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: One of your nurses reports that a group of patients have uploaded unpleasant images of their wounds onto social media. What do you do?

• 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 respect for social media terms of use. There may be military issues over the use of social media by military personnel.

Step 2 – ANALYSE

Patient: Patients have the right to dignity, privacy, and confidentiality. WMA Code Para 13 - In providing medical care, the physician must respect the dignity, autonomy, and rights of the patient.  AND WMA Code Para 22 - The physician must respect the patient’s privacy and confidentiality. – but also the general right of freedom of expression.

Clinical: The posting of personal graphic pictures of war wounds might be an indication of mental health impacts of physical injury.

Legal: there may be legal terms of use for social media that cover unpleasant imagery.

Societal/Military: there may be military policies and procedures regarding the use of social media by military personnel. There might also be security implications for the military patients.

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 freedom of expression must be respected. However, the posting of unpleasant or graphic images of war wounds may have personal consequences for self-identity, may have clinical consequences for themselves or other patients, may be contrary to the use of the social media applications, and may be contrary to military regulations.

Step 4 – DECIDE

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

This behaviour may have negative consequences for the patients, the clinical team, and reputation of the military, including the medical services. It may also have an impact on other patients and other military personnel. This needs to be balanced against the individuals’ rights of self-expression. It is likely that someone will need to talk to the patients to discuss the implications and consequences of this behaviour. It might be necessary to invoke a military regulation to reduce the likelihood of the behaviour being repeated.  

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).