Let`s Concentrate on Saving Lives: Ethical Dilemmas in EMS

Editor’s note: This article is written in response to this Facebook post and was based on this news story.

You are dispatched to a one-year-old infant with a febrile seizure. When you arrive on scene, the infant's mother waits for you outside with her child in her hands, immediately giving you her son. This scene happens every day: someone trusts you, a complete stranger, with their lives or their relative's lives without any hesitation.

Why does this happen? It happens because medical personnel, especially EMS personnel, have an important and sacred role in society: to save lives with no questions asked.

This unique trust is the basis of EMS work, and without it EMS would not function.

In the last few months, a "terror wave" has hit Israel. Some 250 people have been injured, and 25 have died. This "terror wave" is characterized by random stabbings, shootings and cars running over pedestrians. These attacks are carried out by young individuals that try to target Israeli civilians and soldiers. Unlike previous terror attacks that were mostly executed by suicide bombers, in the last few months, the terrorist do not die on the spot and are usually shot by a police officer or a civilian carrying a weapon.

Besides the obvious challenge for the EMS system of being prepared for a mass casualty event around the clock, the reality of treating an injured terrorist alongside injured civilians on scene has become a challenging reality.

A terrorist attack involving a few casualties is a complicated event. While EMS crews in Israel have gained a lot of experience in treating terror attacks over the years, and all the personnel are constantly trained in managing and treating such events, the ethical dilemma has become an issue.

The Israeli national EMS system (Magen David Adom) and the Israeli Medical Association have time and again stated that providers should treat wounded by order of severity regardless if they are the victims or the terrorists. Reality is unfortunately more complicated.

As first responders, any event involving violence is tragic especially when innocent people are randomly involved. When you respond to a terror attack as an EMS provider it is always in a place you know, sometimes even involving people you know. All this makes treating the terrorist much more personal, difficult and even against all normal instinct. In the hospital, sometimes the terrorist and victims lie down next to each other in the trauma room.

Deciding who to treat on scene is not just an ethical issue. It is also a practical issue.

On the practical side, while arriving at the scene, you have to triage the patients, report to dispatch on the number and severity of casualties and start treating them. Reality has shown that sometimes it is unknown in the beginning who the terrorist is and who the victims are.

Two months ago I responded to a shooting in the central bus station of my hometown Beer Sheba in the southern part of Israel. Arriving on my paramedic motorcycle while the terrorist was still alive and shooting, I saw an innocent bystander that was shot multiple times by a security guard mistakenly thinking he was a second terrorist lying down in a pool of blood. He was shot multiple times. I asked one of the policeman to search his body for a bomb or weapon before I could treat him. Then he was evacuated like all the other injured to hospital. Later we found out he was innocent, and he died from his wounds in the hospital. Imagine what would happen if we would not have treated him? How would I feel?

 Twenty years ago, I responded to a scene where a suicide bomber attacked a bus station.  A second suicide bomber waited for first responders and exploded himself, killing 22 people. Since then, the protocol is to let police search the terrorist before EMS treats him.

On the ethical side of things, treating a terrorist deals with the core values of being a medical professional and an EMS provider. If we go back to the example of the mother giving us her baby without hesitation, we need to understand that this trust is gained because people believe we would treat any one without discrimination. Yes, even if he is a terrorist, a murderer, a pedophile, a drug dealer or anyone else. We do not judge the people we treat, and we do not sentence them—we treat them. Some patients we treat have done horrible things, but we treat them the same way. Why? Because it is the ethical thing to do, and because if we started treating patients by our moral code, judgment or beliefs we would lose the sacred trust we have from the public.

In the last few weeks, some public figures and religious leaders in Israel have publicly stated EMS should not treat terrorist at all, or not treat them by the severity of their wounds – treating civilians first. These statements, by people who do not understand the complex reality we deal with and do not understand the daily responsibility we have for our patients, are wrong and damaging.

As most of our patients have not selected to be wounded or sick, we cannot select who to treat. Let law enforcement and the judicial system trial and punish, and let us concentrate on saving lives.

Oren Wacht, PhD, EMT-P, is clinical coordinator at Ben Gurion University of the Negev in Israel, and currently a paramedic with Magen David Adom. Reach him at orenwacht@gmail.com.