All of the scenarios in the policy suit should be considered from the perspective of a health professional in a staff appointment as the lead officer for medical policy within a Ministry of Defence (rank equivalent of OF4/Commander/Lieutenant Colonel/Wing Commander).

Step 1 – IDENTIFY THE PROBLEM(S)

• Briefly state the Scenario: You have provided advice on the medical support requirements for a difficult military operation. You have been told to halve the medical forces so that more combat units can be deployed. How do you respond?  
• 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 mitigation of health risks from a military deployment by providing adequate arrangements for medical support. This scenario lies at the core of military medical planning. You are the technical expert but it is the military commander who owns the responsibility for the overall mission, including any risks inherent with the military plan.

Step 2 – ANALYSE

Patient: there is an institutional duty to military patients to ensure that the care that they receive is appropriate and complies with established medical practice.  

Clinical: there is a personal professional duty on medical planners to provide advice on the medical support plan for a military operation to ensure appropriate levels of care, commensurate with feasibility and practicability. This requires you to be a technical expert in the medical planning process, including understanding risk, application of medical doctrine, allocation of medical capabilities, and implementing the medical plan.  

Legal: military law is likely to place the responsibility for all aspects of a military mission on the military commander, as advised by technical advisers from all staff branches. Your duty is to understand the risks to health and the operational design of the mission, and to provide advice on the best medical support plan to meet the commander’s requirements and mitigate risk.  

Societal/Military: all military missions carry some inherent risk. The military commander has to ensure that the mission is successful balanced against the costs. This may require some fine judgement that cannot be delegated. Your duty is to provide the best advice and any explanation of risk associated with not following the advice.

Step 3 – FUSE

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

This scenario replicates many challenges faced by medical planners, from the strategic allocation of funding for medical services within the whole Defence budget down to the tactical allocation of medical capability relative to all other military functions. You will have to explain any additional risk attributed to the mission by reducing the assignment of medical forces, and whether there are other ways to mitigate this risk (e.g. increase MEDEVAC capability, give higher priority to medical units in subsequent deployments). You might wish to see if the risks to the medical support plan are greater than any other risks inherent in the overall place (e.g. comms, logistics).

Step 4 – DECIDE

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

Your professional duty is to provide the best technical advice. You may wish to seek a second opinion or discuss the situation with colleagues in a higher headquarters. You should seek if there are alternative mechanisms to achieve the same effect. You should be wary about being caught going behind the back of the military commander but you must stick to your professional opinion. You should certain express your concern to the Headquarters Chief of Staff. Depending on your personal judgement, your final escalation would be to seek a personal interview with the commander to explain your assessment and to confirm that he fully understands and accepts your assessment of the risk that he is taking. If he does not change his mind you have a choice between accepting his order, or resigning from your post – both of which mean that his decision remains final. Don’t forget that the responsibility of command cannot be delegated and he is ultimately responsible for the mission.  

Contributor – Air Vice Marshal (Rtd) Alastair Reid CB FFOM, Surgeon General UK Defence Medical Services 2019-2021.