This study investigated the ethical challenges and problems in the collaboration between VFRs and EMS professionals as described by prehospital clinicians.

Ethical principles

The four moral principles in biomedical ethics are described as "(1) Respect for autonomy (the obligation to respect the decision-making capacities of autonomous persons), Non-maleficence (the obligation to avoid causing harm), (3) Beneficence (obligations to provide benefits and to balance benefits against risks) and (4) Justice (obligations of fairness in the distribution of benefits and risks)" [27, 28]. These principles are universally applicable and should function as guidelines for professional ethics [27].

In this context, we identified three overarching categories: Ethical challenges concerning the patients, Ethical challenges concerning collaboration with Volunteer First Responders, and Ethical challenges concerning EMS personnel.

Ethical challenges concerning the patients

The prehospital clinicians in our study found the missing patient consent to the presence of VFRs problematic. The principles of biomedical ethics state the necessity of patients receiving relevant information to understand and assess possible consequences [27]. The patients and health professionals must share a mutual understanding of the terms of authorisation before proceeding with any actions, and the patients' autonomous wishes must be respected [27]. While the prehospital clinicians were concerned about the ethical dilemmas surrounding volunteers entering patients' homes, the European Resuscitation Council values the potential of saving lives higher than the ethical dilemma of the breach of privacy [29].

A study by Dainty et al. [30] concluded that approximately 85% of the study population had no problem receiving CPR from volunteers in their private homes. To our knowledge, no studies have investigated patients' attitudes toward receiving help from volunteers in cases other than OHCA. Breaching of the patient´s privacy by VFRs entering a patient´s home in other cases than OHCA, for example in a case of vaginal bleeding, was the main concern of the prehospital clinicians.

The concept of training and skills among VFRs was also highlighted. As in our study, Dainty et al. [30] reported concern among the study population about receiving help from volunteers who lack training and skills. This finding is relevant to the Danish setting, where there is no requirement for CPR training in the HeartRunner program. The Community First Responder program, on the other hand, requires a first aid course, but our prehospital clinicians still reported a lack of skills in cases other than OHCA.

Beauchamp and Childress refer to the individual right to give other people access to personal information. Even though others may get to know that someone is sick, it will violate the privacy of the person concerned if details about the disease are exposed [27]. This topic was a concern to our prehospital clinicians who reported experiences of volunteers disclosing personal and sensitive information to others, thereby violating their duty of confidentiality. A study by Nabecker et al. [31] described volunteers experiencing difficulties with questions from community citizens after VFR tasks. Confidentiality is a "prima facie" in ethics [27]. The potential for breaches of confidentiality should therefore be addressed in future research.

In our study, prehospital clinicians believed Community First Responders were summoned to many tasks where the Community First Responders did not contribute to appropriate treatment but instead stood in the way. From 2012 TO 2017, only 112 out of 2688 activations of Community First Responders in a small defined rural area within our region concerned cardiac arrests [8]. As the responders in this study primarily found participation by VFRs valuable in cardiac arrest, this may explain our study participants’ attitudes towards the varied use of Community First Responders.

Ethical challenges concerning collaboration with volunteer first responders

The principle of respect for autonomy includes the right to decide what will happen to oneself [27]. The prehospital clinicians in our study experienced that VFRs only sometimes respected when patients rejected their help, and that VFRs considered it their right to help because they were dispatched by the EMDC.

The prehospital clinicians experienced that the motivation for participating in the VFR programs was primarily altruistic. These motivational factors of VFRs are known from other studies [32,33,34]. However, some VFRs may fail to act altruistically because of their self-interest motivations [27, 35]. It has been reported that some volunteers participate as first responders for the thrill and to obtain an "adrenaline rush". This group includes not only laypersons but also general practitioners who wish to receive an "adrenaline rush" [36] as a VFR. Voluntary laypersons describe other voluntary laypersons as "blue-light junkies" [2]. Our findings support this with our prehospital clinicians referring to these VFRs as "disaster tourists".

According to our study, healthcare professionals might feel obligated to join first responder programs. The European Resuscitation Council states that bystander CPR is a voluntary act with no moral or legal accountability [29]. As such, no one is morally obligated to join voluntary programs.

VFRs could, in some situations, act unintentionally careless according to the prehospital clinicians in our study. The prehospital clinicians speculated that this could end up imposing a risk of harm. One example was exceeding the speed limit on the way to the scene; another example was incorrect administration of medicine to patients.

Allowing volunteers without formal medical education to administer drugs can be debated "Professional malpractice is an instance of negligence that involves not following professional standards of care. These standards require proper training, skills, and diligence." [27]. Volunteers are not health professionals and they sometimes deviate from the usual indications when administering drugs. If the volunteers cannot be held accountable for erroneous administration of medicine, it could be argued that they should not be allowed to administrate these types of medicine. The official Community First Responder manual [15] states that Community First Responders act on behalf of the Region of Southern Denmark and are a part of the prehospital setup. Therefore, they should have the same professional care standards as the EMS. Our study’s prehospital clinicians suggested that Community First Responders should only be alerted and sent out to OHCA because of their lack of skills regarding other medical emergencies. This was a major topic among the prehospital clinicians in our study as they experienced Community First Responders as passive and helpless in emergencies.

A study by Nabecker et al. [31] reported that volunteers felt anxious and helpless in cases other than OHCA because they lack the competence to act. Phung et al. [34] reported anxiety and stress among Community First Responders when they were first on the scene.

In our study, prehospital clinicians reported Community First Responders standing passively by in most non-OHCA situations. Therefore, emotional support, education, and triage of VRFs should be improved to protect the VFRs and to protect patients against incorrect treatments performed by the VFRs.

Phung et al. [34] elucidate the feeling of being an asset in providing essential information to the ambulance staff among the Community First Responders. The Community First Responders act as if they gather essential clinical information for the EMS. However, in our study, prehospital clinicians describe the information as a waste of time as they often must collect the information again themselves.

Some studies [16, 37] share our findings regarding the advantages of volunteers in the case of OHCA. These studies state that volunteers and laypersons, in general, are considered an asset in this situation.

Ethical challenges concerning EMS personnel

The high number of VFRs attending an emergency can be challenging for prehospital clinicians. A survey study by Jellestad et al. [16] demonstrated that 20% of MECU physicians experience problems with HeartRunners. These problems include difficulties distinguishing the numerous volunteers from the relatives. However, 92.5% of MECU physicians considered volunteers relevant in OHCA resuscitation, and approximately 68% found the collaboration helpful. Three out of four MECU physicians used volunteers to continue CPR and to carry equipment. These findings correspond with and are nuanced by the findings in our study.

The presence of VFRs could make an already difficult situation even more stressful for prehospital clinicians [37]. This was supported by our study of prehospital clinicians. Ethical challenges in the prehospital emergency setting are not only related to the VFRs. Previous studies have identified other themes regarding situations where EMS experiences challenges and conflicts concerning ethical considerations such as caring for patients, the professional role and self-identity, and external collaboration [18, 19, 38].

Milling et al. showed that EMS personnel are potentially affected by bystanders in cases of OHCA [38]. Bystanders could potentially influence prehospital clinicians to continue CPR and make them feel obligated to continue CPR if the bystanders already had initiated resuscitation to motivate bystander CPR in future OHCAs [38]. The study reports that prehospital clinicians may feel frustrated because of bystanders' unrealistic expectations [38]. Therefore, using VFRs may add a challenging dimension to the work of EMS professionals. This correlates with the results of our study.

Future studies should investigate whether patients and relatives feel well informed about VFRs or if they experience a violation of the principle of respect for autonomy, or even feel unsafe with VFRs present. It is necessary to explore the value of VRFs in cases other than OHCAs to evaluate their influence on patient survival rates in non-OHCAs.

Strengths and limitations

Our study strengths include the first author's active involvement in the daily prehospital work, thereby achieving a deep insight into experiences with first responders. Furthermore, no respondents declined to participate in our study. This suggests a desire to express views and experiences.

Our study has one main limitation. Our results reflect the attitude of the interviewed EMS personnel but might not be generalisable to other settings. However, other studies have described similar challenges associated with professional/volunteer collaboration, although these mainly explore the themes or categories from the volunteers' point of view [31, 32, 39].