Step 1 – IDENTIFY THE PROBLEM(S)

Briefly state the Scenario: When facing staff shortages, under what conditions may you use local volunteers without any medical training?

List the Issues that arise from the scenario

This scenario is looking at expanding your workforce under crises. Augmenting foreign medical teams with local staff presents several important issues:

• Training and expertise: Local staff may not have the same level of training or experience, creating challenges in delivering high-quality care.

• Cultural and language barriers: These can affect the effectiveness of collaboration between foreign and local staff. Misunderstandings may arise, impacting patient care, teamwork, and coordination. Cultural sensitivity training and interpreters may be necessary.

• Trust: Local staff may have differing perceptions of the foreign medical teams due to past experiences, mistrust, or political tensions. Building trust between the two groups is essential for smooth cooperation and the provision of care.

• Safety and security: Local staff may be more vulnerable to local threats or reprisals, especially if they are perceived as collaborating with foreign forces.

• Logistics and resources: The state of the local healthcare infrastructure may make it more difficult to adequately support the foreign medical teams and ensure that local staff have the necessary resources.

• Impact on local healthcare: Relying on foreign teams may weaken local healthcare systems by creating dependency on external aid instead of building and enhancing local capabilities.

Identify Critical Information required and Assumptions to be made

• Do volunteers have any healthcare training?

• Medical professionals are expected to work to the best of their ability – but what is the responsibility of the organisation/leadership?

• What are the responsibilities of the medical unit to ensure its employees are trained for their role, including certification of competence, credentialing, local training etc…

Step 2 – ANALYSE

Patient: Volunteers should be provided with appropriate safety measures, basic hygiene training, and any other necessary equipment to ensure they are not exposed to unnecessary risks while performing their duties, thus supporting the principle of non-maleficence towards patients. In the context of staff shortages, having volunteers perform logistical and basic tasks helps alleviate the pressure on the medical unit, making it more efficient in providing patient care. This minimises the risk of patient harm, aligning with the principles of beneficence and non-maleficence.

Clinical: ‘In armed conflict or other emergencies, health-care personnel are required to render immediate attention and requisite care to the best of their ability.’ - 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/

Local volunteers without medical training should only be assigned to non-clinical tasks that do not require specialised medical knowledge or skills, such as logistics, transport of supplies, administrative support, cleaning, or assisting with basic care under the supervision of trained medical personnel. Acting in clinical roles would put patients and volunteers at risk.

Legal: The involvement of local staff in medical teams must comply with international humanitarian law, particularly the Geneva Conventions. These laws protect local personnel, and it is essential to ensure they are not exposed to legal or military risks. Volunteers must not be assigned to combat-related tasks or duties that could compromise their safety or involve them in military operations. - Geneva Conventions, Rule 25: ‘Medical personnel exclusively assigned to medical duties must be respected and protected in all circumstances. They lose their protection if they commit, outside their humanitarian function, acts harmful to the enemy.’. At: https://ihl-databases.icrc.org/customary-ihl/eng/docs/v1_rul_rule25

Geneva Conventions, Rule 31 emphasises the safety, neutrality, and effectiveness of humanitarian relief personnel in conflict zones, ensuring they can provide aid without being targeted or obstructed by warring parties. At: https://ihl-databases.icrc.org/customary-ihl/eng/docs/v2_rul_rule31

Humanitarian organisations such as the Red Cross or Doctors Without Borders often have strict internal guidelines regarding the use of volunteers, including criteria for non-medical volunteers and the required levels of training and supervision.

Volunteers must be fully informed of their roles and the risks involved. They should voluntarily agree to assist, and their participation should be based on a clear understanding of the non-medical nature of their duties. They should also be informed of their rights, including the right to withdraw at any time.

Societal/Military: Different countries have their own healthcare regulations and professional standards that govern the roles and responsibilities of medical volunteers, especially in conflict or emergencies. These regulations may outline who can perform medical duties and under what circumstances.

The involvement of local volunteers must be approached with sensitivity to local customs, laws, and cultural norms. The military must ensure that volunteer engagement is both legally permissible within the host country and respectful of the local context. Perspectives within local communities may vary; some may see volunteering as an opportunity to contribute positively to the response effort, while others may have concerns about the associated risks or the cultural implications of involving volunteers in healthcare tasks.

Step 3 – FUSE

● Summarise conclusions

● Insert citations to key reference sources for your analysis

● Determine the exact Decision(s) to be made

The safety of local workers must be a priority, and protective measures should be in place in line with international humanitarian law (Geneva Conventions outlined above).

Volunteers without medical training should only be assigned non-clinical duties under supervision, with a clear understanding of their responsibilities, the risks involved, and the option to withdraw at any time. They should be provided with appropriate training and equipment to reduce risks while handling their tasks.

Involving local staff can bolster the capacity of medical teams during emergencies, but it also needs careful planning, cultural sensitivity, and collaboration to ensure safe, effective, and ethical healthcare delivery.

Step 4 – DECIDE

• What is your Decision?

• Why (can you justify it)?

• Residual uncertainly, need for review?

Local volunteers should ideally receive basic training to prepare them for their roles, particularly in health and safety procedures. While they may not be trained medical professionals, equipping them with basic first aid or other essential skills can significantly enhance their ability to provide effective support.

Medical personnel are expected to provide the best possible care to their patients, which places a responsibility on the employing organisation to provide adequate training and experience. This framework also enables local personnel to volunteer for humanitarian response efforts, or to be employed in paid contracted roles.

In summary, local volunteers without medical training can support medical operations in military settings, but only in non-clinical, supervised roles. Their participation must be based on informed consent, appropriate protection, and full adherence to humanitarian and legal standards.

- How is ‘best of their ability’ defined from a medical negligence perspective? Have a look at this paper which discusses the evolution in the UK in the legal interpretation of the ‘standard of practice’. - Lee A. ‘Bolam’ to ‘Montgomery’ is result of evolutionary change of medical practice towards ‘patient-centred care’. Postgraduate Medical Journal. 2017;93:46-50. At: http://dx.doi.org/10.1136/postgradmedj-2016-134236

- How does this apply in the application of ‘medical negligence’ in a military or emergency situation?

Reviewed and formatted by:

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

December 2024

Lee A. ‘Bolam’ to ‘Montgomery’ is result of evolutionary change of medical practice towards ‘patient-centred care’. Postgraduate Medical Journal. 2017;93:46-50. http://dx.doi.org/10.1136/postgradmedj-2016-134236