This paper was submitted as part of a Public Health Ethics course at the University of New Hampshire. This paper is not an indictment of any particular EMS system or agency. In talking with my colleagues across the nation, the themes presented here seem to be present in many other places. This paper is merely an exploration of the disjuncture between the values we proclaim and the actions we demonstrate.

Introduction

In this paper, I will explore the ethical frameworks underpinning the provision of emergency medical services (EMS) in the State of New Hampshire. I will argue that the current business-as-usual approach to funding and operating EMS in NH is not in keeping with the professed ethics of the trade. I will go on to show that there exists a moral responsibility to replace the current system with one that prioritizes public health and fiscal responsibility to minimize suffering and loss of life, maximize health and well-being, and treat the people and communities served with the level of respect due to all humans.

I will argue this position by describing the current state of EMS systems, describing the ethical philosophies commonly applied to the provision of EMS, describing the disjuncture between the stated and demonstrated values of those influencing the delivery of EMS, and exploring the real impact of these ethical implications. I will conclude by describing the logical outcomes of applying common ethical philosophies to the provision of emergency medical care within communities.

Definition of the Problem

Emergency medical services (EMS) refers to the systems which provide out-of-hospital emergency medical care. In the United States, EMS is overseen by the Department of Transportation. EMS educational content is promulgated by the National Highway Transportation Safety Administration (NHTSA), the same body that sets automobile emission and safety standards. The Bureau of Labor Statistics groups all EMS workers under one job code, despite there being three distinct levels of education, certification, and pay. More than half of reimbursement for EMS comes from the Centers for Medicare and Medicaid Services (CMS), which determines reimbursement according to mileage, type of ambulance, and the rurality of the service area.

EMS is most often delivered by nationally certified and state-licensed technicians in an ambulance vehicle licensed by the state. EMS workers in the United States have the lowest training requirements of any developed nation. As such, the EMS workforce lacks the well-developed professional ethic seen in other medical and health professions. Due partly to the low training levels, EMS workers cannot make independent determinations regarding the types of care a patient may or may not need. EMS care is guided by algorithm and protocol and requires that all patients be transported to an emergency department or refuse care. Law, training, licensure, and protocol prevent EMS workers from making transportation or alternative destination decisions. (RSA 153-A:11) Nearly half of the patients transported to an emergency department do not require emergency medical treatment. (Meisel, 2011)

In New Hampshire, local EMS is run by rescue squads, fire departments, and occasionally private companies. Nationally, about 13% of those delivering EMS care do so as volunteers. EMS personnel working in rural areas represent around 74% of those volunteers. (Cash, 2020) 47% of New Hampshire’s population, or around 617,000 people, live in the state’s rural communities. (Druzba, 2014) In New Hampshire, 121 agencies deliver EMS care to 221 rural towns, some agencies covering geographic areas including multiple towns. (NHBEMS, 2022a) To date, no studies have examined the specific demographic makeup of NH EMS workers.

Apart from the pandemic years, the number of patients transported by EMS to emergency departments in NH has increased by 3-5% every year since 2016. (NHBEMS, 2022b) Increasing costs of fuel and medical supplies (BTS, 2022); increasing requirements for education, certification, and licensing for personnel (OEMS, 2021); increasing call volumes (NHBEMS, 2022b), poor systems of reimbursement for care delivery; objectively stressful work conditions (Dodge, 2022); poor worker pay and support; and difficulty recruiting new people are contributing to an unsustainable situation.

EMS systems managers at the local and state level measure the success of EMS agencies through a small set of reported metrics. Two of these metrics are the time elapsed between when a call for help was placed and when an ambulance arrived on the scene; and the number of responders with medical licenses associated with the incident. Over the last three years, NH has seen response times increase in rural areas, including instances where the first EMS agency dispatched does not respond at all and a second or third agency needed to be dispatched from farther away. We have also seen an increase in responses where one or fewer licensed medical personnel were present during patient care and transport, violating NH law. (Saf-C 5900, 2019) The factors associated with these two phenomena are manifold. The rural nature of the state, the historical trends towards decreased volunteerism, the increased incidence of EMS workers leaving the trade, and the necessity to work multiple jobs to support oneself may all be contributory.

When people dial 911 to access the emergency response system, the general expectation is that an ambulance staffed with well-trained medical professionals will arrive promptly and will be able to stabilize the emergency. These conditions are unlikely to occur in the best circumstances outside well-resourced response agencies within urban centers. It is less likely that EMS workers will be able to deliver the expected level of care given the current state of many EMS systems.

Providing EMS is expensive. Reimbursement for services is a function of transportation, not medical care. EMS agencies generate revenue based on the miles traveled while a patient is loaded. Provisions are made for the type of ambulance and license level. However, if a patient’s condition requires more medical supplies or if the distance traveled to the hospital is less than the distance traveled to the scene, and back to the ambulance station, reimbursement can fail to cover the service expense.

Ethical Frameworks in EMS

The 2021 national EMS education standards require that “Ethical principles/moral obligations” be taught to EMS students at all levels. (OEMS, 2021) However, while textbooks at all levels of EMS certification contain chapters on medicolegal and ethical considerations of practice, the actual text of these books is notably devoid of overt discussion of ethical frameworks. (Pollack, 2021; Limmer, 2015; Mistovich, 2018; Alexander, 2017, Sanders, 2019) It is not until a paramedic, the terminal level of certification within EMS moves on to specialty board certification that certain ethical frameworks are named and discussed. (Pollack, 2018).

Following a survey of available and current EMT, Advanced EMT, Paramedic, and specialty paramedic textbooks, the ethical frameworks presented are socialism, utilitarianism, and Kantianism. It must be noted that where discussions of ethics take place in these books, overly simplified or overtly fictional explanations are present. (Pollack, 2018) This paper will now explore each of these frameworks in turn.

EMS as a Socialist Construct

Socialism is both a moral philosophy and an economic system often framed in contrast to capitalism. The definition of socialism has evolved since the time of Marx and now encompasses so many views and theories that it is not practically useful for a general analysis of EMS. (Rappoport, 1924) For the purposes of this paper, socialism will be succinctly defined as a philosophy in which community resources are equitably distributed to the whole community in accordance with needs. Using this admittedly narrow definition, the provision of emergency medical services appears to be a socialist construct.

92% of EMS in NH is delivered by some form of publicly funded agency, whether a fire department or a municipally funded non-profit ambulance agency or rescue squad. (NHBEMS, 2022a) 74% of EMS is delivered by volunteers drawn from the communities served. Private companies, including for-profit businesses and hospital organizations with full-time employees, deliver the remaining 8% of EMS. It follows that most of EMS funding comes from local taxes. Through taxes, the citizens of any given community pay for the provision of EMS to those who access the 911 system.

In practice, EMS interfaces with only an estimated 10% of the population, meaning that most of a community pays for the emergency care and transportation of a minority of its citizens. Americans have a difficult relationship with socialism, at various points seeing it through the lens of Russian communism or through the idea of a welfare state. However, EMS represents one of many examples of socialized systems present in modern America.

EMS as a Utilitarian Construct

Despite a superficial level of ethics training during initial EMS education, many EMS workers intuitively grasp the utilitarian nature of emergency medicine. Utilitarianism is commonly described as preferentially serving the needs of the many over the needs of any individual to maximize total societal benefit. Utilitarianism assumes that the interests of a community are the sum of the interests of the citizens in the community. This assumption is only occasionally true, for example, in the face of the unifying force of tragedy. The experience can be a temporary unifying force for those witnessing an emergency medical event. Absent a unifying force, individuals will often hold self-serving priorities that may conflict with the greater good of society. It is well documented that the suffering of a stranger will seem less urgent than the suffering of a friend or loved one.

EMS is tasked with responding to calls for service within the community, momentarily preferentially placing the health needs of whoever is calling above the health needs of the rest of the community. Around a third of patients transported to an emergency department have publicly funded health insurance. Another quarter has no insurance, meaning the cost of transport and any en-route care is absorbed by the EMS agency and transferred to the taxpayers. (Meisel, 2011)

As discussed above, unnecessary transportation to the emergency department is part and parcel with the provision of EMS. Transportation is the only source of revenue for EMS agencies. Overloaded emergency departments significantly increase the time it takes for patients to be seen. Emergency departments are not staffed or equipped to manage the kinds of non-emergent medical concerns around half of EMS patients have. Using an emergency department for primary care increases healthcare costs and may lead to inappropriate care. (Todd, 2021) The estimated cost of unnecessary transportation of people accessing 911 to an emergency department is around $18.8 billion annually.

While EMS is thought to operate under a set of utilitarian principles, especially when managing large-scale incidents with many patients, it would appear that under the current models of funding and reimbursement, EMS is providing a service for the good of the few at the unnecessary expense of the many.

EMS Through the Lens of Kantianism

Kant was a German philosopher who attempted to distill ethics into a set of rational and practical rules. Kant proposed a set of categorical imperatives which could be used to determine whether an action was ethical. Kant’s second formulation of the categorical imperative essentially states that it is essential to consider the treatment of people with their dignity and inherent value in mind rather than using them to accomplish some personal objective. Kant believed that human beings have inherent value and should never be treated as instruments.

British philosopher Onora O’Neill (2005) provides a more concrete example of Kant’s second formulation by saying, “if a rational person would not consent to my use of her in this way, given that she knew all relevant information, I may not use her in this way.” The practice of medicine has the concept of informed consent, whereby a medical provider must communicate all relevant information to a patient before gaining their permission to proceed. The nature of emergency medicine necessitates some flexibility in gaining consent, allowing for implied consent when the patient’s condition precludes effective communication or requires immediate stabilization.

As described at the beginning of this paper, EMS agencies are reimbursed for transporting people to emergency departments. If an EMS call does not result in transportation, the fixed and variable costs associated with emergency response are absorbed by the EMS agency. Patients delivered to the emergency room may not get the type of care best suited for their condition. The expense of wasted healthcare falls on the patient, their insurance, or the tax-paying public. However, EMS agencies have an economic incentive to encourage their workers to initiate transport even when it is not in the patient’s best interest.

Suppose EMS systems put their workers in a position to transport patients, knowing that the transport is not in the patient’s best interest and is potentially harmful, but incentivizes transport as a means of collecting revenue. In that case, it may violate Kant’s second postulate. An EMS worker would need to clearly communicate to patients with non-emergent presentations the desire to transport them to make money. Would people consent to be used in such as way?

EMS in the Live Free or Die State

Libertarianism is a set of political and economic philosophies that place individual freedom above the requirements of a functional society. Libertarians embrace a free market economy in which individuals can buy and sell goods and services without governmental influences that create inefficiencies and waste. In the libertarian free market economy, EMS is treated like any other service subject to the laws of supply, demand, and profit motivation.

NH EMS exists within a notably moderate swing state. Despite this, New Hampshire is known to have libertarian tendencies. The state does not levy state or local sales tax but has a state liquor commission for the central purchase and distribution of spirits that collects over a million dollars per month in taxes. (NHSLC, 2022) The state does not require seatbelts or helmets to be worn but has a state-coordinated trauma system to care for the kinds of devastating trauma caused by a lack of prevention and protection. (ASCOT, 2016) These facts uphold the libertarian principle against making laws to protect people from themselves, allowing them to make their own choices and decisions without interference from the government or other external forces.

When considering the exigent circumstances surrounding a call for emergency medical aid, the libertarian free market model seems to be a less-than-ideal fit for providing services. Consumers may be unable to make informed choices regarding the type or quality of the service rendered when a private for-profit ambulance arrives. However, in 2019, 14% of the total 911 responses in the State of New Hampshire, around 35,000 patients, were provided transportation by a private for-profit ambulance company known for its predatory billing practices. (Currie, 2019; USDOJ, 2022)

Allowing for-profit emergency response to patients who may be in extremis denies those patients the ability to give informed consent to the type and quality of service they are purchasing. This fact violates both Kant’s second postulate and fundamental libertarian principles, as discussed above.

Conclusion

This paper has briefly explored the common ethical frameworks underpinning EMS education, how those frameworks fit into the provision of emergency medical services, and how the reality of EMS systems tends to violate those ethical frameworks. It seems important to state explicitly that the individual providers, though not explicitly educated in ethics, are, in most cases, doing their best to make good decisions based on a sense of compassion for their patients. In fact, evidence suggests that little of the formal training in ethics EMS workers do have is relied upon during emergent circumstances. Instead, EMS workers use lived experience and situation context to make the best decisions they can. (Barcinas, 2022)

The systems in which those EMS workers provide emergency medicine are not designed to support compassionate care. This paper does not analyze how EMS systems treat their workers unethically. EMS is an objectively toxic work environment (Dodge, 2021). Many private for-profit organizations continuously violate Kantian ethics by using workers as a means to profit without regard for the worker’s health and wellness.

For emergency medical services systems in the United States to demonstrate adherence to the ethical systems and values it claims to uphold, there needs to be vast systemic change in how EMS workers are educated, compensated, and supported in their clinical decision-making.

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