CONCEPTS ethics, prehospital care prehospital care, ethics Ethical Conflicts in the Prehospital Setting From Wilford Hall USAF +~IedicalCenter, Lackland Air Force Base, Texas;* Center for Medical Ethicst and Affiliated Residency in Emergency Medicine,¢ University of Pittsburgh School of Medicine; and Center for Emergency Medicine of Western Pennsylvania,§ Pittsburgh, Pennsylvania. Received for publication December 26, 1990. Revision received November 22, 1991. Accepted for publication March 3, 1992. The views expressed in this paper do not necessarily represent the views of the United States Air Force or the Department of Defense. James G Adams, Capt, USAF, MC*e Robert Arnold, MD t Laura Siminoff, PhD t Allan B Wo]fson, MD* Study objective: To assess the range of ethical conflicts that con- front prehospitar care providers. Design: Convenience sample, from October 1989 te January 1990. Setting: An urban advanced life support emergency medical service that transports approximately 3,000 patients per month. Methods: Six hundred seven paramedic responses were analyzed by a single observer. An ethical conflict was identified when the paramedic faced a dilemma about what "ought to be done" and the paramedic's values conflicted or potentially conflicted with the patient's. Cases with potential ethical consequence were brought to experts in medical ethics and epidemiology for further analysis and classification. Results: Ethical conflicts arose in 14.4% of paramedic responses (88 of 607 cases). Twenty-seven percent of the conflicts involved issues ef informed consent, such as refusal of treatment or transport, conflicts of hospital destination, treatment of minors, and consent for research. Difficulties regarding the duty of the paramedics, usually under threat- ening circumstances, accounted for 19% of the dilemmas encountered. Requests for limitation of resuscitation accounted for 14%. Other cir- cumstances that presented ethical conflicts involved questions of patient competence (17%), resource allocation (10%), confidentiality (8%), truth telling (3%), and training (1%). Conclusion: The data demonstrate a range of ethical conflicts in the prehospital setting and point to areas in which policy needs to be developed. The data also can be used in a prehospital ethics curriculum for paramedics and physicians. Because case sampling was not strictly random, absolute conclusions should not be drawn regarding the fre- quency of the dilemmas. [Adams JG, Arnold R, Siminoff L, Wolfson AB: Ethicar conflicts in the prehospital setting. Ann Emerg Med October 1992;21:1259-1265.] OCTOBER1992 21:10 ANNALS OF EMERGENCY MEDICINE 1259/121