All of the scenarios in the policy suit should be considered from the perspective of a health professional in a staff appointment as the lead officer for medical policy within a Ministry of Defence (rank equivalent of OF4/Commander/Lieutenant Colonel/Wing Commander).

Step 1 – IDENTIFY THE PROBLEM(S)

• Briefly state the Scenario: You receive a formal complaint about the quality of medical care in a coalition hospital on a military mission that your country has responsibility for leading. How do you respond?
• 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 the management of multinational medical units on military operations. It is similar to the scenario JACK DIAMONDS but this answer is focussed on the policy aspects rather than the local aspects that are the responsibility of the Commanding Officer of the coalition hospital.

Step 2 – ANALYSE

Patient: there is an institutional duty to military patients to ensure that the care that they receive is appropriate and complies with established medical practice. This extends to all patients treated by a military health unit, and the obligation for ‘institutional competence’.

Clinical: there is a personal professional duty on medical planners to ensure that the governance arrangements for oversight of clinical practice in military health units are appropriate and functional.

Legal: it is likely that there will be a formal document (e.g. Memorandum of Understanding, MOU) regarding governance of the coalition medical facility including the liability for negligence plus oversight and governance. This should determine the parameters of the ‘investigative process’.  

Societal/Military: it is vital that the countries involved in this coalition hospital retain confidence in the care provided by the clinical team and in the competence of the leadership of the unit. Your approach to the investigation of the issue and resolution of concerns will be vital to maintaining this confidence.

Step 3 – FUSE

• Summarise conclusions
• Insert citations to key reference sources for your analysis
• Determine the exact Decision(s) to be made

This scenario replicates a key challenge faced by countries if they decide to burden-share medical support arrangements on operations. An example of a template for a MOU for a multinational medical unit can be found in the NATO document AMedP-9.2 GUIDELINES FOR A MULTINATIONAL MEDICAL UNIT at https://www.coemed.org/files/stanags/03_AMEDP/AMedP-9.2_EDA_V1_E_2552.pdf . You will need to consider the provenance of the author of the letter: a patient, their representative, or an official body. You will probably need to initiate an ‘investigation’ to understand the complaint about the medical care in the field hospital. The process for investigation will need to comply with the provisions of the MOU, any existing procedures for investigating complaints within your own health system, and with the ethics of consent and confidentiality in regard to the patients and any clinicians involved, and the need for transparency to ensure confidence in your country and the hospital is maintained.   

Step 4 – DECIDE

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

Your professional duty is to provide the best technical advice. It will be necessary to understand the nature and content of the complaint and any restitution desired by the author of the letter. In addition to the conduct of the investigation, it will be necessary to notify relevant stakeholders to balance between awareness, transparency and fairness. You might discuss how investigations into complaints are undertaken within your own medical system.

Contributor – Air Vice Marshal (Rtd) Alastair Reid CB FFOM, Surgeon General UK Defence Medical Services 2019-2021.