RESUMEN
Ethical practice within military health care is a significant topic of professional and academic debate. The term "military health care ethics" enfranchises the entire health care team. Military health care professionals are subject to tension between their duties as military personnel, and their ethical duties as health care professionals, so-called "Dual Loyalty." Some military health care practitioners have suffered moral injury because of the psychological stress associated with ethical challenges on military operations. It is important to define military health care ethics and also to consider how it should be taught. The essence of ethical practice is ethical decision-making. It has become self-evident from our experience of teaching military health care ethics that a simple and agreed framework for analyzing an ethical problem is required. This paper describes the development of the King's Military Healthcare Ethics Framework in support of a military health care ethics policy on behalf of the NATO Military Healthcare Working Group. There is logic to using a stepped approach to analyze an ethical problem in military health care. These steps are: "Identify" the problem, "Analyze" the problem including consideration of perspectives, "Fuse" the analysis, and "Decide". Step 1-Identify-is intended to orientate the decision-making group, and to articulate the problem specifically and clearly in order to determine the exact ethical issue and the secondary issues that arise. Step 2-Analyse-considers the problem from 4 perspectives: patient, clinical, legal, and societal/military. These reflect the breadth of perspectives that impact on health care practice within a military context. Step 3-Fuse-is the culminating step. The conclusions from the analysis of perspectives should be summarized and key references cited. This will determine the exact decision(s) to be made. Step 4-Decide-clearly articulates the decision made and provides the record of the key reasons for making that decision. This may include areas of enduring uncertainly and any planned review of the decision. The King's Military Healthcare Ethics Analytical Framework has been evaluated for content validity through iterative discussion at 4 meetings of the NATO MHCWG and a specific workshop on military health care ethics over 2022/2023. It is included within the draft NATO Standardization Agreement on Military Healthcare Ethics.