Step 1 – IDENTIFY THE PROBLEM(S)

Briefly state the Scenario: In a mass casualty situation, is it ethical for a military medical unit to keep beds empty for new military casualties?

List the Issues that arise from the scenario

• The challenge of allocating military medical capacity for the immediate needs of casualties from conflict when the medical capacity is likely to be exceeded.

• Duty to patients (saving life) vs preserving bed capacity for the military

• Potential effect on locals/society if refusing to act to save lives to keep empty bed

• Potential moral injury if life is lost as a result of keeping empty beds

Identify Critical Information required and Assumptions to be made

• What are the circumstances by which a patient may be admitted to a military medical facility, particularly during operations? ('Medical rules of eligibility)

• What are the obligations for caring for patients?

• What is the difference between 'normal' and mass casualty situations?

• Why might it be necessary to retain a 'medical reserve?

• What tensions might exist between medical ethics and military necessity?

• Who has the ultimate authority to decide?

Step 2 – ANALYSE

Patient: Every patient has the right to receive high-quality care and to be treated fairly and equally. Beneficence dictates that healthcare professionals must act to save lives, and failing to do so could be seen as maleficent. However, it can also be argued that occupying medical resources, such as beds, for patients whose condition is less urgent may be harmful if it prevents more critically ill patients from receiving care, regardless of their military status.

Clinical: Healthcare principles and policies state that in all circumstances, the casualties should be treated solely on the basis of clinical need without discrimination. Healthcare workers must provide good quality care and act in the patient's best interests.

In a mass casualty situation, the medical facility may temporarily lack the ability to provide effective therapy to all.

‘In armed conflict or other emergencies, healthcare personnel are required to render immediate attention and requisite care to the best of their ability. No distinction is made between patients, except in respect of decisions based upon clinical need and available resources.’ - 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/

Legal: "Only urgent medical reasons will authorise priority in the order of treatment to be administered." Therefore, there is no obligation on military forces to treat non-urgent civilian cases. 'Medical rules of eligibility’ is a framework for deciding whether international military medical units should provide care for other populations including local security forces, and local civilians. - Geneva Convention (I) for the Amelioration of the Condition of the Wounded and Sick in Armed Forces in the Field, 12 August 1949. At: https://ihl-databases.icrc.org/assets/treaties/365-GC-I-EN.pdf

Although an Operational Commander has the authority to limit the availability of military medical support to third parties, acute emergency treatment of life-threatening conditions normally must not be denied within the capability/capacity of the medical resources deployed and care must be delivered without discrimination. - IHL: Rule 88. ‘Adverse distinction in the application of international humanitarian law based on race, colour, sex, language, religion or belief, political or other opinion, national or social origin, wealth, birth or other status, or on any other similar criteria is prohibited.’ At: https://ihl-databases.icrc.org/en/customary-ihl/v1/rule88

Geneva Conventions: Rule 110. ‘The wounded, sick and shipwrecked must receive, to the fullest extent practicable and with the least possible delay, the medical care and attention required by their condition. No distinction may be made among them founded on any grounds other than medical ones.’ At: https://ihl-databases.icrc.org/en/customary-ihl/v1/rule110

Societal/Military: In a military setting, medical capacity is likely to be exceeded as a result of a mass casualty incident in which triage decisions are made on the ability to benefit from simple interventions. This is different from a major incident in which casualties are treated in the order of clinical severity. There is a military necessity for empty beds to support the military force, especially in the case of life-threatening casualties, however, it is not possible to accurately predict when the military will sustain casualties requiring beds or how many will be sustained. Societal ethics would not make a distinction between a military and a civilian casualty. There could be significant adverse media and political perceptions of the military if a civilian medical need was deemed ‘less important’ than a military casualty not based on medical need.

Step 3 – FUSE

● Summarise conclusions

● Insert citations to key reference sources for your analysis

● Determine the exact Decision(s) to be made

Military forces may decide to 'keep beds empty to ensure capacity for future military operations on the grounds of military necessity. The 'military necessity' decision can only be made by a military (not medical) commander supported by legal advice. - Gross ML. ‘Saving Life, Limb, and Eyesight: Assessing the Medical Rules of Eligibility During Armed Conflict.’ Am J Bioeth. 2017;17(10):40‐52. doi:10.1080/15265161.2017.1365186

This situation has the potential to result in moral injury to those involved. - ‘In armed conflict or other emergencies, healthcare personnel are required to render immediate attention and requisite care to the best of their ability. No distinction is made between patients, except in respect of decisions based upon clinical need and available resources.’ - 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/

Step 4 – DECIDE

• What is your Decision?

• Why (can you justify it)?

• Residual uncertainly, need for review?

In determining the medical rules of eligibility, one needs to consider the population at risk. For every patient who might be entitled to come into the facility, you need to consider the whole system; the flow of patients, patients from pre-hospital emergency care all the way through to rehabilitation; the resources available, particularly the bed capacity of the whole system, and finally one needs to consider the concept of humanitarian space.

Medical beds should be available for military casualties. However, one needs to determine if a patient arriving at the medical facility needs life-saving care (that is not provided anywhere else), it would be maleficient to refuse to care for them as this would result in the loss of life.

Where possible, patients should be transferred to facilities where they could be cared for/continue their care in the local national hospital, national military, or other facilities if appropriate to allow a positive flow of patients so there are beds available if needed. - Bricknell MC, dos Santos N. Executing Military Medical Operations. BMJ Military Health 2011;157:S457-S459. Republished at: https://www.military-medicine.com/article/3072-executing-military-medical-operations.html

The topic of medical rules of eligibility is more fully discussed in the paper: Bricknell M , Whetham D, Sullivan R and Mahoney P. How Should Access to Military Health Care Facilities Be Controlled in Conflict? AMA J Ethics. 2022;24(6):E472-477

Further issues for consideration:

● Is this argument different for an occupying power rather than an international partner to a sovereign nation?

● Is this argument different if military commanders want to use medical support to care for civilian patients as part of a 'hearts and minds' task?

● Is this argument different for different parts of the medical evacuation system (ambulance evacuation from an incident, field medical care, surgical capacity, intensive care, evacuation out of the country)?

Reviewed and formatted by:

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

December 2024

Further Reading:

Gross ML. Saving Life, Limb, and Eyesight: Assessing the Medical Rules of Eligibility During Armed Conflict. Am J Bioeth. 2017;17(10):40‐52. doi:10.1080/15265161.2017.1365186

Bricknell MC, dos Santos N. Executing Military Medical Operations. BMJ Military Health 2011;157:S457-S459. Republished at: https://www.military-medicine.com/article/3072-executing-military-medical-operations.html