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 overhear a social conversation between two senior officers in your unit discussing the anti-malarials for a forthcoming deployment. One says he will use a new drug that he has found on the internet that has ‘no side-effects’, rather than the drug prescribed to all personnel in keeping with current policy. 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 medical preventive measures. This is a topical subject as anti-malarials in the armed forces has been the subject of legal debate over the use of Mefloquine (Lariam) and the potential side-effects.

Step 2 – ANALYSE

Patient: the patient has a right of informed consent regarding their medical care, including preventive medicine measures. In this scenario, you might consider if they are your ‘patients’ or if they are military leaders – or both.  Military leaders have a responsibility to comply with policy but also, as patients, have a right to autonomy and confidentiality

Clinical: you have a duty to ensure that risks to the health of your patients are mitigated, and that your patients are appropriately informed.

Legal: Prescription and dispensing of drugs via the internet has few legal safeguards and  has a known risk of patient harm. 

Societal/Military: the compliance of members of the armed forces with preventive measures is dependent on the acceptance and role modelling of senior leaders. This conversation, and those that you may not have heard, have the potential to undermine the anti-malarial policy.

Whilst patients have autonomy, decisions around treatment can have consequences and refusing appropriate health protection measures may put them at higher risk of ill-health and death during the deployment and, in some cases, put others at risk. Military patients who refuse health protection measures may be deemed unfit for a deployment depending on a risk assessment. This should be discussed with the patient

Step 3 – FUSE

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

This scenario extends your professional duties from the clinical setting into the wider social setting. You have a duty to try to maximise compliance with the policy for protection against malaria and to prevent the policy from being undermined.

Step 4 – DECIDE

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

You need to need to decide whether to address this conversation in public at the time that your hear it; or whether to speak to the officer who is planning to use this unapproved drug separately as a personal conversation. You may need to consider if the anti-malarial education needs to be augmented or increased because of this opinion. It would be unwise to believe that you have not heard the conversation.

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.