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: A national newspaper reports allegations that civilian patients seem to be taking priority for care over military patients in your military hospital. 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 equity of access and entitlement to care.

Step 2 – ANALYSE

Patient: Patients have the right to access healthcare – WMA Declaration of Lisbon – Para 1 - Right to medical care of good quality, a. Every person is entitled without discrimination to appropriate medical care.

Clinical: The physician should practice medicine without discrimination - WMA Code Para 2 - The physician must practise medicine fairly and justly and provide care based on the patient’s according health needs without bias or engaging in discriminatory conduct on the basis of age, disease or disability, creed, ethnic origin, gender, nationality, political affiliation, race, culture, sexual orientation, social standing, or any other factor – within the rules of the healthcare institution and national policies.

Legal: there may be legal rules on funding that determine the entitlement to healthcare from military health facilities.

Societal/Military: there may be military policies and procedures regarding access to military health facilities by military patients. These might also cover arrangements for private practice by military health professionals, reimbursement and payment for services, and prioritisation between military and civilian patients. This news report could have a detrimental impact on the reputation of the military hospital and the military medical services.

Step 3 – FUSE

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

The news report may be suggesting that the needs of military patients are not being met and that there are unethical reasons for civilian patients receiving healthcare in priority over military patients. However, this may complicated by measures of clinical prioritisation in which civilians may have more urgent medical conditions, resulting in military patients lying lower in the queue for treatment.

Step 4 – DECIDE

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

The ethical requirement for patient access to care and primacy of clinical need are clear. However, almost all health systems have a mechanism to determine entitlement to care, often based on citizenship, occupational status, insurance or other discriminatory measures. The arrangements for the treatment of civilian patients within the military hospital should comply with the relevant rules. The facts behind this newspaper report need to be established, an assessment made as to the validity of the allegations, and determination whether any rules had been broken.

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).