BackgroundMany medical emergency practices are regulated by written procedures that normally provide reliable guidelines for action. In some cases, however, the consequences of following rule-based instructions can have unintended negative consequences. The article discusses a case - described on a type level - where the consequences of following a rule formulation could have been fatal.Case presentationA weak and elderly patient has cardiac arrest, and a Do Not Resuscitate clause is written in the patient’s medical record. Paramedics at the scene cannot (...) see that the patient’s general appearance match conditions which would indicate the DNR clause, so they start cardiopulmonary resuscitation, and the patient survives. This turns out to be a crucial decision. The DNR clause is from an earlier bout with serious disease from which the patient has recovered, against all odds, and someone has forgotten to remove the clause from the medical record.AnalysisIn order to be able to interpret the validity of written guidelines, paramedics and other health workers need to develop personal skills that transcend the ability simply to follow written instructions. Within traditional virtue ethics, personal judgment is conceived of as crucial for being able to make ‘good’ autonomous decisions. Virtue ethical analyses, decision-making abilities and non-technical communication skills are important as conceptual tools when health workers need to make difficult clinical decisions.ConclusionThe case study accentuates the significance of prudent judgment in medical practice. In the case described, the consequence of trusting the written advance directive could have been fatal, but the point is general: for the purpose of achieving excellent organizational performance, it is insufficient for health workers to rely uncritically on rules and procedures. Even the clearest rule formulations must be interpreted contextually in order to determine ethically correct behavior and avoid potential negative consequences that are not in the patient’s best interests. (shrink)