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‘A band of brothers’—an exploration of the range of medical ethical issues faced by British senior military clinicians on deployment to Afghanistan: a qualitative study
  1. Elizabeth M Bernthal1,
  2. H J A Draper2,
  3. J Henning3 and
  4. J C Kelly4
  1. 1Academic Department of Military Nursing, Royal Centre for Defence Medicine (Academia and Research) Medical Directorate, Birmingham, UK
  2. 2Institute of Applied Health Research, University of Birmingham, Birmingham, UK
  3. 3The Academic Department of Military Anaesthesia and Critical Care, Royal Centre for Defence Medicine (Academia and Research), Defence Medical Group North, Northallerton, UK
  4. 4Faculty of Health and Social Care, University of Hull, Hull, UK
  1. Correspondence to Lt Col Elizabeth M Bernthal, Academic Department of Military Nursing, Medical Directorate, Royal Centre for Defence Medicine (Research and Academic), ICT Centre, Birmingham Research Park, Vincent Drive, Edgbaston, Birmingham, B15 2SQ, UK; SenResFellow.ADMN{at}


Aims To identify and explore features of ethical issues that senior clinicians faced as deployed medical directors (DMDs) to the British Field Hospital in Afghanistan as well as to determine the ethical training requirements for future deployments.

Method A qualitative study in two phases conducted from November 2014 to June 2015. Phase 1 analysed 60 vignettes of cases that had generated ethical dilemmas for DMDs. Phase 2 included focus groups and an interview with 13 DMDs.

Findings Phase 1 identified working with limited resources, dual conflict of meeting both clinical and military obligations and consent of children as the most prevalent ethical challenges. Themes found in Phase 2 included sharing clinical responsibilities with clinicians from other countries and not knowing team members' ways of working, in addition to the themes from Phase 1.

Discussion This study has drawn together examples of scenarios to form a repository that will aid future training. Recommendations included undertaking ethics training together as a team before, during and after deployment which must include all nationalities who are assigned to the same operational tour, so that different ethical views can be explored beforehand.


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Key messages

  • The most challenging ethical decisions to make or resolve for deployed medical directors are: working with limited/rationing of resources; working with clinicians from other countries; not knowing team members’ ways of working; a lack of medical intelligence of the indigenous health system; upholding the Medical Rules of Eligibility; and caring for children within the context of an austere environment.

  • Health practitioners must be given appropriate ethical training to prepare them for the ethical issues that they may have to face on deployment.

  • Predeployment training must include all nationalities who are assigned to the same operational tour, so that different ethical views can be explored beforehand.


Exposure to ethically challenging situations is inevitable because of the increased complexity of today's military operations.1 The Ministry of Defence recognises that supporting deploying clinical personnel with appropriate ethical training is an essential educational requirement.2 Healthcare professionals owe their patients a duty of care to provide the best care possible.3–6 Military health professionals are also bound by the Law of Armed Conflict7 and the care of captured persons8 which grant captured personnel and prisoners of war the right to be treated humanely in accordance with standards set by international law.

Ethical decision-making and behaviour in clinical practice require the application and interpretation of ethical and legal principles.9 The clinician must take account of the perspectives and values of all concerned within the specific context in which the clinician is working3 (AN Papanikitas, From the classroom to the clinic: ethics education and general practice, unpublished PhD thesis, King's College, London, 2015). Clinical Guidelines for Operations2 include the ‘four-quadrant approach’ (4QA) to aid ethical decision-making. The four quadrants are ‘medical indications’, ‘patient preferences’, ‘quality of life’ and ‘contextual features’.10–13 Research14 suggests that the 4QA can be a useful tool to collect relevant information to assist ethical decision-making and identifies that participants rely on their previous deployment knowledge to make ethical decisions. However, military clinicians may not be able to rely on previous experience in future contingency operations where the characteristics, environment, circumstances and type of deployment are less likely to have been previously experienced. For example, the ethical issues that clinicians faced in treating Ebola virus disease in Sierra Leone were very different to those encountered during an international conflict.15 An increased knowledge about the factors that make decision-making difficult should facilitate appropriate training programmes to be developed in ethical issues, regardless of the environment, type and context of the military mission.

The role of Deployed Medical Director (DMD) was introduced in the British Field Hospital in Afghanistan (BFHA) in 2009. This was to build upon the previously established role of the clinical director to provide clinical leadership for coping with the increasing complexity of an evolving military trauma system.16 Medical advances in combat casualty care, peacetime experience and intense workload created uncertain and inconsistent decision-making. This made it necessary to establish a senior clinician whose role focused on providing clinical leadership rather than clinical care.16

The Medical Rules of Eligibility (MRoE) state clearly which patient groups can access the military medical system in order to protect medical capacity for the primary mission while adhering to international and humanitarian law.15 ,17 The need to comply with the MRoE within the culture of the indigenous population may create a greater range of ethical issues that Defence Medical Services (DMS) personnel need to address on deployment than that their civilian colleagues need to face in UK.12 Medical advances in Afghanistan have made previously unsurvivable injuries survivable which has created ethical challenges not experienced in previous conflicts15 (T Hodgetts, ‘DMS ethics: research campaign framework’—PowerPoint presentation, Medical Directorate, Joint Medical Command, Birmingham, unpublished presentation for Stakeholders’ meeting, 25 May 2014).

The aim of this study was to capture the experiences of ethical decision-making of DMDs to BFHA, so as to elicit the factors that contributed to creating ethical issues and in particular those that make them difficult to resolve.


A two-phase qualitative study design using an interpretive approach was used. Phase 1 analysed 60 anonymised vignettes of cases that had raised ethical issues for senior military clinicians during recent operations. These were generated from discussion at DMS military ethical symposia between 2010 and 2014.

Phase 2 included two focus groups and an interview with a total of 13 DMDs conducted between January and March 2015. The interview was undertaken at the request of one of the participants from the first focus group. Participants were purposively recruited from the population of 22 Tri-Service personnel who had deployed for 3 months in the role of DMD to the BFHA between 2009 and 2014.

Focus groups took place in a central location in UK at a convenient time for the participants. Moderation of the focus groups ensured the participants' opinions and beliefs were respected. The civilian member of the research team (HD) acted as moderator and undertook the interview to mitigate the impact that the rank may have had upon the discussion. This reduced any potential assumptions being made by two of the military researchers (EMB and JH) who had served in Afghanistan and knew some of the participants. The other author (JCK, a reservist who had not previously met the participants or served in Afghanistan) noted non-verbal communications. The same topic guide was used for each focus group (Box 1).

Box 1 Focus group topic guide

1 What were the most straightforward ethical issues to resolve in the Field Hospital in Afghanistan?

2 What were the most frequent ethical issues to resolve?

3 What factors made ethical issues especially challenging on your deployment?

4 What were the most difficult ethical issues to which you had to respond?

5 To what extent, if at all, did you use ethical frameworks?

6 What do you think is the best training or preparation for tackling ethical challenges such as these?

7 What training do you think would help those deploying in the future to address ethical issues?

8 What do you think is the most important thing we have discussed today?

9 Are there any other points that anybody wanted to raise and have not had a chance to yet?


For Phase 1, the researchers reviewed the vignettes to categorise the types of ethical issues that each highlighted. These were developed into a typology to represent the cases submitted. The individual typologies were then discussed and reviewed until agreement between the researchers was reached to determine the main categories and then themes.

Analysis for Phase 2 began after the first focus group had taken place to make sense of how the data were contributing to answering the research questions. The data were transcribed verbatim and analysed using thematic analysis. Codes and subsequent categories were derived using an inductive iterative approach and allowed to emerge from the data as patterns and themes developed. This initial analysis permitted preliminary themes raised in the first group to be probed in the second group. The interpretations were compared and discussed among the research team to ensure commonality of interpretation. Analysis continued until the writing up process was completed in order to reflect upon the emerged themes.


Participants were provided with written information about the study and gave written consent prior to participation outside the chain of command (CoC) to avoid any perception of coercion. Participants were asked to agree to keep contributions to the discussion confidential to the group. The data were stored securely and anonymised to protect participants' identity. Favourable ethical review was obtained from the Faculty of Health and Social Care, Research Ethics Committee, University of Hull (Ref. No. 153). Ministry of Defence Research Ethics Committee (MODREC) confirmed that it did not need to review the protocol.


Eight participants took part in the first focus group of 87 min duration; two participants joined by telephone. Five participants took part in the second focus group which lasted 90 min, one of whom joined by telephone. The interview lasted 40 min and was completed via telephone. All bar one of the participants were currently serving in the UK.

Phase 1

The themes generated from the analysis of the 60 vignettes can be seen in Box 2. These themes represented ethical concerns at a higher level of generality. There was insufficient detail in some of the vignettes to identify the complexity of all of the cases.

Box 2

Themes––Phase 1

Working with limited/rationing of resources

  • Having to predict and balance the needs of future patients against those of existing patients in light of present resources such as blood

  • Deciding whether and when to prioritise the needs of coalition forces over those of local nationals (LNs).

Dual conflict—military vs professional obligations

  • Challenges of upholding Medical Rules of Eligibility consistently in light of ‘mission creep’—such as frequent changes of eligibility for admission and delay of transfer.

  • Working alongside local facilities which had a lower medical capability than the BFHA.

Decisions related to deciding whether to provide end-of-life care

  • Whether to withholding or withdrawing potentially life-sustaining interventions.

  • Ascertaining the likely quality of life for LNs in the light of available local resources and medical capability.

Patient consent

  • Treating children where there are disagreements about a minor's best interests.

BFHA, British Field Hospital Afghanistan; LN, local nationals.

Working with limited/rationing of resources created the ethical issue of a reduced ability to continue potentially life-sustaining interventions. Examples included continuing specialist care initiated in the BFHA or using the majority of the stock of blood products for one patient in urgent need, thereby potentially reducing availability for future patients (who may have had better survival prospects). Vignettes raised issues related to a tension between meeting the needs of the military mission in light of the MRoE versus the clinician's obligation to treat patients according to clinical need. Contextual issues were raised such as the implications of deploying to an Islamic country and working alongside clinicians from other countries who held different ethical viewpoints.

Phase 2

Themes generated were related to the most straightforward, common and challenging decisions DMDs faced, training requirements and the psychological impact of undertaking ethical decision-making (Box 3).

Box 3

Themes––Phase 2

Most straightforward and common decisions

  • Where there is sufficient time to make a considered judgement

  • When clearly defined within the MRoE

  • Withdrawing care of severely injured patients

Most challenging decisions

  • Working with limited/ rationing of resources

  • Working with clinicians from other countries

  • Not knowing team members’ ways of working

  • Lack of medical intelligence of indigenous health system

  • Upholding the MRoE

  • Caring for children


  • Ethics symposium and courses

  • Predeployment, deployment and postdeployment training

Psychological impact on individual

  • Making ethical decisions in difficult circumstances

  • Cathartic benefit of taking part in the study

MRoE, Medical Rules of Eligibility

Most straightforward and common ethical decisions

The most straightforward and common ethical decisions occurred when there was sufficient time to discuss the management of the patient's treatment with the multidisciplinary team or to monitor the patient's progress:…..where you have had, normally 24 hrs at least of watching their progress or lack of progress and realising that…it was futile to continue…. I found were very easy, because it was very easy to get everybody engaged.Participant (P) 5 Focus Group (FG) 2

The most challenging ethical decisions

The majority of the most challenging ethical decisions arose from working with limited resources and deploying with a multinational team under British doctrine in an austere environment within a Muslim culture.

Working with limited resources

Resources in this context included staff and equipment. One participant viewed limited resources in terms of equipment and staff, and his duty of care to maximise staff safety:….we have an individual who has been blown up, beating heart essentially on a ventilator. Do we task an expensive resource, a C17 and a [Critical Care Air Support Team (CCAST)] to come out and pick up that patient who we know is going to die anyway, if not dead already; er to go back to the UK and give their parents one last chance to hug them. Int 1

Another participant spoke of the challenge that reduced resources had on the ability to treat patients in need:We had to make a decision… decreasing the numbers of ITU beds and we needed to move this patient [when] there was clearly no prospect whatsoever of him … being able to walk again or… surviving. P3 FG1

Working with clinicians from other countries

Ethical challenges were created by collaborative working with international military colleagues who held different ethical viewpoints and wished to prioritise their own nation over clinical need. This was exacerbated as BFHA was under British command and doctrine and not that of the other nations working within it:There were very entrenched views… amongst the clinicians and that often was due to nationality differences. P5 FG1

Not knowing team members' ways of working

Differing clinical opinions and practices could lead to disharmony about the management of care, particularly if the clinicians involved did not know each other:one of the difficult things, … where we hadn't been around long enough to work each other's, you know, gears meshing together, … the lead surgeon who'd been there for three months said ‘I can't help this guy's, he's going to die’, the surgeon who just turned up and was British said ‘well, I can’ …. It created a dynamic straight away. ‘…. which took a long time to settle down between those two surgeons’. P2 FG1

Upholding the MRoE

A lack of knowledge of the capability of local healthcare provision made it difficult to plan the most appropriate care for local nationals (LNs). The requirement to support the indigenous healthcare system to develop its expertise in preparation for coalition forces’ (CFs) withdrawal from Afghanistan had an impact on the treatment options given to CFs, LNs or Captured Persons (CPERS):…….balancing the ethical duties to the individual in front of us with the future population in that region….to look after those patients as well as they could be looked after in that environment. P5 FG1

A two-tiered system within BFHA had to be created, so that the less mature indigenous health system could continue treatment for LNs on transfer; while CFs could be given more complex treatment as this could be continued once evacuated home:They [Afghans] should receive exactly the same standard of care as one of our own soldiers…but what you cannot do is put them on a plane [repatriate]. So you're still constrained with what you can deliver…knowing what capabilities are available within the system within the country. P4 FG1

Additional ethical challenges were created if BFHA had capacity and resources to treat a LN who did not meet the criteria for treatment of the MRoE:If the hospital is empty, you have a lot of staff …doing nothing… well morally and ethically…surely we should be trying to do something. P2 FG2

Caring for children

Caring for children raised a considerable number of ethical challenges, particularly as predeployment training (PDT) presumed that skills, knowledge or equipment for paediatrics would not be required:The ethical issues with children came up much more frequently than you expect, because you are almost told that you are not going to deal with children and that is never the case… P5 FG2

Participants discussed the challenges of cultural differences in which parents had different views of what they felt was best for their injured child:Parents initially refused for us to undertake an amputation of [10 year old daughter] her limb. P2 FG2

Participants reported that other parents wanted the clinicians to do all they could to save their child, regardless of the level of disability:We had a horrendously injured child….His father turned up…he was very grateful to us …. made sure everything was done for him at home [on discharge]. P6 FG1


PDT: developing teamwork

Participants highlighted on the importance of ethical decision-making training and of including the 4QA during PDT in order to prepare them to address difficult challenges as soon as their deployment began:I found the four-quadrant training …and the Ethics Symposium [to practise using the 4QA using different cases] very useful…. You're turning up as the brand new DMD … You can't limber up with a couple of easy [ethical] decisions … you may be faced with the worst decision of your whole career, your whole deployment Int 1

Exposure to cases and guidance by a previous DMD were very helpful:I think it helped and having people [recently deployed DMDs] in discussion groups and having a number of different cases …so you have mentally had exposure to all these different cases and talked out different ways of managing and handling them [before deployment]. P4 FG2

Participants emphasised that all those deploying on the same tour should undertake PDT together to assist team cohesion and iron out different viewpoints:It's important whenever we go away on a joint mission we make sure that whatever nations are going we all have the same training in that perspective or similar. Int 1You can think in advance of what the problems are going to be … and if you discuss those differences in the PDT setting…, as to what the consensus is going to be when you see that with the actual patient. P8 FG1

Training during deployment

Participants stressed that discussions with the team using the 4QA as each ethical challenge occurred increased confidence in dealing with ethical issues and aided an understanding of the rationale for decisions:…it gave me big chunks, coat hangers to hang things on….How do I rationalise this and reconcile this, rather than coming to random decisions as to which way the wind was blowing that day. Int 1

Psychological impact of making ethical decisions

Participants spoke of the psychological impact that addressing ethical issues during their deployment as DMD had upon them: ‘We all carry the scars’ (P6 FG1). This had changed them: ‘you come back with a different world view’ (P8 FG1) and ‘I now live for today’ (P6 FG1). Participants highlighted the importance of debriefing for all levels of staff, so that they could discuss the ethical challenges to which they had been exposed:I'll be quite open about it to juniors…a lot of very, very juniors said ‘Oh, thought I was different…it's nice to know that you go through the same process’. P6 FG1 

Cathartic benefit of taking part in the study

It was rewarding to hear that taking part in the study had been beneficial:This [taking part in a focus group] represents the first chance any of us have had to talk openly about some of the challenges we faced P5 FG2

Such a shared experience had created a group ethos among them; one described this as a ‘band of brothers…the mutual support club’ (P8 FG1).


This is the first study to explore the features of the most challenging ethical decisions that senior British military clinicians have faced. The participants understood what constituted an ethical issue, and they described many different ethical challenges that they had faced. Making important and difficult ethical decisions formed a major part of the DMD's role; professional, clinical and ethical decisions were interlinked. Understanding what makes ethical decisions straightforward sheds light on what makes them challenging. The most straightforward decisions were those that the participants were familiar with making in their non-deployed role and when a patient's eligibility for treatment complied with the MRoE. The impact of experience echoes the findings of an earlier evaluation of the 4QA approach, in which clinicians appeared to view more familiar ethical decisions as clinical ones, even though it was an ethical one.14 The concerns around quality of care are consistent with previous studies.18 ,19

It is difficult to differentiate between professional and moral qualities because they are so closely interwoven: health practitioners' qualities and values are what make them ‘morally good’.20 Professional ethical decision-making assumes a set of key principles and values, and requires individuals to be conscious of these.21 As serving officers, the way the participants discussed the challenges they faced provided evidence of their leadership and that military standards and values (such as a sense of justice) were embedded in them as part of their own personal ones.7 Everyday experience as well as psychological research suggest that, in making complex choices, there is a tendency to reduce the set of possible consequences or outcomes as a means of making the decision manageable.22 Ethical challenges were not caused by moral doubt or uncertainty for our participants in common with Moerwijk's findings.22 The challenging ethical issues raised have illustrated that some situations evoked more intense emotional processing than others due to the large cultural differences and the high stakes of working in an ever-changing deployed environment.1 There are three steps to address an ethical issue11 ,23—moral perception, moral reasoning and moral action. Moral perception recognises that the case presents a moral or ethical question and is the first stage of 4QA.11 ,14 Moral reasoning considers the issue within a relevant moral framework. Moral action implements the judgement that has been reached through moral reasoning.12 The need to take moral action is greater in some environments than others, such as cultural diversity within a military conflict.1 The cultural and contextual factors had a major impact on whether a decision was perceived as an ethical one.

The term ‘moral distress’ has been defined to illustrate the psychological, emotional and physiological suffering that health professionals experience when they have to act in ways that are inconsistent with deeply held ethical values, principles or commitments.24 The responsibility of making ethical decisions for these DMDs highlighted the importance of managing their own distress. Some of the participants had deployed as DMDs up to 6 years before this study took place and spoke of ‘carry(ing) the scars’ ever since. This might be regarded as evidence of moral distress.25 Participants also recognised that they had a role as leaders to psychologically support their junior staff.

What makes an ethical decision challenging?

The most challenging ethical issues resulted from the perceived conflict between complying with the MRoE, and personal and professional ethical values, which require practitioners to act in the best interest of individual patients. This has also been identified by others.26 ,27 The inevitability of limited resources creating ethical tensions is a frequently cited issue.22 ,28 ,29 Rationing of healthcare exists at several levels: at macro level from a government deciding on the mission, the meso level of the intermediate body, such as the CoC, and the micro level, in this case, the DMD.30 There is always a limit to the capacity and resources of medical assets, whatever the mission.17 The execution of the MRoE has to be carefully balanced to ensure the military medical system follows internationally agreed ethical principles and supports capacity building without undermining the development of the indigenous health economy.15 ,17 Working with limited resources also raised a challenge when deployed with other nations if there was a difference of opinion among the clinical team who should be prioritised for treatment; that some nationalities wished to prioritise their own nation's personnel before the host nation is documented in the literature.31

Dual loyalty conflicts occur when the clinician's obligation to the patient is in tension with some specific military roles and duties.21 The participants recognised the tension between their obligations as a doctor to prioritise the health needs of each LN while sustaining their commitment to the MRoE in order to contribute to the military mission. The problems created by dual loyalty are widely discussed.20 ,21 The BMA3 states that ‘doctors’ professional obligations require them to prioritise their ethical duties to their patients over and above their responsibilities and loyalties to the military’; yet, the DMD has to comply with the criteria set by the MRoE to support the military mission which may conflict with their professional obligation to treat individual patients in need. Turning away a LN with non-life threatening injuries was a relatively straightforward ethical decision, as the participants had the confidence that they would be adequately cared for within the local health system. Transfer of LNs in 2014 seemed easier than in earlier years as the need to develop the local health system ahead of the British withdrawal was more urgent. However, as one participant in this study pointed out, if the hospital is not at or near capacity then there is an ethical responsibility in line with the General Medical Council (GMC)4 to provide care, even if this means caring for LNs which may contravene the MRoE. It is reported32 that treating LNs can result in improved morale for the medical team as they felt that they were really making a difference to the care of the indigenous population. However, this can create immense pressure for the DMD who is both responsible and liable for making these decisions.

Many ethical challenges were related to managing conflict among the team, especially with international colleagues. The differences in military practices, doctrines and leadership styles when different nationalities work together, even in the North Atlantic Treaty Organisation (NATO) alliance, are widely recognised.33 ,34 Managing intercultural relationships is an important aspect of military leadership. It is suggested that team-related morally challenging interactions are the most difficult to resolve1 but eased by achieving consensus.35 Our participants understood that their role as DMD was to be arbitrator, although the ultimate decision rested with them.16

The ethical challenges in relation to consent when caring for children are well documented.36 Treating children formed a significant proportion of the deployed clinician's workload. Studies have confirmed that children represent up to 39% of all hospital admissions to British military field hospitals.37–40 In 2013, paediatric casualties accounted for around 10% of admissions to the deployed intensive therapy unit at BFHA.41 Caring for children should be included in PDT, so that health professionals have the skills to care for them.41 There is an obligation for the institution to prepare clinicians prior to deployment for the ethical challenges that they are likely to face.

Training: how to prepare health practitioners to make ethical decisions

BMA4 states that ‘a sound grasp of basic ethical principles can bring clarity to doctors’ decision-making when under pressure’. Training should include instruction in, and assessment of, the application of these principles in practice. However, none of the participants referred to BMA's4 guidance, even though it is aimed specifically at doctors in their position. Participants reported relying on previous experience, and this has been identified elsewhere.14 Relevant and high-quality training in ethical decision-making is necessary to help clinicians feel confident to deal with ethical issues on deployment.

A lack of communication and teamwork is recognised as a major contributor to adverse events.42 The participants acknowledged the importance of undertaking PDT as a team, regardless of the level and nationality. Participants highlighted the importance of simulation training in PDT to enable ‘meshing together’ and to get to know each other and to work out any difference in ethical viewpoints before they deployed. Casualty simulation teaching programmes have enhanced teamwork to treat severely injured casualties in Afghanistan.43 Comprehensive simulation team-training programmes can improve both clinical processes and patient outcomes.44–48 Working with international colleagues presents both opportunities to share practice and to learn from each other, but can create friction where there is a different culture, language, scope of practice, doctrine, governance, treatment guidelines, ways of working and different ethical codes.16

The use of ethical decision-making tools––4QA

Clinicians who make important ethical decisions should be able to give the rationale for their view.3 ,13 While the DMD is the ultimate decision-maker, the study findings support others’ views49 that ethical decision-making is a social process through which participants navigate. Our participants spoke of engaging their clinical team in discussion. Participants in this study, like those from a previous study,14 referred to the pro forma of 4QA as a useful navigation tool that enabled them to check that they had gathered all of the information necessary to arrive at a decision. This is in line with the perceptions of 4QA of Tsai and Harasym.50 Having the relevant information is only the starting point. The 4QA as a tool was designed to facilitate organising relevant information in a specific way, which should be considered in a specific order, as indicated by the arrows on the quadrant.2 ,11 It seems clear from both this data and a previous study14 that the tool might not be used to order the relevance of the different information available and that clinicians do not understand how to employ 4QA beyond using it as a means of gathering information. This indicates that more guidance and explanation may be needed in the Clinical Guidelines for Operations2 and during training. The participants regarded the process of group discussion as a means of demonstrating a willingness to be inclusive and as a means of achieving consensus, even if the final decision rested with them as DMD. This reflects another work49 that identified an increased communication between professional colleagues led to better teamwork.

Psychological impact

Clinicians can suffer long-term moral distress or negative moral emotions because of unresolved issues encountered in healthcare delivery, particularly if they do not discuss them to enable them to reach ‘closure’.51 Evidence suggests that military personnel do not use the opportunity to talk about their own emotions when the operation is finished, and even if support is offered and they are encouraged to do so.28 This was thought to be because of a lack of trust in the CoC not to document it as well as a fear of the stigma associated with not coping. The ‘deburdening’ that seemed to result from participation in the study suggested that debriefing is important, whether formally or informally. Our participants valued informal debriefings and social interaction to provide peer support to discuss their concerns.

Recommendations for training

A number of training recommendations follow on from this study's findings: training in ethical decision-making should be included routinely in clinical training courses, prior, during and postdeployment as part of postdeployment debriefing. Ethics workshops using relevant and current scenarios should continue to be delivered in courses such as the Military Operational Surgical Training course and General Practice Vocational Training course; these scenarios should include children. The predeployment, deployment and postdeployment training should include the whole multinational team, and clinicians must be trained how to use an ethical decision-making tool as well as practise using it before they are exposed to ethical challenges on deployment. Training in ethical decision-making must be continued throughout deployment.

Taking this work forward

A training needs analysis has been completed to ensure that ethical decision-making is incorporated into formal training programmes in the future. A collaborative project with the International Committee of Military Medicine is developing a repository of ethically challenging scenarios and training materials for all health practitioners within NATO to access(D Messelken, Database ‘Cases andscenarios inmilitarymedicalethics’, unpublished report, 2016).Ongoing ethics research projects are focusing on exploring ethical decision-making from the viewpoint of other health practitioners such as nurses, paramedics and operating department practitioners.


A few of the participants were deployed as DMDs many years prior to the study taking place, which may have had an impact on how they recalled the ethical issues they had faced; however, their vivid account of the ethical challenges indicated that this was not the case. It was possible that joining the focus group via telephone may have limited these participants' contributions to the discussion, which was mitigated by the moderator who invited them to speak if they had not added to the discussion.


This study provides some insight into the features of the most common, straightforward and challenging ethical decisions made by DMDs while on deployment to BFHA. It builds on the service evaluation that evaluated 4QA within BFHA.14 Ethical decision-making should remain high on the strategic agenda to ensure that clinicians are supported to make effective ethical decisions. This should also reduce reputational risk.


The authors thank the senior clinicians who participated and the Medical Directorate at the Royal Centre for Defence Medicine (Academia and Research) for funding the study.



  • Contributors EMB was responsible for the study conception and design, obtaining funding, drafting of the manuscript; EMB, HJAD, JH and JCK were involved in the data collection; EMB, HJAD, JH and JCK were all involved in the analysis of Phase 1; EMB and JCK were involved in the analysis of Phase 2; JCK obtained ethical clearance; HJAD, JH and JCK critically reviewed the manuscript.

  • Competing interests None declared.

  • Ethics approval University of Hull Research Ethics Committee.

  • Provenance and peer review Not commissioned; externally peer reviewed.