临床研究与生物伦理学杂志

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Ethics in Paramedic Services: Patients' Right to Make Their Own Choices in a Pre-hospital Setting

Halvor Nordby

This case report discusses an ethical dilemma in pre hospital ambulance work, involving a patient who was reported to have an ailment in a public place. When paramedics arrived, the patient said that he felt fine, and that he did not want to be transported for further examinations. He told the paramedics that he had to catch an important appointment, and he promised that he would seek medical advice later that day if the paramedics thought it was imperative.

Analysis: An initial assessment of vital parameters indicated no sign of serious illness, but the paramedics could not exclude the possibility of underlying brain or heart disease. They therefore faced a dilemma: was it correct to act in accordance with the patient’s expressed wishes, or should they insist that he should undergo further medical assessment? The patient was given detailed explanations about the possibility of illness, but he did not change his mind. Eventually, the paramedics and their supervising doctor concluded that the best option was to let the patient go, as they regarded the patient as capable of making informed decisions.

Discussion: The article uses concepts from ethical theory to argue that this conclusion was justified. As a general rule, if patients are not autonomous, and if letting them decide can have severe negative consequences for them, then ethical paternalism is justified. However, in this case it was not reasonable to assume that any of these conditions were met. The patient seemed sufficiently autonomous, and the probability of serious disease was very low.

Conclusion: The paramedics could not have absolutely certain knowledge that the patient was fully autonomous and not suffering from serious illness, but requiring absolute knowledge would be to require too much. Overruling patient preferences in all situations involving nothing more than a minimal risk of serious disease, contradicts a reasonable interpretation of the principle that patients who are reasonably well informed about their situation should be allowed to make informed choices about their health care.