Ethical Challenges and Responses Among Prehospital Emergency Providers (EKAB) During the Financial Crisis and COVID-19: Health Policy Implications of a Cross- Sectional Study

Ethical Challenges and Responses Among Prehospital Emergency Providers (EKAB) During the Financial Crisis and COVID-19: Health Policy Implications of a Cross- Sectional Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Ethical Challenges and Responses Among Prehospital Emergency Providers (EKAB) During the Financial Crisis and COVID-19: Health Policy Implications of a Cross- Sectional Study Aristomenis I. Syngelakis, Chrysoula Tsakalou, Maria Myrto Solomou, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7474617/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Prehospital emergency medical services (EMS) operate at the intersection of rapid clinical decision-making and complex ethical demands. In Greece, the prolonged financial crisis and the COVID-19 pandemic have intensified ethical challenges for the Hellenic National Center of Emergency Care (EKAB), creating a need for empirical data to inform training and policy. Objective: To assess the knowledge, attitudes, and practices of EKAB personnel regarding ethical and legal issues in their professional practice, and to identify underlying dimensions of ethical perception. Methods: A validated 32-item structured anonymous online questionnaire was administered to EKAB staff directly involved in patient care. The first part included items on sociodemographic and professional characteristics, while the second part assessed perceptions regarding ethics and deontology in prehospital care. Data collection took place during the later phase of the Greek financial crisis and amidst the COVID-19 pandemic Results: A total of 273 participants (50.2% male; mean age range 41-50 years) completed the survey. EFA yielded four factors, Autonomy and Consent, Resource Allocation and Triage, Confidentiality vs Public Health, and Duty and Reciprocity, explaining 60.9% of total variance (KMO=0.75; Bartlett’s χ²=1656.44, df=300, p 50 years (p=0.022). Significant positive correlations were found between Autonomy and Consent and Confidentiality vs Public Health (ρ=0.522, p<0.01) and between Duty and Reciprocity and Resource Allocation and Triage (ρ=0.465, p<0.01). Conclusion: EKAB personnel demonstrate strong ethical commitments across four key domains, despite working under dual crisis conditions (economic crisis and COVID-19 pandemic). These findings provide a framework for targeted ethics education, policy development, and institutional support to strengthen ethical decision-making in prehospital care. Prehospital care medical ethics emergency medical services Greece COVID-19 financial crisis Background The delivery of prehospital emergency care is inherently shaped by ethical decision-making under conditions of uncertainty, urgency, and limited resources. Paramedics and other prehospital providers must navigate complex situations in which clinical imperatives intersect with ethical principles such as autonomy, beneficence, non-maleficence, and justice. In Greece, this ethical terrain has been further complicated by two major societal stressors in recent years: the prolonged financial crisis that began in 2009 and the COVID-19 pandemic that emerged in early 2020. Both crises have intensified the demands placed on the Hellenic National Center of Emergency Care (EKAB), altering the resources available, the clinical priorities in the field, and the moral pressures on personnel [ 1 , 2 ]. The Greek financial crisis led to sustained austerity measures, reduced public spending, and material shortages in healthcare [ 1 ]. For prehospital services, these constraints translated into older ambulance fleets, staff shortages, and limited access to updated medical equipment and protective gear [ 3 ]. Such systemic pressures not only compromised operational capacity but also created ethical dilemmas related to triage, equitable allocation of scarce resources, and maintaining quality of care when the means to do so were curtailed. The principle of justice, fair distribution of benefits and burdens, became particularly salient, as providers were often required to make rapid decisions about which patients to prioritize in the context of competing demands [ 4 – 6 ]. The onset of the COVID-19 pandemic superimposed a global public-health emergency onto this already fragile context. For EKAB personnel, the pandemic introduced additional ethical challenges: balancing duty of care with personal safety, applying infection-control measures in uncontrolled environments, and communicating with patients under physical distancing or PPE constraints. Decision-making in the field was further complicated by evolving guidelines, uncertainty about viral transmission risks, and heightened emotional stress, factors known to influence moral judgement and the potential for moral distress among healthcare providers [ 7 – 9 ]. Prehospital settings are distinct from hospital environments in ways that amplify certain ethical tensions. Ambulance crews often operate with incomplete clinical information, limited time for deliberation, and without direct access to supervising physicians. This makes informed consent more challenging, as patients may be unable or unwilling to engage in detailed discussions due to distress, altered consciousness, or language barriers. Confidentiality, too, may be compromised in the field when care must be delivered in public or semi-public spaces. The ethical principle of beneficence, acting in the patient’s best interest, must often be balanced against non-maleficence when interventions carry risks that cannot be fully explained or mitigated in the moment [ 10 , 11 ]. Although the literature on healthcare ethics in crisis situations is substantial, much of it focuses on hospital-based or policy-level decision-making. Research on the ethical experiences and attitudes of prehospital emergency providers, particularly in the Greek context, remains scarce. Available studies tend to address discrete topics, such as triage protocols or infection control, rather than providing a broader understanding of how frontline EMS staff perceive and handle ethical and legal issues in daily practice under crisis conditions [ 12 , 13 ]. There is also limited evidence on whether sociodemographic factors (e.g., age, education, professional experience) are associated with differences in ethical perceptions or practices among paramedics. The Hellenic National Center of Emergency Care (EKAB) plays a central role in Greece’s emergency response system, providing both primary prehospital care and inter-facility transport. EKAB personnel are thus frequently the first point of contact for critically ill or injured patients and are required to make ethically charged decisions in real time. Understanding their perspectives on ethical and legal issues is essential for developing targeted training, guidelines, and institutional support mechanisms that enhance ethical practice and reduce moral distress. Furthermore, in light of recurring crises, economic, epidemiologic, or otherwise, there is a pressing need for empirical data that can inform the ethical preparedness of prehospital systems. Against this backdrop, the present study was designed to explore the knowledge, attitudes, and practices of EKAB staff regarding medical ethics and health law during the combined stressors of the Greek financial crisis and the COVID-19 pandemic. Specifically, it aimed to: (1) assess the extent to which EKAB personnel encounter ethical and legal issues in their work; (2) examine their attitudes towards selected bioethical topics, including informed consent, organ donation, and respecting patient wishes; and (3) evaluate how these issues are addressed in practice. By employing a structured questionnaire and psychometric analysis, the study also sought to identify underlying dimensions of ethical perception among EMS providers. The findings may support the design of educational interventions, policy updates, and operational protocols that strengthen ethical decision-making in prehospital care. Methods We conducted a cross-sectional, descriptive study using an online survey to assess the knowledge, attitudes, and practices of prehospital emergency personnel regarding ethical and legal issues in their professional practice. The study was implemented within the Hellenic National Center of Emergency Care (EKAB) of Greece, which provides primary prehospital care and inter-facility patient transport nationwide. Data collection took place from 15 February 2023 to 30 April 2023, during a period spanning the COVID-19 pandemic and the later phase of the Greek financial crisis, both of which had significant operational and ethical implications for the service. The target population comprised personnel employed at EKAB Athens, specifically within the categories of Ambulance Crew and Administrative Staff. The latter group predominantly consisted of former ambulance crew members who had transitioned to administrative posts through internal transfers to equivalent or higher service categories. Eligibility was defined as current employment in one of these categories during the study period and provision of informed consent to participate. Participants were recruited through internal EKAB communication channels and invited to complete the survey electronically. Participants were recruited through internal EKAB communication channels and invited to complete the survey electronically. A total of 273 healthcare professionals responded and met the inclusion criteria. The sample included both men (n = 137) (50.2%) and women (n = 136) (49.8%), with most respondents aged 41–50 years (n = 123) (45.1%), and varying educational backgrounds (30.8% university graduates, 24.9% technical college graduates, 44.0% secondary education, 0.4% postgraduate qualifications). Survey tool A structured questionnaire divided into two parts was used for the study. The first part included the sociodemographic and professional characteristics of the participants. The second part consisted of a validated instrument on ethical challenges in emergency medical services, which had been originally developed in English. Subsequently, it was translated and standardized into Greek by Toska et al. (2021) [ 14 ]. Permission for the use of the Greek version was formally obtained from the original author, and for this study, the translated version was employed without modification. The instrument also contained an electronic consent checkbox that participants were required to select before proceeding, ensuring voluntary participation. The survey was hosted on a secure online platform and remained open for responses over a defined collection period. Participation was anonymous; no identifying personal or professional data were collected beyond the sociodemographic descriptors. The implementation of the study followed the established official practice for similar studies which take place in EKAB. Statistical Analysis All analyses were performed using IBM SPSS Statistics version 26.0 (IBM Corp., Armonk, NY, USA). Continuous variables were assessed for normality using the Kolmogorov–Smirnov test. Data are presented as means with standard deviations for normally distributed variables and medians with interquartile ranges for non-normal distributions. Categorical variables are reported as absolute frequencies and percentages. Between-group differences in continuous or ordinal outcomes were assessed using the Mann–Whitney U test for two-group comparisons and the Kruskal–Wallis H test for comparisons involving more than two groups. Associations between ordinal or continuous variables were evaluated using Spearman’s rank correlation coefficient (ρ). An Exploratory Factor Analysis (EFA) with Varimax rotation was performed to identify latent constructs underlying the ethics and legal perception items. Sampling adequacy for factor analysis was confirmed with the Kaiser–Meyer–Olkin (KMO) measure (0.75) and Bartlett’s test of sphericity (p < 0.001). Items with factor loadings ≥ 0.40 were retained in the final factor structure. Internal consistency of each derived factor was assessed using Cronbach’s alpha (α). A two-tailed p-value < 0.05 was considered statistically significant. Ethical Considerations The study was conducted in accordance with the principles of the Declaration of Helsinki. All participants provided informed consent through the online consent checkbox before accessing the questionnaire. Participation was voluntary, and no incentives were offered. The survey was anonymous, and data were stored on a password-protected server accessible only to the research team. Ethical approval for the study was granted by the Board of Directors of EKAB following a positive recommendation from the EKAB Scientific Council. This approval was formally documented in Decision No. 3/17.1.2023 and announced through EKAB Administration Document No. 10369/14.2.2023. Results Participant Characteristics A total of 273 EKAB personnel completed the survey. The sample was balanced by gender (50.2% male, 49.8% female) and most participants were aged 41–50 years (45.1%), followed by 31–40 years (25.6%), over 50 years (20.5%), and under 30 years (8.8%). In terms of education, 30.8% had university-level (UL) degrees, 24.9% Tertiary Education (TE), 44.0% Secondary-level (SE), and 0.4% with only Compulsory schooling requirement (CE) qualifications. Professional roles were predominantly paramedics, with a smaller proportion of nurses and other healthcare staff. Table 1 presents the demographic and professional characteristics of the sample. Table 1 . Demographic and professional characteristics of EKAB personnel (N = 273) Characteristic n (%) Gender Male 137 (50.2) Female 136 (49.8) Age group (years) 50 56 (20.5) Educational level UL (University Level) 84 (30.8) TE (Tertiary Education) 68 (24.9) SE (Secondary Education) 120 (44.0) CE (Compulsory Education) 1 (0.4) Years in service ≤ 5 13 (4.8) 6–15 78 (28.6) 16–25 118 (43.2) > 25 64 (23.4) Exploratory Factor Analysis EFA was conducted on the ethics and legal perception items. The KMO measure was 0.75, indicating sampling adequacy, and Bartlett’s test was significant (χ²=1656.44, df=300, p 1, explaining 60.9%of the total variance: Autonomy and Consent (e.g., obtaining informed consent, respecting patient wishes). Resource Allocation and Triage (e.g., prioritization under scarcity, fair distribution). Confidentiality vs Public Health (e.g., balancing privacy with contact tracing). Duty and Reciprocity (e.g., professional responsibility during personal risk). Items with loadings ≥ 0.40 were retained. Cronbach’s alpha values for the factors ranged from 0.70-0.85, indicating acceptable to good internal consistency. Table 2 shows the factor loadings and reliability coefficients. The analysis yielded four factors with eigenvalues > 1, explaining 60.9% of the total variance: (1) Autonomy and Consent (e.g., obtaining informed consent, respecting patient wishes), (2) Resource Allocation and Triage (e.g., prioritization under scarcity, fair distribution), (3) Confidentiality vs Public Health (e.g., balancing privacy with contact tracing), and (4) Duty and Reciprocity (e.g., professional responsibility during personal risk). Visual inspection of the scree plot confirmed an inflection point after the fourth factor, supporting the decision to retain four factors. Table 2. Factor structure of the ethics and legal perception scale Item Factor 1: Autonomy & Consent Factor 2: Resource Allocation & Triage Factor 3: Confidentiality vs Public Health Factor 4: Duty & Reciprocity Obtain consent before interventions 0.72 Respect patient’s refusal of treatment 0.68 Ensure patient is informed of all options 0.65 Allocate resources to most urgent cases 0.74 Follow triage protocols in mass casualty events 0.69 Consider fairness when prioritizing care 0.66 Maintain confidentiality in field settings 0.71 Share patient data for public health reporting 0.67 Protect sensitive patient information during emergencies 0.64 Continue duty despite personal risk 0.76 Expect institutional protection in high-risk work 0.70 Fulfil responsibilities regardless of workload pressures 0.68 Eigenvalue 4.12 3.28 2.45 1.91 Variance explained (%) 25.3 18.2 10.1 7.3 Cumulative variance (%) 25.3 43.5 53.6 60.9 Cronbach’s α 0.85 0.82 0.78 0.70 Group Comparisons Mann–Whitney U and Kruskal–Wallis H tests revealed significant differences in factor scores by age group and educational level. Personnel aged over 50 scored significantly higher on Duty and Reciprocity compared to younger groups (p = 0.02). University graduates scored higher on Autonomy and Consent compared to those with secondary education (p = 0.03). No significant differences were observed between male and female participants on any factor (p > 0.05). Table 3 summarizes the key group comparisons. Table 3 . Group differences in ethics factor scores by demographic characteristics Factor Demographic Variable Groups compared Median (IQR) – Group 1 Median (IQR) – Group 2 / All Groups Test statistic p -value Autonomy & Consent Education level UL (University) 4.60 (4.20–4.80) 4.40 (4.00–4.60) (non-UL) U= 2290.5 0.030 Duty & Reciprocity Age group > 50 years 4.70 (4.40–4.90) 4.50 (4.20–4.70) (≤50 years) H = 7.64 0.022 Resource Allocation & Triage Gender Male 4.30 (4.00–4.50) 4.40 (4.00–4.80) (Female) U= 4527.0 0.188 Age group ≤ 30: 4.30 (4.00–4.80) 31–40: 4.30 (4.00–4.80); 41–50: 4.40 (4.00–4.80); > 50: 4.30 (4.00–4.80) H = 1.66 0.645 Education level UL: 4.30 (4.00–4.80) TE: 4.40 (4.00–4.80); SE: 4.30 (4.00–4.80); CE: 4.30 (4.00–4.80) H = 0.46 0.926 Confidentiality vs Public Health Gender Male 4.50 (4.20–4.80) 4.50 (4.20-4.80) (Female) U=4598.0 0.861 Correlation Analysis Spearman’s rank correlations indicated moderate positive associations between: Autonomy and Consent and Confidentiality vs Public Health (ρ = 0.522, p < 0.01). Duty and Reciprocity and Resource Allocation/Triage (ρ = 0.465, p < 0.01). Discussion This study provides empirical evidence on the ethical and legal perceptions of prehospital emergency providers in Greece, focusing on the dual pressures of the prolonged financial crisis and the COVID-19 pandemic. Using a validated survey instrument and exploration factor analysis, we identified four underlying dimensions of ethical perception: Autonomy and Consent, Resource Allocation and Triage, Confidentiality vs Public Health, and Duty and Reciprocity, that together explained 60.9% of variance in responses. The high internal consistency of these factors indicates they capture coherent and relevant constructs in the ethical landscape of emergency medical services (EMS). The prominence of Autonomy and Consent as a factor reflects the centrality of patient rights in EMS practice, even in crisis conditions. Similar findings have been reported in studies where prehospital providers prioritized obtaining consent and respecting patient decisions despite operational pressures [ 15 , 16 ]. In the Greek context, legal frameworks such as Law 2071/1992 on patients’ rights and subsequent legislation (e.g., Law 2619/1998 implementing the Convention on Human Rights and Biomedicine) explicitly enshrine informed consent as a non-negotiable standard, granting patients the right to accept, refuse, or withdraw consent at any time [ 17 ]. This statutory emphasis reinforces the ethical imperative observed in our study, where autonomy was highly valued. Our data further show that university-educated participants scored significantly higher on this dimension, suggesting that formal academic training, which typically includes structured bioethics education, may enhance ethical sensitivity towards patient autonomy. This resonates with comparative international findings, where higher education is linked to greater adherence to patient rights in prehospital care. Resource Allocation and Triage emerged as the second major factor, highlighting the ethical weight of distributive justice in EMS. Although our study found no demographic differences on this dimension, the median scores were consistently high, indicating a strong shared commitment to fairness in resource-scarce situations. This aligns with triage ethics literature from mass casualty incidents and pandemics [ 18 , 19 ], where EMS personnel are often the first to operationalize prioritization protocols under extreme pressure. International bioethical frameworks, such as the World Medical Association’s guidance on disaster ethics, stress that triage decisions must balance utility (maximizing survival) with fairness and respect for vulnerable groups [ 20 ]. In the Greek context, emergency medical planning is guided by both national disaster response policies and ethical principles embedded in healthcare law, which emphasize equity in access to care even under crisis conditions. The COVID-19 pandemic provided a contemporary illustration, as EMS systems worldwide faced acute resource limitations that required transparent, ethically justified triage processes to maintain trust [ 21 ]. Our findings suggest that EMS providers internalize these distributive justice principles, treating fairness in resource allocation not as an abstract norm but as a core professional duty. The third factor, Confidentiality vs Public Health, reflects the ethical tension between protecting patient privacy and fulfilling public health duties, a challenge intensified during COVID-19, where contact tracing and mandatory reporting could conflict with confidentiality norms [ 22 ]. The moderate correlation between Autonomy and Consent, and confidentiality versus public health in our data suggests that providers who value patient autonomy also tend to emphasize privacy protections, reinforcing the interdependence of these ethical domains. This interdependence highlights the complex ethical challenges that healthcare professionals face during crises Protecting public health may necessitate temporary limitations on individual liberties, yet such measures can damage patient trust if not accompanied by clear communication, appropriate safeguards, and accountability mechanisms. Reconstructing trust, once it has been compromised, is challenging, and its absence can significantly reduce public adherence to health policies, thereby thwarting the objectives those policies intend to accomplish [ 23 ]. Previous studies have shown that trust is crucial for achieving compliance with public health directives, especially when interventions are viewed as equitable, transparent, and mindful of individual autonomy [ 24 ]. Additionally, ethical decision-making in this context involves more than just a simple choice between privacy and safety; it requires a careful examination of long-term relationships among healthcare providers, patients, and communities, as well as the sociocultural and institutional frameworks in which these relationships are situated [ 25 ]. Thus, nurturing trust is not just an ethical obligation but also a vital strategy for maintaining public health resilience in future crises [ 26 ]. Finally, Duty and Reciprocity, the sense of professional obligation despite personal risk, was rated significantly higher by older participants. This may reflect generational differences in risk perception or professional identity, as seen in previous research on moral duty in high-risk healthcare contexts [ 27 , 28 ]. The correlation between this factor and Resource Allocation and Triage suggests that a strong sense of duty is linked to readiness to make difficult allocation decisions in the field. This relationship highlights how professional identity and moral frameworks shape responses to scarcity and crisis. A heightened sense of duty may provide psychological resilience when navigating morally distressing situations such as triage, where every decision carries profound ethical weight. However, it may also increase the risk of moral injury if providers perceive their sacrifices as unsupported or unreciprocated by institutions and society. Prior literature emphasizes that reciprocity, through adequate protection, institutional support, and recognition, is essential for sustaining healthcare workers’ willingness to accept personal risk and make ethically challenging decisions [ 29 ]. Strengthening this reciprocity could therefore not only safeguard provider well-being but also enhance the fairness and sustainability of crisis responses. Our findings resonate with international research on EMS ethics. A study from another European country during the COVID-19 pandemic reported similar clusters of ethical concern, autonomy, resource allocation, confidentiality, and duty [ 30 ]. However, the Greek setting adds the overlay of a long-term economic crisis, which, as others have noted, can amplify ethical strain by compounding resource shortages and limiting institutional support [ 31 ]. The persistence of high scores across all factors despite this context may indicate a resilient ethical culture within EKAB, though the potential for moral distress should not be underestimated. The interplay between systemic constraints and individual ethical commitments underscores the importance of institutional support in sustaining ethical practice. Research has shown that without adequate organizational frameworks, providers are more likely to experience moral distress, burnout, and ethical erosion over time [ 32 , 33 ]. In Greece, where EMS personnel face chronic underfunding and workforce shortages, the resilience demonstrated in this study may reflect personal commitment rather than structural reinforcement. Strengthening ethics training, establishing clear guidelines for crisis triage, and ensuring psychosocial support mechanisms could help mitigate the cumulative strain of prolonged crises on emergency providers. Moreover, the findings highlight the need for ongoing ethics education that extends beyond initial academic training. While formal education appears to foster greater sensitivity to autonomy, continuous professional development can enhance providers’ capacity to navigate the complex, dynamic dilemmas that emerge in prehospital care. Evidence suggests that scenario-based ethics training and interprofessional workshops improve both ethical awareness and decision-making confidence in high-pressure environments [ 32 , 33 ]. Integrating such programs into EMS systems in Greece could reinforce the ethical culture already present, while also equipping providers to handle future crises with clarity and resilience. Health Policy Implications The identification of four clear ethical dimensions has direct implications for EMS policy and training. First, targeted ethics education can be aligned with these domains, ensuring that EMS providers are prepared to navigate autonomy, allocation, confidentiality, and duty in both routine and crisis operations. Second, institutional policies should provide explicit guidance on managing privacy in public health emergencies and offer protections for staff facing personal risk. Finally, integrating ethics debriefings into post-incident reviews could help mitigate moral distress and reinforce shared professional values [ 32 , 33 ]. Strengths and Limitations Strengths of this study include the use of a validated, psychometrically tested instrument, the relatively large sample size, and the application of factor analysis to identify latent ethical constructs. Furthermore, this is the first study of its kind to be conducted in the nearly 40 years of EKAB’s operation. Limitations include the cross-sectional design, which precludes causal inferences, and the reliance on self-reported attitudes and practices, which may be subject to social desirability bias. In addition, although both ambulance crew and administrative staff participated, the sample was predominantly composed of ambulance personnel, which may limit the representativeness of perspectives across all EKAB staff categories. Finally, the online survey format may have excluded less digitally literate staff. Future Research Future studies should examine how these ethical dimensions evolve, particularly in response to changes in crisis intensity or healthcare policy. Qualitative research could complement these findings by exploring how EMS providers interpret and apply ethical principles in specific, high-stakes incidents. Comparative studies between Greek EMS and services in other crisis-affected countries could further illuminate cultural and systemic influences on ethical decision-making. Conclusion Prehospital emergency providers in Greece operate at the intersection of urgent clinical care and complex ethical decision-making. This study, conducted during the overlapping pressures of a prolonged financial crisis and a global pandemic, identifies four key domains of ethical perception, Autonomy and Consent, Resource Allocation and Triage, Confidentiality vs Public Health, and Duty and Reciprocity. These domains capture the core tensions that paramedical personnel face when balancing patient rights, equitable care, public health responsibilities, and personal risk. The findings demonstrate that, despite severe systemic constraints, EKAB personnel maintain a strong commitment to fundamental ethical principles. However, they also highlight areas where targeted training, institutional support, and clear policy frameworks could further strengthen ethical practice, reduce moral distress, and safeguard both providers and patients. By explicitly integrating these domains into EMS education and operational planning, prehospital systems can build resilience against future crises, whether economic, epidemiologic, or environmental, and ensure that ethical integrity remains central to emergency care delivery. Abbreviations • EKAB Hellenic National Center of Emergency Care • EMS Emergency Medical Services • EFA Exploratory Factor Analysis • KMO Kaiser–Meyer–Olkin (measure of sampling adequacy) • SPSS Statistical Package for the Social Sciences • UL University Level • TE Tertiary Education • SE Secondary Education • CE Compulsory Education • df degrees of freedom Declarations Ethics approval and consent to participate : The study was conducted in accordance with the ethical principles of the Declaration of Helsinki. Ethical approval was granted by the Board of Directors of EKAB following a positive recommendation from the EKAB Scientific Council (Decision No. 3/17.1.2023; Administration Document No. 10369/14.2.2023). All participants provided informed consent electronically prior to survey participation. Consent for publication: Not applicable Availability of data and materials: The datasets generated and/or analysed during the current study are available from the corresponding author on reasonable request. Competing interests: The authors declare that they have no competing interests. Funding: This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Authors' contributions: Aristomenis I. Syngelakis : Conceptualisation, Study design, methodology, supervision, drafting, critical revision. Chrysoula Tsakalou : Conceptualisation, methodology, Data collection, analysis. Maria Myrto Solomou : Interpretation of data, literature review, writing and critical revision. Chrystala Charalambous : Data analysis, results interpretation, critical revision. Aikaterini Toska : Instrument validation, methodology. 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PMID: 33807977; PMCID: PMC7967340. Bakewell F, Pauls MA, Migneault D. (2022). Ethical considerations of the duty to care and physician safety in the COVID-19 pandemic. CJEM , 24(4):407–410. Berlinger N, Wynia M, Powell T, et al. (2020). Ethical framework for health care institutions responding to novel coronavirus SARS-CoV-2 (COVID-19). The Hastings Center. Rimon A, Shelef L. Moral Injury Among Medical Personnel and First Responders Across Different Healthcare and Emergency Response Settings: A Narrative Review. Int J Environ Res Public Health. 2025 Jun 30;22(7):1055. doi: 10.3390/ijerph22071055. PMID: 40724122; PMCID: PMC12294130. Xafis V, Schaefer GO, Labude MK, Zhu Y, Hsu LY. (2020). The perfect moral storm: diverse ethical considerations in the COVID-19 pandemic. Asian Bioethics Review , 12:65–83. Ifanti AA, Argyriou AA, Kalofonou FH, Kalofonos HP. (2013). Financial crisis and austerity measures in Greece: their impact on health promotion policies and public health care. Health Policy , 113(1–2):8–12. Morley G, Grady C, McCarthy J, Ulrich CM. (2020). COVID-19: Ethical challenges for nurses. Hastings Center Report , 50(3):35–39. Epstein EG, Hamric AB. (2009). Moral distress, moral residue, and the crescendo effect. Journal of Clinical Ethics , 20(4):330–342. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7474617","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":530522295,"identity":"7f268975-93d0-47a1-85de-d81af5ae6609","order_by":0,"name":"Aristomenis I. 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16:32:12","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":948923,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7474617/v1/ffab367d-2453-4436-affd-d80b3a649fce.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Ethical Challenges and Responses Among Prehospital Emergency Providers (EKAB) During the Financial Crisis and COVID-19: Health Policy Implications of a Cross- Sectional Study","fulltext":[{"header":"Background","content":"\u003cp\u003eThe delivery of prehospital emergency care is inherently shaped by ethical decision-making under conditions of uncertainty, urgency, and limited resources. Paramedics and other prehospital providers must navigate complex situations in which clinical imperatives intersect with ethical principles such as autonomy, beneficence, non-maleficence, and justice. In Greece, this ethical terrain has been further complicated by two major societal stressors in recent years: the prolonged financial crisis that began in 2009 and the COVID-19 pandemic that emerged in early 2020. Both crises have intensified the demands placed on the Hellenic National Center of Emergency Care (EKAB), altering the resources available, the clinical priorities in the field, and the moral pressures on personnel [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe Greek financial crisis led to sustained austerity measures, reduced public spending, and material shortages in healthcare [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. For prehospital services, these constraints translated into older ambulance fleets, staff shortages, and limited access to updated medical equipment and protective gear [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Such systemic pressures not only compromised operational capacity but also created ethical dilemmas related to triage, equitable allocation of scarce resources, and maintaining quality of care when the means to do so were curtailed. The principle of justice, fair distribution of benefits and burdens, became particularly salient, as providers were often required to make rapid decisions about which patients to prioritize in the context of competing demands [\u003cspan additionalcitationids=\"CR5\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe onset of the COVID-19 pandemic superimposed a global public-health emergency onto this already fragile context. For EKAB personnel, the pandemic introduced additional ethical challenges: balancing duty of care with personal safety, applying infection-control measures in uncontrolled environments, and communicating with patients under physical distancing or PPE constraints. Decision-making in the field was further complicated by evolving guidelines, uncertainty about viral transmission risks, and heightened emotional stress, factors known to influence moral judgement and the potential for moral distress among healthcare providers [\u003cspan additionalcitationids=\"CR8\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e\u003cp\u003ePrehospital settings are distinct from hospital environments in ways that amplify certain ethical tensions. Ambulance crews often operate with incomplete clinical information, limited time for deliberation, and without direct access to supervising physicians. This makes informed consent more challenging, as patients may be unable or unwilling to engage in detailed discussions due to distress, altered consciousness, or language barriers. Confidentiality, too, may be compromised in the field when care must be delivered in public or semi-public spaces. The ethical principle of beneficence, acting in the patient\u0026rsquo;s best interest, must often be balanced against non-maleficence when interventions carry risks that cannot be fully explained or mitigated in the moment [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eAlthough the literature on healthcare ethics in crisis situations is substantial, much of it focuses on hospital-based or policy-level decision-making. Research on the ethical experiences and attitudes of prehospital emergency providers, particularly in the Greek context, remains scarce. Available studies tend to address discrete topics, such as triage protocols or infection control, rather than providing a broader understanding of how frontline EMS staff perceive and handle ethical and legal issues in daily practice under crisis conditions [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. There is also limited evidence on whether sociodemographic factors (e.g., age, education, professional experience) are associated with differences in ethical perceptions or practices among paramedics.\u003c/p\u003e\u003cp\u003eThe Hellenic National Center of Emergency Care (EKAB) plays a central role in Greece\u0026rsquo;s emergency response system, providing both primary prehospital care and inter-facility transport. EKAB personnel are thus frequently the first point of contact for critically ill or injured patients and are required to make ethically charged decisions in real time. Understanding their perspectives on ethical and legal issues is essential for developing targeted training, guidelines, and institutional support mechanisms that enhance ethical practice and reduce moral distress. Furthermore, in light of recurring crises, economic, epidemiologic, or otherwise, there is a pressing need for empirical data that can inform the ethical preparedness of prehospital systems.\u003c/p\u003e\u003cp\u003eAgainst this backdrop, the present study was designed to explore the knowledge, attitudes, and practices of EKAB staff regarding medical ethics and health law during the combined stressors of the Greek financial crisis and the COVID-19 pandemic. Specifically, it aimed to: (1) assess the extent to which EKAB personnel encounter ethical and legal issues in their work; (2) examine their attitudes towards selected bioethical topics, including informed consent, organ donation, and respecting patient wishes; and (3) evaluate how these issues are addressed in practice. By employing a structured questionnaire and psychometric analysis, the study also sought to identify underlying dimensions of ethical perception among EMS providers. The findings may support the design of educational interventions, policy updates, and operational protocols that strengthen ethical decision-making in prehospital care.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eWe conducted a cross-sectional, descriptive study using an online survey to assess the knowledge, attitudes, and practices of prehospital emergency personnel regarding ethical and legal issues in their professional practice. The study was implemented within the Hellenic National Center of Emergency Care (EKAB) of Greece, which provides primary prehospital care and inter-facility patient transport nationwide. Data collection took place from 15 February 2023 to 30 April 2023, during a period spanning the COVID-19 pandemic and the later phase of the Greek financial crisis, both of which had significant operational and ethical implications for the service. The target population comprised personnel employed at EKAB Athens, specifically within the categories of Ambulance Crew and Administrative Staff. The latter group predominantly consisted of former ambulance crew members who had transitioned to administrative posts through internal transfers to equivalent or higher service categories.\u003c/p\u003e\u003cp\u003e Eligibility was defined as current employment in one of these categories during the study period and provision of informed consent to participate. Participants were recruited through internal EKAB communication channels and invited to complete the survey electronically.\u003c/p\u003e\u003cp\u003eParticipants were recruited through internal EKAB communication channels and invited to complete the survey electronically. A total of 273 healthcare professionals responded and met the inclusion criteria. The sample included both men (n\u0026thinsp;=\u0026thinsp;137) (50.2%) and women (n\u0026thinsp;=\u0026thinsp;136) (49.8%), with most respondents aged 41\u0026ndash;50 years (n\u0026thinsp;=\u0026thinsp;123) (45.1%), and varying educational backgrounds (30.8% university graduates, 24.9% technical college graduates, 44.0% secondary education, 0.4% postgraduate qualifications).\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eSurvey tool\u003c/h2\u003e\u003cp\u003eA structured questionnaire divided into two parts was used for the study. The first part included the sociodemographic and professional characteristics of the participants. The second part consisted of a validated instrument on ethical challenges in emergency medical services, which had been originally developed in English. Subsequently, it was translated and standardized into Greek by Toska et al. (2021) [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Permission for the use of the Greek version was formally obtained from the original author, and for this study, the translated version was employed without modification. The instrument also contained an electronic consent checkbox that participants were required to select before proceeding, ensuring voluntary participation. The survey was hosted on a secure online platform and remained open for responses over a defined collection period. Participation was anonymous; no identifying personal or professional data were collected beyond the sociodemographic descriptors. The implementation of the study followed the established official practice for similar studies which take place in EKAB.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\u003ch2\u003eStatistical Analysis\u003c/h2\u003e\u003cp\u003eAll analyses were performed using IBM SPSS Statistics version 26.0 (IBM Corp., Armonk, NY, USA). Continuous variables were assessed for normality using the Kolmogorov\u0026ndash;Smirnov test. Data are presented as means with standard deviations for normally distributed variables and medians with interquartile ranges for non-normal distributions. Categorical variables are reported as absolute frequencies and percentages.\u003c/p\u003e\u003cp\u003eBetween-group differences in continuous or ordinal outcomes were assessed using the Mann\u0026ndash;Whitney U test for two-group comparisons and the Kruskal\u0026ndash;Wallis H test for comparisons involving more than two groups. Associations between ordinal or continuous variables were evaluated using Spearman\u0026rsquo;s rank correlation coefficient (ρ).\u003c/p\u003e\u003cp\u003eAn Exploratory Factor Analysis (EFA) with Varimax rotation was performed to identify latent constructs underlying the ethics and legal perception items. Sampling adequacy for factor analysis was confirmed with the Kaiser\u0026ndash;Meyer\u0026ndash;Olkin (KMO) measure (0.75) and Bartlett\u0026rsquo;s test of sphericity (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Items with factor loadings\u0026thinsp;\u0026ge;\u0026thinsp;0.40 were retained in the final factor structure. Internal consistency of each derived factor was assessed using Cronbach\u0026rsquo;s alpha (α). A two-tailed p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eEthical Considerations\u003c/h3\u003e\n\u003cp\u003e The study was conducted in accordance with the principles of the Declaration of Helsinki. All participants provided informed consent through the online consent checkbox before accessing the questionnaire. Participation was voluntary, and no incentives were offered. The survey was anonymous, and data were stored on a password-protected server accessible only to the research team. Ethical approval for the study was granted by the Board of Directors of EKAB following a positive recommendation from the EKAB Scientific Council. This approval was formally documented in Decision No. 3/17.1.2023 and announced through EKAB Administration Document No. 10369/14.2.2023.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eParticipant Characteristics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of 273 EKAB personnel completed the survey. The sample was balanced by gender (50.2% male, 49.8% female) and most participants were aged 41\u0026ndash;50 years (45.1%), followed by 31\u0026ndash;40 years (25.6%), over 50 years (20.5%), and under 30 years (8.8%). In terms of education, 30.8% had university-level (UL) degrees, 24.9% Tertiary Education (TE), 44.0% Secondary-level (SE), and 0.4% with only Compulsory schooling requirement (CE) qualifications. Professional roles were predominantly paramedics, with a smaller proportion of nurses and other healthcare staff. Table 1 presents the demographic and professional characteristics of the sample.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1\u003c/strong\u003e. Demographic and professional characteristics of EKAB personnel (N = 273)\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 205px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCharacteristic\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e\u003cstrong\u003en (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 205px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 205px;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e137 (50.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 205px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e136 (49.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 205px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge group (years)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 205px;\"\u003e\n \u003cp\u003e\u0026lt; 30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e24 (8.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 205px;\"\u003e\n \u003cp\u003e31\u0026ndash;40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e70 (25.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 205px;\"\u003e\n \u003cp\u003e41\u0026ndash;50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e123 (45.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 205px;\"\u003e\n \u003cp\u003e\u0026gt; 50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e56 (20.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 205px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEducational level\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 205px;\"\u003e\n \u003cp\u003eUL (University Level)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e84 (30.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 205px;\"\u003e\n \u003cp\u003eTE (Tertiary Education)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e68 (24.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 205px;\"\u003e\n \u003cp\u003eSE (Secondary Education)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e120 (44.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 205px;\"\u003e\n \u003cp\u003eCE (Compulsory Education)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e1 (0.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 205px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eYears in service\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 205px;\"\u003e\n \u003cp\u003e\u0026le; 5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e13 (4.8)\u003c/p\u003e\n \u003ctable border=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 205px;\"\u003e\n \u003cp\u003e6\u0026ndash;15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e78 (28.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 205px;\"\u003e\n \u003cp\u003e16\u0026ndash;25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e118 (43.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 205px;\"\u003e\n \u003cp\u003e\u0026gt; 25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e64 (23.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eExploratory Factor Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEFA was conducted on the ethics and legal perception items. The KMO measure was 0.75, indicating sampling adequacy, and Bartlett\u0026rsquo;s test was significant (\u0026chi;\u0026sup2;=1656.44, df=300, p\u0026lt;0.001). The analysis yielded four factors with eigenvalues \u0026gt; 1, explaining 60.9%of the total variance:\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003eAutonomy and Consent (e.g., obtaining informed consent, respecting patient wishes).\u003c/li\u003e\n \u003cli\u003eResource Allocation and Triage (e.g., prioritization under scarcity, fair distribution).\u003c/li\u003e\n \u003cli\u003eConfidentiality vs Public Health (e.g., balancing privacy with contact tracing).\u003c/li\u003e\n \u003cli\u003eDuty and Reciprocity (e.g., professional responsibility during personal risk).\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eItems with loadings \u0026ge; 0.40 were retained. Cronbach\u0026rsquo;s alpha values for the factors ranged from 0.70-0.85, indicating acceptable to good internal consistency. Table 2 shows the factor loadings and reliability coefficients.\u003c/p\u003e\n\u003cp\u003eThe analysis yielded four factors with eigenvalues \u0026gt; 1, explaining 60.9% of the total variance:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e(1) Autonomy and Consent (e.g., obtaining informed consent, respecting patient wishes), (2) Resource Allocation and Triage (e.g., prioritization under scarcity, fair distribution), (3) Confidentiality vs Public Health (e.g., balancing privacy with contact tracing), and (4) Duty and Reciprocity (e.g., professional responsibility during personal risk). Visual inspection of the scree plot confirmed an inflection point after the fourth factor, supporting the decision to retain four factors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2.\u003c/strong\u003e Factor structure of the ethics and legal perception scale\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eItem\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eFactor 1: Autonomy \u0026amp; Consent\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eFactor 2: Resource Allocation \u0026amp; Triage\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eFactor 3: Confidentiality vs Public Health\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eFactor 4: Duty \u0026amp; Reciprocity\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eObtain consent before interventions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.72\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eRespect patient\u0026rsquo;s refusal of treatment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.68\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eEnsure patient is informed of all options\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAllocate resources to most urgent cases\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFollow triage protocols in mass casualty events\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eConsider fairness when prioritizing care\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.66\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMaintain confidentiality in field settings\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.71\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eShare patient data for public health reporting\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eProtect sensitive patient information during emergencies\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.64\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eContinue duty despite personal risk\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.76\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eExpect institutional protection in high-risk work\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.70\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFulfil responsibilities regardless of workload pressures\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.68\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eEigenvalue\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3.28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2.45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.91\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eVariance explained (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e25.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e18.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e10.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e7.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCumulative variance (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e25.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e43.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e53.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e60.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCronbach\u0026rsquo;s \u0026alpha;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.85\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.82\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.78\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.70\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eGroup Comparisons\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMann\u0026ndash;Whitney U and Kruskal\u0026ndash;Wallis H tests revealed significant differences in factor scores by age group and educational level. Personnel aged over 50 scored significantly higher on Duty and Reciprocity compared to younger groups (p = 0.02). University graduates scored higher on Autonomy and Consent compared to those with secondary education (p = 0.03). No significant differences were observed between male and female participants on any factor (p \u0026gt; 0.05). Table 3 summarizes the key group comparisons.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003cstrong\u003eTable 3\u003c/strong\u003e. Group differences in ethics factor scores by demographic characteristics\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"703\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eFactor\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eDemographic Variable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroups compared\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eMedian (IQR) \u0026ndash;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eGroup 1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eMedian (IQR) \u0026ndash;\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eGroup 2 / All Groups\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTest statistic\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ep\u003c/strong\u003e\u003cstrong\u003e-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAutonomy \u0026amp; Consent\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eEducation level\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eUL (University)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4.60 (4.20\u0026ndash;4.80)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4.40 (4.00\u0026ndash;4.60) (non-UL)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eU= 2290.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.030\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eDuty \u0026amp; Reciprocity\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAge group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026gt; 50 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4.70 (4.40\u0026ndash;4.90)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4.50 (4.20\u0026ndash;4.70) (\u0026le;50 years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eH = 7.64\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.022\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eResource Allocation \u0026amp; Triage\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eGender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4.30 (4.00\u0026ndash;4.50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4.40 (4.00\u0026ndash;4.80) (Female)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eU= 4527.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.188\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAge group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026le; 30: 4.30\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(4.00\u0026ndash;4.80)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e31\u0026ndash;40: 4.30 (4.00\u0026ndash;4.80);\u003c/p\u003e\n \u003cp\u003e41\u0026ndash;50: 4.40 (4.00\u0026ndash;4.80);\u003c/p\u003e\n \u003cp\u003e\u0026gt; 50: 4.30 (4.00\u0026ndash;4.80)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eH = 1.66\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.645\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eEducation level\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eUL: 4.30\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(4.00\u0026ndash;4.80)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eTE: 4.40 (4.00\u0026ndash;4.80);\u003c/p\u003e\n \u003cp\u003eSE: 4.30 (4.00\u0026ndash;4.80);\u003c/p\u003e\n \u003cp\u003eCE: 4.30 (4.00\u0026ndash;4.80)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eH = 0.46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.926\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eConfidentiality vs Public Health\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eGender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4.50 (4.20\u0026ndash;4.80)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4.50 (4.20-4.80) (Female)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eU=4598.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.861\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eCorrelation Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSpearman\u0026rsquo;s rank correlations indicated moderate positive associations between:\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003eAutonomy and Consent and Confidentiality vs Public Health (\u0026rho; = 0.522, p \u0026lt; 0.01).\u003c/li\u003e\n \u003cli\u003eDuty and Reciprocity and Resource Allocation/Triage (\u0026rho; = 0.465, p \u0026lt; 0.01).\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study provides empirical evidence on the ethical and legal perceptions of prehospital emergency providers in Greece, focusing on the dual pressures of the prolonged financial crisis and the COVID-19 pandemic. Using a validated survey instrument and exploration factor analysis, we identified four underlying dimensions of ethical perception: Autonomy and Consent, Resource Allocation and Triage, Confidentiality vs Public Health, and Duty and Reciprocity, that together explained 60.9% of variance in responses. The high internal consistency of these factors indicates they capture coherent and relevant constructs in the ethical landscape of emergency medical services (EMS).\u003c/p\u003e\u003cp\u003eThe prominence of Autonomy and Consent as a factor reflects the centrality of patient rights in EMS practice, even in crisis conditions. Similar findings have been reported in studies where prehospital providers prioritized obtaining consent and respecting patient decisions despite operational pressures [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. In the Greek context, legal frameworks such as Law 2071/1992 on patients\u0026rsquo; rights and subsequent legislation (e.g., Law 2619/1998 implementing the Convention on Human Rights and Biomedicine) explicitly enshrine informed consent as a non-negotiable standard, granting patients the right to accept, refuse, or withdraw consent at any time [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. This statutory emphasis reinforces the ethical imperative observed in our study, where autonomy was highly valued. Our data further show that university-educated participants scored significantly higher on this dimension, suggesting that formal academic training, which typically includes structured bioethics education, may enhance ethical sensitivity towards patient autonomy. This resonates with comparative international findings, where higher education is linked to greater adherence to patient rights in prehospital care.\u003c/p\u003e\u003cp\u003eResource Allocation and Triage emerged as the second major factor, highlighting the ethical weight of distributive justice in EMS. Although our study found no demographic differences on this dimension, the median scores were consistently high, indicating a strong shared commitment to fairness in resource-scarce situations. This aligns with triage ethics literature from mass casualty incidents and pandemics [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e], where EMS personnel are often the first to operationalize prioritization protocols under extreme pressure. International bioethical frameworks, such as the World Medical Association\u0026rsquo;s guidance on disaster ethics, stress that triage decisions must balance utility (maximizing survival) with fairness and respect for vulnerable groups [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. In the Greek context, emergency medical planning is guided by both national disaster response policies and ethical principles embedded in healthcare law, which emphasize equity in access to care even under crisis conditions. The COVID-19 pandemic provided a contemporary illustration, as EMS systems worldwide faced acute resource limitations that required transparent, ethically justified triage processes to maintain trust [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Our findings suggest that EMS providers internalize these distributive justice principles, treating fairness in resource allocation not as an abstract norm but as a core professional duty.\u003c/p\u003e\u003cp\u003eThe third factor, Confidentiality vs Public Health, reflects the ethical tension between protecting patient privacy and fulfilling public health duties, a challenge intensified during COVID-19, where contact tracing and mandatory reporting could conflict with confidentiality norms [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. The moderate correlation between Autonomy and Consent, and confidentiality versus public health in our data suggests that providers who value patient autonomy also tend to emphasize privacy protections, reinforcing the interdependence of these ethical domains.\u003c/p\u003e\u003cp\u003eThis interdependence highlights the complex ethical challenges that healthcare professionals face during crises\u003c/p\u003e\u003cp\u003eProtecting public health may necessitate temporary limitations on individual liberties, yet such measures can damage patient trust if not accompanied by clear communication, appropriate safeguards, and accountability mechanisms. Reconstructing trust, once it has been compromised, is challenging, and its absence can significantly reduce public adherence to health policies, thereby thwarting the objectives those policies intend to accomplish [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Previous studies have shown that trust is crucial for achieving compliance with public health directives, especially when interventions are viewed as equitable, transparent, and mindful of individual autonomy [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Additionally, ethical decision-making in this context involves more than just a simple choice between privacy and safety; it requires a careful examination of long-term relationships among healthcare providers, patients, and communities, as well as the sociocultural and institutional frameworks in which these relationships are situated [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Thus, nurturing trust is not just an ethical obligation but also a vital strategy for maintaining public health resilience in future crises [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eFinally, Duty and Reciprocity, the sense of professional obligation despite personal risk, was rated significantly higher by older participants. This may reflect generational differences in risk perception or professional identity, as seen in previous research on moral duty in high-risk healthcare contexts [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. The correlation between this factor and Resource Allocation and Triage suggests that a strong sense of duty is linked to readiness to make difficult allocation decisions in the field. This relationship highlights how professional identity and moral frameworks shape responses to scarcity and crisis. A heightened sense of duty may provide psychological resilience when navigating morally distressing situations such as triage, where every decision carries profound ethical weight. However, it may also increase the risk of moral injury if providers perceive their sacrifices as unsupported or unreciprocated by institutions and society. Prior literature emphasizes that reciprocity, through adequate protection, institutional support, and recognition, is essential for sustaining healthcare workers\u0026rsquo; willingness to accept personal risk and make ethically challenging decisions [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Strengthening this reciprocity could therefore not only safeguard provider well-being but also enhance the fairness and sustainability of crisis responses.\u003c/p\u003e\u003cp\u003eOur findings resonate with international research on EMS ethics. A study from another European country during the COVID-19 pandemic reported similar clusters of ethical concern, autonomy, resource allocation, confidentiality, and duty [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. However, the Greek setting adds the overlay of a long-term economic crisis, which, as others have noted, can amplify ethical strain by compounding resource shortages and limiting institutional support [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. The persistence of high scores across all factors despite this context may indicate a resilient ethical culture within EKAB, though the potential for moral distress should not be underestimated.\u003c/p\u003e\u003cp\u003eThe interplay between systemic constraints and individual ethical commitments underscores the importance of institutional support in sustaining ethical practice. Research has shown that without adequate organizational frameworks, providers are more likely to experience moral distress, burnout, and ethical erosion over time [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. In Greece, where EMS personnel face chronic underfunding and workforce shortages, the resilience demonstrated in this study may reflect personal commitment rather than structural reinforcement. Strengthening ethics training, establishing clear guidelines for crisis triage, and ensuring psychosocial support mechanisms could help mitigate the cumulative strain of prolonged crises on emergency providers.\u003c/p\u003e\u003cp\u003eMoreover, the findings highlight the need for ongoing ethics education that extends beyond initial academic training. While formal education appears to foster greater sensitivity to autonomy, continuous professional development can enhance providers\u0026rsquo; capacity to navigate the complex, dynamic dilemmas that emerge in prehospital care. Evidence suggests that scenario-based ethics training and interprofessional workshops improve both ethical awareness and decision-making confidence in high-pressure environments [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. Integrating such programs into EMS systems in Greece could reinforce the ethical culture already present, while also equipping providers to handle future crises with clarity and resilience.\u003c/p\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003eHealth Policy Implications\u003c/h2\u003e\u003cp\u003eThe identification of four clear ethical dimensions has direct implications for EMS policy and training. First, targeted ethics education can be aligned with these domains, ensuring that EMS providers are prepared to navigate autonomy, allocation, confidentiality, and duty in both routine and crisis operations. Second, institutional policies should provide explicit guidance on managing privacy in public health emergencies and offer protections for staff facing personal risk. Finally, integrating ethics debriefings into post-incident reviews could help mitigate moral distress and reinforce shared professional values [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e].\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eStrengths and Limitations\u003c/h2\u003e\u003cp\u003eStrengths of this study include the use of a validated, psychometrically tested instrument, the relatively large sample size, and the application of factor analysis to identify latent ethical constructs. Furthermore, this is the first study of its kind to be conducted in the nearly 40 years of EKAB\u0026rsquo;s operation.\u003c/p\u003e\u003cp\u003eLimitations include the cross-sectional design, which precludes causal inferences, and the reliance on self-reported attitudes and practices, which may be subject to social desirability bias. In addition, although both ambulance crew and administrative staff participated, the sample was predominantly composed of ambulance personnel, which may limit the representativeness of perspectives across all EKAB staff categories. Finally, the online survey format may have excluded less digitally literate staff.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003eFuture Research\u003c/h2\u003e\u003cp\u003eFuture studies should examine how these ethical dimensions evolve, particularly in response to changes in crisis intensity or healthcare policy. Qualitative research could complement these findings by exploring how EMS providers interpret and apply ethical principles in specific, high-stakes incidents. Comparative studies between Greek EMS and services in other crisis-affected countries could further illuminate cultural and systemic influences on ethical decision-making.\u003c/p\u003e\u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003ePrehospital emergency providers in Greece operate at the intersection of urgent clinical care and complex ethical decision-making. This study, conducted during the overlapping pressures of a prolonged financial crisis and a global pandemic, identifies four key domains of ethical perception, Autonomy and Consent, Resource Allocation and Triage, Confidentiality vs Public Health, and Duty and Reciprocity. These domains capture the core tensions that paramedical personnel face when balancing patient rights, equitable care, public health responsibilities, and personal risk.\u003c/p\u003e\u003cp\u003e The findings demonstrate that, despite severe systemic constraints, EKAB personnel maintain a strong commitment to fundamental ethical principles. However, they also highlight areas where targeted training, institutional support, and clear policy frameworks could further strengthen ethical practice, reduce moral distress, and safeguard both providers and patients. By explicitly integrating these domains into EMS education and operational planning, prehospital systems can build resilience against future crises, whether economic, epidemiologic, or environmental, and ensure that ethical integrity remains central to emergency care delivery.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u0026bull; EKAB\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eHellenic National Center of Emergency Care\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u0026bull; EMS\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eEmergency Medical Services\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u0026bull; EFA\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eExploratory Factor Analysis\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u0026bull; KMO\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eKaiser\u0026ndash;Meyer\u0026ndash;Olkin (measure of sampling adequacy)\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u0026bull; SPSS\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eStatistical Package for the Social Sciences\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u0026bull; UL\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eUniversity Level\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u0026bull; TE\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eTertiary Education\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u0026bull; SE\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eSecondary Education\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u0026bull; CE\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eCompulsory Education\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u0026bull; df\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003edegrees of freedom\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e: The study was conducted in accordance with the ethical principles of the Declaration of Helsinki. Ethical approval was granted by the Board of Directors of EKAB following a positive recommendation from the EKAB Scientific Council (Decision No. 3/17.1.2023; Administration Document No. 10369/14.2.2023). All participants provided informed consent electronically prior to survey participation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u003c/strong\u003e Not applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u003c/strong\u003e The datasets generated and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u003c/strong\u003e The authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' contributions:\u003c/strong\u003e\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003e\u003cstrong\u003eAristomenis I. Syngelakis\u003c/strong\u003e: Conceptualisation, Study design, methodology, supervision, drafting, critical revision.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eChrysoula Tsakalou\u003c/strong\u003e: Conceptualisation, methodology, Data collection, analysis.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eMaria Myrto Solomou\u003c/strong\u003e: Interpretation of data, literature review, writing and critical revision.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eChrystala Charalambous\u003c/strong\u003e: Data analysis, results interpretation, critical revision.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eAikaterini Toska\u003c/strong\u003e: Instrument validation, methodology.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eAspasia Goula\u003c/strong\u003e: supervision, policy implications, critical revision.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eAll authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e: Not applicable\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eEconomou C, Kaitelidou D, Kentikelenis A, et al. The impact of the crisis on the health system and health in Greece. In: Maresso A, Mladovsky P, Thomson S, et al., editors. Economic crisis, health systems and health in Europe: Country experience [Internet]. Copenhagen (Denmark): European Observatory on Health Systems and Policies; 2015. (Observatory Studies Series, No. 41.)\u003c/li\u003e\n \u003cli\u003eBonvin JM, Dembinski P. Ethical issues in financial activities. J Bus Ethics. 2002;37(2):187\u0026ndash;192.\u003c/li\u003e\n \u003cli\u003eKotsiou OS, Srivastava DS, Kotsios P, Exadaktylos AK, Gourgoulianis KI. The Emergency Medical System in Greece: Opening Aeolus\u0026rsquo; Bag of Winds. \u003cem\u003eInternational Journal of Environmental Research and Public Health\u003c/em\u003e. 2018; 15(4):745. https://doi.org/10.3390/ijerph15040745\u003c/li\u003e\n \u003cli\u003eVergano M, Bertolini G, Giannini A, et al. Clinical ethics recommendations for the allocation of intensive care treatments in exceptional, resource-limited circumstances. Crit Care. 2020;24(1):165. doi:10.1186/s13054-020-02891-w.\u003c/li\u003e\n \u003cli\u003eSingh JA, Moodley K. Critical care triaging in the shadow of COVID-19: ethics considerations. S Afr Med J. 2020;110(5):355\u0026ndash;359.\u003c/li\u003e\n \u003cli\u003eEmanuel EJ, Persad G, Upshur R, et al. Fair Allocation of Scarce Medical Resources in the Time of Covid-19.\u0026nbsp;\u003cem\u003eN Engl J Med\u003c/em\u003e. 2020;382(21):2049-2055. doi:10.1056/NEJMsb2005114\u003c/li\u003e\n \u003cli\u003eBakewell F, Pauls MA, Migneault D. Ethical considerations of the duty to care and physician safety in the COVID-19 pandemic. CJEM. 2022;24(4):407\u0026ndash;410.\u003c/li\u003e\n \u003cli\u003eBerlinger N, Wynia M, Powell T, et al. Ethical framework for health care institutions responding to novel coronavirus SARS-CoV-2 (COVID-19). The Hastings Center; 2020.\u003c/li\u003e\n \u003cli\u003eWorld Health Organization. Novel Coronavirus (2019-nCoV) Situation Report \u0026ndash; 13. Geneva: WHO; Feb 2, 2020.\u003c/li\u003e\n \u003cli\u003eSouza SED, Jeelani G, Leena Q. Patient rights: a study on patient\u0026rsquo;s knowledge and nurse\u0026rsquo;s practice in a multispecialty teaching hospital. Int Educ Res J. 2016:25\u0026ndash;26.\u003c/li\u003e\n \u003cli\u003eTruog RD, Mitchell C, Daley GQ. The toughest triage\u0026mdash;allocating ventilators in a pandemic. N Engl J Med. 2020. doi:10.1056/NEJMp2005689.\u003c/li\u003e\n \u003cli\u003eXafis V, Schaefer GO, Labude MK, Zhu Y, Hsu LY. The perfect moral storm: diverse ethical considerations in the COVID-19 pandemic. Asian Bioeth Rev. 2020;12:65\u0026ndash;83. doi:10.1007/s41649-020-00125-3.\u003c/li\u003e\n \u003cli\u003eKr\u0026uuml;tli P, Rosemann T, T\u0026ouml;rnblom KY, Smieszek T. How to fairly allocate scarce medical resources: ethical argumentation under scrutiny. PLoS One. 2016;11(7):e0159086.\u003c/li\u003e\n \u003cli\u003eToska A, Pantazopoulos I, Kiekkas P, Staikou C, Karanikolas M. Ethical challenges in prehospital emergency care: Development and validation of a Greek version of an international questionnaire.\u0026nbsp;\u003cem\u003eArch Hell Med\u003c/em\u003e. 2022;39(1):63\u0026ndash;72.\u003c/li\u003e\n \u003cli\u003eSalavrakos I. (2015).\u0026nbsp;\u003cem\u003eEthics and Law in Medicine\u003c/em\u003e. Athens: Papazisis Publications\u003c/li\u003e\n \u003cli\u003eAvramidis E. (2018). The principle of consent in medical practice.\u0026nbsp;\u003cem\u003eMedical Deontology\u003c/em\u003e, 25(1):12\u0026ndash;20.\u003c/li\u003e\n \u003cli\u003eHellenic Republic. Law 2071/1992: Modernisation and organisation of the Health System. Government Gazette A 123/15.7.1992.\u003c/li\u003e\n \u003cli\u003eHick JL, Hanfling D, Wynia MK, Pavia AT. (2020). Duty to plan: health care, crisis standards of care, and novel coronavirus SARS-CoV-2.\u0026nbsp;\u003cem\u003eNAM Perspectives\u003c/em\u003e. doi:10.31478/202003b.\u003c/li\u003e\n \u003cli\u003eVergano M, Bertolini G, Giannini A, et al. (2020). Clinical ethics recommendations for the allocation of intensive care treatments in exceptional, resource-limited circumstances.\u0026nbsp;\u003cem\u003eCritical Care\u003c/em\u003e, 24:165.\u003c/li\u003e\n \u003cli\u003eWMA (2024) Archived: WMA Statement on Medical Ethics in the Event of Disasters. Available at: https://www.wma.net/policies-post/wma-statement-on-medical-ethics-in-the-event-of-disasters/\u003c/li\u003e\n \u003cli\u003eKucewicz-Czech, E., \u0026amp; Damps, M. (2020). Triage during the COVID-19 pandemic. Anaesthesiology intensive therapy, 52(4), 312\u0026ndash;315. https://doi.org/10.5114/ait.2020.100564\u003c/li\u003e\n \u003cli\u003eBeauchamp TL, Childress JF. (2013).\u0026nbsp;\u003cem\u003ePrinciples of Biomedical Ethics\u003c/em\u003e. 7th ed. Oxford University Press.\u003c/li\u003e\n \u003cli\u003eLindholt, M. F., J\u0026oslash;rgensen, F., Bor, A., \u0026amp; Petersen, M. B. (2021). Public acceptance of COVID-19 vaccines: cross-national evidence on levels and individual-level predictors using observational data. BMJ open, 11(6), e048172. https://doi.org/10.1136/bmjopen-2020-048172\u003c/li\u003e\n \u003cli\u003eBavel JJV, Baicker K, Boggio PS, Capraro V, Cichocka A, Cikara M, Crockett MJ, et al. Using social and behavioural science to support COVID-19 pandemic response. Nat Hum Behav. 2020 May;4(5):460-471. doi: 10.1038/s41562-020-0884-z. Epub 2020 Apr 30. PMID: 32355299.\u003c/li\u003e\n \u003cli\u003eO\u0026apos;Malley, P., Rainford, J., \u0026amp; Thompson, A. (2009). Transparency during public health emergencies: from rhetoric to reality. Bulletin of the World Health Organization, 87(8), 614\u0026ndash;618. https://doi.org/10.2471/blt.08.056689\u003c/li\u003e\n \u003cli\u003eAyalon L. Trust and Compliance with COVID-19 Preventive Behaviors during the Pandemic. Int J Environ Res Public Health. 2021 Mar 5;18(5):2643. doi: 10.3390/ijerph18052643. PMID: 33807977; PMCID: PMC7967340.\u003c/li\u003e\n \u003cli\u003eBakewell F, Pauls MA, Migneault D. (2022). Ethical considerations of the duty to care and physician safety in the COVID-19 pandemic.\u0026nbsp;\u003cem\u003eCJEM\u003c/em\u003e, 24(4):407\u0026ndash;410.\u003c/li\u003e\n \u003cli\u003eBerlinger N, Wynia M, Powell T, et al. (2020). Ethical framework for health care institutions responding to novel coronavirus SARS-CoV-2 (COVID-19). The Hastings Center.\u003c/li\u003e\n \u003cli\u003eRimon A, Shelef L. Moral Injury Among Medical Personnel and First Responders Across Different Healthcare and Emergency Response Settings: A Narrative Review. Int J Environ Res Public Health. 2025 Jun 30;22(7):1055. doi: 10.3390/ijerph22071055. PMID: 40724122; PMCID: PMC12294130.\u003c/li\u003e\n \u003cli\u003eXafis V, Schaefer GO, Labude MK, Zhu Y, Hsu LY. (2020). The perfect moral storm: diverse ethical considerations in the COVID-19 pandemic.\u0026nbsp;\u003cem\u003eAsian Bioethics Review\u003c/em\u003e, 12:65\u0026ndash;83.\u003c/li\u003e\n \u003cli\u003eIfanti AA, Argyriou AA, Kalofonou FH, Kalofonos HP. (2013). Financial crisis and austerity measures in Greece: their impact on health promotion policies and public health care.\u0026nbsp;\u003cem\u003eHealth Policy\u003c/em\u003e, 113(1\u0026ndash;2):8\u0026ndash;12.\u003c/li\u003e\n \u003cli\u003eMorley G, Grady C, McCarthy J, Ulrich CM. (2020). COVID-19: Ethical challenges for nurses.\u0026nbsp;\u003cem\u003eHastings Center Report\u003c/em\u003e, 50(3):35\u0026ndash;39.\u003c/li\u003e\n \u003cli\u003eEpstein EG, Hamric AB. (2009). Moral distress, moral residue, and the crescendo effect.\u0026nbsp;\u003cem\u003eJournal of Clinical Ethics\u003c/em\u003e, 20(4):330\u0026ndash;342.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Prehospital care, medical ethics, emergency medical services, Greece, COVID-19, financial crisis","lastPublishedDoi":"10.21203/rs.3.rs-7474617/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7474617/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003ePrehospital emergency medical services (EMS) operate at the intersection of rapid clinical decision-making and complex ethical demands. In Greece, the prolonged financial crisis and the COVID-19 pandemic have intensified ethical challenges for the Hellenic National Center of Emergency Care (EKAB), creating a need for empirical data to inform training and policy.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eObjective: \u003c/strong\u003eTo assess the knowledge, attitudes, and practices of EKAB personnel regarding ethical and legal issues in their professional practice, and to identify underlying dimensions of ethical perception.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e A validated 32-item structured anonymous online questionnaire was administered to EKAB staff directly involved in patient care. The first part included items on sociodemographic and professional characteristics, while the second part assessed perceptions regarding ethics and deontology in prehospital care. Data collection took place during the later phase of the Greek financial crisis and amidst the COVID-19 pandemic\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eA total of 273 participants (50.2% male; mean age range 41-50 years) completed the survey. EFA yielded four factors, Autonomy and Consent, Resource Allocation and Triage, Confidentiality vs Public Health, and Duty and Reciprocity, explaining 60.9% of total variance (KMO=0.75; Bartlett’s χ²=1656.44, df=300, p\u0026lt;0.001; α=0.70–0.85). Higher Autonomy and Consent scores were observed among university-educated staff (p = 0.030), and higher Duty and Reciprocity scores among those \u0026gt; 50 years (p=0.022). Significant positive correlations were found between Autonomy and Consent and Confidentiality vs Public Health (ρ=0.522, p\u0026lt;0.01) and between Duty and Reciprocity and Resource Allocation and Triage (ρ=0.465, p\u0026lt;0.01).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003eEKAB personnel demonstrate strong ethical commitments across four key domains, despite working under dual crisis conditions (economic crisis and COVID-19 pandemic). These findings provide a framework for targeted ethics education, policy development, and institutional support to strengthen ethical decision-making in prehospital care.\u003c/p\u003e","manuscriptTitle":"Ethical Challenges and Responses Among Prehospital Emergency Providers (EKAB) During the Financial Crisis and COVID-19: Health Policy Implications of a Cross- Sectional Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-17 16:35:01","doi":"10.21203/rs.3.rs-7474617/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"f231998e-0fe6-48ad-8b54-036241bd8811","owner":[],"postedDate":"October 17th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-12-11T04:23:42+00:00","versionOfRecord":[],"versionCreatedAt":"2025-10-17 16:35:01","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7474617","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7474617","identity":"rs-7474617","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}