All of the scenarios in the garrison healthcare suit should be considered from the perspective of a health professional working in military garrison clinic with responsibility for the clinical care of patients and management of the clinic. 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 see 4 soldiers with symptoms of a sexually transmitted disease from the same sub-unit. You refer them for immediate clinical assessment. A medic comes in to tell you that their platoon officer has not allowed them to attend the clinic. 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, confidentially, and patient autonomy. It specifically covers the right of a military patient to receive appropriate medical care. It also has implications for the reporting of medical fitness, especially infectious disease, to the military authorities. Finally, there may be an issue regarding sexual behaviour within the unit.  

Step 2 – ANALYSE

Patient: your patients have sought medical advice, they have the right to receive relevant investigation and treatment.

Clinical: the management of these patients requires investigation and treatment beyond your capacity and you have made an appropriate referral. There is also a need for contact tracing. WMA Code 22. The physician must respect the patient’s privacy and confidentiality, even after the patient has died. A physician may disclose confidential information if the patient provides voluntary informed consent or, in exceptional cases, when disclosure is necessary to safeguard a significant and overriding ethical obligation to which all other possible solutions have been exhausted, even when the patient does not or cannot consent to it. This disclosure must be limited to the minimal necessary information, recipients, and duration.

Legal: It would be illegal to deny military personnel access to appropriate medical care. You have a duty to ensure that this is reported to the military authorities.

Societal/Military: There is also a potential issue regarding sexual behaviour within the soldiers’ unit.  The platoon officer is exceeding their authority and giving an illegal order.

Step 3 – FUSE

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

These soldiers need to be investigated and receive any necessary treatment for their medical condition, independent of causation. The public health and health education dimensions, and the conduct of the platoon officer, in this scenario also need to be addressed.

Step 4 – DECIDE

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

You need to make the necessary calls to determine the facts to ensure that these soldiers are enabled to attend the clinic to which you have referred them. You may wish to escalate this as the refusal to allow this to happen is a significant issue. You should also consider how to address the contact tracing, behaviour, and health education dimensions of this scenario.   

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.