Step 1 – IDENTIFY THE PROBLEM(S)

• Briefly state the Scenario: You are the SNCO in charge of a small medical unit. One of your medics is brought in by a friend disorientated and smelling of alcohol. He is on duty in 4 hours. 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 the autonomy of the patient to make their own decisions about their care, and the right to confidentiality balanced against the right of an employer to know the medical fitness of their employees.

Step 2 – ANALYSE

Patient: The principle of autonomy, beneficence and non-maleficence applies.  The patient has the final right to autonomy – however it is important that they fully understand the consequences (health and wider employment) of not being able to give that consent whether due to permanent or temporarily incapacitation. Autonomy relates closely to consent and capacity.

There may be wider personal circumstances that need to be explored in order to understand why the soldier is under the influence of alcohol prior to going on duty.  

Clinical: Autonomy is a crucial aspect of healthcare as any procedure or care or treatment cannot proceed unless it represents the patient’s wishes. Furthermore, the patient should not have any undue influence on their decision making and must be free of manipulation, coercion and deceit. In other words, clinicians must ensure that they do not force a patient into making a decision and that they are truthful with the information that is presented to the patient. Any decision ought to be informed and given voluntarily. However, in such circumstances as this, it is clear that the patient is not able to make an informed decision over any proposed treatment.

Legal: Every adult is presumed to have capacity to consent, unless proved otherwise. However, in this circumstance, as the ‘friend’ is disorientated, it is unlikely they have the ability to give valid informed consent at that particular time. Therefore, it seems appropriate to act in the patient’s best interests whilst their ability to give valid consent is temporarily incapacitated. This prevents harm to the ‘friend’s’ patient and ensures that the healthcare professional treating the medics ‘friend’ follows their professional duty in giving the appropriate care and treatment. If the SNCO is not a healthcare professional the most appropriate healthcare professional ought to treat this patient.

Best Internets

Best interests’ in health necessitates the healthcare professional reaching the required ‘standard objectives of healthcare practice’.  In practical terms medical [healthcare professional] must consider, so far as reasonably ascertainable - (a) the person’s past and present wishes and feelings, (b) the beliefs and values that would be likely to influence their decision if they had capacity and (c) the other factors that they would be likely to consider if they were able to do so.  In such a circumstance, to ensure valid consent, the healthcare professional must be able to demonstrate that they have acted in someone’s best interest if they have had to provide care in an emergency or where the situation requires an immediate decision. ‘Best interests’ can relate to fluctuating or temporary incapacity.  Therefore, as long as ‘best interests’ is the patient’s ‘best interests’, and not the wishes of the healthcare professional, this provides a defence against a battery and should reduce any ethical dilemmas for the healthcare professional. The healthcare professional/SNCO, may, therefore, determine that medics ‘friend’ lacks capacity to consent for themselves and, therefore, the SNCO can act in the medics ‘friend’s’ ‘best interests’ and treat him according to his current medical condition.

Societal/Military: the employer (Adjutant) has the right to know about the fitness for work of his employees.  As the soldier is due to go on duty in four hours it is reasonable for the healthcare professional to determine that they will not be fit to do so. Military personnel are trained to the highest standards and whilst responsible consumption of alcohol is accepted, it is unprofessional and dangerous for alcohol to make you unfit for duty. As confidentiality is not an absolute right it may be legitimate in this circumstance for the health care professional to inform the Adjutant of the exact reason why the soldier is not fit for duty.

Step 3 – FUSE

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

This scenario balances patient autonomy, clinical care, and military duty (discipline). There might also be a discussion about discipline of the soldier, why they are drinking to this extent and the dual loyalty of clinical professionalism balanced against military obligations.

Step 4 – DECIDE

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

This is unlikely to be a complex issue for the healthcare professional in determining what to do. Whilst they will treat the patient with care and dignity, it is unacceptable for any soldier to be inebriated by alcohol, to the extent they cannot go on duty.  All healthcare professionals where their patients are unable to give consent are trained to give care and treatment in the patient’s best interests.  It may be reasonable for the healthcare professional to notify the chain of command regarding the situation. To eliminate any underlying reason for the soldier’s condition, it may require further investigations and or conversations with the soldier to determine why this has happened.  Undoubtedly it will involve a disciplinary investigation. 

References and Further Reading

International Council of Nurses (Revised 2021), The ICN Code of Ethics for Nurses at Code. Available at ICN_Code-of-Ethics_EN_Web_0_0.pdf; accessed 24 August 2023

Nursing Midwifery Council: Future nurse: Standards of proficiency for registered nurses. Available at future-nurse-proficiencies.pdf (nmc.org.uk); accessed 24 August 2023

Nursing Midwifery Council. The Code: Professional standards of practice and behaviour for nurses, midwives and nursing associates. Available at The Code: Professional standards of practice and behaviour for nurses, midwives and nursing associates - The Nursing and Midwifery Council (nmc.org.uk) accessed 24 August 2023

Nursing and Midwifery Board of Australia. Available at https://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/Professional-standards/registered-nurse-standards-for-practice.aspx; accessed 24 August 2023

Contributor - Lt Col Janet Kelly VR RGN RM DIpHSM MA (HRM) LLB (Hons) PGHCE PhD. Senior Lecturer in Midwifery, Healthcare Law & Ethics; University of Hull. Chair for the Nursing Midwifery Council's Fitness to Practise Conduct and Competence Committees (2013 to 2021). She has served as a commissioned officer in Queen Alexandra's Royal Army Nursing Corps both as a regular and reservist for over 30 years and is now at the rank of Lieutenant Colonel.