Centre for Military Ethics: Ethics Playing Cards

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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?

Specific Topic(s):

• This scenario covers the ethics of clinical decision-making when the nature of patient’s injuries may seem to make their future life futile. This also includes a discussion on the withdrawal of life-sustaining treatment when the clinical prognosis is very poor.

• This is linked to the scenario in 8 Clubs.

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.

Geneva Conventions:

Protocol Additional to the Geneva Conventions of 12 August 1949, and relating to the Protection of Victims of International Armed Conflicts (Protocol I), 8 June 1977. Article 10

Protocol Additional to the Geneva Conventions of 12 August 1949, and relating to the Protection of Victims of Non-International Armed Conflicts (Protocol II), 8 June 1977. Article 7

In all circumstances they (wounded, sick and shipwrecked) shall be treated humanely and shall receive, to the fullest extent practicable and with the least possible delay, the medical care and attention required by their condition. There shall be no distinction among them founded on any grounds other than medical ones.

Customary IHL:

Rule 87. Humane Treatment. Civilians and persons hors de combat must be treated humanely. https://ihl-databases.icrc.org/customary-ihl/eng/docs/v1_cha_chapter32_rule87 - specific categories of persons: the wounded, sick and shipwrecked, persons deprived of their liberty, displaced persons, women, children, the elderly, the disabled and infirm.

Ethical principles:

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

A PHYSICIAN SHALL be dedicated to providing competent medical service in full professional and moral independence, with compassion and respect for human dignity.

A PHYSICIAN SHALL give emergency care as a humanitarian duty unless he/she is assured that others are willing and able to give such care.

A PHYSICIAN SHALL always bear in mind the obligation to respect human life.

A PHYSICIAN SHALL act in the patient’s best interest when providing medical care.

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.

1. Right to medical care of good quality:

c. The patient shall always be treated in accordance with his/her best interests. The treatment applied shall be in accordance with generally approved medical principles.

Discussion:

Review of the question: The question considers clinical decision-making for a single individual throughout their care pathway, including long-term physical and mental rehabilitation and recovery.

Interpretation of the principles/policy from the references:

• There is a clear obligation under International Humanitarian Law and ethics to provide emergency treatment for acute injury or illness in accordance with their clinical priorities without discrimination.

• Emergency treatment should always be given with the intention of saving the life of the casualty.

• Medical ethics requires clinical care to be provided in the best interests of the patient, which may be balanced between sustaining medical treatment and the patient’s quality of life.

• Once a casualty is stabilized, it may be appropriate to review the level of clinical intervention according to their physical, mental and social prognosis.

Framework for answering the scenario/question:

• Does the patient have signs of life? If yes - provide emergency care to best practice.

• Is the patient clinically stable? If NO, continue emergency care

• If YES, conduct physical, mental, social health review.

• Who should be involved in the review? How is the patient represented?

• What is the physical prognosis?

• What is the mental prognosis? Including consequences of brain injury.

• What is the social prognosis? – [are they covered by existing ‘rules of medical eligibility, are they eligible for further medical evacuation and medical care, what is the quality of health and social care system etc.]

• How is the decision recorded?

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?

Author: Professor Martin Bricknell