· Medical · Centre for Military Ethics

Step 1 – IDENTIFY THE PROBLEM(S)

• Briefly state the Scenario

Can military medical staff be ordered to deliver care if doing so involves severe risk of injury or death to themselves?

• List the Issues that arise from the scenario

The issue of wanting to give aid to military combatants but this has to be balanced with risk to themselves.

The issue of wanting to comply with orders given by a military professional, but the issue of recognizing when this is unlawful.

• Identify Critical Information required and Assumptions to be made

It assumes that considerable risk of injury is involved.

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?

‘Protecting Healthcare’ and ‘Healthcare in Danger’ document both outline that military medical professionals must give impartial treatment to patients regardless of their affiliation. A just use of resources is treating every patient on the basis of clinical need and likelihood of recovery, regardless of their affiliation.

‘Protecting Healthcare’ document emphasizes the principles of impartiality, beneficence, and non-maleficence (acting in patients' best interest while avoiding harm) https://healthcareindanger.org/wp-content/uploads/2021/03/4504_002-ebook.pdf

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?

The clinical team may feel anxious about such a mission and might consider refusing the order.

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

When a military staff signs the contract to work as a medical professional working in the military, they agree to a level of risk they are expected to subject themselves too. They are expected to subject themselves to risk inherent to working in armed forces. For example, providing medical care to front lines of an operation in active combat zone, or travelling in a vehicle of which there is risk to being targeted by enemies.

That being said, employers or leaders of military operations must ensure that basic measures to reduce risk of harm to medical professionals in different situations has been taken. Basic measures includes provision of defensive gear (armor, helmet or PPE such as immunizations in infectious scenarios).

Medical professionals will face legal consequence if they do not follow orders from leader of an operation team, provided that those orders are legal under the IHL.

1. Basic measures to protect medical personnel have been taken (basic defensive gear such as armor and helmets, or PPE in infectious scenarios)

2. The effectiveness of the operation is judged to outweigh the risks

If these requirements have not been met, then military medical professionals are protected under IHL and have right to refuse order without legal consequence.

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?

Military duty to accept inherent risk in situations is codified in values that are written to instill ethos in military. They also intersect with legal obligations.

Examples include:

United States: The Soldiers’ Creed underscores an obligation to "never quit" and to "stand ready to deploy, engage, and destroy" threats, regardless of risk.

This is quite consistent across different military services. For medics, there are certain humanitarian laws that are relevant for them to uphold but not so much military combatants.

They teach this through case studies, role-play and simulations of high-risk scenarios.

Step 3 – FUSE

Military medical professionals are expected to accept certain risks, such as providing care in combat zones, treating infectious diseases, or traveling in vulnerable vehicles. However, leaders must ensure that protective measures like armor, PPE, and immunizations are provided to reduce these risks. If these protections aren’t in place, medics can refuse orders under International Humanitarian Law (IHL). Medics must treat patients based on need, regardless of their affiliation, following ethical principles like impartiality and beneficence. Unlike humanitarian volunteers, military medics can face legal consequences for refusing lawful orders. Risk is managed through training and military values.

Step 4 – DECIDE

Military medical professionals are expected to balance their duty to accept inherent risks with the protections provided under IHL and ethical guidelines. Non-compliance with lawful orders may lead to disciplinary action, but protections exist against unreasonable or unlawful exposure to harm.

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