Military Medical Ethics Issues Regarding Dual Loyalties: Workshop Summary (2009) / Chapter Skim
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Dual loyalties exist in many medical fields, from occupational health to public health. Military health professionals, as all health professionals, are ethically responsible for their patients' well-being.
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The hunger strike case study showed that two factors are fundamentally important in ethical decision making: the presence of organizational resources to help physicians manage ethical quandaries without having to resort to heroic tactics, and the recognition of the particular and often distinctive circumstances of each case. At times there is a cultural component to ethical issues involving hunger strikers.
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• Models used in occupational medicine, sports medicine, and prison medicine, among others, can be informative in consider ing ways to address ethical issues in military medicine. • Some important differences exist between international declara tions and DoD health policies regarding hunger strikes.
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These four central questions were the starting point for discussion at an all-day workshop, "Military Medical Ethics: Issues Regarding Dual Loyalties," conducted by the Institute of Medicine (IOM) of the National Academies on September 8, 2008.
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. The workshop focused on two specific situations in which military health professionals may face ethical conflicts because of dual loyalties -- decisions regarding returning servicemembers to duty following an injury or health concern and decisions regarding the care of hunger strikers.
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However, once articulated in the abstract, these obligations also must be effectively imparted to, and internalized by, current and future physicians likely to face such dilemmas. Educational models for medical ethics exist in several settings, such as military medical education, training in end-of-life care, and preparation of medical ombudspersons.
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Joseph Kelley, Deputy Assistant Secretary of Defense for Clinical and Program Policy, observed that issues of medical ethics in the military often correspond to contentious issues in civilian medical practice. For example, the military decision about return to duty is similar to the decision in sports medicine about keeping a player in a game, and the military physician's need to recognize organizational interests is similar to the pressure exerted on the managed care physician to deny expensive medical procedures that are not cost-effective.
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• Who is the ultimate decision maker regarding decisions on return to the battlefront? • What mechanisms or resources would help the health professional in resolving this conflict?
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Colonel Elspeth Cameron Ritchie, Medical Director for Strategic Communication in the Army Medical Department, noted an increased emphasis in military medicine in recent years on patient education, prevention, and early diagnosis. The commander has the final call regarding return to duty, said Ritchie, but usually relies on physician recommendations, particularly when there is a recommendation for a medical evaluation board.
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Occupational Health Parallels Occupational health professionals face ethical conflicts that may be instructive to their military counterparts. Several professional associations, including the American College of Occupational and Environmental Medicine and the International Commission on Occupational Health, have addressed dual loyalties -- to the patient and to the employer -- and call for putting responsibility to the patient first (ACOEM, 2008; ICOH, 2002)
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Harrison described ethical conflicts that typically involve competing "rights." Some matters, such as protections of employee confidentiality, are now prescribed by law and are dealt with through legal approaches. On ethical issues without legal mandates, Harrison noted that there are few if any algorithmic-type answers.
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As in occupational medicine, the sports medicine physician's primary responsibility is to the individual; in sports, this includes a duty to describe the risks and benefits of alternative treatments as well as the risks, and possible benefits, of continuing play. Transparency in decision making is essential.
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Under the second scenario, if the patient does not have residual symptoms then the player can return, and the challenge is to regain the motivation to perform at a high level as part of the team. Discussion Comments focused first on the aptness of the analogies between problems arising in occupational and sports medicine and problems confronted in the military environment.
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Ritchie noted that the medical profiles provided to commanders focus on what the soldier can or cannot do and on any problems that affect readiness to meet job demands. Regarding psychiatric issues in the military, session moderator Paul S
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. The panel's purpose was to explore BOX 2 Case Study 2 Treatment of Detainees: Role of Military Health Professionals Ten detainees in a national security facility have gone on a hunger strike to protest the conditions of their confinement.
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Hernan Reyes, Medical Coordinator for Health in Detention of the International Committee of the Red Cross, stated that hunger strikers do not intend to commit suicide; however, strikers are willing to use their bodies to protest degrading conditions or to promote their cause. To qualify as a hunger strike, a refusal of food must involve "purpose and determination," that is, a willingness to harm oneself if necessary, but only as a last resort; the objective is to convince the authorities to respond to the hunger striker's complaints.
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, issued the Malta Declaration, stating that physicians are obliged to respect hunger strikers' autonomy (WMA, 2006)
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Detainees have the right to refuse treatment, except for "lifesav ing emergency medical care provided to a patient incapable of providing consent or for care necessary to protect public health, such as to prevent the spread of communicable diseases." • Medical treatment or intervention may be directed without con sent of the detainee "in the case of a hunger strike, attempted suicide, or other attempted serious self-harm" when treatment is necessary "to prevent death or serious harm." • Involuntary treatment must be preceded by a thorough medical and mental health evaluation and counseling concerning the risks and "carried out in a medically appropriate manner." This policy includes "parity," in which detainees are entitled to treatment similar to that provided to U.S. servicemembers.
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Allen, Co-Director of the Brown University Center for Prison Health and Human Rights, discussed the similarities and differences between the health professional's responsibilities regarding hunger strikers in civilian correctional and military detention environments. Foremost in both settings is the importance of establishing trust with the patient.
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Human Rights Perspectives Although the classic dilemma in the medical response to hunger strikes is a clash between the moral principles of autonomy and beneficence, Leonard S Rubenstein, President of Physicians for Human Rights, stated that the correct moral decision is clear in cases where human rights violations are occurring.
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Most fundamentally, when detainees' human rights are violated, Rubenstein stated that physicians should not use their skills and knowledge to "enable, advance, or permit torture or cruel, inhuman, or degrading maltreatment." Cultural and Religious Issues Mahmud A Thamer, retired Assistant Professor at the Johns Hopkins University School of Medicine and former member of the faculty of Medicine at Baghdad Medical School, asked several leading Islamic scholars of the Sunni and Shi'a traditions about hunger strikes.
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In addition to determining whether there are indications of depression or other mental illnesses, health professionals should consult individually with each hunger striker to determine whether he or she has been subjected to peer pressure or coercion. The participants discussed the differences between the DoD policy and the WMA Malta Declaration.
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Also acknowledged were positive changes that have been made at Guantanamo and the professionalism of many military health professionals. Productive efforts to engage both human rights organizations and military health professionals in discussions about the revisions to the Army field manual on interrogation were highlighted.
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ETHICS TRAINING The participants in the third panel discussion considered approaches to informing or instructing physicians (and other military health professionals and health care workers) about ethical issues.
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The ethics course was accredited for both continuing medical education and continuing nursing education. Participants included not only military health professionals but also U.S.
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The ethics course was case-based and included structured discussion; this format elicited a great deal of discussion about personal experiences. The training also adapted a human rights impact assessment tool for public health interventions and policies (Box 3)
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Improving the Teaching of Ethics Experiences in teaching medical ethics in palliative care and geriatrics -- disciplines that concentrate on the whole person rather than on disease processes -- could inform training in medical ethics in a range of contexts. Joshua Hauser, Assistant Director of the Northwestern University Buehler Center on Aging, Health & Society, noted that ethical issues in palliative care include medical futility, informed consent, assisted suicide, autonomy, and team responsibility.
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Schor answered that they should be shown at the start of medical missions and commented that in the onboard exercises, participants such as military physicians and Project HOPE volunteers enjoyed learning each other's perspectives. Emerging information technologies offer exciting opportunities for disseminating and sharing information, opinions, and experiences regarding ethical challenges.
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Further, it supports these decisions by providing necessary communications, education, and other organizational processes. A just organization communicates openly about decisions after the fact to effect improvements, and it commends rather than punishes individuals for bringing ethical issues to light.
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In this con nection, most lapses in implementation can be attributed either to psychological barriers, such as fear and hopelessness, or practi cal barriers, in which the individual does not know how to decide or where to turn for consultation. To illustrate the importance of dialogue about these components of ethical conduct with members of an organization at all levels, Ozar recounted the changes at one hospital that occurred through asking employees about impediments to realizing the hospital's core values.
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Emanuel discussed building learning and layered accountability into organizations. Ensuring that organizations act ethically requires layered stages of professional voices, including an external voice, she said, as well as organizational feedback, deliberation, organized advocacy, and disobedience when necessary.
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; and • involvement of multiple professions, such as clergy, educators, and social workers. As the military continues in its efforts as a learning organization, it is important to identify, refine, and institutionalize mechanisms for continued deliberation on issues in military medical ethics.
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Lieutenant General Eric Schoomaker, U.S. Army Surgeon General, commented that the discussion in the workshop had recognized that the ethical issues faced by military health professionals are a microcosm of ethical issues faced by the larger medical community in the United States.
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Although the workshop focused primarily on the policy perspective, it will be important for future discussions, Kelley noted, to focus on the perspective of the practitioner. Kelley stressed that the military is not monolithic but has provisions in place for military health professionals to exercise their right of conscience, including support for health professionals who have ethical concerns and are seeking to determine ethical courses of action.
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• The military has provided greatly increased guidance on medical ethics since 2006, including a substantial body of policy and standard operating procedures at the operational level. The DoD continues to be a learning organization on issues raised by de tainee treatment -- including hunger strikes, forensic roles, and training -- and dual loyalty.
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36 MILITARY MEDICAL ETHICS: ISSUES REGARDING DUAL LOYALTIES sial, and it was suggested that a forum specifically exploring these issues might be useful.
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