· Medical · Centre for Military Ethics

Step 1 – IDENTIFY THE PROBLEM(S)

• Briefly state the Scenario: A distraught local national father refuses to allow the transfer of his badly injured daughter to another allied medical unit where more appropriate care can be provided. What do you do?

• List the Issues that arise from the scenario.

• Identify Critical Information required and Assumptions to be made:

The core issue is that the father of a badly injured child refuses to allow the transfer of his daughter to a better-equipped medical facility where more appropriate care can be provided. The situation is complicated by the child’s likely inability to consent due to her injuries, placing the responsibility for decision-making on the father. Critical information needed includes the severity of the child’s injuries, the availability of appropriate care, and the cultural or personal reasons behind the father’s refusal. Assumptions must be made about the father’s legal right to act on behalf of his child, the child’s age and capacity, and the availability of translators or other means to understand and mediate the father’s position.

Step 2 – ANALYSE

Patient: The healthcare team must prioritize the patient’s best interests and ensure the necessary care is provided to alleviate suffering. If the patient is a child and cannot consent to treatment, the parent (in this case, the father) typically serves as the legal representative. According to the WMA International Code of Medical Ethics (https://www.wma.net/policies-post/wma-international-code-of-medical-ethics/), the physician’s primary obligation is to the patient’s well-being. If the father’s refusal to transfer his child is based on cultural or personal reasons, these must be addressed while still ensuring that the child receives the medical care needed.

Clinical: Clinically, the decision must consider whether the child’s condition requires immediate transfer to a better-equipped medical facility. If the father’s refusal poses a risk to the child’s health, healthcare workers must act in the child’s best interests, even if that means challenging the father’s decision. In situations of medical urgency, the WMA Declaration of Lisbon on the Rights of the Patient (https://www.wma.net/policies-post/wma-declaration-of-lisbon-on-the-rights-of-the-patient/#:~:text=Every%20person%20is%20entitled%20without,with%20his%2Fher%20best%20interests.) emphasizes that healthcare professionals may override parental refusal if the child’s well-being is at risk.

Legal: Legally, the father may have the right to make decisions on behalf of his child. However, if the decision conflicts with the medical team’s assessment of the child’s needs, the physician must act in the best interest of the patient. International humanitarian law and medical ethics prioritize the provision of appropriate medical care without delay, as outlined in the Geneva Conventions (Protocol I, Article 10; Protocol II, Article 7, https://ihl-databases.icrc.org/applic/ihl/ihl.nsf/Article.xsp?action=openDocument&documentId=2F86D0055DF0E6ECC12563CD0051DA8A).

Societal/Military: From a societal and military perspective, the cultural, religious, or personal reasons for the father’s refusal should be carefully considered. Cultural sensitivity and understanding are critical in managing such situations. Using a translator or involving local NGOs could help mediate the situation and understand the father’s concerns more effectively. However, the healthcare team must remain focused on ensuring the child receives the best possible care.

Step 3 – FUSE

• Summarise conclusions

• Insert citations to key reference sources for your analysis

• Determine the exact Decision(s) to be made

The conclusion is that the father’s refusal to allow the transfer must be carefully examined in light of the child’s best interests. If the father’s refusal is based on personal, cultural, or religious reasons, the healthcare team should attempt to mediate the situation with the help of translators or local organizations. However, if the child’s medical condition warrants immediate care that cannot be provided at the current facility, healthcare professionals have an ethical and legal obligation to ensure that the child receives appropriate care, even if that means challenging the father’s decision. References such as the Geneva Conventions (Protocol I, Article 10) and the WMA Declaration of Lisbon on the Rights of the Patient (https://www.wma.net/policies-post/wma-declaration-of-lisbon-on-the-rights-of-the-patient/#:~:text=Every%20person%20is%20entitled%20without,with%20his%2Fher%20best%20interests.) support the primacy of patient welfare in medical decision-making.

Step 4 – DECIDE

• What is your Decision?

• Why (can you justify it)?

• Residual uncertainly, need for review?

The decision is to engage the father in a dialogue to understand his reasons for refusal and explore possible compromises, such as having a female healthcare provider involved in the transfer. However, if the child’s health is in immediate danger and cannot be treated at the current facility, the healthcare team must prioritize the child’s best interests and facilitate the transfer despite the father’s objections. This decision is justified by the WMA International Code of Medical Ethics (https://www.wma.net/policies-post/wma-international-code-of-medical-ethics/) and the WMA Declaration of Lisbon on the Rights of the Patient (https://www.wma.net/policies-post/wma-declaration-of-lisbon-on-the-rights-of-the-patient/#:~:text=Every%20person%20is%20entitled%20without,with%20his%2Fher%20best%20interests.), which prioritize the patient’s well-being and autonomy. Residual uncertainty may exist if the father continues to refuse consent, but in emergency situations, acting in the patient’s best interest should take precedence.

Reviewed and formatted by: Alexandros Carver, 3rd Year Medical Student KCL, December 2024