Step 1 – IDENTIFY THE PROBLEM(S)

•Briefly state the Scenario: A rape victim asks to be given a ‘morning-after pill’ which your clinic has available. However, it is illegal in the country where you are operating. What do you do?

List the Issues that arise from the scenario

• The legalities of emergency contraception in the country you are in.

• Is it maleficient to not provide treatment due to legislation?

• If no contraception is offered, the patient could be put in harms way emotionally and physically.

Identify Critical Information required and Assumptions to be made

• What are the arrangements in your military for emergency healthcare for a victim of an alleged rape?

• What are the arrangements in your military for reporting and investigation (including collection of forensic samples) for a victim of an alleged rape?

• What legal instruments allow foreign medical personnel to undertake clinical practice in a host country?

• Insight into your conscience regarding fertility control.

Step 2 – ANALYSE

Patient: If we consider patient autonomy, she should have the right to access the morning-after pill. Considering beneficence, it is important to have the best interests of the patient at the centre of their healthcare (both psychological and physical well-being) which brings into question whether not giving the patient the pill would constitute as maleficence.

Sexual violence may be a significant internal issue within security forces. This includes ensuring that survivors have access to suitable emergency health services for their physical and emotional needs, and proper forensic and investigative support to ensure that assailants are brought to justice.

Clinical: Clinical personnel should practice in accordance with their parent national registration arrangements. Patients should only receive clinical care that is licenced in their home country unless there are overriding emergency considerations (e.g. a licensed medicine is not available).

Healthcare personnel shall at all times act following relevant international and national law, ethical principles of health care and their conscience. - 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/

People who have been harmed and who are in need of medical support may receive no support within their community; healthcare professionals may find this a very difficult dilemma causing moral injury.

Medicins sans Frontiers. ‘Sexual and gender-based violence (SGBV) is a medical emergency’. At: https://www.msf.org.uk/issues/sexual-and-gender-based-violence

ICRC. ‘Healthcare in danger: The Responsibilities of Healthcare Personnel working in Armed Conflict and Other Emergencies’. 2020. At: https://healthcareindanger.org/wp-content/uploads/2015/09/icrc-002-4104-the-responsibilities-health-care-personnel.pdf

Legal: While common Article 3 of the Geneva Conventions does not explicitly mention rape or other forms of sexual violence, it prohibits “violence to life and person” including cruel treatment and torture and “outrages upon personal dignity”. Sexual violence is prohibited under human rights law primarily through the prohibition of torture and cruel, inhuman or degrading treatment or punishment. - Geneva Conventions: Rule 134. ‘The specific protection, health and assistance needs of women affected by armed conflict must be respected.’ At: https://ihl-databases.icrc.org/en/customary-ihl/v1/rule134

In addition, the Statute of the International Criminal Court classifies “rape, sexual slavery, enforced prostitution, forced pregnancy, enforced sterilisation, or any other form of sexual violence of comparable gravity” as a crime against humanity and “rape” constitutes a crime against humanity. Also, the legislation of many states provides that rape and other forms of sexual violence are war crimes. - Customary IHL Rule 93: ‘Rape and Other Forms of Sexual Violence’. At: https://ihl-databases.icrc.org/en/customary-ihl/v1/rule93#Fn_3C5B94FA_00007

Societal/Military: Most military operations will be conducted under a legal ‘Status of Forces Arrangement’ with a host country which will include provision for the military personnel to operate under the legal jurisdiction of their parent nation. This includes ‘licencing for medical practice’. Similar arrangements will be established where medical personnel work in a multi-national unit.

Professionals may find themselves treating patients from a culture where decisions are made by the heads of families or by local leaders. Ethical practice requires the patient’s agreement, but local law and custom might require that of someone else. - International Review of the Red Cross. ‘Medical ethics in peacetime and wartime: the case for a better understanding’. 2013. At: https://international-review.icrc.org/sites/default/files/irrc-889-nathanson.pdf

Step 3 – FUSE

● Summarise conclusions

● Insert citations to key reference sources for your analysis

● Determine the exact Decision(s) to be made

Healthcare personnel shall at all times act in accordance with relevant international and national law, ethical principles of health care and their conscience.

Military medical services must consider the specific health needs of women within their military and those populations that are entitled beneficiaries. Normally, patients should only receive clinical care licenced in their home country.

Assess if the patient has access to suitable emergency health services for their physical and emotional needs and the support available; consider how these issues are addressed within your security service, and what you might do if you witness this behaviour in partner security forces.

Maria Eriksson Baaz, Harriet Gray, Maria Stern, What Can We/Do We Want to Know? Reflections from Researching SGBV in Military Settings, Social Politics: International Studies in Gender, State & Society, Volume 25, Issue 4, Winter 2018, Pages 521–544. At: https://doi.org/10.1093/sp/jxy033

Step 4 – DECIDE

• What is your Decision?

• Why (can you justify it)?

• Residual uncertainly, need for review?

We need to assess if the healthcare needs of the victim are being addressed and if you have the necessary authority, qualifications and experience to investigate, document or verify rape. If not, you should find someone who does. - ICRC. ‘Healthcare in danger: The Responsibilities of Healthcare Personnel working in Armed Conflict and Other Emergencies’. 2020. At: https://healthcareindanger.org/wp-content/uploads/2015/09/icrc-002-4104-the-responsibilities-health-care-personnel.pdf

Patients should only receive clinical care that is licenced in their home country unless there are overriding emergency considerations. When deciding if this case meets this standard, you might want to seek the advice of a colleague or senior.

Additionally, other forms of contraception that aren’t illegal in the country can be considered and discussed as the patient might not be aware of them.

Medical officers should ask before deployment for information about and training concerning any local cultural practices that they are likely to encounter.

This question has not determined the ‘type’ of female – what differences apply if the female is a civilian international contractor, a member of the local security forces, or a local civilian?

Reviewed and formatted by:

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

December 2024

Most military operations will be conducted under a legal ‘Status of Forces Arrangement’ with a host country which will include provision for the military personnel to operate under the legal jurisdiction of their parent nation. This includes ‘licencing for medical practice’. Similar arrangements will be established where medical personnel work in a multi-national unit. Clinical personnel should practice in accordance with their parent national registration arrangements. Patients should only receive clinical care that is licenced in their home country, unless there are over-riding emergency considerations (e.g. a licensed medicine is not available).

Maria Eriksson Baaz, Harriet Gray, Maria Stern, What Can We/Do We Want to Know? Reflections from Researching SGBV in Military Settings, Social Politics: International Studies in Gender, State & Society, Volume 25, Issue 4, Winter 2018, Pages 521–544, https://doi.org/10.1093/sp/jxy033

Sexual and gender-based violence (SGBV) is a medical emergency. Medicins sans Frontiers. Available at: https://www.msf.org.uk/issues/sexual-and-gender-based-violence accessed 29 May 20