Step 1 – IDENTIFY THE PROBLEM(S)

• Briefly state the Scenario: A soldier on an operational tour has a positive pregnancy test. She is unsure how many weeks she is and begs you not to say anything to anyone.  She refuses to give her consent for her pregnancy to be disclosed.   What should 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 the autonomy of the patient to make their own decisions about their care, and the right to confidentiality balanced against the right of an employer to know the medical fitness of their employees.

Step 2 – ANALYSE

Patient: the principle of Autonomy applies. The patient has the final right to autonomy – however it is important that they fully understand the consequences (health and wider employment) of refusing treatment. There may be wider personal circumstances that need to be explored in order to understand her refusal to accept the consequences of her pregnancy.

Clinical: while there may be understandable reasons for the patient’s denial, it is important to explain the reasons for conducting a clinical assessment. There will be implications of her pregnancy on her continued employment on the operational tour.

Legal: The International Council of Nurses Code of Ethics is at: https://www.icn.ch/sites/default/files/2023-04/ICN_Code-of-Ethics_EN_Web_0_0.pdf . This requires nurses to ensure informed consent, accept the patient’s rights to choose or refuse treatments, and to hold in confidence personal information regarding a patient.

Societal/Military: the employer (adjutant) has the right to know about the fitness for work of his employees and also has a duty to provide welfare support to military personnel. There may already be policies regarding the suitability of deployment for pregnant women. In this instance the ‘military necessity’ of ensuring personnel on operations are medically fit may take precedence over her right of confidentiality.

Step 3 – FUSE

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

This scenario balances patient autonomy, clinical care, and military duty. There might also be a discussion about the dual loyalty of clinical professionalism and military obligations.

Step 4 – DECIDE

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

This is likely to be a complex personal issue for the patient with multiple dimensions to the consequences of discovering her pregnancy during an operational tour. It is important to undertake a full clinical assessment to estimate her expected date of delivery and to ensure that she is fully fit. It may be reasonable to withhold notification of her pregnancy to her chain of command for a short period. However, it will be necessary to tell her chain of command and to apply military policy within a few days in order to protect her, her unborn baby, and ‘her employer’ from any risks associated with remaining on the deployment.

References and Further Reading

International Council of Nurses (Revised 2021), The ICN Code of Ethics for Nurses at Code. Available at ICN_Code-of-Ethics_EN_Web_0_0.pdf; accessed 24 August 2023

Nursing Midwifery Council: Future nurse: Standards of proficiency for registered nurses. Available at future-nurse-proficiencies.pdf (nmc.org.uk); accessed 24 August 2023

Nursing Midwifery Council. The Code: Professional standards of practice and behaviour for nurses, midwives and nursing associates. Available at The Code: Professional standards of practice and behaviour for nurses, midwives and nursing associates - The Nursing and Midwifery Council (nmc.org.uk) accessed 24 August 2023

Nursing and Midwifery Board of Australia. Available at https://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/Professional-standards/registered-nurse-standards-for-practice.aspx; accessed 24 August 2023

Contributor - Lt Col Janet Kelly VR RGN RM DIpHSM MA (HRM) LLB (Hons) PGHCE PhD. Senior Lecturer in Midwifery, Healthcare Law & Ethics; University of Hull. Chair for the Nursing Midwifery Council's Fitness to Practise Conduct and Competence Committees (2013 to 2021). She has served as a commissioned officer in Queen Alexandra's Royal Army Nursing Corps both as a regular and reservist for over 30 years and is now at the rank of Lieutenant Colonel.