The numbers of participants, reported by role-group and period of deployment, and interview length, are shown in Table 1. Face to face interviews tended to be longer than telephone interviews, though the shortest interview was one conducted face-to-face.
From this rich data set, this paper reports on the broader ethical challenges that the participants experienced. Our findings are illustrated with selected quotations that reflect typical responses and the range of participants within each of the three broad groups. To protect participants’ identity, given the relatively small population size, we have not included rank or role using instead a simple numbering system (P1, P2 etc.). To avoid repetition, asterisks (* ** *** etc.) are used to identify particular quotations and participants that are referred to again later.
Attitudes to and motivations for deploying
Many participants regarded themselves as having volunteered for deployment. Indeed, some participants reported making strenuous efforts to go. This may have been a misperception given that, as one participant explained: "It’s not done as ‘Are you willing to go because if you are not you don’t have to’ ...[it’s] only used in order to prioritise people...so the idea of volunteering...it’s a bit of a misnomer." (P17) Nonetheless, for these participants, the decision to volunteer was an ethical one. The majority felt compelled to respond to the unfolding humanitarian crisis and human suffering it was generating. Some cited having the skills/ability to make a difference as a motivation and one participant reported feeling a personal affiliation with the African people.
...it was very clear that there was a, a desperate humanitarian crisis going on and so there was a desperate need. (P12).
I was watching this suffering on the TV… I’d watched the TV and think, ‘I'm a nurse, an experienced nurse,’ and I, I, I sort of knew in my heart. I ... really wanted to do something. I knew I had the skills, as it were, to alleviate suffering. (P7).
A significant minority sought to deploy primarily as a career opportunity, sometimes related to their medical speciality or command/rank ambitions, or they simply welcomed the opportunity to deploy.
I was immediately interested ... but only in a role that is relevant to my rank, because what I didn’t want to be doing was taking time out from work or from my reservist role if I felt that it was ... a role that wasn’t also going to career develop me and professionally develop me... I was desperately keen to go but I wanted to make it the best opportunity possible ... and which will then translate to skills that I bring back into my workplace. (P12).
Rarely did participants provide a single motivation and most cited a combination of the above reasons (as P12 above). Of those who did not report actively seeking to deploy, most reported feeling sanguine about the prospect, regarding deployment as part of military life; others were part of a high readiness unit and were therefore already on notice to deploy. A small minority reported being very negative about the prospect, feeling that this type of mission was not what they signed up for when they joined the military.
I wasn’t given the order to go, but I am in the military and that’s what’s expected of me. (P11).
...as a military or army medic we all joined up to maintain the fighting strength of the British Army and this just wasn’t anything to do with that. (P5*).
This view is in contrast to those who reported joining the military to do humanitarian work and/or being disappointed by how few opportunities had arisen to do so.
I thought I was joining up to travel round the world and to save people...I’ve done nearly eighteen years now and this is the first humanitarian work I’ve done...when I was joining up I thought we would be doing a lot more disaster relief kind of work. (P19).
Only a very few participants made no reference to concerns about the personal risks involved, most expressed at least initial concerns. All of the participants expressed confidence in the PPE training they had received and found this reassuring. Some referred explicitly to having trust in the military to look after them, and one reservist reported that whilst they had volunteered to deploy with the military they would not have gone as a National Health Service (NHS) volunteer.
Sheer terror because I thought it was operation certain death. (P5).
...it would always be one of those things that would happen – which would be human error rather than actually anything you hadn’t done yourself to prevent...we were taught very much to be very sensible...not to take any risks and to practice our drills...But there are obviously occasions that are completely out of your hands, when dealing with patients that are confused or agitated... (P21).
I wasn’t really worried about catching Ebola because I did have a lot of trust in training we had and I felt confident that as long as I stuck to my ‘drills and skills’ and we looked after each other, we’d be fine. (P13***).
Perceptions of ‘the mission’ and concerns for personal safety
The participants provided a uniform account of the mission, namely that they were deploying to provide high quality care to EVD-infected healthcare workers so as to bolster confidence internationally (other countries would send medical teams to help) and locally (healthcare professionals would continue working knowing they would get treated if they became infected); some also made reference to containing the spread of EVD.
Well all the civilian healthcare people out there, they are basically like ‘If the army aren’t there, then we’re not going to be here’. So if the army aren’t there then the healthcare professionals won’t be there, so then no one will get treated...and then it’s just going to be...a massive pandemic of Ebola...it’s just going to go global. (P16).
Their perception of the mission, however, varied. Some participants believed that they were embarked on a fundamentally humanitarian mission whilst others regarded it as a non-combat contingency mission. Participants often suggested that that there was an overriding desire from the top of the chain of command to minimise the risk that personnel would be infected.
Whereas the army certainly has not done a humanitarian mission like this before I don’t think and has not done much in the way of humanitarian, medical humanitarian stuff for a long time. (P1).
...it was more interesting because it was something so different and we hadn’t done a contingency op before so that made it a bit more interesting but generally not more important I don’t think than previous deployments. (P15).
...people senior to us were terrified of military personnel contracting Ebola or dying out in Africa or over-stretching resources back in the UK. (P5).
Participants’ understanding of the nature of the mission, however, affected their views on how minimal risk should be conceived. Successfully delivering the mission and minimising risk was experienced as a significant ethical challenge. The participants’ perceptions about risk helped to inform our understanding of why this was, as we shall now explain.
No participants seemed inherently risk-adverse, and several stated explicitly that risk-taking is part and parcel of what the military do.
...if you join the Army you are expecting to get sent into risky places and the, the whole purpose of the Army is so that we can take that risk and so that the UK can remain safe. I mean that’s the whole point about having an army at all is, is for the promotion of the safety of home. So, I personally don’t think that anyone who was deploying should have felt that their safety was above that of... the population back at home. (P17**).
Equally, a minority felt that they had not ‘signed up for’ these particular risks, suggesting that risk-perception was related closely to their understanding of the justification for risk-taking (see P5* above). Some thought that the risk from EVD was a different sort of risk to that normally taken without necessarily suggesting that it was therefore a greater risk. Reference was made to infection being a risk that could not be seen, unlike normal combat risks.
Ebola is an unseen killer. You can’t see it and of course what we’re used to in a trauma-type environment is, is things which are very visible. So the fact that it is...it is invisible it’s scary. You know there’s no, there’s no doubt about it, it’s scary. (P12).
This observation was probed in later interviews because it was not obvious that normal military risks are clearly visible; snipers, landmines and improvised explosive devices (IEDs), for instance, are most effective when their position has not been detected. Moreover, larger medical units are generally located at a relatively safe distance from combat operations. Accordingly, it seemed to us that combat duties may also entail an element of ever-present but unseen danger. Probing brought some clarity to the concerns being expressed. The sense that the risk was invisible was heightened because one might be infected for several days before realising it. Bullets and explosives leave obvious injuries that can then be responded to; the gravity or otherwise of these is more immediately clear, and the treatment pathways more familiar.
one of the guys said, that he thought it was much worse than being on patrol; not because it was actually more dangerous but that if he was on patrol and he stepped on a landmine, he knew about it, whereas, if he caught Ebola, he wouldn’t know about it till the week later, which was – which a lot of us found a very disturbing concept, once we started thinking about that... it’s almost better to be harmed in a way that you’re aware of immediately than to have something in your body that’s harming you and you don’t know, you’re either harmed or you’re not harmed ... when you’re on the ground. ... we had exposures to Ebola, there were a lot of people who found that very difficult; the idea of, ‘I might actually have caught this yesterday and I just don’t know it yet’ ...a lot of people said they found that very uncomfortable; the not knowing if they’d already made the mistake. (P18).
Some participants who regarded the mission as primarily a humanitarian one felt the scale of the outbreak justified a higher risk threshold. Other participants also felt that the risk-aversion governing the mission ran counter to the general willingness to expose military personnel to risk in combat operations.
Our mission wasn’t to go there and not get infected, our mission was to go there and have a safe ETU [Ebola treatment unit] to treat healthcare workers and we’ve done that and if the mission is important enough to have to acknowledge some risk there and people think, if they think you can eliminate risk in looking after people with Ebola down there, it’s impossible and you can’t and you will always have a human factor or a human error as how someone will get infected and that’s a disaster but if you believe in the overall mission, which I do, then I think it’s justified. (P2).
We are always quoted a figure of risk when we deploy. But you know people have deployed for the last ten years, into areas where they are risking their lives, and we are medics, we are doctors. What’s the difference? We are all in the same organisation and it’s a risk. (P21).
Some staff with specialist knowledge in infectious disease or managing contamination thought the risks of becoming infected whilst wearing PPE were over-stated. As we have already noted, generally staff felt confident that they were fairly safe if they followed their training.
I must admit I wasn’t as nervous about this deployment because I think I’d managed to put the disease into perspective before I’d even got there and sort of said statistically it’s actually quite low risk so long as you are sensible in those key moments when you might be dealing with a patient. (P10).
Several mentioned the ‘body-mapping’Footnote 2 exercise  during training and had found this very reassuring. Participants who deployed during the period when, in rapid succession, one colleague was confirmed to be EVD positive and two others experienced needlestick injuries, felt that concerns about risk had been heightened as a result.
I think that people were just wary about going into the facility then [after the needle sticks and infection] they didn’t really think...I think people were just a bit scared then. (P16).
All participants thought that their own safety should be a priority, and many found it reassuring that the mission was conducted according to this principle. Views differed, however, on how this should be operationalised. Some cited a target of 0% or 1% infection for mission success, which they understood had been politically motivated. Those who cited this figure tended to think it was meaningless or unrealistic. Those who were responsible for the safety of others (team leaders, for instance) reported operationalising their own judgements about what was risky. Some participants felt that acceptable risk was a subjective matter that was down to each individual to decide at the time.
...my priority was keeping my people safe...I would not send my people into the facility unless there was a good reason for them to go. (P14).
I think that people, even in a military system, people do need to be able to opt out of a scenario where there is a 1 % risk of getting infected with a life-threatening disease...ultimately if someone doesn’t want to be there...they will find a way to go sick or they won’t do their job very well so I would rather not have someone there who did not want to be there. (P3).
Some, however, reported having had to deal with colleagues who they thought were unduly risk averse.
I would have described [colleague] as making some fairly risk-averse – surprisingly risk-averse decisions in some cases and then not in others. (P17).
One also reported the need to rein in those who regarded undertaking invasive procedures in the red zone as a “badge of honour” (P18).
The management of risk was widely regarded as requiring compromises to be made in how patients were cared for and in particular how they were nursed.
...our priority was staff health and patient health and safety but there was an element of risk aversion that made it difficult for the practitioners to feel that they were contributing fully and I can understand why that was because Ebola is a killer so you don’t want people to have too much freedom (P9).
The participants reported that risk management presented a significant ethical challenge, and the need to balance risk to self with patient care is reflected in some of the specific ethical issues that participants discussed (Table 2).
Reactions to ‘empty beds’
The most commonly reported ethical challenge was whether the unit should have treated more patients.
Our participants reported that the treatment unit was consistently running under capacity: "the facility was never full, it never got beyond 50% capacity and yet there were clear groups of people it wouldn’t take". (P10). Many regarded this as a significant ethical challenge because the facilities, expertise and resources were standing idle in a sea of need.
There we were sat in the best treatment facility in the whole of Africa, fantastic equipment and staff...products that were expiring each week and getting thrown away...sat there in a facility that I think only had about four patients in it at the time... a complete catastrophe going on all around us ...and people really struggled with that. (P3).
The biggest challenge was the justice component...because we had so much we could offer but we were treating hardly any patients and that didn’t sit very well with any of us because working in a place where there is lots and lots of suffering and disease and death and things and knowing that we could help but we’re not allowed to, that was awful. (P5).
A minority disagreed with efforts to increase the number of patients admitted.
Some of the staff got a bit anti for that because ‘Hang on a minute, why are we putting ourselves at risk you go and look after someone who’s not even on our profile list?’. (P6).
One participant took the view that although the resources deployed seemed excessive given the number of patients treated, they may not have been disproportionate to the resources used to care for Ebola patients back in the UK. This realisation enabled the participant to take pride in what was achieved.
...deep down as a doctor you always want...to see as many patients as possible, and help as many patients as possible, and treat as many patients as possible. I didn’t really have that choice because I was deploying on a military operation...The Royal Free is an example of – some of the physicians at the Royal Free were dealing with tiny numbers of [Ebola] patients, with huge numbers of healthcare workers involved in the care of one patient. [If you take this on board] then you don’t feel guilty but feel proud of the work that you’ve actually managed to do in your specific role. (P21).
Most participants were able to articulate some version of both sides of the argument, but participants in favour of greater bed occupancy tended to be those who regarded themselves to be on a humanitarian mission. Views also reflected perceptions of risk outlined above. Strong feelings may have been exacerbated by the fact that the opposite problem had been anticipated, namely that the unit would be overwhelmed.
...we kind of expected to be a bit more overwhelmed with patients, we would have perhaps to be choosing between who we had beds for and who we didn’t have beds for similar to a lot of other operations where you have your eligibility criteria (P15).
The medical staff in particular tended to think that the integrity and spirit of the mission would have been preserved by loosening the MRoE or making greater use of the commanding officer’s discretion to accept patients outside the MRoE: "…maybe they weren’t briefed about how restrictive the medical rules of eligibility were ... even if we were asking for patients of Ebola, we couldn’t get them in because [of the MRoE]" (P19). Many participants were conscious that staff safety would be better preserved running at a consistent capacity since this avoided skill fade.
...for maintaining safety of the staff it is better to have a continual level of work than it is to surge up and down with small numbers of cases...(P2).
The feeling of being under-utilized, which was frequently associated with the MRoE, often prompted participants to comment that Operation GRITROCK was highly politicised. Many participants expressed a belief that decisions about matters of detail, including in relation to medical management, were being taken at a very high (some thought ministerial and even prime ministerial) level.
...it was a very political deployment....in the sense that there was an awful lot of scrutiny from on high...we were having regular briefings from Cobra [Cabinet Office briefing room AFootnote 3]...there was an awful lot of scrutiny from Number 10 [Downing Street], it was the run up to the election... (P10).
This was experienced as unprecedented and unwelcome interference particularly for clinicians used to exercising clinical judgement fairly autonomously. It is possible that this was the result of our participants’ perception that Operation GRITROCK was essentially a medical operation whereas military healthcare personnel normally deploy to support combat missions, meaning that clinicians are more insulated from higher-level political preoccupations. Whatever the cause, the effect was that some participants in all groups were left with the impression that those on the ground were unable to take responsibility for, or justify, the decisions being made, leaving them to implement decisions that, as far as they were concerned, did not make sense in the context of their understanding of the mission. This was also a source of perceived ethical tension.
I mean we are in the armed forces, it is not a democracy you know. If someone just is honest and says: ‘no this decision has been made end of, just put up with it’, then although we might not be happy with it, we will put up with it because we know that’s the organisation. But to obfuscate because someone had made a decision that people may be ethically unhappy with but they are not willing to say, ‘yes, I have made that decision and I am going to stand by it’, is something that was very frustrating, we didn’t know at what stage those decisions were really being made or enforced. (P4).
Points of reference for participants’ values
A shared understanding of what was meant by an ethical challenge was established either during the interview or immediately before it commenced. We took as our working definition that adopted by Schwartz et al.: ‘situations where either the HCPs [health care professionals] knew what they felt was the right thing to do but were somehow prevented from enacting it, or where “doing the right thing” also caused harm’ .
Their values and norms manifested themselves in either how participants perceived ethical challenges to have arisen – where they felt unable to act in accordance with their values – or in how they perceived and addressed the specific ethical challenges (see Table 2 above) they faced. Only a few participants used terms (the technical language of ethics) that spoke directly to specific ethical principles or values.
Our participants’ understanding of what ‘the right thing’ was tended to be informed by values and norms derived from a combination of:
Previous deployment experience
For most (but not all) participants this was combat experience. Previous deployment experience was influential in shaping expectations and norms with regard to the application of MRoE and risk perception (see previous section on risk) but was also referred to in relation to specific issues such as the dignified handling of human remains.
I have worked in resource limited settings before and certainly in Afghanistan… we had at least two patients who would have been dialysed if they’d been in the UK and who died because we did not have any dialysis available. So I am used … to dealing with that and the concept that you can’t give people care that you don’t have available. (P1).
Previously on tours in Afghanistan that I’d done, the bodies were handled with a lot of dignity afterwards. (P22).
The bodies of those who die from EVD are highly contagious. This meant that the usual rituals around death (both for staff and in terms of the local culture) could not be observed. The loss of these rituals added to the discomfort of staff.
Deviations from previous experience created uncertainties that, where unresolved, generated what our participants perceived as ethical challenges.
I am not naive enough to think that at an operational level you truly understanding the wider picture but if you are...on the front line implementing the decisions that are made higher up...I did enforce them [MRoE] the year before when I was in ... Afghanistan...and that was a very difficult decision to make...but I never had so many struggles with what I felt was unethical. (P2).
Similarities with familiar practices were a source of reassurance and dissimilarities prompted reflection if not discomfort.
Because deep down inside you know that you should be, you know, there’s this patient does he need a bowel management system? Well actually no he wouldn’t do if he was back in the UK because you wouldn’t do it because it benefits us ‘cause we have to go in and change him all the time. (P13).
There was an understanding that we’d prioritise the military side first but...I see a child of say seven years old from the Save the Children side, in my mind, I prioritise, just like the NHS, I prioritise the child. (P19).
Another example was the rationale P21 recalled above that “the Royal Free were dealing with tiny numbers of [Ebola] patients, with huge numbers of healthcare workers involved in the care of one patient.” This perceived similarity with the situation in the treatment unit enabled that participant to feel pride in what was achieved.
Professional values were a clear source of guidance as one might expect but also create the ‘dual obligation’ problem. This participant, for instance, thought that adherence to professional values was more important than following orders, and indeed may be a measure of the legality of orders.
You’ve kind of got two sets of rules for want of a better word that you kind of have to abide by...I have my Code of Conduct, the NMC [Nursing and Midwifery Council] Code of Conduct. I would like to think that if I was asked to do anything militarily that came into conflict with that NMC code I would be able to stand up and say ‘No’ and that you could then put that down to erm an unlawful order that’s been given you. (P11).
Unsurprisingly, our data suggest that our participants were highly conscious of being military personnel. References to values, including military values, were often not explicitly expressed or identified but can be inferred from the sentiments being expressed by the participants. A summary of UK military values can be found in Table 3.
Some participants expressed trust in, or at least acceptance of, the chain of command, although for others Operation GRITROCK undermined this trust. A sense of obligation within the chain of command resulted in paternalistic benevolence to those under one’s command, such as bolstering troop morale and serving their interests (and this may at least partly account for the trust in the chain of command).
As their boss, it’s my job to look after them and keep them safe...in my previous roles, I’ve always taken my responsibility to looking after my soldiers very seriously...I will always refer to my personnel as soldiers; I think of myself as a soldier...It does make me fiercely protective of my soldiers...where the risk and the danger was so real...it directly affected us it just makes my fiercely protective of my people. (P14).
Participants generally demonstrated a willing, but not blind, adherence to ‘the mission’. As we have seen in relation to motivation and risk perception the nature of the mission was itself a yardstick against which to measure the right response to situations. Some participants, like P17** above (‘we can take that risk and so that the UK can remain safe’), clearly expressed the view that being in the military meant being in service to, and taking risks on behalf of, the nation. As we have seen already, again in relation to risk, (for instance, P13*** above: “I felt confident that as long as I stuck to my ‘drills and skills’ and we looked after each other, we’d be fine”) there was also a strong identification with a team or unit. In this respect, the ‘self’ was regarded as part of, important to, and protected by the collective or team.
you can’t do rushing in... you can’t do anything more than you can do. You take it slowly because...accidents to our own staff then compromise even more people because then you’ve got a situation where you’ve gotta send another team in to get them out. (P12).
Although many regarded the mission as humanitarian, participants did not refer specifically to the humanitarian codes of conduct such as those advocated by Sphere  or the International Committee of the Red Cross [19, 20]; though the United Nations Office for the Coordination of Humanitarian Affairs (UNOCHA) humanitarian principles  are listed in relevant doctrine (the 3rd edition, most current edition of which was published December 2016 but the principles are also listed in the 2nd edition published 2012) . These do, however, have much in common with e.g. professional values. One participant seemed, however, to have some familiarity with the humanitarian principles and had come to question whether the military should have a role in humanitarian missions as a result.
When we do a purely military operation, you know, I believe our role is to look after our service men, as military doctors to look after them...someone said to me recently ‘well couldn’t we shape the military to be more of a humanitarian response?’ and after GRITROCK I think we shouldn’t; I don’t think we have much of a role to play in humanitarian response because of the lack of adhering to kind of basic humanitarian principles – independence, humanity etc... (P2).