Centre for Military Ethics: Ethics Playing Cards

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There is a shortage of beds and you have a stable but ventilated patient who can be moved to a local hospital but you know there are no nurses on night shifts. This could mean a death sentence.

What do you do?

Step 1 – IDENTIFY THE PROBLEM(S)

• Briefly state the Scenario: There is a shortage of beds and you have a stable but ventilated patient who can be moved to a local hospital but you know there are no nurses on night shifts. This could mean a death sentence. What do you do?

• List the Issues that arise from the scenario.

• Identify Critical Information required and Assumptions to be made:

The primary issue is a shortage of beds, and the dilemma is whether to transfer a stable but ventilated patient to a local hospital where the care standard may be lower, particularly with no nurses on the night shift. The challenge involves the ethical decision of whether it is right to move the patient, knowing that this could result in a higher risk to the patient’s survival. Critical information needed includes the exact prognosis of the ventilated patient, the capability of the local hospital, and the availability of resources. Assumptions must be made regarding the capacity of the local hospital to care for the patient, the clinical judgment on whether extubation is possible, and the potential involvement of military necessity in making the transfer decision.

Step 2 – ANALYSE

Patient: The core ethical responsibility is to preserve the life and well-being of the patient while respecting clinical standards. The decision to move a stable but ventilated patient must consider the risk of moving the patient to a lower standard of care, as this could result in a death sentence. Ethical principles highlight that care should not be withdrawn to free up capacity unless clinically necessary (WMA International Code of Medical Ethics, https://www.wma.net/policies-post/wma-international-code-of-medical-ethics/).

Clinical: Clinically, the patient’s prognosis and ability to be extubated must be carefully assessed. If the patient is stable and can be moved without significant risk, transferring the patient may be the most ethical option to preserve life. However, if the patient’s prognosis is poor and moving them risks compromising their care, it may be better to retain them at the facility where they are currently receiving care. Decisions regarding the capacity of the local hospital and the available resources need to be taken into account, as local hospitals may not have the required staff or equipment (Geneva Conventions, https://ihl-databases.icrc.org/applic/ihl/ihl.nsf/Article.xsp?action=openDocument&documentId=2F86D0055DF0E6ECC12563CD0051DA8A ).

Legal: Legally, healthcare personnel must provide care based on clinical need and available resources. International Humanitarian Law prohibits discrimination in healthcare access, but it does not require treatment beyond the capacity of the healthcare provider. If the local hospital cannot provide adequate care, transferring the patient could result in a violation of ethical obligations to ensure the best care possible, as outlined in Customary IHL Rule 88 (https://ihl-databases.icrc.org/customary-ihl/eng/docs/v1_rul_rule88 ).

Societal/Military: From a military perspective, the decision may be influenced by operational needs, but medical necessity and patient welfare must remain the primary concern. Military personnel must make decisions based on clinical priority, ensuring that resources are allocated in a way that provides the best possible care for all patients, including local civilians. Ethical frameworks, such as the WMA Statement on Armed Conflicts (https://www.wma.net/policies-post/wma-statement-on-armed-conflicts/), emphasize the importance of equitable treatment and avoiding discrimination in healthcare allocation.

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 patient care should be based on clinical need and available resources. If the local hospital cannot provide the necessary care, it may be better to retain the patient at the current facility, even if this means operating under strained conditions. The Geneva Conventions and WMA ethical codes support the provision of care without discrimination and with humanity, even when resources are limited. It is essential that the patient’s welfare remains the central focus of any decision, with a robust review of the capacity of the local hospital and the clinical need of the patient being moved.

Step 4 – DECIDE

• What is your Decision?

• Why (can you justify it)?

• Residual uncertainly, need for review?

The decision is to carefully evaluate whether the local hospital can provide the same or better care for the patient, considering the availability of staff and resources. If the local hospital cannot provide adequate care, the patient should remain at the current facility, even if this means maintaining them on the ventilator longer than ideal. This is justified by the ethical principles that require healthcare to be based on clinical need and available resources, and by the legal framework that ensures non-discriminatory access to care. Residual uncertainty may arise about the local hospital’s ability to meet the patient’s needs, so regular communication and review are essential to ensure the best possible outcome.