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: You have just performed a pregnancy test for a female recruit.  The test is positive.  In tears, she tells you that the father is a training instructor and requests a secret termination of pregnancy. There are strict rules prohibiting sexual relationships between recruits and instructors in the training camp. 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 termination of pregnancy, medical confidentiality, safeguarding, and military discipline.

Step 2 – ANALYSE

Patient: the patient has a right of informed consent regarding their medical care, including requesting a termination of her pregnancy. She can request that this information is kept confidential.

Clinical: you have a duty to ensure she is appropriately referred.

Legal: depending on the law, the father may/may not have a right to know that your patient is pregnant. There may be specific legal rules regarding ‘safeguarding’ and inappropriate relationships in the training camp setting.

Societal/Military: the instructor has clearly broken the rules concerning sexual relationships with recruits, and there may have been a coercive element to both the relationship and the patient’s request for a termination. It will not be possible for her absence from duty to receive medical care to be secret; and that there is a risk that the reason for the referral may become public knowledge.

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 receives the medical care that she seeks. You also have to consider the wider implications of the circumstances.

Step 4 – DECIDE

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

You need to judge the stage of her pregnancy and make appropriate referrals, with the legal arrangements for termination of her pregnancy. You will need to ensure her full consent, including assessment of any risk of coercion in her decision. You will also have to consider how you report the training instructor for breaking the rules regarding sexual relationships with recruits.

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.