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: The partner of an unconscious patient with a poor prognosis wants to arrange for ovarian egg harvesting. There is no pre-existing consent. Can this 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 egg and sperm harvesting, retention, and fertilisation. This is an issue in military healthcare practice due to the likelihood of damage to the reproductive organs from mines and improvised explosive devices. This discussion will cover generic issues. Very specific clinical and legal advice should be sought for specific cases.

Step 2 – ANALYSE

Patient: Clinical interventions may only be undertaken on the basis of informed consent. Where the patient cannot do this, a representative of the patient should do this on the patient’s behalf. Any pre-existing directives by the patient should be respected. WMA Code Para 16 - When a patient has substantially limited, underdeveloped, impaired, or fluctuating decision-making capacity, the physician must involve the patient as much as possible in medical decisions. In addition, the physician must work with the patient’s trusted representative, if available, to make decisions in keeping with the patient’s preferences, when those are known or can reasonably be inferred. When the patient’s preferences cannot be determined, the physician must make decisions in the patient’s best interests. WMA Declaration of Lisbon – Code Para 4 - The unconscious patient:

a. If the patient is unconscious or otherwise unable to express his/her will, informed consent must be obtained whenever possible, from a legally entitled representative.

Clinical: The collection of eggs (or sperm), storage, and subsequent fertilisation to create an embryo is highly technical. The patient should be referred to appropriate clinical experts to advise on feasibility of the procedures.  

Legal: there may be legal restrictions on the collection of eggs (or sperm), storage, and subsequent fertilisation to create an embryo. Any clinical plan should comply with the law.

Societal/Military: this type of case is highly sensitive and may attract media attention which should be carefully handled. This is a predictable clinical conundrum for severely injured military personnel. It may be appropriate to formulate clinical/legal/ethical policy to cover such cases, including the establishment of a clinical and ethical review board to consider individual cases.

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 with the consent of their legally entitled representative. This is a complicated scenario which requires careful consideration.

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. It may be appropriate to convene a clinical/ethical/legal case conference to work through all of the issues in order to determine the best course of action for the patient, and their partner.  

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).