Step 1 – IDENTIFY THE PROBLEM(S)

• Briefly state the Scenario: An experienced soldier has an infected leg that requires surgical intervention and antibiotics. The soldier is refusing all treatment. The Adjutant has rung the ward asking when he will be discharged and fit for duty. What are the ethical issues??
• 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: 3 principles of Autonomy, Beneficence, Non-maleficence apply. The patient has the final right to autonomy – however it is important that they fully understand the consequences (health and wider employment) of refusing treatment.

Clinical: it seems difficult to understand why the patient is refusing treatment when the value of the intervention seems clear cut. It is important to fully explore this with the patient – is there something else going on? – bullying, not wanting to return to duty etc

Legal: The International Council of Nurses Code of Ethics is at: ICN_Code-of-Ethics_EN_Web.pdf . This requires nurses to ensure informed consent, accept the patient’s rights to choose or refuse treatments, and to hold in confidence personal information regarding a patient.

Societal/Military: the employer (adjutant) has the right to know about the fitness for work of his employees and also has a duty to provide welfare support to military personnel. However, it is not permissible to pass clinical/personal information about the patient to a third party.

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. There might also be a discussion about the dual loyalty of clinical professionalism and military obligations.

Step 4 – DECIDE

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

The Adjutant should be given factual information regarding the immediate implications of the patient’s condition on fitness to work. This is likely to be that the patient remains under hospital care and is unlikely to be discharged in the next few days. There is clearly an issue regarding the patient’s refusal of treatment that needs to be addressed, while respecting their autonomy. Can the patient be ordered to accept treatment? – via military court?  

References and Further Reading

Blyth v Birmingham Water Works [1843-60] All ER Rep 478

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.