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 have conducted a routine medical on your Commanding Officer and found a significant heart murmur. He does not wish you to refer him to a military cardiologist and wishes to go private. 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 consent, confidentially, and patient autonomy. It has implications for the reporting of medical fitness to the military authorities. This is a classic ‘dual loyalty’ issue. There may also be implicit, rank-based, coercion between your Commanding Officer and you. This is similar to Role 4 - Three

Step 2 – ANALYSE

Patient: the patient has expressed a clear preference to be referred outside the military system. They have the right of ‘autonomy’ to choose their healthcare WMA Code 15. The physician must respect the patient’s right to be informed in every phase of the care process. The physician must obtain the patient’s voluntary informed consent prior to any medical care provided, ensuring that the patient receives and understands the information needed to make an independent, informed decision about the proposed care. The physician must respect the patient’s decision to withhold or withdraw consent at any time and for any reason.

Clinical: You have a duty to refer WMA Code 20. If any aspect of caring for the patient is beyond the capacity of a physician, the physician must consult with or refer the patient to another appropriately qualified physician or health professional who has the necessary capacity.

Legal: The military ‘employer’ has the right to know about the medical fitness of an employee for work and any limitations that may be necessary to protect the employee’s health. You are likely to have a duty to ensure that the patient’s fitness for duty continues to be reported through appropriate occupational health reporting mechanisms.

Societal/Military: There may be rules in military procedure regarding referrals and reporting of medical conditions. Both you and your Commanding Officer are obliged to follow these from both a legal and leadership perspective.

Step 3 – FUSE

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

Your Commanding Officer has the right to autonomy to choose how they seek medical care, but the military system may remove payment or insurance cover if they choose to seek care outside of the official referral pathway. You have a duty to report your Commanding Officer’s fitness for work, and would expect to receive a clinical report from the private cardiologist after they have assessed the patient.

Step 4 – DECIDE

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

Ethically, you should not refuse your Commanding Officer’s request to be referred for assessment outside the military system. However, you should explore the reasons why and the consequences of doing so (cost, continuity of care etc). You should also emphasise your responsibilities to report their medical fitness, and the likelihood for reducing their medical grading even while they are being investigated. You should explain that you will receive a report from the private cardiologist, and that you may still need to refer the patient for assessment for medical fitness to a military cardiologist or specialist occupational physician. You might want to seek advice from your medical chain of command if you feel that your Commanding Officer is placing undue coercion upon your clinical decision-making.  

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.