Introduction

In May 2021, Eleanor Turner, a 28 year old paramedic employed by the West Midlands Ambulance Service in the UK, admitted to charging £150-an-hour for threesomes with her partner police detective, DC Nick Taylor, 39. The couple had been selling sex for at least two years, with X-rated snaps and videos online showing the medic having sex with multiple people.

Although sex work in the UK is legal, an investigation by Turner’s employer, West Midlands Ambulance Service, was conducted to determine if she should retain her job. The investigation concluded that she could continue to practise as a paramedic. Popular media outlets, such as British tabloid newspaper The Sun (Jehring & Crowson, 2019) have suggested that she should not be able to continue to practise.Footnote 1So, who is correct? Should Turner have been allowed to continue to practise as a paramedic, or not? And if such a case were to occur in Australia, where paramedicine has only recently been recognized as a profession, should the result be the same?

To help us answer these questions we first (in Section “Role models and Ethos”) consider whether it is ever permissible to dismiss someone from their employment because they are a sex worker. We focus on a potential paradigm case of permissible dismissal for engaging in sex work – that of being employed as a Catholic role model. Considering such a paradigm case is helpful, for if such a dismissal is actually impermissible then it is likely that the dismissal of a paramedic for being a sex worker would also be impermissible (since the latter case is weaker). If, on the other hand, the dismissal is permissible in the paradigm case, then it will be useful to understand the underlying principles that make it so.

We then (in Section “Professionals and Ethos”) take these underlying principles (that make the dismissal of a sex worker from the position of Catholic role permissible) and expand them. We generalise outwards from Catholic institutions to professions, and from upholding the ethos of Catholicism (as a role model should) to upholding the ethos of a profession (as a professional should). We then (in Section “The Ethos of Professional Paramedics”) apply these underlying principles (gleaned from the paradigm case) to the paramedic profession in particular. We find that, due to the paramedic ethos being far less developed than Catholicism, that these underlying principles do not permit the dismissal of sex workers from paramedicine.

We then (in Section “Public Interest and Public Confidence”) consider an alternative argument for the permissible dismissal of sex workers from paramedicine – namely whether recourse to a duty to maintain public confidence in a profession could be called upon to justify such dismissals. Finally (in Section “Separating conduct from performance”) we put pressure on this alternative argument, suggesting that professions sometimes have a duty to challenge certain biases even if, in doing so, public confidence in the profession may be undermined.

Role Models and Ethos

Father Krzysztof Olaf Charamsa worked in the Vatican’s doctrine office. After coming out as gay he was dismissed (Reuters, 2015). Father Pierre Valkering, a 57 year old Catholic priest from Amsterdam, was fired after publishing a book which discussed his experience as a gay man (Dutch News 2019). Father Warren Hall was a Catholic priest working as a campus chaplain at a University in New Jersey. He was dismissed from his position on the grounds that “his identity as a gay man undermined church teaching” (Gibson, 2015). Are such dismissals, dismissals based on a person’s sexual activities and/or preferences, permissible?

Our focus is not on whether such dismissals are legally permissible;Footnote 2this will depend upon the relevant laws in place.Footnote 3Rather, our focus is on whether they are morally permissible. Our aim in this section is to determine which underlying principles, if any, might morally justify dismissals of this kind; and then, in Sect. “Professionals and ethos”, consider how such principles might relate to the conduct of professionals in general. Then, in Sect. “The Ethos of Professional Paramedics”, we shall determine how such principles might apply to paramedics in particular.The debate over whether such dismissals are morally permissible typically centres on the conflict between two freedoms: freedom from unjust discrimination and freedom of thought, conscience, and religion.Footnote 4Please note that we are using the term ‘discrimination’ here in it’s neutral senseFootnote 5, where to discriminate means (roughly) to discern a difference between things; we reserve the term ‘unjust discrimination’ to refer to instances where people unjustly (and often prejudicially) discern a difference between things.We don’t want employees to be dismissed from their jobs because of unjust discrimination; but we do want employers to, within reason, be free to follow and act upon their own deeply held convictions. So, when the basis of discrimination is a deeply held conviction it is important to determine whether this discrimination is just. But what argument can be given to ground such a determination?

In defence of several Catholic schools firing openly gay teachers,Footnote 6the Catholic Diocese of Evansville stated,Because of their participation in teaching the religious precepts of the Roman Catholic Church and duty to serve as role models for their students, teachers in the schools of the Catholic Diocese of Evansville are required to maintain a lifestyle, including marital status, in harmony with the teachings of the faith of the Roman Catholic Church. All teachers employed by the Catholic Diocese of Evansville are aware of what’s expected of them and sign annual contracts of agreement. (Web, 2020)

This argument might be formulated as follows,

  1. 1.

    Catholic role models act in accordance with the Catholic ethos

  2. 2.

    Openly gay people do not act in accordance with the Catholic ethos. So,

  3. 3.

    Openly gay people are not Catholic role models.

  4. 4.

    Catholic institutes should be able to dismiss people who are not Catholic role models (if they were legitimately hired to be Catholic role models). So,

  5. 5.

    Catholic institutes should be able to dismiss openly gay people.

Premise 1 seems true by definition. 2 is open to debate, however for the sake of argument we shall assume its truth for now. 3 follows from 1 to 2. And 5 follows from 3 to 4. So, our critical gaze (for now) should be squarely on 4. That is, we should focus on whether Catholic institutes should be able to dismiss people who are not Catholic role models.

To help us answer this question, it’s worth considering whether Catholic institutes should be able to hire people to be (at least partly) Catholic role models. Why? Because presumably, if it is permissible to hire someone to perform a set of duties that are inherent requirements of some job, but the hired person is subsequently unable to perform such duties, then it will (normally) be permissible to dismiss them on this basis.Footnote 7So, if Catholic institutes are permitted to hire Catholic role models, then it will be permissible for such institutes to dismiss such hires if they subsequently fail to fulfil their duties as role models. Hiring role models in general seems to be an acceptable practice.Footnote 8For example, when parents send their children to the scouts, they do so on the understanding that the scout leaders are role models, and hired as such; people whose character and behaviour reflect the ethos of the scouts. To the extent parents are comfortable with such an ethos, they should be comfortable with their children being around such role models. And were parents to find that a scout leader was not a role model in this sense, and instead, for example, modelling behaviour that was incompatible with the ethos of the scouts, they might be permissibly aggrieved. Of course there is a gulf between something being widely practised/socially accepted and it being morally permissible. However, on the assumption that a given ethos is itself morally permissible, it is hard to see how hiring someone to model such an ethos could be impermissible. So where does all this get us? So far, we have suggested that if it is morally permissible to hire role models and it is morally permissible to act in accordance with the Catholic ethos, then it is morally permissible to hire Catholic role models. And if this is the case, then it is likewise permissible to dismiss someone hired to be a Catholic role model for not fulfilling their duties as such. Why? Because of a more general principle: that it is (normally) permissible to dismiss people for not being able to fulfil the duties for which they were legitimately hired.

Please note that we are not suggesting that it is permissible to dismiss openly gay priests from Catholic institutions. This is because, we leave open the possibility that being openly gay is not against the Catholic ethos. We also leave open the possibility that the Catholic ethos itself (perhaps because of its stance on homosexuality) is morally impermissible. Rather, we are suggesting that if being openly gay is against the Catholic ethos and the Catholic ethos is permissible, then it is also permissible (given the permissibility of hiring role models) that someone might be dismissed as a Catholic role model for being openly gay.

So how does all this relate to the case of Eleanor Turner and her role as a paramedic? We shall argue that religious role models (such as priests and chaplins) are not the only types of positions that people may be permissibly dismissed from for not adhering to a particular ethos; professionals may also be dismissed on similar grounds.

Professionals and Ethos

Religions are not the only groups that have an ethos central to their identity. Some professions have also established a culture and ethos particular to them. For example, school teachers have established an ethos focusing on the care and education of children. And a teacher who acts in a manner contrary to that ethos may, and should, be dismissed from their profession on this basis.

This issue of sex work and the teaching professional was debated in New Zealand when a teacher was found to have been working as a sex worker at night (Grunwell, 2008). Despite the fact sex work is legal, it is possible that such work may be incompatible with the ethos of the teaching profession. The New Zealand Teachers Council has a code of conduct that reflects the culture and ethos of their profession. This code “sets out the high standards for ethical behaviour that are expected of every teacher,” which includes a commitment to the teaching profession to “maintain public trust and confidence” in the profession by demonstrating a “high standard of professional behaviour and integrity” (Our Code Our Standards. Code of Professional Responsibility and Standards for the Teaching Profession. New Zealand). These values are reflected in the Education and Training Act (2020, Part 1 s.10), which requires members of the teaching profession not to act in a way that “reflects adversely on the teacher’s fitness to be a teacher; or…may bring the teaching profession into disrepute.” The Teachers’ Council director Peter Lind stated that “It’s a case of whether the outside employment is regarded as incompatible with the role of a teacher in terms of role modelling…” (NZPA, 2009).

We are not suggesting here that a teacher who engages in sex work is doing anything illegal or immoral. Indeed if sex work is legal, and a teacher’s performace is not unduly affected by them also engaging in sex work, then arguably the school has no business sanctioning or dismissing teachers who are also sex workers; a view held by Catherine Healy, national co-ordinator of the Prostitutes Collective, who stated, “There is no incompatibility between a woman who is a teacher and who works as a sex worker” (Chan, 2008). A similar sentiment was expressed by Judge Wright (1999) regarding a case where Michelle Hollingsworth applied to enter the NSW Police Service. She had previously worked as a sex worker but did not declare this on her application form. The matter went to a legal tribunal for adjudication. The court found that,

…the standards of suitability which Ms. Hollingsworth is required to meet for recruitment in the Police Service should be no more nor less than the standard applying generally to other police recruits at present…We are not a court of morals but one of law. More particularly, the evidence before us does not establish a moral basis for the respondent’s submissions that a former stripper and prostitute is not a fit and proper person to be a police officer; certainly the evidence did not establish that the appellant herself was disqualified from being a police officer for that reason. (Wright, 1999)

The court essentially ruled that the professional ethos required of a police officer isn’t incompatible with being a former sex worker.

However, if the ethos of being a professional (such as a teacher, police officer, or paramedic) was incompatible with being a sex worker, and, if it is permissible to hire people on the basis that their behaviour adheres to a particular ethos, then it may be morally permissible to dismiss them if their behaviour doesn’t adheres to this ethos. The general form of this argument can be expressed as follows:

  1. 1.

    Members of profession X should behave in accordance with the professional ethos of X.

  2. 2.

    People that exhibit Y behaviours do not behave in accordance with the professional ethos of X. So,

  3. 3.

    People that exhibit Y behaviours should not be members of profession X.

  4. 4.

    Employers of X professionals should be able to dismiss people who should not be members of profession X (if they were legitimately hired to be members). So,

  5. 5.

    Employers of X professionals should be able to dismiss people that exhibit Y behaviours.

It is important to note that just because it may be morally permissible to dismiss a person because they exhibit certain behaviours it doesn’t follow that these behaviours are themselves immoral. For example, imagine that the professional ethos of accountants included being sufficiently numerate (to be able to uphold the standards of their profession). Even though it may be morally permissible to dismiss someone hired to be an accountant for not being sufficiently numerate, it doesn’t follow that not being sufficiently numerate is immoral. Likewise, even if it were morally permissible to dismiss a teacher, police officer or paramedic for being a sex worker, it doesn’t follow that being a sex worker is itself morally impermissible. That is, just because an ethos and a behaviour are incompatible, it doesn’t follow that the behaviour itself is immoral, even though someone might be permissibly dismissed for exhibiting it.

The Ethos of Professional Paramedics

With this argument laid out, let us now return to cases like that of Eleanor Turner, the paramedic who also engaged in sex work. Is it morally permissible for an employer to dismiss such a paramedic? Let us lay out the argument for this dismissal being permissible, and then evaluate it.

  1. 1.

    Professional paramedics should behave in accordance with the paramedic professional ethos.

  2. 2.

    Sex workers do not behave in accordance with the paramedic professional ethos. So,

  3. 3.

    Sex workers should not be professional paramedics.

  4. 4.

    Employers of professional paramedics should be able to dismiss people who should not be professional paramedics (if they were legitimately hired to be professional paramedics). So,

  5. 5.

    Employers of professional paramedics should be able to dismiss people that are sex workers.

The structure of this argument seems valid, so our focus should be on whether its premises are true. It is premise 2 that deserves significant attention, as this is arguably the weakest premise.

Premise 2 holds that sex workers do not behave in accordance with the paramedic professional ethos. However, unlike the Catholic Church - that clearly has its own ethos, it is not clear at all that the paramedic profession (at least in Australia) has its own distinct ethos yet.

Paramedicine is a relatively new profession. It has no accepted theory of identity or universal set of values that reflect the profession’s culture and ethos. This gap can create space for professional moral ambiguity that contributes to a failure of the profession to be able to safely navigate through ethical dilemmas… (Townsend & Luck, 2019, 7).

So, it seems that premise 2 may be false. The ethos of professional paramedics themselves may not be developed sufficiently to strongly suggest that its values are in opposition to that of being a sex worker.

However, rather than appeal to their own ethos, a regulatory board might appeal to the ethos of the public to find sex work unsuitable for paramedics.

Public Interest and Public Confidence

The Paramedic Board of Australia (PBA) is a regulatory body that is made up of members of the paramedic profession. So, in this sense, the paramedic profession is self-regulatory. The PBA is responsible for identifying and establishing the ethos of the profession and communicating those values to its members and the public. As such, the Board is legally authorised to establish, interpret and apply standards of professional conduct.

Although paramedic employers may have different standards to the PBA (for example, standards that apply to all employees, including non-paramedics) there are some standards regarding the professional conduct of paramedics that are often shared by both the employer and the PBA. And one such shared value, which is salient to this discussion, is that paramedics are required to work in the public interest.

To work in the public interest paramedics must place the interests of the public above their own. One way this is done is by maintaining public confidence in the profession, even if, in doing so, one’s own interests are not best served. This is because an action that undermines public confidence in the profession is also against the public interest – as such confidence is required to provide proper care (a patient who doesn’t trust a paramedic may not allow them to administer the appropriate treatment). In which case, if it was determined that a paramedic engaging in sex work is undermining public confidence in the profession, it may be found that this work, which presumably is in their own interests, is not in the public interest. Thus the paramedic risks placing their own interests above that of the public.

Such an outcome might justify an employer’s decision to dismiss, or the PBA decision to deregister, a paramedic who engages in sex work. However, it might not - as per the court’s reasoning in case of police officer Michelle Hollingsworth (as reported in Sect. “Professionals and Ethos”). In this case it was determined that being a former sex worker was compatible with being a member of the profession. In terms of performance this ruling seems straightforward - being a sex worker doesn’t obviously impede one’s ability to fulfil one’s duties as a police officer. However, performance and conduct are distinct.

Separating Conduct from Performance

Performance and conduct are able to be distinguished from one another in theory, but in practice the two intersect, being overlapping elements of professional behaviour. And professional behaviour itself should meet both performance and conduct standards. For the purpose of this discussion we will consider performance to be associated with clinical competency; that is, the way in which practitioners actually perform their paramedic role. The expectation is that paramedics will work to a clinical standard that does not place patients at risk of harm.

By comparison, professional conduct is broader than the provision of clinical services. Professional conduct incorporates knowledge of law, ethics, responsibility and all obligations associated with the privilege and benefits of being part of a particular profession. And in the case of paramedicine this includes any obligation associated with receiving the trust and goodwill of the general public.Footnote 9Maintaining the trust and goodwill of the general public, requires the profession to be sensitive to public sentiment about what is acceptable conduct for paramedics. If public sentiment deems the only standard expected of a paramedic is to not place patients at risk of harm (i.e. it is performance focused), then any sufficiently well performing paramedic should be permitted to continue to work; including those who are also sex workers.Footnote 10Footnote 11However, if public sentiment deems the standards of a professional paramedic to also include a certain level of conduct, then the question remains somewhat open. For example, arguably one manner to undermine public confidence is for a paramedic’s conduct to be merely contrary to community expectations. And the community may not expect paramedics to also be sex workers. If this possibly contrary behaviour was determined to be undermining confidence, and so working against the public interest, then sex work may be found to be unsuitable for paramedics.

However, a note of caution should be voiced regarding such an outcome. Although public sentiment is an important element in determining the ethos of a profession, (a) it is only one element, and (b) the public (as a collection of individuals) are susceptible to the same unreasonable biases we all are. For example, it has been reported (Leonov, 2013) that many people don’t trust female pilots. If this were true, should women be barred from becoming professional pilots because public confidence in the profession might be undermined? Surely not. Likewise, if it was determined that many people unreasonably distrust members of a particular religion or cultural group, should such members be forced to give up their religious convictions or cultural ties in order to become a professional paramedic; and if they fail to do so, does their failure to put the public’s interests before their own make them unprofessional. Of course being a sex worker is different to being a woman or a member of a religion or culture. But the general point still stands. Public sentiment is only one measure, and sometimes if such sentiment is based on an unreasonable bias, professional bodies should challenge such sentiments, rather than bend to them. In fact, the current AHPRA Code of Conduct (2019) shared by the paramedic profession (and other health practitioners) states that paramedics should “adopt practices that respect diversity, avoid bias, discrimination and racism, and challenge belief based upon assumption” (s.3.1d.)

Given that there is a bias against sex workers,Footnote 12if a professional body wishes to exclude them from the profession, so as not to undermine public confidence, they are in effect upholding the view that this bias isn’t unreasonable. Such an exclusionary stance places an onus on such bodies to justify this bias as reasonable. In other words, they need to argue that it is reasonable to be biassed against sex workers.Footnote 13And care must be taken when providing such an argument to distinguish between sex workers and other factors. For example, even if it were reasonable to be biased against the sex work industry because it has, and/or continues to, exploit women, it may not be reasonable to be biased against sex workers.Footnote 14And although it is beyond the remit of this paper to provide an argument for the intrinsic rightness or wrongness of sex work, we do feel that the issues are important and complex enoughFootnote 15that professional bodies should not be upholding the existing bias without serious reflection.

Concluding Remarks

As things stand the paramedic ethos reguarding sex work is either maximally inclusive (by virtue of being largely unstated) or underdeveloped. Both possibilities may be problematic. In order for paramedic professionalism to be a guiding force for paramedics it’s ethos (be it enshrined in a code, or law) should provide an insight into cases such as the one we have highlighted. It should help paramedics to determine their values as a professional body and guide their conduct. And although the public sentiment might be appealed to as an indicator of those activities that might undermine confidence in the profession, professions may have a responsibility to challenge such sentiments if they are based on unreasonable biases.

To help address this, we recommend two possible actions to professional bodies, like the Paramedic Board of Australia (PBA). The first is to explicitly adopt a stance of maximal occupational inclusion. A stance which holds that all legal occupations should be compatible with membership to the profession, providing that undertaking such an occupation doesn’t reasonably undermine public confidence in the profession. This could perhaps be achieved by adding “occupation” to the list of examples given in Sect. 1d of the AHPRA Code of Conduct (2019), like so.

To ensure culturally safe and respectful practice, good practice includes that you:

….

(d) adopt practices that respect diversity, avoid bias, discrimination and racism, and challenge belief based upon assumption (for example, based on gender, disability, race, ethnicity, religion, sexuality, age, occupation or political beliefs).

Alternatively, explicit reason should be given as to why some legal occupations are incompatible with the profession. And if such reasons include reference to the undermining of public confidence, it should be made clear why it is reasonable for public confidence to be so undermined. We would also recommend that, in the absence of such measures, professional bodies should adopt the practice of maximal occupational inclusion in the interim. In other words, such professions should adopt a practice that assumes it is morally permissible for paramedics to also be sex workers, until which time their ethos is sufficiently developed to relevantly guide them on this matter. In which case, it would currently be permissible for paramedics to also be sex workers.

Lasty, although we have focused here on the paramedic profession, we wish to suggest that the arguments presented may generalise to any profession whose current ethos doesn’t provide sufficient guidance on the compatibility of sex work with the profession. For example, given that AHPRA Code of Conduct is shared with other health professions in Australia, the same arguments may equally apply to the following professions: Chiropractic; Dental; Medical radiation practice; Occupational therapy; Optometry; Osteopathy; Pharmacy; Physiotherapy and Podiatry.