All of the scenarios in the Role 4 suit should be considered from the perspective of a health professional working in a military hospital receiving casualties from military operations with responsibility for the clinical care of patients and management of the facility. 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/ supported by the WMA Declaration of Lisbon on the Rights of the Patient at: 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. 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: An immobile bilateral amputee in long-term rehabilitation wants to invite a person he has met on a dating site to visit him in the military hospital. A member of staff thinks that this is a prostitute. Can the visit go ahead?
• 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 patient autonomy, including the right to a sex life. This is complicated by the possibility that the relationship involved prostitution, which may be illegal. It is also likely that the sexual act will occur on military premises, which carries a reputational risk.

Step 2 – ANALYSE

Patient: The patient has the right to freedom of behaviour including to a sex life. WMA Code Para 1- The physician must provide care with the utmost respect for human life and dignity, and for the autonomy and rights of the patient. AND WMA Code Para 13 - In providing medical care, the physician must respect the dignity, autonomy, and rights of the patient. For disabled patients receiving medical care, their ability to exercise this choice may be significantly restricted, and the clinical team should try to make suitable adjustments to support the patient’s choices.

Clinical: The clinical team should determine how the patient might be supported to leave the hospital to establish and maintain a personal social life, including a sex life. The might suggest support groups who can give the patient advice.

Legal: if prostitution is illegal, the military leadership must avoid active support to an illegal activity.

Societal/Military: this case could be very sensitive – balancing the rights of the patient with protecting the reputation of the military hospital. It should be remembered that a hospital is a clinical setting with the responsibility to care for the physical, mental, and social health of the patient.  

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 they need covering physical, psychological, and mental health. Sexual health is an important element of holistic health that needs consideration for disabled personnel.

Step 4 – DECIDE

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

This type of case is beyond the decision-making competence of a single clinician. The patient should have access to confidential support to discuss their needs and approach to resolution. This might require a trusted third party to negotiate with the hospital leadership team a solution that meets the patient’s needs without breaking the law or risking military reputation.

Contributor – Group Captain (Rtd) Teresa Griffiths CBE ARRC. Military Chief Nurse, Royal Centre for Defence Medicine (2010 - 2013) and Commanding Officer Defence Medical Rehabilitation Centre Headley Court/Stanford Hall (2016-2018).