Specific Topic(s): consent and the importance understanding communication capacity of patients.

Key references:

‘Ethical principles of health care in times of armed conflict and other emergencies’

• Health-care personnel act in the best interest of their patients and whenever possible with their explicit consent.

• Health-care personnel respect patients’ right to confidentiality. It is ethical for health-care personnel to disclose confidential information only with the patient’s consent or when there is a real and imminent threat of harm to the patient or to others

Geneva Conventions:

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 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. - A mentally competent adult patient has the right to give or withhold consent to any diagnostic procedure or therapy. The patient has the right to the information necessary to make his/her decisions. The patient should understand clearly what is the purpose of any test or treatment, what the results would imply, and what would be the implications of withholding consent.

Discussion:

Review of the question: this question examines consent and the importance of understanding the communication capacity of patients.

Interpretation of the principles/policy from the references:

• The principle of patient consent is a fundamental foundation of medical ethics based on the principle of autonomy – ‘the right of competent adults to make informed decisions about their own medical care’.

• The provision of health services in conflict and humanitarian crisis should be based on an assessment of the full population at risk – including the specific groups listed in International Humanitarian Law.

• The planning of medical services should include an assessment to how to communicate with each group; including language.

Framework for answering the scenario/question:

• What is the potential population at risk which might present to your medical facility? – consider the specific categories of persons listed in humanitarian law (are there any others – see further issues and Sphere documents in further reading).

• What are the communication needs of each of these populations to enable informed consent? – language, advocates, senses (vision, hearing, speech)?

• How have you provided these?

• Do you have a mechanism for ‘independent advocacy’ in difficult cases?

• Depending on the particular situation, doctors will need to consider and balance their duty to respect the individual’s right to consent and their duty to protect patients from harm (see BMA).

Further issues for consideration:

• Are there any ‘even more’ special groups? [prisoners, LBGTQI, patients with prejudicial medical conditions (e.g. HIV/AIDS, leprosy), unaccompanied children, deafness as result of weapons, ‘child soldiers’]

• What other circumstances require careful consideration of consent? [e.g. emergency intervention, research, release of patient information, photography/media]

Sphere. Core Humanitarian Standard. Available at: https://www.spherestandards.org/humanitarian-standards/core-humanitarian-standard/ and Sphere Handbook at: https://www.spherestandards.org/handbook-2018/

BMA’s Ethical decision-making for doctors in the armed forces: a tool kit. Available at: https://www.bma.org.uk/media/1218/bma-armed-forces-toolkit-oct-2012.pdf