Step 1 – IDENTIFY THE PROBLEM(S)

• Briefly state the Scenario

When faced with an infectious disease outbreak, should military personnel be willing to accept greater risks than civilian medical workers?

• List the Issues that arise from the scenario

The balance between wanting to help patients but also protecting yourself from danger.

The balance of protecting yourself as a military medical professional and the duty to do good for the military.

• Identify Critical Information required and Assumptions to be made

There is the assumption that military medical professionals are exposed to more risk than civilian healthcare workers.

Step 2 – ANALYSE

Patient: What are the views of the Patient? (and ‘patient group’)? How do 4 principles of : Autonomy, Beneficence, Non-maleficence and Justice apply? Other perspectives?

‘Protecting Healthcare’ and ‘Healthcare in Danger’ document both outline that military medical professionals must give impartial treatment to patients regardless of their affiliation. A just use of resources is treating every patient on the basis of clinical need and likelihood of recovery, regardless of their affiliation.

‘Protecting Healthcare’ document emphasizes the principles of impartiality, beneficence, and non-maleficence (acting in patients' best interest while avoiding harm) https://healthcareindanger.org/wp-content/uploads/2021/03/4504_002-ebook.pdf

Clinical: What are the clinical diagnosis, prognosis, treatment options? Is this scenario covered by professional regulation or guidance? What are the views of individual members of the clinical team? Other perspectives?

The ‘greater risk’ that military medical professionals a lot of the time are exposed to in comparison to civilian healthcare workers come in two forms:

Infectious risk: Military medical professionals are often operating in environments that is more restricted on resources. This is due to unstable nature of war environments which can for example disrupt supply chains. Also, the military is designed for mobility and so cannot physically carry that much resources. One example of lack of resources that presents with infectious risk is lack of PPE.

Operational risk: Military medical professionals are often working in environments that are more conflict prone, such as working front line in the military.

Military medical professionals can get hazard pays which means you get extra pay for working in a higher risk environment. There are death benefits which compensate families of passed loved ones in the military. Disability benefits given to military personnel who have been injured and cannot return to military. These benefits help integrate them back into civilian life. There are even such things as reduced work on return from working in high risk environments and psychological support services available.

Legal: Is scenario covered by IHL, Geneva Conventions, military law, other law? Other perspectives?

Military medical professionals are under legal obligation to follow military order and can face legal repercussions if they do not. That being said, the orders themselves must be ethical. And considerations must be followed. Like for example is basic protection is provided like PPE and routine health checks? Do they have pre-existing health conditions? If these are not considered, then military medical personnel are protected under IHL and can refuse order without legal repercussion.

The benefits of the mission must outweigh the risks and include considering things like secure transport in high risk environments, guarded facilities, and clear evacuation plans.

Societal/Military: Is there a military necessity? Is this scenario covered by military regulation or military perspective? Is this scenario covered by public health or societal ethics? Other perspectives?

Civilians should also be given basic PPE protection. There is a certain level of risk that when working under the military you accept as inherent risk such as operating in front line military. And if the benefits of this outweigh the risk, and you refuse order then there is legal consequence. But for a civilian volunteer, because they are volunteering they can refuse.

When there is uneven level of risk exposure amongst different nations, this can be seen as unfair. The unequal distribution of high-risk duties it reasonable to some extent because some nations will have access to different resources which means that they will provide different functions within war. Some countries have different policies around safety regulation. However, as much as possible, it is better to distribute high risk duties amongst different nations. Not doing so can perpetuate distrust between nations. By maintaining transparency in military objectives and operations, this can be mitigated.

Step 3 – FUSE

Military medical professionals are bound by international humanitarian law (IHL), Geneva Conventions, and military law to provide impartial treatment based on clinical need, not affiliation. Orders must be ethical, ensuring basic protections like PPE, health checks, and safety measures. If these are absent, personnel can legally refuse orders under IHL.

Military medical professionals face greater risks, including infectious diseases due to resource constraints and operational hazards in conflict zones. Compensation like hazard pay, death/disability benefits, reduced duties, and psychological support aim to address these risks.

Military necessity must balance risk and benefit. Unequal risk distribution among nations may strain alliances but can be mitigated through transparency and resource-sharing.

Step 4 – DECIDE

Military medical professionals should be willing to accept more risk than civilian healthcare workers, provided that these risks from medical operations are ethical (basic requirements for protection like PPE have been satisfied and military operation overall has more benefit than risk).

Reviewed and formatted by: Yvonne Zhou MBBS Year 3 King’s College London Dec 2024

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Bricknell M, Hodgetts T, Beaton K, et al. Operation GRITROCK: the Defence Medical Services’ story and emerging lessons from supporting the UK response to the Ebola crisis. BMJ Military Health 2016;162:169-175. http://dx.doi.org/10.1136/jramc-2015-000512 (full access requires a subscription)