2
In a mass casualty situation, is it ethical for a military medical unit to keep beds empty for new military casualties?
3
The local culture or national legal framework has only weak protections against domestic violence or gender-based violence. How do you respond to a badly injured female who reveals that her husband attacked her?
4
A rape victim asks to be given a ‘morning-after pill’ which your clinic has available. However, it is illegal in the country where you are operating. What do you do?
5
Under what circumstances would it be appropriate to use local donors to provide blood for patients in a military medical facility in place of the usual standard of care to pre-screen blood donors and use fully screened blood?
6
When facing staff shortages, under what conditions may you use local volunteers without any medical training?
7
How do you balance time taken for patient care with record keeping? What is the minimum information you should record?
8
The command asks you in a routine situation to act in a capacity that your professional body would not recognise you as having the correct qualifications or training to perform.
What should you do?
9
Clinical governance is not equal across organisations; how might you respond to an allegation that care in another nation’s medical facility is not clinically acceptable?
Would it/should it affect where you allocate cases?
10
What should a health care professional do if faced with an order from a commanding officer requiring them to violate the principles of medical ethics?
J
A talented and irreplaceable staff member is accepting bribes in order to prioritise patients for care.
How might this be addressed?
Q
A badly injured enemy combatant claims that his injuries were caused after he had been captured.
How do you respond?
K
Your local military commander asks for off duty medical personnel to contribute to guarding the perimeter of the military compound.
How do you respond?
A
Special forces capture a combatant who, they believe, has vital information about a future terrorist attack. The combatant refuses a life-saving treatment stating that he would “rather die than live as a prisoner and traitor”.
What can/should you do?
2
Violent non-state actors may recruit under-18s into their forces.
What are the duties of medical personnel towards 'children' as combatants?
3
In order for you to get access to the wounded and sick, you have to share information with the host-nation authorities and/or the UN about the identities of the patients in your care.
Do you share the information?
4
How do you decide the first person to treat or the allocation of single resources between two casualties with the same triage score?
5
A badly injured, unaccompanied female child has been left at your emergency department.
What are the ethical challenges associated with consent for treatment and how might you address these?
6
You suspect the host-nation base guards are refusing some people access to healthcare because they are from the 'wrong' area or tribe.
What do you do?
7
You have evidence a government is committing atrocities against its own citizens. Should health care personnel allow media access to the patients in order to publicize the alleged crimes?
What else could a health care professional do?
8
There is a shortage of beds and you have a stable but ventilated patient who can be moved to a local hospital but you know there are no nurses on night shifts. This could mean a death sentence.
What do you do?
9
The divorced parents of a very badly injured soldier in your base hospital refuse to be present together but each insists that only they can speak on behalf of their son.
His brain injuries are such that he is not competent to consent to medical treatment. How do you resolve this?
10
Should you allocate extra support to people with disabilities during an emergency evacuation if that means expecting apparently able-bodied people to manage by themselves?
J
The husband of a badly wounded female refuses to permit your male medics to treat her.
What do you do?
Q
A distraught local national father refuses to allow the transfer of his badly injured daughter to another allied medical unit where more appropriate care can be provided.
What do you do?
K
If you were faced with limited resources, how would you balance palliative care priorities with pain relief for incoming trauma patients?
A
With modern medicine it is possible to save the lives of people with devastating injuries that will profoundly change their lives forever.
Are there limits to how far treatment should be taken? Who decides?
2
Faced with an outbreak of a highly infectious disease, you have insufficient PPE for every patient-facing clinician, though you have adequate supplies of equipment used for normal infection control.
To whom do you allocate the higher level of protection? Do you require everyone else to continue working with the lower level equipment?
3
Can military medical staff be ordered to deliver care if doing so involves severe risk of injury or death to themselves?
4
You are deployed to a conflict area where the enemy are deliberately and consistently violating the laws of armed conflict. You have been tasked to send an ambulance on a very dangerous mission to collect enemy casualties.
Should your own personnel be put in harms’ way to save the life of someone who would not reciprocate?
5
You are struggling to justify your country’s involvement in a war you believe to be unwinnable.
How do you cope?
6
Your team has been working under intense conditions for days; you are all sleep-deprived and are making errors that put patients at risk. There is no back-fill support available.
As team leader, what is your duty of care to protect your team and yourself?
7
Pre-deployment you had concerns about a colleague struggling with his mental health after multiple tours of duty. His performance is erratic. One day he seems fine the next he is making preventable errors.
His surgical skills are desperately needed. What can you do?
8
Inevitably, the delivery of health care in conflict means not everything goes the way you would like or had planned, even when you have tried to do everything right.
How do you manage a sense of failure e.g. a patient death or a missed diagnosis?
9
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 a risk of being attacked.
Is the commander right?
10
Can medications be used pending regulatory approval or ‘off label’ for non-licensed indications to save the lives of military personnel?
J
Is it acceptable to allow firearms into a medical facility?
If so, who may carry them?
Q
A local patrol commander tells the attached medical personnel to remove their Red Cross arm bands because this disrupts camouflage.
Is this acceptable?
K
The commander of a logistic convoy wishes to put food and water into the ambulance of the convoy.
Should this be permitted?
A
When faced with an infectious disease outbreak, should military medical personnel be willing to accept greater risks than civilian medical workers?
2
You will lead a medical unit and have a one week pre-deployment training period together in the country capital before setting up the unit.
How might you communicate to the team members before you meet them, and what ground rules would you wish to establish?
3
You will lead a medical unit. 3 countries have agreed to provide medical personnel.
What cultural barriers might challenge the creation of successful team dynamics and how might you address these.
4
You will lead a medical unit. There may be differences between members of the team. What characteristics are 'protected' under discrimination law?
How might you respond to an allegation of direct discrimination by one of your team members?
5
You will lead a medical unit. There is a risk that poor communication across the team could result in patient harm.
How might you set up a system to review adverse clinical events that could sensitively identify weakness in teamwork?
6
Your new unit has had its first Mass Casualty event. The following day, a senior male intensive care nurse takes you to one side and tells you that he refuses to work with the female orthopaedic surgeon as she is rude and incompetent.
What do you do?
7
Four months into your tour as leader of a medical unit, your deputy comes into your office to tell you that senior members of your team are concerned about your mood and behaviour towards them.
What do you do?
8
You will lead a medical unit. 3 countries have agreed to provide medical personnel.
How might you assess the credentialing and competence of each member of staff so as to ensure that they are suitably qualified for their role?
9
You are conducting a daily round of ward patients and notice several new entries for a drug that is not in the hospital formulary.
The ward nurse explains that a new doctor has brought the drug as he wants to conduct a drug trial. What do you do?
10
A Mass Casualty incident has just been called and the senior emergency department nurse cannot be found. After 30 mins, you are told that he is in his bed and refusing to come out.
What do you do as the team leader?
J
Four months into your deployment, you are told that a fourth country will be sending a medical team to work in your unit to treat their casualties because of complaints about medical care.
What do you do?
Q
You are the leader of a multinational medical unit. One country’s leader insists they will wear national uniform and refuses to allow her personnel to wear the set of surgical scrubs that all personnel wear when on duty in a clinical role.
What do you do?
K
You will lead a medical unit. The leader of one contingent insists that his country has agreed to provide 'one shift' in a three-shift system and will not allow rostering at department level.
What do you do?
A
You and your team have had a very successful tour. 2 of the 3 national contingent leaders want to organise a farewell party and to allow alcohol to be consumed, acknowledging the other contingent is forbidden to drink alcohol.
What do you do?
2
Core Principles from the Geneva Conventions
Covers: the conduct of armed conflict, protection for those not involved in armed conflict (plus medical units and transport), and protection for those unable to participate in armed conflict (wounded, sick, shipwrecked and prisoners)
1
The Four Principles of Medical Ethics
Beneficence, Justice, Autonomy and Non-maleficence
2
A friend is a battalion commander. He is also a patient in your clinic. His wife asks for your help because he is drinking heavily, is abusive, and seems to be spending money recklessly.
What do you do?
3
A female recruit with a positive pregnancy test requests a termination, revealing the father is a training instructor. Relationships between recruits and instructors are banned.
What do you do?
4
Overhearing a conversation between two senior officers in a social context, you learn that one plans to use a new, unapproved anti-malarial drug found online for a deployment. The senior officer claims that the drug has no side effects.
What do you do?
5
An X-ray report shows a serious pelvic stress fracture in a young recruit that you have been treating for six months with painkillers and physiotherapy. You only arranged the X-ray at her insistence.
What do you do?
6
A soldier complains that a senior female doctor includes a genital examination as part of the annual routine medical review for male soldiers. When challenged, she states that this is good medical practice for screening.
What do you think?
7
You receive four separate requests for medical reports from the lawyers of your patients who are claiming that they have suffered non-freezing cold injury during a recent field deployment. Their notes lack any record of this condition.
What do you do?
8
A person to whom you recently prescribed contraception invites you out on a date. You are attracted to them.
What do you do?
9
A patient complains about her private medical information being discussed by your staff. Reviewing her health record, you find a junior nurse was the last viewer.
What do you do?
10
You’re ordered to start a vaccination programme against a biological weapon despite known side effects. Having personally experienced severe side effects, you disagree.
What do you do?
J
Reviewing the health record of a young soldier whom you suspect is being bullied, you notice a colleague seems to have deleted some notes.
What do you do?
Q
Four soldiers from the same sub-unit show symptoms of a sexually transmitted disease. You refer them for immediate medical investigation, however a medic informs you that their platoon officer has denied them access to the clinic.
What do you do?
K
During a routine medical exam, you find a significant heart murmur in your Commanding Officer. He wishes to see a private cardiologist instead of a military one.
What do you do?
A
Your partner criticises you for working too hard, which is affecting your relationship with them and with your children. Seeking support from superiors, you are told no help is available and duties are the same for everyone.
What do you do?
2
You are the SNCO in charge of a small medical unit. One of your medics is brought in by a friend, disorientated and smelling of alcohol. They will be on duty in four hours.
What do you do?
3
You are the SNCO in charge of a small medical unit. A female soldier does not want to attend the facility as she is worried that she will face disciplinary action for getting sunburnt.
What should you do for her to receive the right care and treatment?
4
You are an Advanced Practitioner. A soldier presents with lower back pain. Following an assessment, you take them off guard duty, but they inform you that this will affect their promotion prospects.
What should you do?
5
Two nurses at the rank of captain have been in a relationship with each other that has now broken down. They are using a friend of yours as a line of communication, who is feeling quite stressed about the situation.
What should you do?
6
You are a junior NCO on an operational tour. You witness a verbal altercation between the senior nursing officer and the senior consultant, who are both Cols. Both patients and staff can hear this altercation.
What should you do?
7
You are a Sgt in a field hospital. An anaesthetist uses a rapid infuser with the incorrect bore size for a deteriorating patient. They shout, claiming that you are incompetent. You make an offensive comment and walk away.
What are the ethical issues?
8
As the SNCO of the unit, a patient has reported to you that a female medic has made an inappropriate sexual remark to a male nurse in front of them.
What actions should you take?
9
A Sgt who is a patient in your unit has behaved inappropriately by using offensive language towards a junior soldier admitted for a mental health crisis. A visiting soldier witnesses this and reports it to you.
What should you do as a Corporal?
10
A nurse of the same rank heard a male nurse say of a 43-year-old female Warrant Officer admitted for abdominal pain, ‘I wonder why at 43 years old she is not married. Do you think she is a lesbian?’
What should the nurse do?
J
A Sgt is in charge of the medical unit. A doctor at the rank of Lt Col, who is renowned for being abrasive, has prescribed a soldier penicillin despite them being allergic to it. This is the second time the doctor has done this.
What should the Sgt do?
Q
A corporal who qualified two years ago has noted that, on a few occasions when administering medication, the captain (a qualified nurse) did not check the patient’s drug card and their identity.
What should the corporal do?
K
A soldier on an operational tour has a positive pregnancy test. She is unsure how many weeks she is and begs you not to say anything to anyone. She refuses to give her consent for her pregnancy to be disclosed.
What should you do?
A
An experienced soldier has an infected leg requiring surgical intervention and antibiotics. The soldier is refusing all treatment. The Adjutant has rung the ward, asking when the soldier will be discharged and fit for duty.
What are the ethical issues?
2
You have been tasked to organise the deployment of a field hospital overseas to add capacity to local services in managing the outbreak of a highly lethal infectious disease.
Can your staff be ordered to go into such a situation?
3
You have written performance reports on your subordinates. Your superior officer seems to be demonstrating favouritism in their own reports towards a specific group of your people.
What do you do?
4
You receive formal notification of a complaint of bullying against you. The complainant has recently received an adverse performance report from you.
What are your ethical duties?
5
In addition to your staff role, you are also senior clinician. A friend asks for your support in an investigation of a clinical incident. On reviewing the documents, you believe that your friend was negligent.
Do you agree to support them?
6
You receive a formal complaint about the quality of medical care in a coalition hospital on a military mission that your country has responsibility for leading.
How do you respond?
7
You believe that the quantity of medical support tasks is affecting the ability of clinical personnel to maintain their full range of professional skills.
Can you stop the deployment of medical personnel to address this?
8
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?
9
You receive a letter from a drug company complaining that the research project that they were sponsoring in a military hospital is being badly managed. There is no record of this project receiving approval.
What do you do?
10
A consultant has refused to deploy for a military mission, which you suspect is because of their private practice. You receive a report that they have just been medically downgraded below the deployment standard.
Can he/she be ordered to deploy?
J
You are asked to write a rebuttal for an adverse news report on the provision of mental health services to veterans. You know that your request for more funding for this service was rejected.
Is it ethical to write a media release?
Q
Military commanders want to use a new drug to protect against travellers' diarrhoea. Medical and microbiology advisers disagree on its effectiveness.
Can the drug be introduced?
K
The medical services are asked for their judgement on the military effectiveness of a new weapon that uses sound to incapacitate the enemy.
Is this ethical?
A
A medical equipment company invites your leadership team to an important overseas medical conference that cannot be funded from your budget. You have just approved a major contract with them to supply equipment to military medical units.
Do you accept?
2
A national newspaper reports allegations that civilian patients seem to be taking priority for care over military patients in your military hospital.
What do you do?
3
A military patient insists on being discharged so that they can go to a private civilian hospital for their medical care.
Do you agree?
4
One of your nurses reports that a group of patients have uploaded unpleasant images of their wounds onto social media.
What do you do?
5
The wife of the Commanding Officer of several patients in your hospital wishes to visit them.
What do you need to check before you might allow this?
6
A badly injured patient has returned to the ward after their third admission to ITU. She is requesting to complete a ‘do not resuscitate’ form, but the junior staff object to this.
Should the patient be allowed to sign the document?
7
At a routine meeting, one of your consultants proudly announces the publication of a research paper reporting outcomes of patients treated in your unit. This project had not been submitted to the unit Research Ethics Committee.
What do you do?
8
A military charity requests that publicity material is handed to patient relatives. It contains photographs of patients that could only have been taken in your hospital without your knowledge.
What do you do?
9
A junior nurse has publicly disagreed with the treatment plan proposed by a senior consultant in a multidisciplinary review meeting because she believes that the patient does not want this. The consultant has ordered her to leave the room.
What do you do?
10
You receive three soldiers with life-threatening heatstroke and two others with moderate symptoms. The conduct of this military event training suggests that basic prevention rules were not followed.
What should you tell their relatives?
J
An immobile bilateral amputee in long-term rehabilitation wants to invite a person he has met on a dating site to visit him in the military hospital. A member of staff thinks that this person is a prostitute.
Should the visit go ahead?
Q
A young soldier with a severe head injury has met the criteria of ‘brain death’ and the clinical team seek to turn off mechanical ventilation. One of the soldier’s divorced parents refuses this decision.
Can the ventilator be switched off?
K
The partner of an unconscious patient with a poor prognosis wants to arrange for ovarian egg harvesting. There is no pre-existing consent.
Can this go ahead?
A
A senior nurse complains to you that there have been too many visits from senior military officers to your hospital, which is disrupting patient care.
What do you do?