By Dr. Kevin Kupietz
Although heroic actions are to be commended and celebrated, often they come with a cost. Too many emergency responders die in the line of duty each year. Often these deaths are preventable and result in no perceivable benefit to the community, such as the saving of a civilian life. Beneficence ethics examines the risk-versus-reward of actions in terms of the patient or the one needing help. This article discusses the beneficence ethics of taking risk by the responder and the rewards to be gained by the individual or the community to the cost that may be realized through these actions. By understanding the relationship of risk to ethics, responders will be able to more realistically examine organizational behavior to determine if adjustments may need to be made in the name of ethics.
How Do Beneficence Ethics Affect Prehospital Care Responders' Risk?
Bagpipes played a mournful version of Amazing Grace as the procession of fire trucks entered into the cemetery. They passed slowly under the arched ladders that held the national colors at half mast. Hundreds of firefighters from different departments dressed in their best stood at attention, white gloved hands poised at their brow, as the casket laden fire truck passed them. The bell sole fully rang as the honor guards gently pulled the flag-draped coffin from the fire truck. His family cried and the radios echoed the firefighter's last call as his coffin was slowly lowered into the ground to follow the path that so many firefighters had journeyed before. One would think that this firefighter died making a heroic rescue of a young child from a fire or a daring rescue from the side of a skyscraper. The truth is he left his community, his department, and his family because he took the risk of driving without a seat belt returning from a call.
Ethics of Risk
For decades, more than 100 firefighters died annually in the line of duty, with approximately 25 percent of those deaths being from motor vehicle accidents (USFA, 2004). Although the death toll has finally ducked under 100, firefighters still are injured and die at an alarming rate. Firefighting is an inherently risky occupation (Klein, 2001). Although most would agree that it is noble and ethical to risk life and limb to save another, the question begs an answer: at what point does the risk become unethical or needless?
Ethical risk is a question that needs to be looked at for all first responders, firefighters, law enforcement officers, and paramedics. For example, the attacks on the World Trade Center in 2001 killed 343 firefighters and 60 other responders (Petrecca, DiBlasio, & Dorell, 2012). This is more than any other single event in American history. At the time, the perceived risk was low while the perceived benefit was high. Thousands of people were in those buildings and at risk. At the time it had been an accepted practice to enter skyscrapers on fire because of the safety factors engineered into the structures. It could be argued that the decisions of risk that day were ethical. Days and weeks after 9/11, responders working in the rubble looking for the dead were exposed to hazardous atmospheres, often without any respiratory protection. Almost 70 percent of the Ground Zero responders and workers have reported respiratory ailments since their work in the rubble of the World Trade Center (Shapiro, 2006). Not only were risks taken during 9/11, but arguably needless risks were taken in the cleanup process (Rappaport, 2002). An argument could be made that this risk was not ethical since the resulting benefit did not correspond to the potential risk.
The same ethics argument could be made for the firefighter killed returning from a call and wearing a seat belt in a moving apparatus. There was no perceived reward for his risk. Therefore, you could draw the conclusion that the risk was unethical. Vehicle accidents serve as a good example of the risk-versus-reward aspects of emergency response. Approximately 25 percent of the firefighter deaths annually come from vehicle accidents. The national Highway Transportation Agency reports that emergency medical service (EMS) workers experience a vehicular fatality rate of 9.6 per 100,000 workers. Law enforcement touts a rate of 6.1, and firefighters a rate of 5.7 per 100,000. These numbers may seem low, but the national average of all occupations is only 2.0 per 100,000 workers (Williams, 2007). These numbers suggest that responders are either at more risk in their driving operations or are poorer drivers than the other occupations. Since responders are subjected to a multitude of driver training , I will assume that the risks to the responders driving are greater than that of the other occupations. Beneficence concepts of ethics need to be considered more often when responders view what they perceive to be an acceptable level of risk within their occupation.
Beneficence is considered by many to be a foundation of medical ethics (Beauchamp & Childress, 2009). In simple terms, beneficence is putting the patient's needs ahead of the caretakers' (Jonsen, Siegler & Winslade, 2006). More specifically, beneficence is removing harm with a positive benefit to the action (Kerkhoff, Hanson, Guenther & Ashkanazi, 1997). When a healthcare provider decides on a treatment plan, the overall impact needs to be considered. For example, the cure for many illnesses in medieval times was bloodletting. If a patient was ill, the physician would literally drain the blood from the body in hopes of dissipating that thing causing the illness. Modern science now knows that this decrease in blood actually can weaken the body's immune system and in many cases will cause the death of the patient. In most cases, the positive benefit of bloodletting does not outweigh the potential harm to the patient.
Traditionally, beneficence has been looked at from the patient's perspective only. In more modern times, this framework has also been applied to the health care provider. Is the benefit to the patient going to outweigh the risk to the rescuer? In dealing with the benefits of a treatment, the sacrifice should not outweigh the treatment (Beauchamp & Childress, 2009). Should a weak swimmer risk his life by swimming into a swift current to save another? Using beneficence as a guide, the risk far outweighs the positive benefit, so the ethical answer would have to be no (Jonsen, Siegler & Winslade, 2006).
Keeping this ethical answer in mind, though, we find examples of professionals like firefighters taking similar risks. For example, a firefighter died while attempting to rescue a drowning victim in a flash flood, he was wearing structural firefighting gear instead of an appropriate life preserver (USFA, 2004). The firefighter fell into the water. The structural firefighting gear he was wearing quickly became saturated with water, which acted like an anchor, weighing him down. The extra weight took him under the quick current and turned him from rescuer to victim. This firefighter died trying to rescue another with improper equipment, improper training, and a non-functioning plan.
The ethics of this operation could be questioned under the guise of beneficence. Was the risk worth the possible reward? Many firefighters would say it was; others may argue that it was not. The emotional ties to a rescue sometimes make it hard to answer. This question becomes even more clouded in the heat of the battle for the rescue of another.
Two common ways to look at beneficence is that of specific groups and of general groups (Beauchamp & Childress, 2009). A specific group is a group that is of special meaning to the provider, for example family or friends. The general category consists of everyone else to the provider. Conventional ethics would demand that a higher degree of risk is acceptable for family members then that of a stranger. For the general population, this may be acceptable to everyone. In the case of emergency service professionals--law, fire, and EMS--this is not an easily definable line. Within the realm of emergency responders, a feeling of responsibility tends to transcend from all victims to each responder, whether there has been prior contact or not (Kupietz, 2012).
The fire service is an honorable and respected profession that has long been known for bravery in the face of danger. Thousands of people in communities around the world owe their lives, families, and property to the jobs that these individuals perform daily and the risks that they take. No one will question that these men and women are needed and that risk is part of the job to save the lives of others. The question still remains, though: how much risk is too much risk? Risk has to be analyzed for the proper operation of an incident as well as the emergency services as a whole (Stittleburg, 1995). The fire service has to learn from those who have gone before and heard their last call. The fire service has to apply an ethical gauge to the question of risk and determine what is ethical and what is not. This task cannot be done overnight and it is set against hundreds of years of tradition based on the righteous beliefs of the crusading knights of old. With time and leadership, though, these issues can be worked out. The Fallen Firefighter Foundation is focusing on their "Everyone goes home" campaign to reduce the firefighter death rate to zero (Everyone Goes Home, 2013). While this number is probably not practical because of the scope and magnitude of the job, it is an admirable and possibly an ethical goal. The bottom line is that beneficence concepts of ethics need to be considered more often when responders are considering what they perceive to be an acceptable level of risk at an incident. Without this consideration, the results could be expensive in terms of money, community protection, life, and moral virtue.
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Dr. Kevin Kupietz is a 20-year veteran firefighter/paramedic. He is currently the full time School Director for Fire and EMS for Halifax Community College in North Carolina. He also serves as adjunct faculty for American Military University's Emergency Management Graduate program. Kevin works with the North Carolina Regional Response Team 1 as a Hazmat Technician and serves with the North Carolina Disaster Medical Assistance Team.