HCiD-toolkit-for-Doctors-2015

Toolkit for Doctors
Working in
Situations of Violence

A contribution of the
World Medical Association
to the
Health Care in Danger
Initiative of the
International Committee
of the Red Cross

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THE WORLD MEDICAL ASSOCIATION, INC.

Original Doc: MEC 201/HCiD toolkit for Doctors/Oct2015
PROPOSAL FOR A TOOLKIT FOR DOCTORS WORKING IN
SITUATIONS OF VIOLENCE
Approved for publication by the
201st
WMA Council Session
Moscow, Russia, 16th
October 2015

This toolkit for doctors working in situations of conflicts
and other emergencies has been developed for the WMA
by the British Medical Association within the framework
of the project Health Care in Danger (ICRC).

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Introduction

The World Medical Association believes that medical ethics is identical in times of armed conflict
to those in times of peace. In stating this the WMA recognizes that the tensions within the
ethical decision making that doctors, nurses and other health workers experience will differ as
they are strongly affected by the clinical, social and environmental situation, including the
presence of armed conflict.

Some examples of relevant ethical codes are made at the end of this document under further
reading. This includes a set of Ethical Principles recently agreed between the WMA, ICN, FIP and
ICMM.

All health care workers share responsibility for protecting the ethical rights of every patient,
including where they are working on public health issues, the rights of the community at large,
and as health workers they must balance their duties to their patients, the public, their
colleagues and to themselves. In doing so they are guided by ethical standards set out in codes
and in explanatory documents by national and international bodies, such as the World Medical
Association and the International Council of Nurses as well as other health care professional
groups such as midwives and pharmacists. These standards take note of national and
international laws but are held by many health care professionals, including the World Medical
Association to have a higher status especially over domestic laws. While the WMA and ICN have
no disciplinary power, their guidance is regarded as binding on doctors and nurses by courts and
tribunals around the world.

Ethical standards do not tell doctors, nurses and others what to do. Rather, they provide a
framework for recognizing the ethical conflict and for examining it, in a manner that recognizes
the duty the health care worker owes to the patient and to society. This framework guides the
decision making process, and should help to provide consistency.

Some countries have codes of medical ethics, which may be legally binding on health care
workers. But even these cannot be specific and complete for every clinical situation. Doctors
and nurses are expected to be able to adapt those codes to the specific circumstances in which
they and their patients find themselves. This booklet carries out the same function for those
working in situations of armed conflict.

It is recognized that during armed conflict, circumstances will arise that individuals have not
experienced before. This guidance is designed to help health workers become comfortable with
examining clinical situations for areas of ethical challenge, and to applying frameworks of ethics
decision making to those challenges. It is hoped that it will be read before those challenges are
real. The guidance has been written around a series of clinical cases, to demonstrate where the
conflicts and challenges arise. None of these cases is based upon a single specific case, all are
based upon real cases experienced in many different countries and situations.

Throughout this document, the term health care workers is used to describe the people involved
in making decisions, with the patient, about the care of individuals and communities. In some
cases the teams of health care workers will be led by a doctor, in others by a nurse and in some
by another worker including an administrator, or public health specialist.

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The ICRC has published a research paper (include reference) explaining the pressures that
individuals caring for patients face. While the major relationship is between health worker and
patient there are also links to the employer and to the system – including national and local
government.

Surrounding this complex are all the external pressures, including local, national and
international law and regulation, which will impact and affect all the factors inside the ellipse.

Further reading on ethical codes or general ethical frameworks is available from a number of
sources, including the WMA. A list of such sources appears at the end of this guidance.

Cases
1. An 18-year old woman is admitted with abdominal pain and vaginal bleeding. You are
working in a place where the culture puts a very high value on virginity and her life
may be at risk if she is known to have been sexually active, even where this has been
due to rape. You are also aware that during the current conflict, sexual violence
including rape has been used as a “weapon” or tactic of war.

The overwhelming duty of all health care workers is to seek to help the patient. In this case the
clinical care needs to be offered in such a way that it does not undermine the duty of
confidentiality. While confidentiality of patient data is not absolute, it is very important. In most
countries the duty to keep information confidential applies to the individual; that is each person
as an individual has the right to expect that information about them will not be shared with
others. In some countries cultural norms allow the sharing of information with family members
or local leaders, such as village elders. Failure to share with them would be a very serious breach
of ethical and cultural norms, but health workers have a duty to consider whether such sharing
could have an impact on the health expectancy of the patient, and if it would, should not share
Employer
HCW
Government
Patient
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regardless of the cultural norms. Where there are risks to the future health of individuals such
sharing should not take place. Health care workers have a duty to understand the local cultural
norms, especially where these will impinge on medical decision-making.

In this case the health care worker should also be prepared to help the patient understand what
has happened, and to collect evidence for a potential prosecution if the patient wishes to
proceed down this route, but do so in a way which continues to protect the confidentiality of the
individual. It is often frustrating for health care workers when patients who have been victims of
violence, including interpersonal violence and sexual violence, do not wish to report the matter
to the police or other authorities. Health care workers might also feel that reporting of this case
might prevent future cases. The role of the health care professional is to help the patient as a
person, to recognize her fears and to protect her from further harm. Gathering evidence for use
at a later date may be the best possible assistance.

In considering this case, the health worker must communicate with the patient and ensure she is
aware that information will remain confidential. In some circumstances patients might not come
forward for care, fearing that attending a clinic will be visible within the community and
precipitate questions from family members and others. Those organising health facilities should
consider the need for attendance to be confidential in the same way that the content of the
consultation is, and make suitable arrangements. In these circumstances, arrangements that
make reaching the health centre easy for those without independent access to transport can also
be essential.

Frequently the patient presenting in this way is under the age of consent, and family members
may be very insistent on knowing what has happened. The same guidance applies – it is for the
patient to decide who knows what. Even patients who are not competent to consent to
treatment have a right to medical confidentiality.

Where clusters of such patients are appearing there is a clear duty to inform the authorities so
that they can act, and to do so in a way that does not identify individual patients. At the same
time, and to encourage patients to present for help, clinic arrangements should be made in such
a way that it will not be obvious to others who is presenting and for what type of care.

2. The motorcade of the local political leader comes under attack as he is arriving to visit
colleagues being treated at your hospital, and the leader is admitted with gunshot
injuries. You have witnessed the attack. The media are present in the emergency
clinic. You also admit bystanders injured in the same attack including women and
children and injured soldiers.

Decisions about who to treat first are based upon an assessment of the need of the individual
patients, not on their relative positions in society. In mass casualty events a system of triage is
used, to identify those needing immediate care and those who can wait, or who need simple first
aid.

The principle behind triage is of equity or justice, that is that treatment decisions including
priorities will be based upon need and no other non-medical factors. While in some situations
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triage may include a decision not to treat someone who will not survive whatever treatment is
offered, and instead to prioritise those likely to survive, this is rarely done. It is legitimate to
refrain from offering heroic medical interventions to those who, when assessed, are unlikely to
survive whatever is done but they must be offered treatments to deal with pain and suffering.
Attempts to perform curative treatments would be classified by some as futile in such cases;
while others would argue with the word «futile» the key factor is that the patient would be
exposed to interventions that were intrusive and possibly painful for no hope or expectation of
benefit. No patient should be abandoned and the emphasis should be on receiving suffering,
usually pain.

All health care workers face, from time to time, pressures to treat one person before another,
with such pressures often coming from family members or others intimately involved with the
injured or sick person. Such pressures must be resisted, not only because it leads to inequity in
treatment decisions but because the basis of general acceptance of priority setting by health care
workers is that this is always done on the basis of need and no other measure of merit. Although
individuals may protest and express distress when their loved one is not rated first, there is a
generalised acceptance, provided they see that no one jumps ahead of the queue on anything
other than medical necessity.

In this case the fact that one of the injured is a local leader does not give him more priority than
should be given to the others injured including the women and children.

Events that lead to mass casualties often bring with the media interest. If someone prominent is
hurt that interest may be even more intense. The media will seek to obtain information about
the injured including details of their injuries.

Every patient has a right to confidentiality, regardless of the public interest in them. Patients
should never be exposed to the media unless they have given consent to being interviewed,
filmed or otherwise identified. While families are often pleased to see media interest as it gives
them an opportunity to express their outrage to abide audience, this should not occur within the
health care setting if it exposes patients to a loss of their right to privacy.

Occasionally after mass casualty incidents prominent persons will visit the institution – including
politicians – often bringing media with them. Again, the rights of patients must not be ignored,
and they should be able to refuse such a visit or to refuse being filmed or recorded during such a
visit. Families and others close to patients should also be made aware of the right of the patient
to privacy.

In most countries, the law supports medical confidentiality and recognises that the patient must
decide who is told about their medical condition. This right means that families will only be told
the essentials when a patient cannot consent (or refuse) to sharing information. Similarly the
family will only be told full information about a competent patient with his/her agreement.
Families may find this difficult to accept and expect to be kept completely aware. It is essential
that health care workers explain the concept of confidentiality and encourage patients to share
information with their close family.

The media frequently ignore concepts of confidentiality and assume that the broader public has
a right to know everything that has occurred; TV filming in hospital emergency rooms is
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commonplace. Every institution should have someone nominated and trained to deal with the
media, keeping them out of patient treatment areas unless privacy can be maintained. While
those working at the institution may wish to bring local conditions to international attention, as a
means of seeking some help or a resolution, they cannot do so without full regard to the right of
every individual to confidentiality.

3. The local militia makes an armed entry into the clinic to search for rebel soldiers and
their supporters. They state they are prepared to use force against you and the clinic
staff if you do not let them search for, and remove, any enemy combatants.

Hospitals, dispensaries and clinics should be exempt from intrusion by local or national militia,
police or other agents of the state and of non-state actors. Such incursions at the very least
might disrupt the functioning of the institution and the delivery care to those in medical need of
such care. Sadly it is becoming increasingly common for such incursions to put the life and safety
of staff and patients alike at risk. This is a major theme of the ICRC project Health Care in
Danger.

There are circumstances in which it is legitimate for armed entries to occur. The key points here
are that these circumstances are limited and should take place in a manner that limits the
adverse impact on the delivery of care to patients.

There are times when such incursions are a sign of significantly higher than usual tensions;
prevention, or clarity about the circumstances in which they are acceptable are better achieved
in negotiation beforehand.

It is essential that those responsible for managing the health care facility attempt to link with
people who are likely to have the type of power and responsibility that make them key decision
makers in terms of such incursions. The nature of the discussions should be about how to handle
security concerns about activities within the health care institution and, where possible, how to
reduce the likelihood of incursions.

Those working in Health Care Institutions should understand that recognition of the institutions
neutrality and immunity from becoming part of any armed conflict actions, under IHL, require
that the Institution itself, and its staff, maintain proper neutrality. While neutrality is legally
different from coping with security issues, those working in the institution should understand
that it might appear to show the institution as being part of the security problem, and make
discussions aimed at avoiding security crises more difficult.

While it might appear attractive to enhance the security of patients and staff by providing
security services within the institution, including armed guards or systems to limit access, these
seriously may distort attitudes to and confidence in the institution and may also significantly
obstruct access by those in need of health care.

Doctors, nurses and other health staff are as likely as any other member of society to hold
political views. It is essential that these are not expressed to the broad public from the platform
of the institution as this threatens its neutrality.
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Advance discussions with local political and military leaders should be based around
understandings of neutrality coupled with the requirement of health care professionals, and thus
the institutions in which they work, to treat all those in need of care regardless of their political
views, race, religion, gender or other potential areas of discrimination.

Where those in positions of power seek to stop medical or other health care help from being
delivered to those from opposition groups, they must be made aware that this damages the
neutrality of the institution and could eventually affect the ability to offer care in difficult
situations to their supporters.

There is global concern about the lack of understanding of this aspect of medical neutrality and
more examples of threats to its recognition are welcome as part of the on-going campaign to
increase understanding and compliance at national and local levels.

Patients have a right to expect that the place in which they are offered treatment will be as safe
as possible. This does not mean that the institution must arm or fortify itself, but that it will seek
in the first instance to ensure that its neutral position will be understood and recognised by key
power brokers in the locality. Arming and fortification should not be the first preference in terms
of protection, although they may be the last resort.

Patients must also be able to expect that health care staff will not put them at risk, either by
willfully breaching neutrality or by readily complying with demands from outside agencies for
access to patients, or even just to patient names.

If there is an armed incursion into the institution, staff have rights, as do patients, that their
safety will be considered by those running the institution. Again this requires the institutions
leaders to make local connections in advance of a crisis to reduce the likelihood of such risks
arising. If the institution is unable to obtain reasonable security undertakings they should
consider withdrawing from the area, to protect their staff that have a legitimate expectation of
working in a place that is reasonably safe.

It is understood that during periods of armed conflict, political and military unrest and other
emergencies, the safety of different places may change quite quickly. Institutions should ensure
that they are able to respond, and again early discussions with emerging leaders are essential.

4. A civilian is brought in from a riot. He has sustained a head injury, probably from
blunt force trauma sustained during the riot. He is wearing the colours of the
supporters of the uprising. You have no training in neurosurgery, but the nearest
neurosurgeon cannot reach you because of the on going riots. Do things change if
the patient is 13 years old?

It is a clear principle of health care ethics that health care workers should not exceed their levels
of competence. It follows from this that when managing a patient with a head injury only a
clinician trained in neurosurgery should operate. Medical regulators often express this as not
overstepping the boundaries linked to your training and expertise; in all ethical guidance
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physicians are required to explain to patients, within the process of gaining consent for any
intervention, their own level of expertise and experience linked to the likely outcome for this
patient. In normal civilian practice the lack of experience and expertise by one clinician rarely
causes a problem as well established systems exist for referral on to a relevant specialist.

Non-intervention by the non-expert is a counsel of excellence. In some real clinical
circumstances this would leave patients with no recourse to necessary treatment. In every
clinical circumstance health care workers, and especially doctors are those with the highest level
of training and the broadest ability to make diagnoses, and indeed assessing the impact of
choosing not to treat because of the absence of a suitably qualified expert.

The ethical requirement is to assess the impact of either not treating, or of waiting for access to
an expert from elsewhere (which might mean transferring the patient). Against this, the doctor
should weigh the alternative of a treatment attempt by the non-expert. There may well be
circumstances where such an intervention is the least- worst option for the patient. It should
also be clear that the intervention should be limited to what is essential, and planned in such a
manner as to limit the potential for iatrogenic damage or risk.

Consent to treatment is a requirement for each and every treatment offered to every patient.
There are circumstances where a patient is unable to consent because of their medical condition;
this is likely to be the case after a serious head injury requiring emergency surgical intervention.
While most legislations do not recognise consent given by those other than the patient, it is good
practice for health care workers to discuss options and their intentions with those close to the
patient, where that is possible. In some legislatures there may be alternative systems for gaining
agreement to a clinical procedure on an incompetent patient – they should be followed. Where
there is no such procedure or where the use of it is impossible (and not just inconvenient) it is
ethically appropriate for life-preserving treatment to be offered provided there is no competent
advance refusal of such treatment.

Consent describes the concept within which individuals make decisions about the treatment they
will receive. That decision is based upon the information they are provided by health care
workers including doctors and nurses, and will be influenced by their own understanding of that
information, including on the risks and benefits of different treatment options.

It is a fundamental ethical principle that individuals are autonomous, that is they determine for
themselves what should happen to them, and that nothing can be done to them without their
understanding and agreement. It follows from this that individuals have the right, and must be
given the opportunity to make such decisions, and that these decisions will be respected even
where the decision made is not one that would be made by others in the same clinical
circumstances. This is sometimes explained as recognising and respecting the right of individuals
to make decisions, including bad decisions, about their future health care.

It also follows that for individuals to make such decisions there is a strong requirement on health
care workers to communicate effectively with the patient. Unless there is good quality
communication it is unlikely that the patient will have the best information, which is needed to
make an informed (and therefore legally valid) decision.

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There are many blocks to good communication between patient and health care worker. In
situations of armed conflict, this will include time, and often language. Give the importance of
consent to all and any treatment, systems to deal with communication between health worker
and patient should be established including managing language differences, by employing
translators and producing basic information in local languages. This should include all forms
which patients might be expected to sign. Ideally simply written leaflets in local languages that
enable patients to read about the decisions they are being asked to make should be available,
especially in relation to the most commonly performed procedures.

In most legislations the ability to make decisions on medical treatment is linked to the age of
majority or legal competence as well as to other elements of competence to make decisions.
One alternative is described in law in England to allow young people below the age of legal
majority to make decisions provided they understand the concepts they need to understand to
make that decision. The health care professional assesses the competence of the young person,
informally «testing» their understanding of relevant issues such as risk before considering their
belief on what treatment should be offered. The age of the patient then becomes relevant only
in that adults are, in most legislations, regarded as a default position to be competent to make
decisions for themselves, but that young people not yet legally adults, have to be tested for
competence.

In the case described above, such a discussion would give the opportunity to express concerns
over the lack of access to a fully trained and expert neurosurgeon, and to obtain the views of the
patient or others making decisions on behalf of the patient. At the very least it offers an
opportunity to explore the relative risks of non-treatment and of treatment by a non-expert.

It is likely that in some cases decisions will have to be made without any discussion with those
considering matters from the point of view of the patient. It is strongly advised that the clinician
should if possible discuss his/her intent to treat with other clinician colleagues to ensure that
his/her decision is one that would be supported by others. This will also give an opportunity to
share concerns with other clinicians, and to take into account their views about what treatment
should be offered, and where the treatment limits should lie.

5. A man arrives at your ICRC clinic for war wounded. He has been in a motor bike
accident just down the street and is a local police officer.

Many health care institutions will treat all or any patient presenting to them. There are,
however, some that are set up with a specific remit. When institutions are established by
charities or other non- state and often non- national groups, they may have to register a very
specific remit and group of patients, who are all they are entitled or allowed to treat. Breaching
that duty would potentially open them to criminal charges and threaten their ability to continue
to provide care to their specific group of patients.

Against this is the ethical requirement on health care professionals to that all those needing
treatment without favouritism. In this case doing so might risk the ability of the ICRC to continue
to treat other patients.

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If the patient will suffer untreatable harm, or where there is a risk of death than the limits that
would otherwise apply cannot be followed; again there is a key issue of institution managers
ensuring that local leaders and other major stakeholders are aware that these are exceptional
cases and do not reflect a widening of the remit of the institution.

Where it becomes clear to those managing the institution that they are the only facility capable
of offering care to a group of patients, and that their current remit prohibits them from making
that offering then they must enter into discussion about how either they can extend their role or
that they can encourage and support the provision of an alternative facility.

6. You are admitting many patients with severe diarrheal disease, and suspect an
outbreak of Cholera. Most of the patients have just crossed the border to where your
clinic is, from a place in the middle of a conflict. Many refugees are gathering on that
border and want to cross into the safer areas near your clinic, and then to move
deeper into the country to stay with relatives and friends, but the local government is
asking for your advice in terms of the outbreak. There are few local facilities, and you
know that the refugee camps have no secure water supply or sewerage systems.
Does it make a difference if those wanting to move are IDPs1
? Does it make any
difference if the epidemic is transmissible?

Many of the facilities provided by humanitarian organisations and other non-state agencies and
providers in failing States or in states undergoing armed conflict are likely to have good or
excellent abilities to collect and analyse data. This may well mean that they are the first with the
ability to spot an emerging trend such as an emerging epidemic. They must have a process in
place for handling the information, including liaison with local public health authorities and
possibly also with WHO or other global or intergovernmental agencies.

In the situation set out in the case study there are a number of complicating factors including the
place on a national border and the possible infectious/contagious nature of the outbreak. It
should also be remembered that such outbreaks can cause more loss of life than the conflict
itself.

Epidemics of all sorts need immediate and comprehensive plans for management, including
establishing who will be informed. It is clearly part of the expertise of those establishing
management plans to consider the nature of the epidemic, and particularly the elements that
will decrease transmission. Airborne, water borne and other forms of transmissible disease need
different management processes.

One element of managing the epidemic is ensuring that the institution does not itself become
the major vector for increasing the number of people affected; that is that there is no avoidable
transmission within the institution. It is fully understood that in many epidemics health care staff
might be infected when they treat patients. While institutions have a responsibility to staff to
provide as safe as possible a working environment, it is always been accepted that there can be
1
Internally Displaced Persons
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some risks in treating patients. Institutions should do all they can, including providing personal
protective equipment, vaccinations and immunisations and reasonable opportunities for
treatment if any is available.

In the case cited, it is essential that the institution (which may well mean you as the physician)
should ensure that local civil and political leaders are involved in planning as one large element
of stopping the epidemic is providing safe potable water, and good sewerage facilities as matters
of urgency. There is also a clear need for leadership in providing a clinical response to help those
already affected as well as a public health need to ensure planning for epidemic containment is
adequate and appropriate.

The civil or political status of those affected makes no difference to you as a clinician, and one
element of your role may be to persuade local authorities that political interference with their
movement into a treatment facility will have serious and immediate consequences clinically and
to epidemic control.

The nature of the epidemic has a significant impact on the public health planning. Managing an
outbreak of, say, influenza has different requirements from managing, say, Ebola Viral Disease.
Planning must be based upon an understanding of the nature of transmissibility as well as other
factors. Interfering with the liberty of individuals, including their ability to leave the area, or
even the health care facility, can only be ethical if it is proportionate and necessary within the
epidemic response.

The Nuffield Council of Bioethics published what they call a ladder of intervention. This sets out
that the more a step would limit individual freedoms the more it must be demonstrable that it is
an essential step to dealing with a public health problem, that there is evidence that it will work
and that it is proportionate to the harm done by not intervening.

There is an ethical duty on local authorities to ensure that the public they serve are protected
from avoidable harm – so they also have a requirement to put systems in place that will reduce
the likelihood of epidemics. But a culture of blame does not help resolve the problem when an
epidemic occurs. If as a physician you see no epidemic but conditions deteriorating to those that
are likely to hasten an epidemic, then you have a duty to bring the attention of authorities to the
problem. Using medical evidence can help to persuade authorities; dealing with the
consequences of an epidemic usually costs more than basic steps to prevent it from occurring,

Refugees and IDPs have little political power and with some other groups in society may have
little traction in seeking help or support form governments, nationally and locally. The role of
doctors is to advocate that all people have the same basic rights, and that public health requires
protection of everyone regardless of whether they have political power or not. Those who are
not citizens are also the responsibility of the state within whose borders they find themselves, at
the very least for safe environmental conditions in which to live while decisions about their right
to stay are being made.

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Finally

Throughout this guidance it should have been clear that many of the cases are most easily dealt
with when a relationship of trust has been established with the local community including the
political and social leaders. This allows tensions to be defused and may reduce the risk of issues
such as hospital searches for “the enemy” far less likely.

It is the duty of health care workers to ensure that such dialogues have been opened up, and to
be part of the dialogue process if they can add anything constructive to it. It is also clearly the
duty of the employers of those HCWs is to ensure that they are suitably protected, and such
dialogues are a practical means of achieving this.

These dialogues also give an opportunity to consider other important issues, many of which will
have a major ethical component. These will include the responsibility that the health care
institution has to the local health care infrastructure – not to undermine it, to remove its trained
staff, or to override local cultural norms. At the same time imported health care workers should
not be expected to ignore matters where local cultural norms conflict significantly with ethical
norms – such as assisting with Sharia’a punishments, or with practices such as Female Genital
Cutting. In these circumstances the Institution must be clear that it will not take part in these
practices, and in the latter case it may choose to try to remove the potential for harm by working
with local activists seeking to end this practice.

Further reading
Williams J R Medical Ethics Manual WMA [Internet]. 2015; Available from:
https://www.wma.net/en/30publications/30ethicsmanual/pdf/Ethics_manual_3rd_Nov2015_en.pdf
World Medical Association WMA Declaration of Geneva [internet]. 2006; Available from:
https://www.wma.net/en/30publications/10policies/g1/
World Medical Association WMA International Code of Ethics [Internet]. 2006; Available from:
https://www.wma.net/en/30publications/10policies/c8/
BMA Ethics department Everyday medical ethics and law. West Sussex: Wiley-Blackwell; 2013
BMA Ethics department Ethical decision-making for doctors in the armed forces: a tool kit
[Internet].2012; Available from: http://bma.org.uk/support-at-work/ethics/armed-forces-
ethical-decision-making-toolkit
Coupland R Health care in danger: the responsibilities of health-care personnel working in armed
conflicts and other emergencies. [Internet]. 2012; Available from:
https://www.icrc.org/eng/assets/files/publications/icrc-002-4104.pdf

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