Many participants felt morally motivated to volunteer for deployment; but for some personal interests were also a consideration. A small minority felt negatively about deploying, others that deployment was part of military service. Almost all had initial concerns about their personal safety but were reassured by their pre-deployment training and equipment. Risk perceptions were interpreted through their understanding of their military service. Patient care was felt to be affected by efforts to minimise risk. Significantly, some thought the humanitarian nature of the mission justified tolerating greater risk. A high level of trust in the military as an organisation and their colleagues was expressed; many participants referred to the obligation of the chain of command to protect those under their authority. There were strong reactions to the Medical Rules of Eligibility (MRoE), which resulted in the unit running well below capacity. Most participants thought more patients could and should have been treated: this was perceived to be the most prevalent and serious ethical issue.
The mission was regarded as highly politicised in ways that were unwelcome. Points of reference for participants’ values were previous deployment experience, previous UK/NHS experience, professional values and distinctly military values. Many and varied cases raising ethical issues were reported. These included: different aspects of providing end of life care to those with Ebola, evacuation/repatriation policy, the use of cameras to monitor patients remotely, local transportation of patients, relationships with the civilian general treatment unit, engagement with the local community and the separation of parents and children for treatment purposes.
Summary of findings related to end of life care
Issues around end of life care were reported to have caused particular difficulties, even though most participants were accustomed to dealing with the dying and dead. Specific issues included: uncertainty about the course of the disease in individuals (patients who were recovering died unexpectedly/ patients thought to be ‘hopeless’ survived) – this resulted in, amongst other things, a ‘hybrid’ approach to palliation; the trade-off between infection control and providing ‘normal’ end of life care and comfort; moving dying patients over long distances to receive palliative care; preparation of the dead for burial.
The military-run Ebola treatment unit (ETU) was well staffed and resourced. It aimed to provide a standard of care as close as possible to that provided in the UK. Nonetheless compromises had to be made between three imperatives: public health measures (containment), the need to protect staff from infection (obligations to employees/self/colleagues) and the duty to care for patients (‘normal’ professional obligations). Elsewhere local and NGO health carers were working in much more austere ETUs, with similar mortality rates and larger numbers of patients. As well as managing these competing imperatives they had to balance providing care for the dying against channelling energy and resources to those with the best chance of living. This raises serious concerns about how palliative care (as opposed to symptom relief per se) fits into a disaster response; particularly where a severe infectious disease is concerned. The inability to provide symptom relief and the lack of opportunity to provide palliative care is likely to be a source of moral distress to a healthcare professional. This distress may persist even when set against successes in saving life and controlling spread.