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: You receive 4 separate requests for medical reports for lawyers on your patients who are claiming that they have suffered non-freezing cold injury during a recent field deployment. There is no record in their notes about this condition. 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 the writing of medical reports and the potential for fraudulent claims for occupational injury from military duties. Non-freezing cold injury has been a source of litigation against the armed forces in some countries. The diagnosis is primarily based on symptoms with very few objective signs.

Step 2 – ANALYSE

Patient: the patient has a duty to be honest. The absence of any entries in the medical records of these patients would be a trigger to suggest that they might be making a dishonest claim, assuming that consultations are routinely recorded correctly. You ask to see the patients and the history of cold exposure and the symptoms they describe do not match the diagnostic criteria for non-freezing cold injury. Neurological examination is normal.

Clinical: It is important to firstly establish whether the symptoms have previously been presented at consultation and to ensure any required investigation and treatment is undertaken.  In this situation, you are providing a report to a third party (the lawyers) and your duty is to them rather than your patients. Therefore your report must be objective and honest. – e.g. WMA Code Para 8 - When providing professional certification, the physician must only certify what the physician has personally verified. AND WMA Code Para 23 - If a physician is acting on behalf of or reporting to any third parties with respect to the care of a patient, the physician must inform the patient accordingly at the outset and, where appropriate, during the course of any interactions. The physician must disclose to the patient the nature and extent of those commitments and must obtain consent for the interaction. You should also consider if you will be expected to provide a medical report on behalf of lawyers acting for the Ministry of Defence if a claim for damages is submitted.

Legal: There may be military law regarding the handling of requests for medical reports and claims against the armed forces. There may also be a law about the right of patients to see medical reports provided to third parties (lawyers, insurers etc).

Societal/Military: You should also consider if these patients have a genuine claim and whether there could be reasons why they have not sought medical advice for a genuine condition.

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 fraudulent attempt to make a claim for damages against the Ministry of Defence for injury, or a genuine claim that needs to be supported by medical reports.  

Step 4 – DECIDE

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

You will need to reply to the lawyer’s request. You will need to check whether you have been requested to provide a report based on the clinical notes or whether you have also been asked to undertake a medical examination. You will also need to inform the patients that you have received the request for a report. It would be sensible to see each patient take a full clinical history, to examine them, to understand their claim, and prepare the medical report. You should be wary of taking any payment for these reports in case you end up with a conflict of interest if you are required to write a medical report in defence of any legal claim.

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.