Step 1 – IDENTIFY THE PROBLEM(S)

Briefly state the Scenario: What should a healthcare professional do if faced with an order from a commanding officer requiring them to violate the principles of medical ethics?

List the Issues that arise from the scenario

• Responding to potentially unlawful commands while maintaining medical ethics

• The principle of humanity during armed conflict.

• Potential patient harm and/or violation of the pillars of medical ethics.

Identify Critical Information required and Assumptions to be made

• What does the command entail?

• Does it go against the Geneva Conventions/IHL?

• Does it put patients at risk of harm?

• The specific nature of the command is not detailed; however, for the purposes of this scenario, we will assume that the command issued is both unethical and potentially unlawful.

Step 2 – ANALYSE

Patient: Medical ethics prioritise the well-being of patients by ensuring they receive appropriate care. Ethical principles like beneficence (doing good) and non-maleficence (avoiding harm) help prevent actions that might harm patients physically, mentally, or emotionally. The principle of autonomy allows patients to maintain control over their own health, providing them with the freedom to choose what is best for them after being informed of the options. All patients have the right to medical treatment (justice) preventing discrimination based on factors such as socioeconomic status, race, or gender.

Clinical: “Healthcare personnel shall at all times act in accordance with relevant international and national law, ethical principles of health care and their conscience.” & “Health-care personnel shall never be punished for executing their duties in compliance with legal and ethical norms.” - WMA, ‘Ethical principles of health care in times of armed conflict and other emergencies’. At: https://www.wma.net/policies-post/ethical-principles-of-health-care-in-times-of-armed-conflict-and-other-emergencies/

You need to maintain the dignity, autonomy, and confidentiality of all patients (regardless of their status in the military e.g. prisoners of war) and ensure valid consent for any procedure.

Legal: Geneva Conventions: AP1, Art 16: “2. Persons engaged in medical activities shall not be compelled to perform acts or to carry out work contrary to the rules of medical ethics or to other medical rules designed for the benefit of the wounded and sick or to the provisions of the Conventions or of this Protocol, or to refrain from performing acts or from carrying out work required by those rules and provisions.” At: https://ihl-databases.icrc.org/applic/ihl/ihl.nsf/4e473c7bc8854f2ec12563f60039c738/b0bf1d4a2800d97fc12563cd0051d841

Customary IHL: Rule 26. “Punishing a person for performing medical duties compatible with medical ethics or compelling a person engaged in medical activities to perform acts contrary to medical ethics is prohibited.” At: https://ihl-databases.icrc.org/customary-ihl/eng/docs/v1_rul_rule26

Societal/Military: Dual loyalty refers to the conflict of medical professionals between the duty to provide medical care to patients and the obligation to support the military objectives or chain of command.

Medical ethics provide a framework for healthcare professionals to act with integrity, professionalism, and accountability. It helps them navigate complex situations, including conflicts of interest, making decisions that align with moral standards and the expectations of society.

Step 3 – FUSE

● Summarise conclusions

● Insert citations to key reference sources for your analysis

● Determine the exact Decision(s) to be made

Following medical ethics in military medicine is crucial for protecting the rights and dignity of all patients, fostering trust, ensuring fairness, and upholding international laws. It also serves to preserve the integrity of military medicine as a profession and helps prevent abuses that could damage both the healthcare system and the military's moral standing.

Healthcare personnel are bound to act according to medical ethics in all circumstances. This principle is widely accepted and supported by a number of IHL regulations. As a result, healthcare personnel cannot be expected to act against medical ethics, must not be ordered to do so and have a moral and legal right to refuse the order of the commanding officer. - See references in the Legal section.

This also applies to the treatment of prisoners of war – see A Clubs.

Step 4 – DECIDE

• What is your Decision?

• Why (can you justify it)?

• Residual uncertainly, need for review?

Whenever possible, medical staff should explain to the commanding officer why they cannot implement the order, as they may not be aware of their special duties. They should seek support from their colleagues or from legal advisors in the military. Some militaries have separate command structures for their medical components in order to avoid situations like the one described on the card.

It is important to note that not all ethical challenges have a binary answer, it is important to share decision-making in uncertain circumstances.

- What can you do to instil broader acceptance of the specific obligations of HCP among all members of the military? – Consider the roles of policies, training and education.

- What arrangements exist in your nation, armed forces, or military unit? Could these be improved?

Reviewed and formatted by:

Adriana Salas Yeguez, MBBS Year 3 King’s College London

December 2024

Discussion:

Review of the question: At face value, this seems to a simple question with a simple answer – refuse to comply with the order. However, the purpose of the question is to discuss how to come to the interpretation that an order is unethical and what to do beyond just ‘saying no’.

Interpretation of the principles/policy from the references: Health Care Personnel are bound to act according to medical ethics in all circumstances. This principle is widely accepted and also supported by a number of regulations in IHL. As a result, health care personnel cannot be expected to act against medical ethics, must not be ordered to do so and have a moral and legal right (or even duty?) to refuse the order of the commanding officer.

Framework for answering the scenario/question:

• Why are the ethical obligations of HCP different and why is it important that HCP can work according to medical ethics? – discussion of dual loyalty (military and medical), and the primacy of professional obligations. Whenever possible, HCP should explain to the commanding officer why they cannot implement the order, as s/he may not be aware of the special duties of HCP. They should seek support from their colleagues or from legal advisors in the military. Some militaries have separate command structures for their medical components in order to avoid situations like the one described on the card.

• Is there any situation, when HCP should be allowed to act against medical ethics and, if so, why and who should decide about it? Not all ethical challenges have a binary answer, it is important to share decision-making in uncertain circumstances.

• What can you do to instill broader acceptance for the specific obligations of HCP among all members of the military? – consider the roles of policies, training and education. What arrangements exist in your nation, armed forces, military unit?

Author: Dr Daniel Messelken, University of Zurich, Center for Military Medical Ethics