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: You receive 3 soldiers with life-threatening heat stroke and two others with moderate symptoms. The history of the conduct of this military event training suggests that basic prevention rules were not followed. Do you tell their relatives?
• 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 transparency and honesty. It also covers the requirement to support investigations or other follow-up after an adverse event.

Step 2 – ANALYSE

Patient: The patients should receive all necessary clinical treatment.

Clinical: The clinical team should ensure that the full circumstances of the patients’ admission is recorded in the clinical notes. The clinical team have a duty to report the circumstances of this admission to the appropriate military authority. WMA Code Para 4 - 4. The physician must practise with conscience, honesty, integrity, and accountability, while always exercising independent professional judgement and maintaining the highest standards of professional conduct.

Legal: The patients have the right to be protected from excessive risk associated with their work. There may be specific duties of the armed forces under military law and health and safety law.

Societal/Military: this case could be very sensitive in view of the numbers of patients. It is likely to be the subject of a formal investigation. Exertional heat illness is a recognised risk of military training. It is likely that there will be specific military instructions for the prevention of cases.   

Step 3 – FUSE

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

Your primary duty is to ensure that your patients receive the medical care that they need and that the medical record contains all relevant facts. It is likely that these will form part of the follow-up investigation.

Step 4 – DECIDE

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

This type of case is likely to be sensitive. It is unlikely that your team will know the full circumstances leading to the admission of the patients. Therefore, the most important duty to the patients is to ensure competent medical care and full and accurate medical records. The clinical team should be wary of expressing personal opinions but should be prepared to answer factual questions from the relatives.  

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).