The husband of a badly wounded female refuses to permit your male medi · Medical

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J The husband of a badly wounded female refuses to permit your male medics to treat her. What do you do?

Specific Topic(s):

• This scenario is about the cross-cultural application of consent and links to scenarios in 5 Spades, 9 Spades, and Queen of Spades.

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.

6. Health-care personnel act in the best interest of their patients and whenever possible with their explicit consent. If, in performing their professional duties, they have conflicting loyalties, their

primary obligation, in terms of their ethical principles, is to their patients.

8. 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:

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 act in the patient’s best interest when providing medical care.

A PHYSICIAN SHALL respect a competent patient’s right to accept or refuse treatment.

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 highlights the cross-cultural challenge of obtaining consent for treatment. This question assumes that the badly wounded female is the wife of the ‘husband’. No information has been provided about her age or ability to consent (consciousness, language).

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’.

Framework for answering the scenario/question:

• Is it practicable for a female to be involved in her care? (e.g. translator, chaperone, healthcare provider)? Is this acceptable to her husband?

• If no – Is the patient ‘competent’ and able to consent/refuse treatment? If yes, she receives the treatment to which she consents.

• If no – Is the patient’s medical condition an immediate threat to her life? If yes, she should receive the treatment she needs in her best interests.

• Is it practicable to transfer her to a local medical facility? If yes, she should be transferred.

• If no – Is the husband the only person who could advocate on her behalf? (examples of alternatives: parent, adult child) If yes, his decision takes precedence. If not, these additional advocates may be involved.

• How might this decision-making be reviewed and recorded?

Further discussion points

• How would the decision-making be altered if the patient was a child?

• How might you respond if the patient consented to treatment and the father made threats (e.g. to kill her, to leave her in your care, arrange for the medical facility to be targeted)?

• What might be the cultural/religious background to the husband’s views?

• What might be the impact on relationships with the local community, locally employed workers of any decision?

Author: Professor Martin Bricknell