ETHICAL CHALLENGES IN PREHOSPITAL EMERGENCY CARE: A SYSTEMATIC REVIEW OF THE LITERATURE ON DECISION-MAKING IN AUSTERE ENVIRONMENTS

Prehospital care in austere environments presents a unique set of ethical challenges that extend beyond clinical decision-making. This systematic review synthesizes the literature to identify and characterize the ethical dilemmas faced by emergency medical providers in these high-stakes settings. The analysis reveals five predominant themes: (1) triage and resource allocation under scarcity, (2) consent and patient autonomy in crisis situations, (3) determining the limits of beneficence and non-maleficence, (4) professional role integrity and moral distress, and (5) balancing duty of care with provider safety. These challenges are influenced by system-level, provider-level, and situation-level factors and have significant consequences for both patient care quality and provider well-being, including moral distress, burnout, and PTSD. The findings underscore the erosion of standard bioethical frameworks in austerity and highlight the critical need for enhanced ethics education, robust support systems, and the development of practical decision-making aids. We propose the concept of "Prehospital Ethical Resilience" as a necessary focus for future efforts aimed at supporting providers and ensuring ethically sound care in these demanding environments. Keywords: Prehospital Ethics, Moral Distress, Austere Medicine, Resource Allocation, Emergency Medical Services