Ethics and Decision Making During Critical Incidents

As a paramedic, I am faced with ethical decisions fairly frequently. As an example, I am usually the sole responding paramedic to an incident that might involve a number of seriously ill or injured patients (e.g. car accidents, fires, carbon monoxide). These incidents are challenging in that I have to choose which patient(s) will be treated at the higher level of care that I can provide versus the lower level of care that the basic life support units can provide. Typically, I base my decision merely on which patient is more ill or injured; however, many times I am faced with a number of critical patients and must decide based on ethical criteria, such as who would benefit more from my care in the long run, including the fact that adolescent and adult patients tend to fair better than elderly and infant patients (Broos, D’Hoore, Vanderschot, Rommens, & Stappaerts, 1993; Kypri, Chalmers, Langley, & Wrigh, 2000; McGwin, Melton, May, & Rue, 2000).

One of the problems with attempting to remain ethical while decisions during an emergency response is that the situational picture is almost never as clear as you need it. This is especially true as the scope and scale of the incident increases. As the magnitude of an incident grows, the incident command team become inundated with information, and it is common to be overwhelmed. We do, though, try our best to be just and fair in our determinations. We need to make our decisions based on the current information and not dwell on if they were right or wrong (Walsh et al., 2012), only if we could have approached the problem more effectively and efficiently, and this should be done only in the debriefing.


Broos, P. L. O., D’Hoore, A., Vanderschot, P., Rommens, P. M., & Stappaerts, K. H. (1993). Multiple trauma in elderly patients. Factors influencing outcome: importance of aggressive care. Injury, 24(6), 365-368. doi:10.1016/0020-1383(93)90096-O

Kypri, K., Chalmers, D. J., Langley, J. D., & Wrigh, C. S. (2000). Child injury mortality in New Zealand 1986–95. Journal of Paediatrics and Child Health, 36(5), 431–439. doi:10.1046/j.1440-1754.2000.00559.x

McGwin, G., Melton, S. M., May, A. K., & Rue, L. W. (2000). Long-term survival in the elderly after trauma. Journal of Trauma, Injury, Infection, & Critical Care, 49(3), 470-476.

Walsh, D. W., Christen, H. T., Callsen, C. E., Miller, G. T., Maniscalco, P. M., Lord, G. C., & Dolan, N. J. (2012). National Incident Management System: principles and practice (2nd ed.). Sudbury, MA: Jones & Bartlett.