Chapter 107 The Ethics of Wilderness Medicine
Ethics is the application of moral values and principles to guide human action. Providing care for others often involves intense human interactions and health care providers must frequently examine ethical issues in their work. Although the moral issues in wilderness medicine are an extension of traditional medical ethics, they are not directly comparable with the moral issues that arise either in medicine delivered in health care facilities or the care delivered by urban emergency medical services. Wilderness medicine is unique, and its special attributes create unique ethical problems (Table 107-1). The working environment, concepts that involve standards of care, safety of the rescuers and patients, and even the relationship between the provider and the patient are different in a remote environment than in a traditional medical setting. For example, a hospital’s working environment is rarely a factor considered by the hospital-based practitioner in the determination of what medical care to deliver, but the working environment is of major concern in the wilderness. Similarly, whereas patients usually have a clear legal relationship with the hospital practitioner and arrive requesting care, neither condition is necessarily true in the wilderness setting. Even more striking are the differences between the hospital and the wilderness settings with regard to equipment availability, personnel training, the need for evacuation or rescue, and the provision for the safety of those involved. All of these differences can lead to unique ethical dilemmas in wilderness medicine.
This chapter provides an overview of ethical values as they are applied to wilderness medicine. It describes a model for bioethical decision making in wilderness medicine, and provides examples of unique dilemmas that may be encountered in wilderness settings.
Moral values are acquired throughout life from many sources and develop into ethical action guides. In everyday situations, individuals may be unaware that these values are guiding their actions. However, when faced with situations that are rarely encountered, people may question how they should apply their values to solve practical problems. Such situations develop in wilderness medicine because the settings can challenge practitioners to demonstrate expertise outside the usual scope of their medical specialties.
Both patients’ and clinicians’ values control patient–clinician encounters. When patients express their values, clinicians can get an impression of patients’ views about necessary treatment, desired quality of life, and other complex attitudes that control the willingness to seek and accept medical care. The clinician’s own values—both personal and professional—are also part of the relationship and sometimes conflict with the patient’s values.
Ethical discussions often revolve around applying ethical principles in a consistent manner or in a way that could be applied by all practitioners in the same situation. Ethical principles or rules should be applied consistently across all scenarios. If an accepted principle is that a patient with decision-making capacity may make his or her own decisions about health care, then this principle should be applied to all situations, not just when it is convenient for the health care provider. Likewise, if the principle is universal to medical practice, then all health care providers (not just a privileged or unique group) should be able to apply it to their practices.
Moral values are the guideposts used to structure an individual’s actions in life. They signify a person’s duties and responsibilities, what is important to them, and how they interact with others. Thomas Aquinas said that there are three vital things for each person: “to know what he ought to believe; to know what he ought to desire; and to know what he ought to do.”1
Moral values derive from many sources: family, society, school, religion, the media, and professional training and related interactions. Family and religion generally guide the development of values during the formative years. For nearly all people, these values form the bedrock on which their lives are structured. Emphasizing the importance of early childhood learning is the maxim: if you control a child’s life until he or she is 6 years old, then he or she is likely to be yours forever. Additional significant influences are the media, schooling, and society. In this electronic age, the media begins to influence an individual’s values early in life. Education broadens a child’s experiences and values beyond the home. Finally, societal pressures continue to influence most individuals’ value systems throughout life. Taken as a whole, different individuals’ values derived from these multiple sources may conflict, leading to disagreements when ethical dilemmas arise over which action to take.
Professional schooling and interactions further refine how a person’s values are applied. For example, one reason that medical students take anatomy courses is to destroy an ingrained cultural value against mutilating the dead. This allows them to accept and acquire the values of beneficial mutilation (i.e., surgery), handling the dead (i.e., resuscitation, pathology, transplantation), and invading another’s body (i.e., invasive medical procedures).9 In addition, when exposed to clinical practice, medical students, nurses, medics, and other health care providers learn to adopt the values of their preceptors. In any residency program, trainees learn intrinsic professional values, and the majority of trainees behave remarkably like the faculty.
Another category of professional values, which is sometimes referred to as the Georgetown bioethics catechism, has emerged as an ideal for modern medicine, especially in the United States. These values include autonomy, beneficence, nonmaleficence, and distributive justice.
For the past two decades in the United States, the overriding professional and societal bioethical value has been a patient’s autonomy. Autonomy recognizes an adult’s right to accept or reject recommendations for his or her personal medical care (even to the extent of refusing all care) in the presence of an appropriate decision-making capacity. Current bioethical opinion demands that clinicians respect patient autonomy. This is the counterweight to the long-practiced paternalism of the medical profession, wherein the physician alone determined what was good for the patient. Coupled with paternalism is coercion, which is the threat or use of violence to influence behavior or choice. The august figure in white (or in a medic’s or search-and-rescue team’s uniform) who implies that there will be dire consequences if medical recommendations are not followed remains a potent challenge to patient autonomy.
At the patient’s bedside, beneficence, which is the act of doing good, and confidentiality, which is the nondisclosure of personal health information (and which was not part of the original Georgetown list), have been long-held and nearly universal tenets of the medical profession. Likewise, personal integrity—the adherence to one’s own moral and professional standards—is basic to ethical thought and action. The basic tenet taught to all medical students is nonmaleficence: “First, do no harm.” This credo, often stated in its Latin form as Primum non nocere, derives from the historic knowledge that patients’ encounters with physicians can be harmful as well as helpful. It recognizes every physician’s fallibility.
The concept of comparative or distributive justice suggests that all individuals and groups in society should share equitably in the benefits and burdens of that society. Many society-wide decisions about the allocation of limited health care resources are based on this principle. However, it is a fallacy to extrapolate from this valid principle the idea that individual clinicians can arbitrarily limit or terminate care on a case-by-case basis simply because there exists a need to limit resource expenditures.15
Safety is wilderness medicine’s controlling value in most circumstances. Safety or security signifies a measure of responsibility toward oneself, one’s companions, and the patient. In the unique setting of wilderness medicine, this responsibility extends to the wilderness team’s safety from the environment, victims, and their own poor judgment; this is a concept more familiar to emergency medical services personnel than to health care providers in normal medical practice. However, this value is of paramount importance in wilderness medicine. Safety is the responsibility of any wilderness medical provider, even if he or she is not officially designated a provider but must take over during a medical crisis as a result of possessing special knowledge or skills. Decisions about rescue, evacuation, terminating group travel, or even attempts to perform certain medical interventions must include safety considerations.
Concerns about safety are applied in the following order: oneself, other team members, and then the patient. Ethical theory supports this hierarchy. Beneficence by medical personnel does not imply the need to endanger oneself, and, indeed, if medical skills are to be useful, medical personnel must be able to render care. In addition, inherent in any leadership position is the responsibility to protect one’s team. Therefore, the team members’ safety is the second responsibility. Finally, the patient’s safety should be ensured, but never at the expense of the medical team’s safety. This is to say that, in unknown or unknowable circumstances, the medical leader may have to weigh potential risks against benefits. All risks must be considered in these “calculations,” such as in the case of a badly injured trekker who might survive if evacuated by aeromedical transport. If the helicopter team is willing to attempt a pickup, then the wilderness medical care provider must determine whether local conditions are sufficiently safe to justify the request, balancing the chance of benefit to the patient with potential safety risks.
One such example illustrating security issues occurred in the Pacific Northwest near Mt Baker. A group of adults and adolescents were on a hike above some snowfields when two parents and their daughter decided to glissade down one of the fields, something they had done before. As the mother and daughter sped over a crest, they dropped into a crevasse and were injured. The father pieced together what had happened and sought help. Eventually, a group of climbers was enlisted. No one was eager to descend into the trench, but one man from the climbing group agreed to be lowered on a rope, telling the group, “Just make sure you get me out.”
The ethical question here is how much risk and responsibility untrained volunteers have in this type of wilderness crisis. A second issue that has to be considered is the capability of the group to attempt a rescue without endangering themselves and possibly creating the need for a second rescue. As a member of the hiking group, the father in this situation had a responsibility to help; however, because he was technically incapable of the rescue, his only responsible avenue of action was to seek help. Alternatively, bystanders have no fundamental responsibility to help or to assume any risk beyond what they are willing to assume. The man who agreed to be lowered into the crevasse would have been acting ethically if at any point in the rescue attempt he had signaled to the group to pull him up without helping the victims or if he had walked away and not allowed himself to be lowered into the trench in the first place. Despite entreaties from others, bystanders need not justify their participation or nonparticipation to anyone but themselves.20
In contrast, Ernest Shackelton, the appointed leader of a 19th-century attempt to be the first to reach the South Pole, had the responsibility to do his utmost to see his men safely home. During the voyage, their ship broke up in the ice, and the men had to pull lifeboats over ice to reach open sea while struggling against all odds to reach safety. Shackelton’s steady and undaunted leadership is credited with helping all of his men to reach safety.16
A unique ethical problem that arises in wilderness settings—and that has often led to disasters—is when the team (especially the nonmedical team leader) ignores or overrides the medical person’s decision. Individual team members have been harmed and multiple team members lost because factors other than the team members’ safety and well-being were given priority.14,22 Heeding the demands of safety is especially important, because the majority of people who are in the wilderness have risk-taking personalities, leading them to downplay security in favor of adventure.
In the language of ethics, utilitarian thinking plays a dominant role in wilderness ethics. Utilitarianism is the philosophy that promotes the greatest good or happiness for the greatest number of individuals. When applied to wilderness medicine, it promotes the well-being of the many over the well-being of the individual. This can be defended by simply recognizing the unique aspects of wilderness medical practice, such as the uncontrolled environment, unfamiliarity with the patient, rudimentary equipment, and changeable situations, all of which contribute to safety concerns.
The ultimate application of utility in remote settings was described in the great survivor story of the men of the Essex; this is the doomed whaling ship that was the basis for Herman Melville’s Moby Dick.21 As was common after shipwrecks, the men drew lots to decide who would be sacrificed and die so that the others in the small boat could live a little longer without starvation.24 One can argue that, if all of the men consented to this process, then it was ethical, but the very nature of the situation put each man under such extreme duress that it would be questionable if any man’s consent could be considered voluntary. In these types of extreme circumstances, the ethics of draconian decisions such as survivor cannibalism are always fraught with paradoxic ethical dilemmas.9
Many ethical dilemmas in emergency medical care revolve around ascertaining a patient’s decision-making capacity, often linked with consent to—or, more often, refusal of—a medical procedure. Because a basic canon of both ethics and law, as stated by Justice Cardozo, is that “[e]very human being of adult years and sound mind has a right to determine what shall be done with his own body,”23 these decisions about what action to take can often be made clearer by understanding what is meant by the term decision-making capacity and how it relates to consent. (Note that the word competent is often used when capacity is really what is meant. Competent, meaning, “possessing the requisite natural or legal qualifications,” is a legal term; competency can be determined only by the court.19)
Capacity is always decision-specific rather than global. To have adequate decision-making capacity in any particular circumstance, a person must understand the available options and the consequences of acting on the various options, and he or she must be able to compare any chosen option against the costs and benefits related to a relatively stable framework of personal values and priorities3,4 (Box 107-1). This last requirement is the most difficult to understand and requires a subjective interpretation. The easiest way to assess it is to ask why the individual made such a decision. Disagreement with the physician’s recommendation is not in and of itself grounds for determining whether a person is incapable of making his or her own decisions. In fact, even the refusal of lifesaving medical care may not prove that the person is incapable of making valid decisions if it is made on the basis of firmly held religious beliefs (e.g., a Jehovah’s Witness refusing a blood transfusion).
Components of Decision-Making Capacity
From Buchanan AE: The question of competence. In Iserson KV, Sanders AB, Mathieu D, editors: Ethics in emergency medicine, ed 2, Tucson, Ariz, 1995, Galen Press.
A person must be permitted to consent to or to refuse any medical intervention if he or she has decision-making capacity for that decision and if the clinician respects the patient’s autonomy. Three general types of consent exist: presumed, implied, and informed. Presumed consent, sometimes called emergency consent, covers the necessary lifesaving procedures that any reasonable person would wish to have if he or she was lacking decision-making capacity; controlling hemorrhage and securing an airway in an unconscious victim of a fall are common examples. Implied consent is when a person with decision-making capacity cooperates with a procedure, such as holding out an arm to donate blood or to allow initiation of an intravenous line. Informed consent is when a person who retains decision-making capacity is given all of the pertinent facts regarding the risks and benefits of a particular procedure, understands them, and voluntarily agrees to undergo the procedure.11
Questions applying to consent in the wilderness setting can be difficult. Does the victim have the capacity to understand the situation? Will decision-making capacity be questioned only if a person refuses “good” medical care? In addition (and this is unresolved even in standard medical practice), one must consider which procedures require informed rather than implied consent. The requirement to obtain informed consent varies in practice and the law from area to area. This variation stems from differing local practice standards and state laws and disparities in physician training. Determining decision-making capacity and providing an opportunity for a patient to consent to a procedure when appropriate are crucial to respecting that patient’s autonomy.
Both standard bioethics and wilderness medical ethics often involve difficult situations with no “correct” answer. Usually more than two possible actions exist. When faced with such a dilemma, how should the health care practitioner respond? Health care professionals often apply their values without much conscious deliberation: they act instinctively based on their prior behavior and training. Values are constantly (although not necessarily consistently) applied to everyday decisions. Of course, most decisions are not ethical decisions. Ethical dilemmas arise from a conflict between two seemingly equivalent values that are represented by different and mutually exclusive possible actions.
An example of a bioethical dilemma in wilderness medicine may help illustrate ethical decision making. For example, a distress call is received from anxious relatives or by radio from a plane flying over a wilderness area. The victim is in a hazardous area or, more commonly, caught in terrible weather. The clinician directing the search and rescue team must decide how to respond to the call in a setting that may put the team in danger. The standard bioethical value of beneficence directly competes with the bioethical value of safety in wilderness medicine. Each has a strong pull on the decision maker, with each value providing good arguments for sending or not sending the rescue team. Although the value of safety may often be considered paramount in the wilderness setting, the emotional and altruistic pulls of beneficence make this a difficult choice. Considering this case, a word should first be said about rights and duties in relation to health care.
Although the word rights is glibly used in many situations, a personal right is present only if another person or society as a whole has an identifiable duty to the individual. One person has a right to receive a service from another person only when the second person has a duty and therefore an obligation to provide that service. Correspondingly, no health care practitioner has a duty to provide all of the health care that people desire or need. However, practitioners do have a duty to provide safety, when possible, for those whom they direct in wilderness settings.
Because an ethical dilemma arises when two or more seemingly correct actions appear to have equal benefits, the choice of actions should be examined first. How are these proposed “correct” actions determined in the first place? After that, which of these actions is the more ethically acceptable?
Jonsen and colleagues12 have suggested four groups of factors to consider when determining a course of action in the face of a bioethical dilemma in the standard clinical paradigm. These include the medical indications for the action, the patient’s preferences, consideration of the quality of life, and other contextual factors. These can be seen as an “ethical square,” with the top two boxes (i.e., the first two factors) having more weight (Figure 107-1).