All of the scenarios in the garrison healthcare suit should be considered from the perspective of a healthcare professional working in a military garrison healthcare centre with responsibility for the clinical care of patients and management of the healthcare centre. The primary supporting reference for this suit is the World Medical Association International Code of Medical Ethics (WMA Code) at: https://www.wma.net/policies-post/wma-international-code-of-medical-ethics/ . You should also consider your national professional ethical codes and relevant military law or guidance.

Step 1 – IDENTIFY THE PROBLEM(S)

• Briefly state the Scenario: A friend is a battalion commander. He is also a patient in your clinic. His wife asks for your help because he is drinking heavily, is abusive, and seems to be spending money recklessly. 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 treatment of mental ill-health and the treatment of a friend.

Step 2 – ANALYSE

Patient: the patient is almost certainly in need of support. It is likely that his mental ill-health is significant if his wife has sought your help. He is entitled to compassion and confidentiality (unless there is an overriding reason to breach confidentiality).

Clinical: Once you have established he has mental ill-health, you have a duty to ensure he is given appropriate support.

Legal: depending on the law, the battalion commander may be committing offences through misuse or abuse of his position.

Societal/Military: a battalion commander is a very senior and important military role. They exert consider authority and power, and so there are considerable risks to the battalion if he has mental ill-health. You may have a military duty to report his medical condition to his superiors.

Step 3 – FUSE

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

Your primary duty is to ensure that your patient received the medical care that he needs. You also have to consider the wider implications of his mental ill-health on military effectiveness.

Step 4 – DECIDE

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

You will need to decide how to broach the problem with your friend/Battalion Commander. You will also need to decide whether it is appropriate for you to manage his care, even if you make referrals to mental health professionals. You will also need to decide whether to report his circumstances to his senior commander. There are additional considerations if the wife is also registered with your practice as she may also have health concerns. There are further considerations on the appropriateness of your involvement if you hold a leadership role in the practice such as the lead clinician or with specific responsibility for care quality that may see you having oversight of care even if primary responsibility has been passed to another clinician. In view of the complexity of the case, you might discuss this case with a senior colleague. This is especially important if the Battalion Commander has any role in writing your performance report.

Contributors – Brigadier (Rtd) Charles Beardmore MBBS MRCGP MFOM MA MSc MBA LLM. Charlie is a qualified General Practitioner with 32 years of military service that culminated in the role of Head of Defence Primary Healthcare in the UK. He is studying for a PhD on the topics of military healthcare ethics. Brigadier Phil Carter MBChB MRCGP MPH MA. Phil is a qualified General Practitioner with 28 years of military service, He recently served as Commander of Defence Primary Healthcare in the UK and Chief Medical of a multinational operational headquarters in the Middle East.