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

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<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 > 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.