A distraught local national father refuses to allow the transfer of hi · Medical

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Q A distraught local national father refuses to allow the transfer of his badly injured daughter to another allied medical unit where more appropriate care can be provided. What do you do?

Specific Topic(s):

• This scenario is about the application of consent and links to scenarios in 5 Spades, 9 Spades, and Jack 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.

The legally incompetent patient: If a patient is a minor or otherwise legally incompetent, the consent of a legally entitled representative is required in some jurisdictions. Nevertheless the patient must be involved in the decision-making to the fullest extent allowed by his/her capacity.

If the legally incompetent patient can make rational decisions, his/her decisions must be respected, and he/she has the right to forbid the disclosure of information to his/her legally entitled representative.

If the patient’s legally entitled representative, or a person authorized by the patient, forbids treatment which is, in the opinion of the physician, in the patient’s best interest, the physician should challenge this decision in the relevant legal or other institution. In case of emergency, the physician will act in the patient’s best interest.

Discussion:

Review of the question: this question highlights the challenge of obtaining consent for treatment. This question assumes that suitable care is not available from local medical facilities and so the child has to be moved to another international military medical unit.

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’. However, in this case the patient is a child and therefore may not be deemed to be competent, and so the father may act on behalf of the patient.

Framework for answering the scenario/question:

• What is the background to the father’s refusal to allow his child to be transferred?

• Can you use an interpreter or local NGO as a mediator?

• Is child old enough/well enough to express a view?

• Is it ethical to separate the child from their father in order to transfer the patient? [NO!]

• What alternative care pathway is possible? [hold in the current medical unit, transfer to a local facility, discharge from care]

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

Further discussion points

• What might be the practical/cultural/religious background to the father’s views? How might you understand this? [consider using translators, local NGOs to run workshops for your personnel on local culture and health beliefs]

• What happens if the father agrees to the transfer but insists on money to provide his subsistence whilst he is with his child?

Author: Professor Martin Bricknell