Step 1 – IDENTIFY THE PROBLEM(S)

Briefly state the Scenario: The local culture or national legal framework has only weak protections against domestic violence or gender-based violence. How do you respond to a badly injured female who reveals that her husband attacked her?

List the Issues that arise from the scenario

• This scenario covers both the duty of healthcare professionals to safeguard patients and also the duties to protect civilians (which might be the background to admission) and reduce gender-based violence.

Identify Critical Information required and Assumptions to be made

• There are many obstacles in this situation we need to consider including the options that might exist to protect the safety of the patient, whether she does or does not consent to your safeguarding plans, and if the safeguarding plans are compliant with the law or practice in the host country.

Step 2 – ANALYSE

Patient: The woman has the right to withhold consent for her information to be disclosed, in accordance with the principle of autonomy. You should seek her explicit consent before sharing any information, unless there is a compelling reason to disclose it without her permission, such as the involvement of a minor (beneficence). It is also important to consider the family dynamics, particularly if abuse is suspected or may be present within the household. A thorough understanding of the patient's wishes is crucial - she may have a clear plan for how to proceed, or she may feel uncertain about how to protect herself. Exploring her perspective is essential to providing appropriate support.

Clinical: Healthcare 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. - ‘ WMA, ‘Ethical principles of health care in times of armed conflict and other emergencies’. At: https://www.wma.net/policies-post/ethical-principles-of-health-care-in-times-of-armed-conflict-and-other-emergencies/

Vulnerable groups such as women, children, the elderly, and people with disabilities (recognised under international law) need to be taken into account when assessing healthcare needs in armed conflicts and other emergencies. There are others who, because of their vulnerabilities, have been subject to sexual violence. Healthcare professionals have a responsibility to consider and, if possible, address this issue in policies and practice.

It is important to note that you should seek advice if considering disclosure without consent or if consent is refused.

You should also record your reasons for disclosing information and whether or not you have consent for disclosure, and document your reasons if you decide not to share information.

MDU. ‘Domestic Abuse: Your legal and ethical duty’. 30 January 2024. At: https://www.themdu.com/guidance-and-advice/guides/domestic-abuse-your-legal-and-ethical-duty#:~:text=What%20is%20your%20legal%20and,spotting%20signs%20of%20domestic%20abuse%3F&text=Doctors%20and%20other%20healthcare%20professionals,has%20detailed%20advice%20for%20GPs.

Legal: Customary IHL prohibits violence against women and The Universal Declaration of Human Rights recognises domestic violence as a violation of human rights. - United Nations General Assembly. ‘Universal Declaration of Human Rights’. 10 December 1948. At: https://www.ohchr.org/sites/default/files/UDHR/Documents/UDHR_Translations/eng.pdf

Geneva Conventions: Rule 134. IHL Databases. At: https://ihl-databases.icrc.org/customary-ihl/eng/docs/v1_cha_chapter39_rule134

Sexual violence is prohibited under human rights law primarily through the prohibition of torture and cruel, inhuman or degrading treatment or punishment. There is an increased recognition of the need to punish all persons responsible for sexual violence. - UN General Assembly, Res. 48/104 proclaiming the UN Declaration on the Elimination of Violence against Women (ibid., 1687); Committee on the Elimination of Discrimination Against Women, General Recommendation No. 19 (Violence against Women) (ibid., 1735); European Court of Human Rights, S. W. v. UK (ibid., 1740)

Societal/Military: The Human Rights Council and the General Assembly have adopted numerous resolutions that address violence against women, including the Declaration on the Elimination of Violence Against Women. We have a duty to protect civilians in armed conflict and those in vulnerable groups (women in this case). - UN Peacekeeping Operations. ‘Protecting civilians’. At: https://peacekeeping.un.org/en/protecting-civilians & UN Peacekeeping Operations. ‘Women, peace and security’. At: https://peacekeeping.un.org/en/promoting-women-peace-and-security

Step 3 – FUSE

● Summarise conclusions

● Insert citations to key reference sources for your analysis

● Determine the exact Decision(s) to be made

Healthcare professionals have a duty to safeguard the health of their patients, especially more vulnerable groups such as children, women and the elderly. Specific duties might also arise from the mandate for the military operation (e.g. UN peacekeeping operations) and also from professional duties mandated by national healthcare regulating organisations (e.g. General Medical Council).

You may want to consider electing a named senior person within the practice to identify and engage with local services for victims of domestic abuse and establish a care pathway for victims to access these services.

Step 4 – DECIDE

• What is your Decision?

• Why (can you justify it)?

• Residual uncertainly, need for review?

The first step in this scenario would be to discuss with this woman possible safeguarding plans and if she has taken any steps to protect herself.

We need to consider if the specific healthcare needs of victims of domestic violence are being addressed and whether or not you have the necessary authority, qualifications and experience to investigate, document or verify domestic violence. If not, you should find someone who does. - ICRC. ‘Healthcare in danger: The Responsibilities of Healthcare Personnel working in Armed Conflict and Other Emergencies’. 2020. At: https://healthcareindanger.org/wp-content/uploads/2015/09/icrc-002-4104-the-responsibilities-health-care-personnel.pdf

As previously discussed, you should seek consent before disclosing information, unless there is a compelling reason not to do so.

Further issues for consideration:

● Is this argument different for children, the elderly, and LBGTQ patients?

● There can also be challenges at the other end of the spectrum. For example, some jurisdictions require mandatory reporting of any domestic violence incidents. What would you do if a victim of domestic violence begs you not to call the police and says she will not stay and receive badly needed aid if you do?

Reviewed and formatted by:

Adriana Salas Yeguez, MBBS Year 3 King’s College London

December 2024