations co-exist in a way that one can be respected only by violating the others and vis-versa thus the conflict rests on what is the most moral choice to make (Beauchamp and Childress, 2013). Restraining is defined here as restricting or threatening to restrict an individual of their freedom (Mohr et al, 2003).Consequentialism resolves conflicts by judging the morality of an action through the outcome it produces and the ethical choice is the one that creates the most “good” (Herring, 2012). Therefore, a “wrong” action may be justifiable if it leads to an overall good. However disagreements arise on how to define ‘good’ (Herring, 2012). Utilitarianism, a popular consequentialist theory, defines good as the overall happiness; commonly for the greater number (Eaton, 2019, p.30). In the above case study, the decision by the crew to restrict the patient’s freedom can be argued from a utilitarian perspective, where solely the patient’s overall happiness was the desired outcome. Reduced GCS, alterations in behaviour and loss of consciousness are signs of a severe TBI secondary to a significant mechanism of injury (Parikh et al, 2007). It has a high morbidity and mortality rate (Bruns and Hauser, 2003) requiring prompt specialist treatment (Parikh et al, 2007). Although other causes such as drugs or alcohol produce similar alterations in mental status (Griffin, 2013) this could not be confirmed with the patient. Therefore, assuming that survival brings the greatest happiness to the patient, justified restraining and transporting the patient. However, this approach can be criticised. The understanding of happiness is highly subjective (Eaton, 2019 p. 30). Utilitarianism could equally justify restraining or not a patient based on an understanding of happiness that is external to the patient (Herring, 2012). For example, using restraints to time on scene or simplify patient management. This supports the criticism of utilitarianism as a theory that would justify the treatment of patients without consent (Herring, 2012). Furthermore, consequences of actions remain unpredictable (Smart, 1993) however as elaborated this was reduced by evidence-based practice. This presents limitations to using this approach as guide of moral action. Nevertheless, its common-sense approach is useful in practice as it allows one to weigh the pros and cons of treatments and allows for clinical judgement (Eaton, 2019 p. 30). In contrast, in ethical decision-making, principalism theory argues for the use of four ethical principles: autonomy, non-maleficence, beneficence and justice (Beauchamp and Childress, 2013). However since the patient lacked capacity, only the principles of non-maleficence and beneficence will be addressed below. The principle of non-maleficence is an obligation not to harm and not to increase risk of harm (Beauchamp and Childress, 2013). Although limited, the literature surrounding the effects of restraints on patients reveals harmful outcomes (Strout, 2010). Harm is inflicted physically by use of physical force (Agens, 2010); although minimal force was used in the case study. It is also a serious affront to a person’s dignity (Petrini, 2013), and has been shown to provoke fear, a sense of violation, disempowerment and dehumanization (Wynn, 2004), which Harrosh (2011) argues is a also a form of harm to consider. This can be exacerbated by a lack of understanding by the patient of the clinician’s intents (Wynne, 2004) which considering the patient’s confusion may have occurred. Restraints can also increase the patient’s agitation (Chien et al, 2005), this is particularly relevant in the management of traumatic brain injuries, as it can cause an increase in blood pressure, potentially increasing intercranial pressure (Association of Anaesthetists of Great Britain and Ireland Safer Pre-Hospital Anaesthesia Guidelines, 2017). However, this was mitigated, as the patient was not combative.
The crew also had a duty of beneficence, defined as the positive obligation to do good, where good is understood as promoting the patient’s welfare (Beauchamp and Childress, 2013). As elaborated above, doing good involved undertaking actions to protect life. Patients that lack capacity are often vulnerable (McKenzie and Rogers, 2013) and with the absence of indications otherwise and under the universal assumption that if the patient had capacity he would consent to treatment (Beauchamp and Childress, 2013); the crew had an obligation of protection. Therefore the duties of non-maleficence and beneficence conflict. Beauchamp and Childress (2013) argue that all principles have equal standing, however the principle of beneficence was upheld by the crew due to a greater importance in preserving life. Nevertheless, multiple attempts at reasoning were first pursued.The ethical reasoning brought forward above resonates in the legal boundaries pertaining to restraints in British Law. Indeed under common law, restraining a patient, depriving them of their liberties and giving treatment without consent is an act of battery and or assault punishable by law (Oates, 2000) as it goes against their fundamental right to autonomy (The Human Rights Act, 1998). However, consent is only valid where the patient has decision-making capacity (Gillon, 1994). Prior to 2005, in emergency situations, the treatment of nonconsenting patients that lacked capacity was done under the doctrine of necessity (Amblum, 2014). Now this is done under the MCA (2005) where patients must be treated in their best interest. The act provides the statutory framework for assessing patient capacity but also the specific circumstances under which paramedics can legally restrain (Gainsford, 2018). In the case study, based on the two-stage assessment test of the MCA(2005) the patient’s capacity was not conflictual. Limitations to this test have been argued in situations where the assessment of capacity is not straightforward, and the severity of the patient’s condition has been shown to influence the decision (Moskop, 2006). The challenge stemmed from his refusal of treatment and deciding whether it was necessary to force the treatment on the patient (Herring, 2012). It is important to note that the MCA(2005) distinguishes between restriction and deprivation of liberty, where the later involves a more intense or prolonged removal of liberty (Gainsford, 2018). However, in both cases, it is only lawful under section 6 of MCA (2005) where the clinicians must reasonably believe that it was necessary in order to prevent harm to the patient and it was commensurate to the seriousness of the harm expected. In other words, it was necessary in order to provide vital acts and it was the least restrictive measure available to reach the goal (MCA, 2005). This was previously argued. Furthermore, since the incidence occurred on the street, the patient was alone and a poor historian, it was difficult to establish the patient’s beliefs and values in regard to his refusal of treatment, as per the requirements given in section 4 of the MCA (2005). As trained health care professionals, paramedics have a duty of care to their patients that lies within the boundaries of the paramedic scope of practice established in the Standards of Proficiency (SoP) of The Health and Care Profession Council (HCPC) (2014). Failure to fulfil this duty may lead to the tort or criminal charge of clinical negligence; in order to be judged negligent, a breach of duty and causation must be established (Herring, 2012). In legal decision-making, the Bolam test is often used to determine if a breach of duty occurred (Herring, 2012). It judges whether given the same circumstances, clinicians within the same field would provide the same treatment and care (Bartlett and Eaton, 2019, p.109). In the case study, the act of omission could have been judged to be in breach of the crew’s duty of care. It is within the paramedic scope of practice to identify life threatening injuries, appropriately undertake capacity assessments using the MCA(2005), and provide treatment accordingly (HCPC, 2014). Therefore, not only is it sometimes legally justifiable to restrain patients but failure to do so may be in breach of the paramedic’s duty of care (Gainsford, 2018). Nevertheless, since the legal judgement is based on standards set by fellow practitioners it
not unquestionably exclude cultures of bad practice (Herring, 2012). The Bolam test has been criticised in the backdrop of the Montgomery v Lanarkshire (2015) case and new criteria are being used (Hobson, 2016). Although, mainly pertaining to doctors (Herring, 2012), an example of this in paramedic practice could be giving unnecessary treatment such as intravenous (IV) cannulation (Gainsford, 2017). Another boundary to consider in the case study is the legislation regulating paramedic administration of medicines, particularly POM. According to the Human Medicines Regulation (HMR) (2012), POM’s are medications that can only be prescribed and administered by a trained and licensed prescribers, which paramedics are not (HCPC, 2014). However, a legal exemption exists for the POM listed in schedule 17 of the HMR (2012); they can be administered parenterally by paramedics without a prescription in emergency situations where there is an immediate clinical need (England, 2016). However, legal practice may only be done within the scope of practice set out by the HCPC’s SoP and adherence to Association of Ambulance Chief Executives (2019) (AACE) 2019 UK Ambulance Services Clinical Practice Guidelines is essentially recommended (England, 2016). IV paracetamol for example is indicated in the management of severe pain, where opioids are contraindicated such as head injured patients exhibiting altered mental status (AACE, 2019). Oral paracetamol may have been considered as a less invasive option since the patient lacked capacity, however based on the severity and the level of distress, this may not have addressed the patients pain fast enough (Duggan and Scott, 2009). Therefore, arguably, the crew practiced within these limits. Specific guidelines ensure safe practice regarding paramedic medicine administration (England, 2016), however this arguably contradicts with the concept of paramedic autonomous practice as stated by the HCPC (2014).
Page 8 of 8Policies also influence paramedic practice (Blaber, 2010). Although limited, in 1990 a study revealed that patients with life-threatening conditions refusing treatment were often not transported by paramedic for fear of litigation (Stark et al (1990). The MCA (2005) was enacted to protect patients that lacked capacity (Gainsford, 2018) and therefore to preventsuch occurrences. However, a study undertaken by Evans et al (2007) still identified a lack of knowledge by emergency practitioners, including paramedics, in assessing patient capacity. In 2010, the East of England Ambulance Service drafted the Capacity to Consent Policy with in-depth guidance regarding its application within paramedic practice. An Internet search reveals multiple similar policies from various ambulance trusts. According to the World Health Organisation, a policy identifies and defines goals set forward by a specific institution, providing set actions in order to achieve them. In the case study, appropriate application of the MCA (2005) was undertaken therefore conceivably these policies are effective and have enhanced paramedic patient care. Nevertheless, no evidence was found to substantiate this claim. To conclude, this essay has shown how ethics and law are closely associated. Although not exhaustive and pertaining solely to one case study, this essay provides insight into the principles of ethical and legal decision making associated with patient care and highlights the complex and numerous boundaries within which paramedics practice. This is particularly relevant as patient care shifts away from clinicians that know best and towards patient’s autonomy (Herring, 2012) and as the paramedic scope of practice expands (Donaghy, 2008).