All of the scenarios in the garrison healthcare suit should be considered from the perspective of a healthcare professional working in a military garrison healthcare centre with responsibility for the clinical care of patients and management of the healthcare centre. The primary supporting reference for this suit is the World Medical Association International Code of Medical Ethics (WMA Code) at: https://www.wma.net/policies-post/wma-international-code-of-medical-ethics/ . You should also consider your national professional ethical codes and relevant military law or guidance

Step 1 – IDENTIFY THE PROBLEM(S)

• Briefly state the Scenario: A soldier complains that a senior female doctor includes a genital examination as part of the annual routine medical review for male soldiers. When challenged, she states that this is good medical practice for screening. What do you think?
• List the Issues that arise from the scenario.
• Identify Critical Information required and Assumptions to be made:

This scenario covers the ethics and law regarding appropriate medical examination and exploitation of professional authority or status. It also includes the need for special care in the conduct of intimate examinations, and the importance of having a chaperone.

Step 2 – ANALYSE

Patient: the patient has a right to expect that a clinician’s assessment will be appropriate and sufficient. This includes the conduct of opportune health screening but not inappropriate or exploitative questioning or examination.  The patient has a right to decline to be examined.

Clinical: A clinician must never exploit a patient - WMA Code Para 27 - The physician must maintain appropriate professional boundaries. The physician must never engage in abusive, exploitative, or other inappropriate relationships or behaviour with a patient and must not engage in a sexual relationship with a current patient. A clinician must also report misconduct – WMA Code Para 32 - The physician should report to the appropriate authorities conditions or circumstances which impede the physician or other health professionals from providing care of the highest standards or from upholding the principles of this Code. This includes any form of abuse or violence against physicians and other health personnel, inappropriate working conditions, or other circumstances that produce excessive and sustained levels of stress.

Legal: You will have duty to investigate this complaint under military law.

Societal/Military: This is a situation that might be exacerbated by the rank disparity between the doctor and the patient. You should consider if your response would, for example, be different if the doctor was male or, for example, if the patient was female and a male doctor was conducting routine breast examinations.

Step 3 – FUSE

• Summarise conclusions
• Insert citations to key reference sources for your analysis
• Determine the exact Decision(s) to be made

This could be a clear case of misconduct, unless there was a very clear instruction that male genital examinations should be conducted to screen for testicular cancer and that the doctor has ensured that there was consent and a chaperone present on every occasion.

Step 4 – DECIDE

• What is your Decision?
• Why (can you justify it)?
• Residual uncertainly, need for review?

You will need to report this complaint to appropriate authorities. You should be very wary of undertaking any further investigation yourself after the reply that you have received, as this suggests that the doctor does not perceive there to be any issue. You are also likely to be a witness in any investigation or disciplinary action.

Contributors – Brigadier (Rtd) Charles Beardmore MBBS MRCGP MFOM MA MSc MBA LLM. Charlie is a qualified General Practitioner with 32 years of military service that culminated in the role of Head of Defence Primary Healthcare in the UK. He is studying for a PhD on the topics of military healthcare ethics. Brigadier Phil Carter MBChB MRCGP MPH MA. Phil is a qualified General Practitioner with 28 years of military service, He recently served as Commander of Defence Primary Healthcare in the UK and Chief Medical of a multinational operational headquarters in the Middle East.