All of the scenarios in the garrison healthcare suit should be considered from the perspective of a healthcare professional working in a military garrison healthcare centre with responsibility for the clinical care of patients and management of the healthcare centre. 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/ . 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: You receive a complaint that a patient heard some other personnel talking about her private medical information. Reviewing her health record as see that a junior nurse was the last recorded viewer. What do you do?
• 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 confidentiality. It is similar to the JACK scenario, but also included your vicarious liability for the behaviour of one of your staff.

Step 2 – ANALYSE

Patient: your patient has the right to confidentiality of their medical information and that it will only be shared with those who need it for their care.

Clinical: all healthcare staff have a duty to maintain patient confidentiality – e.g. WMA Code Para 19 - The physician should be considerate of and communicate with others, where available, who are close to the patient, in keeping with the patient’s preferences and best interests and with due regard for patient confidentiality.

Legal: You have a legal duty as a senior leader to ensure that your personnel are educated on their duties and that they comply with their legal and ethical duties – including maintaining patient confidentiality. You will also have a duty to appropriately investigate any complaints.

Societal/Military: There may be clauses in military law that emphasise the duty of confidentiality, including the occasions when confidentiality may be broken for military reasons – see KING and QUEEN of this suit.

Step 3 – FUSE

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

If you have received a complaint from a patient, you are obliged to investigate. In the case of understanding the potential breakdown of patient confidentiality, you will also need to ask your staff about how this might have happened.  

Step 4 – DECIDE

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

You will need to find out further information of the circumstances of the patient’s complaint. This must be done within any policies or procedures regarding the investigations of complaints. You will need to interview the junior nurse, and anyone else who might be implicated. You will have to keep an open mind, and determine if the reported conversation happened, what was discussed, whether it was for the benefit of the patient, and whether confidentiality was broken. You will then need to consider if any disciplinary investigation or sanction is needed. Finally, as you have a senior managerial role, you will need to consider whether to undertake any wider staff training or other programme to ensure that it doesn’t happen again. This might include a check on policies and procedures to make sure that there is no ambiguity over anyone’s responsibility to maintain patient confidentiality.

Contributors – Brigadier (Rtd) Charles Beardmore MBBS MRCGP MFOM MA MSc MBA LLM. Charlie is a qualified General Practitioner with 32 years of military service that culminated in the role of Head of Defence Primary Healthcare in the UK. He is studying for a PhD on the topics of military healthcare ethics. Brigadier Phil Carter MBChB MRCGP MPH MA. Phil is a qualified General Practitioner with 28 years of military service, He recently served as Commander of Defence Primary Healthcare in the UK and Chief Medical of a multinational operational headquarters in the Middle East.