Step 1 – IDENTIFY THE PROBLEM(S)

• Briefly state the Scenario

You are in a convoy that drives past the aftermath of a roadside bomb. Several local nationals are in need of emergency care. The commander orders you not to stop because the road is dangerous and there is risk of being attacked. Is the commander right?

• List the Issues that arise from the scenario

The balance between wanting to help patients but also not putting a military operation or other military personnel at large risk.

• 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?

Patients should be treated on the basis of clinical need and regardless of their status (such as whether they are a combatant or a civilian).

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?

If risk is seen as not immediate, then there are ways to provide care that takes into account relative risk of situation.

For example, remote assistance could be provided. This could be done by dropping off supplies to civilians via drones. Radios can be used to give civilians or responders instructions to deliver first aid. Other organizations such as local civilian medical responders, police, or humanitarian organizations to provide aid.

The commander could be persuaded by reminding him/her of the IHL.

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

Care for the Wounded and Sick (Geneva Convention I, Article 12) states that medical professionals working in the military must treat all patients based on clinical need, regardless of their allegiance (such as belonging to enemy forces).

The commander has a duty to consider the safety of the mission. If the benefits outweigh the risk, then the order is legitimate.

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?

To determine the level of risk in this situation, a few things need to be considered.

Whether the road is known for ambushes or secondary explosive devices (explosives that intentionally planted that may set off when civilians or responders respond to the aftermath of the first explosion).

Another consideration for level of risk is the ‘mood’ of the crowd. The crowd may be angry due to chaos of the situation and blame military forces for their situation. A way for this to be mitigated is to deploy loudspeakers or interpreters that can diffuse the situation.

Standard Operating Procedures will have existing guidelines on how to act in these situations. This would take into account risk levels, feasibility of help that is able to be provided, what type of aid to provide, identifying external resources for help and effective handover procedures.

Step 3 – FUSE

· Summarise conclusions

· Insert citations to key reference sources for your analysis

· Determine the exact Decision(s) to be made

Patients must be treated based on clinical need, regardless of status or allegiance, per ethical principles (autonomy, beneficence, non-maleficence, and justice) and international law (Geneva Convention I, Article 12). The commander’s decision hinges on balancing mission safety against the obligation to provide care; orders are valid if benefits outweigh risks. Clinically, aid may include remote assistance (e.g., supply drops, radios, coordination with NGOs). Military considerations include evaluating risks like ambushes or hostile crowds. Standard Operating Procedures guide actions, addressing risk levels, aid feasibility, external resources, and handover procedures, ensuring alignment with military, legal, and humanitarian responsibilities.

Step 4 – DECIDE

• What is your Decision?

• Why (can you justify it)?

• Residual uncertainly, need for review?

The commander’s decision relies on assessing the level of risk and whether providing aid can be done safely. If there’s an obvious, immediate threat, focusing on security is understandable. However, if the risk is low or manageable, providing aid is the right thing to do, in line with ethical duties and international standards.

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