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 are told to start a vaccination programme against a biological weapon, though there are known side effects. You don’t agree with the use of this vaccine as you have had very severe side-effects, 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 consent, vaccination, and conscience. This topic has been clouded by the discussion regarding COVID vaccination, specifically the potential mandatory requirement for occupational purposes. The decision to start a vaccination programme is likely to have been taken at the most senior levels within the Ministry of Defence, including consideration of classified or sensitive information.

Step 2 – ANALYSE

Patient: your patient has the right be vaccinated to be protected against known threats to their health; including biological weapons. They also have the right to be appropriately informed in order that they can consent to an intervention.  The patient also has a right to decline vaccination although this course of action may result in restricted employment or perhaps cessation of service.

Clinical: you have a responsibility to ensure that your patients receive appropriate care. However, WMA Code Para 29 - 29. This Code represents the physician’s ethical duties. However, on some issues there are profound moral dilemmas concerning which physicians and patients may hold deeply considered but conflicting conscientious beliefs.

The physician has an ethical obligation to minimise disruption to patient care. Physician conscientious objection to provision of any lawful medical interventions may only be exercised if the individual patient is not harmed or discriminated against and if the patient’s health is not endangered.

The physician must immediately and respectfully inform the patient of this objection and of the patient’s right to consult another qualified physician and provide sufficient information to enable the patient to initiate such a consultation in a timely manner.

Legal: You also have a duty to comply with a legal military order, which includes offering and administering (to those providing informed consent) vaccinations to prevent militarily important diseases.

Societal/Military: There is a military imperative to minimise preventable disease amongst the military population. The administration of vaccinations to reduce the impact of an attack with a biological agent will be a highly sensitive issue and some of the decision-making will be classified. Some information will need to be provided to ensure all personnel can provide suitable informed consent and this will need to be factually accurate.

Step 3 – FUSE

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

Military personnel will need to be provided access to immunisation if the risk assessment for an attack using biological weapons is sufficiently great to justify this intervention as a mitigation of the threat. You are unlikely to have been provided all of the information used in formulating the policy. You will have to decide whether your disagreement with the vaccination programme affects your professional and personal judgement about supporting the programme. If so, you will need to consider how to highlight this to your executive and or/medical chain of command and whether you need to seek advice from colleagues or professional organisations.

Step 4 – DECIDE

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

You may decide that you will follow the orders to implement the vaccination programme and to keep your concerns to yourself. You might decide to seek further advice from your executive and/or medical chain of command, including the opportunity to see some of the technical documentation about the decision-making process. If you decide that you cannot be involved in the vaccination programme, you will need to inform your superiors and to check your obligations and rights under medical ethics and military law.

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.