Specific Topic(s):

• This scenario covers the ethics of resource allocation for competing medical conditions. This scenario is unlikely to apply to international military medical units as it would be unusual for them to be treating cancer patients. However, this is a common challenge for local medical facilities in emergency situations when clinical care for routine patients, especially those with long-term conditions is disrupted by the volume of acute cases.

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 strive to use health care resources in the best way to benefit patients and their community.

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.

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:

e. In circumstances where a choice must be made between potential patients for a particular treatment that is in limited supply, all such patients are entitled to a fair selection procedure for that treatment. That choice must be based on medical criteria and made without discrimination.

Discussion:

Review of the question: The Geneva Conventions primarily apply to emergency medical provision for populations affected by conflict and are not so explicit for chronic medical conditions. Whilst the specifics of this scenario are not directly relevant for international military medical units, the principles are important as some form of ‘rationing’ constrains access to medical care in all medical systems. It is also important to inform military medical personnel of the likely pressures on civilian medical systems and their patients in crisis situations.

Interpretation of the principles/policy from the references:

• There will be trade-offs in the provision of healthcare if the demand for emergency health care increases. This often means that care for chronic non-communicable diseases or longer-term conditions (e.g. diabetes, renal failure, cancer, mental health conditions, raised blood pressure, disability) diminishes.

• The treatment of acute, life-threatening emergencies will take priority over chronic conditions.

Framework for answering the scenario/question:

• What is the normal prescribing pathway for analgesics for palliative care? [hospitals, primary care, government pharmacies, private pharmacies]

• What is the supply system and volume for all forms of analgesics, including opioids?

• What is the stock and likely demand for non-trauma patients?

• What is the likelihood of needing the use the whole stock for acute trauma patients?

• Is there sufficient stock to prescribe for other patients? Can the protocols for allocate be codified?

Further discussion points

• What is the state of the global opioid supply?

• An international donor has approached you as a trusted party to advise on a donation of medical supplies to the local hospital. Do might you assess their needs?

• Would you accept donations and/or use out of date drugs to treat patients if you had limited supplies?

• What are the guidelines for donating medical equipment/drugs in humanitarian emergencies?

Author: Professor Martin Bricknell

Further reading:

Sphere Handbook Chapter Chapter 8 Health. 2.6 Non-communicable disease and 2.7 Palliative Care at: https://spherestandards.org/handbook-2018/

Integrating palliative care and symptom relief into the response to humanitarian emergencies and crises. A WHO guide. 20 February 2018 at: https://www.who.int/publications/i/item/integrating-palliative-care-and-symptom-relief-into-the-response-to-humanitarian-emergencies-and-crises

Nouvet, E., Sivaram, M., Bezanson, K. et al. Palliative care in humanitarian crises: a review of the literature. Int J Humanitarian Action 3, 5 (2018). https://doi.org/10.1186/s41018-018-0033-8

Afsan Bhadelia, Liliana De Lima, Héctor Arreola-Ornelas, Xiaoxiao Jiang Kwete, Natalia M. Rodriguez, Felicia Marie Knaul, “Solving the Global Crisis in Access to Pain Relief: Lessons From Country Actions”, American Journal of Public Health 109, no. 1 (January 1, 2019): pp. 58-60.

https://doi.org/10.2105/AJPH.2018.304769 PMID: 30495996

Knaul FM, Farmer PE, Krakauer EL, De Lima L, Bhadelia A, Jiang Kwete X, Arreola-Ornelas H, Gómez-Dantés O, Rodriguez NM, Alleyne GAO, Connor SR, Hunter DJ, Lohman D, Radbruch L, Del Rocío Sáenz Madrigal M, Atun R, Foley KM, Frenk J, Jamison DT, Rajagopal MR; Lancet Commission on Palliative Care and Pain Relief Study Group. Alleviating the access abyss in palliative care and pain relief-an imperative of universal health coverage: the Lancet Commission report. Lancet. 2018 Apr 7;391(10128):1391-1454. doi: 10.1016/S0140-6736(17)32513-8. Epub 2017 Oct 12. Erratum in: Lancet. 2018 Mar 9;: PMID: 29032993. https://doi.org/10.1016/S0140-6736(17)32513-8

Marks IH, Thomas H, Bakhet M, et al. Medical equipment donation in low-resource settings: a review of the literature and guidelines for surgery and anaesthesia in low-income and middle-income countries. BMJ Global Health 2019;4:e001785. http://dx.doi.org/10.1136/bmjgh-2019-001785

Sally McDonald, Alice Fabbri, Lisa Parker, Jane Williams, Lisa Bero. Medical donations are not always free: an assessment of compliance of medicine and medical device donations with World Health Organization guidelines (2009–2017). International Health, Volume 11, Issue 5, September 2019, Pages 379–402, https://doi.org/10.1093/inthealth/ihz004