Step 1 – IDENTIFY THE PROBLEM(S)

• Briefly state the Scenario

Faced with an outbreak of a highly infectious disease, you have insufficient PPE for every patient-facing clinician, though you have adequate supplies of equipment used for normal infection control.

To whom do you allocate the higher level of protection? Do you require everyone else to continue working with the lower level equipment?

• List the Issues that arise from the scenario

The balance between the duty to treat patients but also the right for a HCP to protect their own safety.

The problem of scarce resources and thus the need for prioritisation of giving PPE to those who are greatest risk of infection.

The problem with the uncertain nature of the infectious disease (if it is the first outbreak there might be uncertainty around it’s lethality and transmission).

• Identify Critical Information required and Assumptions to be made

Critical Information required:

The nature of the infectious disease (mode of transmission and lethality)

Risk factors for infection (comorbidities, coming into close contact with infected person)

Step 2 – ANALYSE

Patient: What are the views of the Patient? (and ‘patient group’)? How do 4 principles of : Autonomy, Beneficence, Non-maleficence and Justice apply? Other perspectives?

HCPs do have duty to provide care and do good (beneficence) for patients. However, it could be argued that the physical harm and psychological harm inflicted upon HCPs might affect the level of care they are able to provide to patients in the long term.

The principle of justice applies to the distribution of PPE. It must be distributed on the basis of risk.

Clinical: What are the clinical diagnosis, prognosis, treatment options? Is this scenario covered by professional regulation or guidance? What are the views of individual members of the clinical team? Other perspectives?

Nature of disease, lethality and mode of transmission should be determined.

Basic protective measures for healthcare professionals could include providing high-level PPE, such as N95 masks and face shields, for those involved in high-risk tasks. In contrast, lower-level PPE, such as strict hand hygiene practices, could be sufficient for lower-risk environments. Healthcare professionals who are pregnant, immunocompromised, or have pre-existing conditions that make them more vulnerable should, whenever possible, be assigned to lower-risk duties.

Rapid identification of infected patients and their isolation are critical. This reduces the number of individuals exposed to high viral loads.

Rigorous hand hygiene, enhanced cleaning protocols, proper waste disposal, and physical barriers where feasible should complement PPE use

Legal: Is scenario covered by IHL, Geneva Conventions, military law, other law? Other perspectives?

First Geneva Convention (Geneva Convention for the Amelioration of the Condition of the Wounded and Sick in Armed Forces in the Field):

• Article 12: This article outlines the protection of medical personnel and facilities. It states that medical personnel must be respected and protected in all circumstances. They should be allowed to perform their medical duties without being obstructed, provided they do not engage in activities that conflict with their medical responsibilities.

• Article 21: Medical personnel are to be provided with all necessary means to carry out their tasks, which includes protective equipment if needed to maintain their safety. In the case of insufficient resources, a key ethical question is how to allocate what resources are available while still upholding the rights and safety of medical personnel.

Healthcare professionals have both an ethical and legal obligation to provide impartial care, which means treating patients without discrimination based on affiliation (such as home or enemy) or status (whether combatant or civilian). This duty can sometimes conflict with a healthcare professional's right to safeguard themselves from excessive risk. While national military codes may criminalize refusal to follow military orders, International Humanitarian Law (IHL) offers protection for individuals who refuse unlawful orders. For instance, Articles 16 and 21 of the First Geneva Convention stipulate that: 1) Authorities must take all possible steps to search for and care for the wounded and sick, and 2) Medical personnel engaged in medical duties must be respected and protected. These provisions suggest that healthcare professionals should be provided with basic protections, such as immunizations, when working with infectious diseases. If such basic precautions are not in place, healthcare professionals are protected under IHL in refusing assignments they consider unsafe.

Societal/Military: Is there a military necessity? Is this scenario covered by military regulation or military perspective? Is this scenario covered by public health or societal ethics? Other perspectives?

Effort could be made to educate HCPs about the risks, available protections, and their rights to refuse assignments that they perceive as unacceptably dangerous.

In the education of HCPs working in the military, volunteerism for high-risk tasks could be encouraged, ensuring that these individuals are adequately supported psychologically and materially in the event of harm. Adequate support could come in the form of financial compensation or counselling.

There should be an effort to remain transparent with the public to maintain their trust and to be open in communicating the severity of the situation and what is being done about it. In this way, there might cooperation by other humanitarian aid organisations that could help.

Step 3 – FUSE

· Summarise conclusions

· Insert citations to key reference sources for your analysis

· Determine the exact Decision(s) to be made

Healthcare professionals must prioritize patient welfare while balancing legal, clinical, and societal obligations. Legally, military healthcare workers may refuse orders lacking adequate protections, such as PPE, if risks outweigh benefits, though this may lead to consequences under military law. Clinically, high-risk scenarios (e.g., aerosol-generating procedures) demand high-level PPE, with isolation and infection control critical. HCWs at higher vulnerability (pregnant, immunocompromised) should take lower-risk roles. Societally, military necessity and public health ethics intersect, emphasising education on risks and encouraging volunteerism for high-risk tasks, with psychological and material support ensuring readiness and resilience in facing danger.

Step 4 – DECIDE

• What is your Decision?

• Why (can you justify it)?

• Residual uncertainly, need for review?

Healthcare professionals must balance patient care, legal, clinical, and societal factors. Military HCWs can refuse unsafe orders if risks outweigh benefits, though legal consequences may apply. High-risk tasks (e.g., aerosol-generating procedures) require advanced PPE, while vulnerable HCWs should take lower-risk roles. Infection control and patient isolation are essential. There could be education on risks and volunteerism for high-risk roles, supported by psychological and material resources.

Reviewed and formatted by: Yvonne Zhou MBBS Year 3 King’s College London Dec 2024

Bricknell M, Hodgetts T, Beaton K, et al. Operation GRITROCK: the Defence Medical Services’ story and emerging lessons from supporting the UK response to the Ebola crisis. BMJ Military Health 2016;162:169-175. http://dx.doi.org/10.1136/jramc-2015-000512 (full access requires a subscription)

Bakewell F, Pauls MA, Migneault D. Ethical considerations of the duty to care and physician safety in the COVID-19 pandemic [published online ahead of print, 2020 Apr 24]. CJEM. 2020;1‐4. doi:10.1017/cem.2020.376

Binkley CE, Kemp DS. Ethical Rationing of Personal Protective Equipment to Minimize Moral Residue During the COVID-19 Pandemic. J Am Coll Surg. 2020;230(6):1111‐1113. doi:10.1016/j.jamcollsurg.2020.03.031

Thomas JP, Srinivasan A, Wickramarachchi CS, Dhesi PK, Hung YM, Kamath AV. Evaluating the national PPE guidance for NHS healthcare workers during the COVID-19 pandemic [published online ahead of print, 2020 May 1]. Clin Med (Lond). 2020; clinmed.2020-0143.

Reidy, Pelagia & Fletcher, Tom & Shieber, Clare & Shallcross, Jane & Towler, Helen & Ping, Michelle & Kenworthy, Leigh & Silman, Nigel & Aarons, Emma. (2017). Personal Protective Equipment Solution for UK Military Medical Personnel working in an Ebola Virus Disease Treatment Unit in Sierra Leone. Journal of Hospital Infection. 96. 10.1016/j.jhin.2017.03.018.