You are struggling to justify your country’s involvement in a war you · Medical

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5 You are struggling to justify your country’s involvement in a war you believe to be unwinnable. How do you cope?

Step 1 – IDENTIFY THE PROBLEM(S)

• Briefly state the Scenario

You are struggling to justify your country’s involvement in a war you believe to be unwinnable. How do you cope?

• List the Issues that arise from the scenario

The balance between wanting to do good for your country but also protecting yourself.

• Identify Critical Information required and Assumptions to be made

Step 2 – ANALYSE

Patient: What are the views of the Patient? (and ‘patient group’)? How do 4 principles of : Autonomy, Beneficence, Non-maleficence and Justice apply? Other perspectives?

The World Medical Association stresses the importance of humanity, impartiality.

This can go against military orders if the orders are not impartial (clinicians do not end up treating people on the basis of clinical need).

Clinical: What are the clinical diagnosis, prognosis, treatment options? Is this scenario covered by professional regulation or guidance? What are the views of individual members of the clinical team? Other perspectives?

Considering why you chose to be a military health professional is important.

Why did you choose to join the armed forces? Was it out of sense of duty? External pressures?

Why did you choose healthcare within armed forces? Was it to alleviate suffering in hostile environments regardless of a patient’s affiliation?

What comes with being part of the military is the expectation that you follow orders for missions that are judged to yield more benefit than pose risk. This means that you might disagree on judgement of a commander from time to time which might mean that assignments do not become voluntary.

Conscript forces don’t really have personal choice of what mission they get deployed to. Volunteer forces do.

Unless orders are unreasonable in that the mission is deemed to pose more risk than benefit, conscript forces will face legal repercussions if they refuse order. Volunteers do not.

Moral injury is when people feel psychological impact from failing to prevent or committing an action that at least a part of them thinks violates their own moral codes.

Legal: Is scenario covered by IHL, Geneva Conventions, military law, other law? Other perspectives?

Legal obligations as military worker:

To obey order. Refusal of obeying orders can result in legal consequence. The exception to this is if the order for a mission is deemed to pose more risk than to yield benefit.

Legal obligations under the IHL:

Healthcare workers are mandated to provide patient care based on clinical need and not on status such as whether they are a civilian or a combatant.

Healthcare workers working in the military should avoid participating in combat.

Healthcare workers working in the military should try to protect confidentiality of patients.

To take care of one’s own mental health, establish a support network. If your observations warrant concern, then talk to your peers.

Try to undertake stress-reducing activities.

Societal/Military: Is there a military necessity? Is this scenario covered by military regulation or military perspective? Is this scenario covered by public health or societal ethics? Other perspectives?

Military organizations should have dedicated personnel to report concerns to (like an ethics committee etc.)

When explaining what you think is the problem, use precise language. Describe why you think this mission yields more risk than benefit. Why this goes against legal obligations. And is possible, propose a solution.

Discuss with peers if possible.

Record details of incidents (date, time and place).

If internal mechanisms fail, consider consulting outside organizations like the IHRC

While expressing dissent, maintain professionalism in your role. Try to distinguish between personal discomfort and genuine violations of ethical codes.

Step 3 – FUSE

· Summarise conclusions

· Insert citations to key reference sources for your analysis

· Determine the exact Decision(s) to be made

Patients in conflict zones expect impartial, need-based care, aligning with the principles of autonomy, beneficence, non-maleficence, and justice. The World Medical Association emphasizes humanity and impartiality, potentially conflicting with military orders. Legally, under IHL and the Geneva Conventions, healthcare workers must treat based on clinical need, safeguard confidentiality, and avoid combat involvement. Mental health care is crucial; establish support networks and practice stress management. Clinicians face ethical dilemmas when orders conflict with beneficence or justice. Military protocols should allow dissent via formal channels. Professional dissent must be precise, documented, and lawful to ensure systemic accountability without compromising roles.

Step 4 – DECIDE

• What is your Decision?

• Why (can you justify it)?

• Residual uncertainly, need for review?

Patients expect impartial, need-based care per autonomy, beneficence, non-maleficence, and justice. IHL mandates healthcare workers treat based on need, protect confidentiality, and avoid combat. Consider your duty, why you chose to become a medical professional within the military. Ethical dilemmas arise if military orders conflict with impartiality. Mental health care, peer support, and stress management are vital. Dissent must be precise, documented, and lawful, raised through formal channels while maintaining professionalism.

Reviewed and formatted by: Yvonne Zhou MBBS Year 3 King’s College London Dec 2024