All of the scenarios in the Role 4 suit should be considered from the perspective of a health professional working in a military hospital receiving casualties from military operations with responsibility for the clinical care of patients and management of the facility. 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/ supported by the WMA Declaration of Lisbon on the Rights of the Patient at: 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. 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 military patient insists on being discharged so they can go to a private civilian hospital for their medical care. Do you agree?

• 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 patient autonomy and their right to choose their healthcare provider, versus the military need to understand the health status of military personnel.

Step 2 – ANALYSE

Patient: Patients have the right to choose their physician and source of healthcare – WMA Code Para 13. In providing medical care, the physician must respect the dignity, autonomy, and rights of the patient. The physician must respect the patient’s right to freely accept or refuse care in keeping with the patient’s values and preferences. AND WMA Declaration of Lisbon – 2.  Right to freedom of choice: a. The patient has the right to choose freely and change his/her physician and hospital or health service institution, regardless of whether they are based in the private or public sector.

Clinical: The physician is also obliged to support continuity of care for the patient – WMA Code Para 7 - When medically appropriate, the physician must collaborate with other physicians and health professionals who are involved in the care of the patient or who are qualified to assess or recommend care options. This communication must respect patient confidentiality and be confined to necessary information.

Legal: there may be legal restrictions on funding for healthcare provided by non-military sources if the patient chooses a different provider.

Societal/Military: there may be military policies and procedures regarding the use of civilian or private health providers outside the military system; including the obligation to ensure all medical information relevant to the patient’s occupational role is communicated back to the military health system.

Step 3 – FUSE

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

The patient’s autonomy to choose their provider of healthcare should be respected. However, there are wider contextual issues that need to be explained to the patient.

Step 4 – DECIDE

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

The patient’s wishes should be respected, including understanding the reasons for their choices. The process should comply with military policies, which will require the exchange of information to/from the private provider and recognition that armed forces need sufficient information to be able to manage the patient’s occupational health.

Contributor – Group Captain (Rtd) Teresa Griffiths CBE ARRC. Military Chief Nurse, Royal Centre for Defence Medicine (2010 - 2013) and Commanding Officer Defence Medical Rehabilitation Centre Headley Court/Stanford Hall (2016-2018).