Risking Death over Debt:The Moral Distress of EMTs Treating Patients Afraid of Medical Bills


G. M. Trujillo, Jr, PhD, Yedid Fernandez, EMT-B

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Risking Death over Debt:The Moral Distress of EMTs Treating Patients Afraid of Medical Bills
Tag(s): Editor's pick
Topic(s): Informed Consent

In the USA, some patients in emergency situations refuse treatment because they’re scared of medical bills. Even if they’re ill, they don’t want to incur the cost of medical assessment or transport to a hospital. This makes it impossible for emergency medical technicians (EMTs) to do their jobs. And it racks their consciences with moral conflicts.

Case: A Car-Crash Victim Refuses Treatment

Consider the following case:

A drunk driver crashes into a woman’s car, destroying the car and injuring the woman. EMTs arrive after a bystander calls emergency medical services. After examining the woman, EMTs recommend she go to the hospital. But the woman refuses, saying, “Why am I gonna waste money on a medical bill I don’t need right now? Besides, I don’t feel bad.” EMTs explain that adrenaline or shock might prevent her from feeling her injuries, and in cases of internal bleeding or brain trauma, the potential injuries could result in death. But the patient is alert, oriented, and fully aware of what she is saying, and she maintains her refusal.

Realistically and practically, EMTs face two options here, both involving moral ick: (1) make the patient sign a refusal form or (2) wait to see if the patient loses the capacity to refuse.

Option 1: Make the Patient Sign a Refusal Form

EMTs could ask the patient to sign a refusal form. Once signed, this document releases the medical team from legal liability related to injuries sustained during the accident but not treated at the patient’s request. However, even if this resolves legal issues, the moral problems are numerous.

First, this practice places the burden of decision-making in an emergency situation on distressed patients who lack relevant medical knowledge to assess their own injuries. Patients in situations like these are betting their lives on not being badly injured, despite reasonable evidence indicating otherwise and EMTs offering assessment.

Second, EMTs feel obligated to provide the best care they can. And in a case like this, it is obvious that the patient needs assessment and treatment at a medical facility. But the patient refuses, and further treatment cannot be done against the patient’s will.

So, EMTs feel morality pulling in two directions: (1) EMTs can respect the patient’s autonomy, which means letting her refuse care. But (2) EMTs also feel the obligation to actively do good and avoid future harms, which means questioning the patient’s autonomy in cases of serious injury as indicated above. Important here is that no EMT could fulfill both moral obligations in a case like this. EMTs either respect autonomy or abide beneficence/nonmaleficence, but not both.

It is also worth mentioning one further complication with respect to autonomy in these cases. If we take a simple standard such as fully-informed, voluntary consent, it is not clear the woman in this case meets this standard, at least morally speaking. Even if fully informed, the problem here is the voluntariness. She appears coerced by her financial situation. This is an unjust and immoral pressure, but it is a real one. Roughly one third of the USA’s population carries medical debt. This makes the dilemma even more potent.

Option 2: Wait to See If the Patient Loses Capacity to Decide

Alternatively, EMTs could wait to see if the patient loses the capacity to make decisions. The injuries could be so severe that they might alter the patient’s mental status. This means she’d lose the ability to answer questions such as, “What’s your name?” “Do you know what day it is?” and “Do you know what happened to you?” Or she might fall unconscious. When patients lose capacity to make decisions, the medical team can assume consent to be transferred, even if she expressed not wanting to be taken in. But there are myriad problems here too.

Primarily, the medical team knows the patient’s original wishes: she said not to treat her. And by taking her to the hospital when she loses capacity to decide, EMTs act against the patient’s wishes. The medical team treats the patient to prevent death but does so under a strange but accepted practice of waiting for the patient’s incapacity. But this seems better than having the patient sign a refusal form, especially if her injuries would have worsened and led to death.

Therefore, the two options that face EMTs in situations like these are: (1) treat the patient as autonomous (even though her primary reason for not seeking further care is financial), and have her sign a refusal form, or (2) wait to see if the patient loses capacity to make decisions, and if she loses capacity, take her to a hospital against her initial wishes. 

Neither feels good, but both are accepted practices.

EMTs Face Moral Distress, and No One Writes About It

Patients and emergency medical workers face the brunt of this social problem. Patients suffer worse healthcare outcomes due to fear of price. And EMTs face moral distress and moral injury. They anguish at knowing someone deserves and will benefit from medical care, but are prevented from providing it by institutional or cultural barriers. EMTs fret over legal liabilities too, especially in either (a) providing care against patient wishes or (b) potentially letting the patients’ financially-influenced refusal kill them.

There is almost no ethical literature focused on the problems that emergency medical workers face. Some ethicists talk about lying to insurance companies to get healthcare coverage. Or they talk about the ways transfers to hospitals are affected by insurance. Many ethicists discuss the distribution of medical care in the USA in relation to ideal theories. 

None of this addresses the tangible, unique concerns of EMTs, especially due to the acuity of their patients and the rapidity of their decisions. 

Philosophical deliberation has the luxury of time. Treating people as an EMT does not.

We Can Help

We recommend three things. First, the medical ethics community should talk with more emergency medical workers, listen to their accounts, and address the day-to-day struggles that they face.

Second, if the medical ethics community cares about healthcare outcomes, they should consider staying informed on local elections and city budget issues. For example, cities can redistribute the exorbitant fees that patients pay for EMS to other departments in the city, such as firefighters or police. And if those departments become dependent on that money, there will be institutional pressure to keep EMS fees high. And that is worrisome but preventable.

Third, communities should consider funding volunteer EMS like volunteer firefighters. In fact, the first emergency service staffed by paramedics in the USA was the Freedom House Ambulance Service, founded in 1967 by Black medical workers to serve the Black communities of Pittsburgh. All this was done in a time when Black neighborhoods were underserved and when white communities refused care from Black medical workers and actively raised political objections. It would be nice if EMTs did not have to work in conditions of political adversity. But history shows that they can and that we all benefit when we help them.

EMTs will continue to serve communities, no matter how patients pay, and no matter the political implications. They will endure the ethical dilemmas and moral distress. We owe a lot to these workers. The least we can do is discuss their ethical challenges and look for ways to give them more resources and support.

G. M. Trujillo, Jr., Ph.D., is Visiting Assistant Professor in the Department of Philosophy at the University of Texas at El Paso.

Yedid Fernandez, EMT-B, is a full-time EMT and a forensic science major in the Honors Program at the University of Texas at El Paso.

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