Centre for Military Ethics: Ethics Playing Cards

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Special forces capture a combatant who, they believe, has vital information about a future terrorist attack. The combatant refuses a life-saving treatment stating that he would “rather die than live as a prisoner and traitor”.

What can/should you do?

Step 1 – IDENTIFY THE PROBLEM(S)

• Briefly state the Scenario: With modern medicine it is possible to save the lives of people with devastating injuries that will profoundly change their lives forever. Are there limits to how far treatment should be taken? Who decides?

• List the Issues that arise from the scenario.

• Identify Critical Information required and Assumptions to be made:

The key issue is determining the limits of medical intervention when treating individuals with devastating injuries that could profoundly affect their future quality of life. This includes balancing life-sustaining treatment with considerations of long-term prognosis, patient autonomy, and the ethical obligation to alleviate suffering. Critical information includes the patient’s clinical stability, physical and mental prognosis, and social context. Assumptions must address the availability of resources, the patient's wishes if known, and the involvement of family or legal representatives in the decision-making process.

Step 2 – ANALYSE

Patient: The primary duty is to provide emergency care aimed at saving the patient’s life, ensuring respect for their dignity and autonomy. According to the WMA Declaration of Lisbon on the Rights of the Patient (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.), treatment should always align with the patient’s best interests and be consistent with approved medical principles. Healthcare professionals must consider not only the immediate physical prognosis but also the long-term implications for mental and social well-being.

Clinical: Emergency care must follow best practices to stabilize the patient. Once stabilized, a comprehensive review of their physical, mental, and social health is essential. If the prognosis indicates a life of profound disability with limited quality, it may be appropriate to reassess the level of medical intervention. The Geneva Conventions (Protocol I, Article 10, https://ihl-databases.icrc.org/applic/ihl/ihl.nsf/Article.xsp?action=openDocument&documentId=2F86D0055DF0E6ECC12563CD0051DA8A ) emphasize providing medical care to the fullest extent practicable and with the least delay.

Legal: International humanitarian law and medical ethics require decisions to be made in the best interests of the patient, balancing life preservation with the alleviation of suffering. The WMA International Code of Medical Ethics (https://www.wma.net/policies-post/wma-international-code-of-medical-ethics/) underscores the importance of competent, compassionate care, respecting the patient’s dignity and independence. Withdrawal or withholding of life-sustaining treatment must align with ethical and legal frameworks, ensuring fairness and adherence to established standards.

Societal/Military: In military or crisis contexts, decisions may also involve considerations of resource limitations and the feasibility of continued care, particularly in local or resource-constrained facilities. The impact on families and broader societal norms must be considered, requiring transparent communication and careful documentation of decisions.

Step 3 – FUSE

• Summarise conclusions

• Insert citations to key reference sources for your analysis

• Determine the exact Decision(s) to be made

The conclusion is that treatment decisions must prioritize the patient’s best interests, balancing the goal of preserving life with considerations of quality of life and prognosis. Emergency care should always aim to stabilize the patient, but subsequent interventions should involve a multidisciplinary review of their physical, mental, and social outcomes. Ethical and legal principles, such as those outlined in the Geneva Conventions (Protocol I, Article 10) and the WMA International Code of Medical Ethics (https://www.wma.net/policies-post/wma-international-code-of-medical-ethics/), provide clear guidance for ensuring that care respects human dignity and minimizes suffering.

Step 4 – DECIDE

• What is your Decision?

• Why (can you justify it)?

• Residual uncertainly, need for review?

The decision is to provide life-sustaining treatment in emergencies but reassess the level of intervention once the patient is stabilized. Multidisciplinary input, including legal, ethical, and clinical perspectives, should guide this decision-making process. When the prognosis is poor, and the quality of life is severely compromised, it may be appropriate to consider withholding or withdrawing treatment in alignment with the patient’s best interests and ethical principles. References such as the WMA Declaration of Lisbon (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.) and guidance from professional organizations like the UK General Medical Council (https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/treatment-and-care-towards-the-end-of-life ) support the balance between preserving life and alleviating suffering. Residual uncertainty may arise in cases where the patient’s wishes are unknown, requiring careful documentation and consultation with ethical committees.

Further discussion points

• One patient can be evacuated with a critical care team back to their home country; another is being transferred into a resource limited local health system. Does this influence your decision?

• What is the difference in the principles described in this scenario and triage in a mass casualty situation? hint - mass casualty triage is about access to medical care in a highly resource-constrained situation and therefore doing the 'best for the most

• Is it ethical to give a severely injured patient with unsurvivable wounds a lethal dose of morphine?

• What is the difference between withholding medical treatment and withdrawing medical treatment?

• How does the decision-making in this scenario differ from clinical decision-making in severe cases of COVID-19?

Reviewed and formatted by: Alexandros Carver, 3rd Year Medical Student KCL, December 2024