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?

Specific Topic(s):

• This scenario is about the application of Medical Rules of Eligibility and pathways of care for different categories of patients in actual clinical practice.

Key references:

‘Ethical principles of health care in times of armed conflict and other emergencies’ –

3. The primary task of health-care personnel is to preserve human physical and mental health and to alleviate suffering. They shall provide the necessary care with humanity, while respecting the dignity of the person concerned, with no discrimination of any kind, whether in times of peace or of armed conflict or other emergencies.

7. In armed conflict or other emergencies, health-care personnel are required to render immediate attention and requisite care to the best of their ability. No distinction is made between patients, except in respect of decisions based upon clinical need and available resources.

Geneva Conventions:

Non-discrimination is covered across the Geneva Conventions and associated Protocols https://ihl-databases.icrc.org/applic/ihl/ihl.nsf/vwTreaties1949.xsp :

First Geneva Convention, Article 12;

Second Geneva Convention, Article 12;

Third Geneva Convention, Article 16;

Fourth Geneva Convention, Article 13;

Additional Protocol I, Article 75(1);

Additional Protocol II, Article 4(1);

Customary IHL:

Rule 88. Adverse distinction in the application of international humanitarian law based on race, colour, sex, language, religion or belief, political or other opinion, national or social origin, wealth, birth or other status, or on any other similar criteria is prohibited. https://ihl-databases.icrc.org/customary-ihl/eng/docs/v1_rul_rule88

Ethical principles:

WMA INTERNATIONAL CODE OF MEDICAL ETHICS - https://www.wma.net/policies-post/wma-international-code-of-medical-ethics/

A PHYSICIAN SHALL not allow his/her judgment to be influenced by personal profit or unfair discrimination.

WMA STATEMENT ON ARMED CONFLICTS - https://www.wma.net/policies-post/wma-statement-on-armed-conflicts/

11. The WMA recognizes that the impact of armed conflict will be most significant upon women and vulnerable populations, including children, the young, the elderly and the poorest members of society. Physicians should seek to ensure that allocation of medical care resources does not have a discriminatory impact.

Discussion:

Review of the question: this question highlights the real clinical challenge of providing appropriate care of the various types of casualties that might present to a military hospital. This might include international armed forces personnel, international civilians/contractors, local armed forces personnel, local civilians, prisoners, possibly including women, children and the elderly.

Interpretation of the principles/policy from the references: all of the references emphasise the legal and ethical duties to provide medical care in an emergency solely on the basis of clinical priority and without discrimination. The care should be provided to the clinical standards appropriate to the medical facility but it does not imply a commitment to further treatment/referral/evacuation in the care pathway (particularly outside of the country of operations). For local civilians, their continuing care will be provided by local medical services and they should be transferred from international military facilities as soon as clinically and organisationally possible. It might involve a step down in quality of care. However, it would be unethical to withdraw treatment solely on the basis of freeing up capacity.

Framework for answering the scenario/question:

• What is the nature of the ‘shortage of beds’? Can more capacity be made available through the allocation of more resources?

• What is the exact nature and prognosis for the ventilated local casualty? Could the patient be extubated?

• What is the exact capability and prior experience of transferring casualties to the local hospital?

• Is the local hospital willing to accept the patient?

• Who will participate in the discussion about the clinical decision and risk? How will this be recorded?

• How will the patient’s representatives be involved in the decision process?

• At what point could military necessity be considered a legitimate order for the patient transfer to take place? Who would make the ‘order’?

Further discussion points

• How is this different from the application of ‘medical rules of eligibility’ for criteria for entry into the military medical system?

• Is it ethical to ‘triage to withdraw care’, versus ‘triage to allocate care’?

• What complex clinical scenarios are predictable and therefore should be considered prior to the event? [severe burns, peri-natal maternal-child complications, head injury, spinal injury, acute medical conditions, etc.]

• How do international humanitarian organisations manage ethics in clinical decision-making?

• How might clinical standards in local medical facilities be improved? When is it acceptable to divert/transfer patients to local facilities if their standard of care is lower than international military medical units?

Author: Professor Martin Bricknell