ETHICAL, LEGAL, AND SOCIAL ASPECTS OF MEDICAL CARE

Session III: Military Medicine

September 8, 1998

Prioritized Learning Objectives:

1. To consider whether military physicians during combat should attempt to save their own soldiers lives by giving less than optimal treatment to captured enemy soldiers to elicit information from them.

2. To consider the extent of military physicians' obligations to enemy soldiers.

3. To consider military physicians' potential moral conflicts when providing care to civilian patients in occupied territory in part for political gain.

4. To consider military physicians' duty when serviceperson/patients give them confidential information.

5. To consider military physicians' duty to warn serviceperson/patients who come to them for treatment that they will report information these servicepersons disclose prior to servicepersons' disclosing it.

6. To consider military physicians duty when they treat soldiers during combat who want to return or to be relieved from duty.

7. To consider ethical dilemmas which can arise in mass casualty situations when injured persons include one's own troops, enemy soldiers, and civilians.

8. To consider the extent of military physicians' ethical obligations to servicepersons and other beneficiaries of military medical care during peace.

Computerized Learning Experience: Lesson F

Required Reading:

1. Beauchamp, TL, Childress, JF: Principles of Biomedical Ethics, Oxford Press, 4th Edition, 424-429, 434-436, 1994.

2. Smith, AM: The Ethos of the Military Surgeon. The Pharos, 11-14, 1993.

3. Howe, EG: Ethical Issues Regarding Mixed Agency of Military Physicians. Social Science and Medicine 23:803-815, 1986.

4. Livingston, G.: Serving Two Masters: The Ethical Dilemmas That Military Medical Students Want to Avoid--But Can't. The Washington Post, December 22, 1996.

5. Pincus, W.: CIA Manual Discussed 'Coercive' Interrogation. The Washington Post, January 28, 1997.

Recommended Readings:

1. Anderson, CW: The Clinical Psychologist's Role in Treating Gay People in the U.S. Military. The Military Psychologist: The Official Newsletter of Division 19 of the APA, 12(1), 5-8, 1995.

Prioritized Recommended Reading on Reserve in the Library:

1. Vastayan EA: Warfare. In the Encyclopedia of Bioethics, Reich, Ed., New York, The Free Press, 1977.

   (This article discusses ethical issues involved in military physicians treating civilians in occupied territory in part for military gain.)

2. Veatch R: Soldier, Physicians and Moral Man. In Case Studies in Medical Ethics. Cambridge, Mass., Harvard University Press, 1977, pp. 61-64.

   (A discussion of whether military physicians should treat civilians in an occupied territory from a different perspective.)

3. Lifton RJ: German Doctors and the Final Solution. New York Times Magazine, September 21, 1986, pp. 64+.

   (A review of a book in which the author reports his findings from interviewing several physicians who participated in Nazi atrocities. He describes more specifically the process by which they came to ignore their Hippocratic Oath to collude in these acts.)

4. Gaylin: What's an FBI Poster Doing in a Nice Journal Like That? Moral Problems in Medicine. Ed., Gorovitz, Englewood Cliffs, New Jersey, Prentice Hall, 1976.

   (A discussion of an issue arising in civilian medicine comparable in some ways to the issue discussed in #1 and #2 above.)

5. Curran, Casscells: The Ethics of Medical Participation in Capital Punishment by Intravenous Drug Injection. NEJM 302:226-230, 1980.

   (Further discussion of the nature of a physician's professional medical obligations and, specifically, whether or not there is a conflict between being a physician and participating in capital punishment.)

6. Veatch R: The Psychiatrist's Role in War. In Case Studies in Medical Ethics. Cambridge, Mass., Harvard University Press, 1977.

   (A short discussion of whether a military psychiatrist who "treats" a soldier with combat fatigue who wants to get out of duty does him a service or disservice.)

7. Callahan, Gaylin: The Psychiatrist as Double Agent. Hastings Center Report, February, 1974, pp. 12-14.

   (A discussion of ethical conflicts stemming from a physician's mixed loyalty in a civilian context: namely, what should a psychiatrist do when he knows that a student applying to medical school has severe mental illness?)

8. Bellamy: Contrasts in Combat Casualty Care. Military Medicine 150:405-410, 1985.

   (Data and discussion of the different priorities placed by German and American troops during World War II. The Germans gave more priority to furthering the military mission; the American to treating wounded soldiers.)

9. Sommers CH: Once a Soldier, Always a Dependent. Hastings Center Report 16(4):15-17, August 1986

   (This article argues that society has an obligation to treat veteran's non-service connected health problems due to its "paternalistic" relation to the soldier.)

10. Howe EG: Medical Ethics: Are They Different for the Military Physician. Military Medicine 146:827-342, 1974.

    (An overview of some key ethical issues affecting military physicians; a much briefer version of the third required reading.)

11. Vastyan EA: Warriors in White: Some Questions About the Nature and Mission of Military Medicine. Excerpts from Texas Reports on Biology and Medicine 32:327-342, 194.

    (More discussion of the issues raised in readings 1 and 2, above).

12. Logan: Probers Called to See `Needless' Death. The Washington Post August 16, 1977.

    (The article describes the conflict on which the last case for discussion is based.)

13. Howe EG: Trust Between Military Physicians and Servicepersons with HIV: Implications for Civilian Medicine. Biolaw 2:5101-5112, 1988.

    (An article which addresses triage situations in the military and compares the ethical implications of these approaches to civilian practice.)

14. Swann S: Euthanasia on the Battlefield. Military Medicine 152(11):545-549, 1987.

    (The author, a USUHS student who recently graduated, argues that in rare instances, active euthanasia would be justified.)

15. Quigley J: International Limits on Use of Force to Elicit Confessions: A Critique of israel's Policy of Interrogation. Brooklyn Journal of International Law, 14(3):485-502, 1988.

    (An article reviewing international policy in regard to the use of coercion to gain information from captured enemy personnel with specific reference to the policy in Israel.)

INTRODUCTION TO SESSION III

September 8, 1998

This session addresses ethical dilemmas in military medicine. Initially, Jon Spelman will give a dramatic presentation based on diaries of servicepersons who served in Vietnam. This will provide some context for the speakers who follow. Next, Gordon Livingston, M.D., a psychiatrist who went to West Point and served in Vietnam, will discuss his experiences and exposure to atrocities. Robert Leitch, COL, MBE, will discuss several contemporary ethical conflicts regarding military medicine during war. Finally, Dr. Craig Llewellyn, Colonel, MC, USA (Ret), whom you know, will share his view of what you might gain from these presentations.

The assertion "all is fair in war" has profound ethical implications for military personnel since, theoretically, it would permit behavior of any kind during combat. Consider this situation: An enemy soldier is captured who possesses information which could save one hundred of your own soldiers' lives, but he refuses to disclose this information. Suppose that attempts to "extract" this information by using pain are considered. Should they be ethically permissible? What if you, a military physician, became aware during combat that such events were occurring? Should you say nothing? Or should you speak out? Why? Why not? If you believe that you should act, how certain would you have to be that painful procedures were being implemented? These are the kinds of questions you will be discussing in your groups.

What do servicepersons feel when they have been in combat for some length of time? Consider these findings regarding soldiers' reasons for fighting during WWII: In 1944 veteran infantrymen in the Mediterranean were asked, "Generally, from your combat experience, what was most important to you in making you want to keep going and do as well as you could?" The incentive the men cited most -- 39 percent of the time -- was "getting the task done," that is, putting the war behind them and getting back home. Solidarity with the group, or "buddies," was less important (14 percent) than it was in helping a man pull through a specific, "tough" combat situation.

What could be called "idealistic" reasons figured in only one answer out of twenty. In sum, if the men who were polled represented their several million fellow soldiers, they were fighting mainly so they could go home again. This view is illustrated in the recent movie, Saving Private Ryan.

Or compare this description of soldiers in The Civil War: "The changing nature of combat weakened drastically the original soldier's conviction that at the center of war stood the confident individual. On the contrary, this war had demonstrated its power to punish all soldiers far more severely than any personal deficiency could possibly penalize the single soldier. In short, private concerns regarding one's courage or cowardice began to yield to the collective experience, and soldiers became more concerned with survival than with any private triumph of values."

Vietnam also was not the first conflict in which soldiers' behavior was other than exemplary in selected instances. Consider this passage describing the Civil War: "However emotionally unprepared, soldiers had marched to war expecting to kill. They had not, however, expected to steal, burn, and destroy, and the unease they felt on those counts drew them closer to others who had acted identically. Far more intense than casual home town friendship, comradeship offered support in combat that the soldier of 1861 would have denied he would ever require; a compensation for the emotional support of the home folks that seemed surprisingly less relevant; and a reassurance that, though he was acting in ways that would have been abhorrent three years before, he had not become an evil person."

Illegal or immoral behavior during combat may be rare, but you could find yourself learning of such instances in your capacity as a physician. It is important, therefore, that you consider their ethical implications now.

The first issue you will consider, then, in Cases 1-3 in your discussion groups is the degree, if any, to which you should participate in acts which could save the lives of your own soldiers but which are illegal or whose legality is ambiguous. A simple answer is never. This point is implicit in the third recommended reading by Lifton, which describes the process by which Nazi physicians came to perform atrocities during World War II. Yet, as the number of soldiers potentially saved becomes larger and the illegal status of an act less clear, some may disagree, especially if they experience their own soldiers dying first hand.

Even if military physicians believe that they should never be involved in acts whose legality is questionable, they still could face the question what to do when they suspect that immoral acts are going on outside their treatment facility. Should they ignore illegal acts that they suspect are going on during combat or should they "blow the whistle?"

Case 4 involves the question whether the military physician who treats civilians in occupied foreign territory in part for military gain is wrongfully exploiting these patients' vulnerability. This question was raised when military physicians treated Vietnamese civilians. A somewhat analogous question has been raised in regard to whether or not civilian physicians should place pictures of wanted criminals with skin disorders in dermatology journals to assist in their being apprehended. In both instances, physicians can be seen as using their profession to exploit these patients' illness to further ends other than their patients' needs. Is doctors using criminals' dermatological illness for the purpose of law enforcement right or wrong? Do this and the military example raise the same or different morally relevant factors? The fourth recommended reading discusses this civilian dilemma.

Consider that depending on how military physicians treat civilians in occupied territory, there may be multiple levels of concern. Treating such patients in order that they will feel favorable towards the military is one level of concern. But such patients could also be treated only on the condition that they divulge that family members or friends are members of enemy troops. This latter policy would be of more serious concern. The major concern when military physicians treat civilians in occupied territory is the exploitation of patients' vulnerability.

Yet, strong arguments favor military physicians treating civilians in occupied countries. First, the treatment benefits civilians. Second, international law intends to make war more humane. Although the usual means of waging war involves destruction, attempting to achieve victory by providing medical care to civilians is more humane.

The issues raised in Cases 5 and 6 discuss whether military physicians should keep information they obtain from serviceperson/patients regarding behavior such as homosexuality and illegal drug use confidential, and whether they should warn these patients prior to these patients disclosing potentially self-incriminating information. Military regulations regarding homosexual servicepersons have change. Consider these cases as they arose prior to the changes made under President Clinton. The principles remain important and fixed.

Military physicians often decide whether to keep servicepersons' disclosures of homosexuality confidential, and whether to "warn" them if they will not. When military physicians have conflicting obligations to the military and serviceperson/patients in cases such as these, they may perceive their duties to be defined by the military without regard to patients' individual factors. This view is called a role-specific ethic. This approach is followed by police officers when they give out parking tickets. The advantages of this approach include furthering equity and consistency, supporting the authority of the military, and removing a military physician's personal risk from making an improper judgment.

Its major disadvantage is that if military physicians follow military requirements to the letter in all cases in which the requirements apply, they could act extremely harshly. Little may be gained by the military, for example, from a physician's reporting a female soldier's having a single stress-precipitated homosexual encounter during basic training. From the standpoint of the soldier, however, much might be lost.

On the other hand, suppose military physicians choose to decide each case on a case by case basis, reporting some soldiers but not others. On what criteria should they base these decisions? They might give most weight to the military's underlying intent in adopting a regulation, the consequences to the military of their not reporting a soldier's illegal behavior, and likely consequences to soldiers if they do report them. The seventh recommended reading discusses somewhat analogous considerations in a civilian context, namely, those which arise when a psychiatrist knows that a patient who has severe mental illness is applying to medical school. Ethically, do you think the psychiatrist should respect the patient's confidentiality or breach it? If the psychiatrist breached it, would this be for the sake of the patient, for the sake of future patients whom his patient might mistreat, or both?

Consider an illustration not included in your cases for discussion. Suppose that a memorandum requires Navy physicians to report any serviceperson using marijuana and that a Navy physician sees a patient on active duty who reports using marijuana but who wishes to remain in the Navy. One line of argument would support the physician reporting this patient's use of marijuana because the physician has a duty to the military. The patient should know that marijuana use is illegal and that the physician has a duty as a military officer to report illegal behavior. This argument does not take fully into account, however, that the patient may, even knowing both, still believe that the military physician would keep this information confidential, because physicians generally keep patients' communications confidential.

The presumptions that patients know or should know are, incidentally, very different kinds of presumptions. The first presumes a fact, the second, a moral priority. What are the different ramifications of each of these presumptions?

Consider these two dilemmas which have previously been presented in the Human Context Course:

CLINICAL PROBLEMS

Case 1 - A 28-year-old navy Petty Officer Third Class comes in to see you accompanied by his wife. He explains that he wants you to reassure her that "I'm not drinking any more than the rest of the guys", as he has told her, and that he does not have a drinking problem, as she maintains. He tells you, and his wife concurs, that although he had always been a drinker, it never bothered her until he came back from a recent cruise when he had gone out drinking with his buddies whenever they put into port. Since his return, he has continued to do that on weekends, and although he often has to be driven home by a buddy and may not remember what happened, he never has more than two beers at night during the week, and his work in personnel has continued to be praised by his supervisor. He is certain that any reference to alcoholism on his records will destroy his hopes for a successful career in the Navy. What do you do?

Case 2 - A 42-year-old Air Force Lieutenant comes in to see you accompanied by his wife. He explains that he wants you to reassure her that the hand tremor he has recently developed is a result of "tension" at work, as he has told her, and not a result of his drinking, as she maintains. He tells you, and his wife concurs, that the tremors began about two months ago, shortly after a new, and generally unpleasant supervisor was assigned to his office. At that time, he began to take a third and fourth martini when he came home after work, "to settle down". he is a procurement officer for the Air Force Systems Command, and is certain that any reference to alcohol problems on his records will destroy his opportunity for promotion. What do you do?

These two cases involve active duty persons using alcohol, not marijuana. Are there relevant differences between these two substances, such as different prognoses regarding these servicepersons' potential future impairment?

Case 7 raises this issue: What should military physicians do when they treat patients during combat who want to return to duty but are impaired to a degree that might endanger the unit or themselves? Case 8 raises this issue: What should military physicians do when a patient has combat fatigue or a minor physical injury and wants to get out of combat duty, but is capable of returning?

These cases raise several issues. First, are the military physicians violating duties to their patients if they put the unit's needs first? In general, this answer is no. The unit's goals are more important and the soldier should expect that during combat the unit will come first.

Note the relative shift in presumption when considering military physicians' obligations during combat versus peace. During combat, there is greater justification in presuming that the soldier knows that the military physician will place the unit first. During peace, the justification is less strong. Why?

Second, are military physicians violating duties by permitting themselves to be a link in the chain of events which sometimes leads to a soldier's being killed in battle? The physician in most contexts attempts to save lives. The fifth recommended reading raises the issue whether civilian physicians should participate in capital punishment. Can you distinguish these two situations?

Further, when military physicians treat serviceperson/patients during combat so that they can return to the front, this furthers the equity between these soldiers and other soldiers who have remained at the front. If military physicians "rescued" soldiers from combat when they received minor injuries, their doing so would discriminate against soldiers who had remained healthy. Also, the decision to wage war is political, not the physician's.

What if a soldier during battle decides that he is no longer willing to fight? This ethical dilemma is presented in at least two "texts" on medical ethics, one of which is the sixth recommended reading. A first important issue this article raises is whether or not a military physician is particularly prone to misconstruing a soldier's wanting out of battle as combat fatigue when it may be his genuine desire.

Military physicians, as anyone, are susceptible, wittingly or unwittingly, to adopting the biases of their profession, medical specialty, institution, or country. A bias of the medical profession, for example, may be that preserving life is of higher value than relieving suffering. Some believe that due to this bias, physicians now impose more suffering on patients than they should since technology can keep patients alive for longer periods of time.

A political bias was exemplified by psychiatrists in the former Soviet Union who diagnosed persons as mentally ill who protested against that political system, and then committed them to an institution. Yet such protests may be a symptom, and some Soviet psychiatrists did not believe that they were using psychiatric diagnoses for political purposes. If Soviet psychiatrists' clinical inferences did reflect political bias and they were unaware of this, all physicians may be similarly prone to bias of which they are unaware.

Combat fatigue is a normal response to severe stress during battle. Brief, supportive treatment best enables soldiers experiencing combat fatigue to resume normal functioning. However, returning these soldiers to hospitals runs a high risk of converting symptoms of combat fatigue which would otherwise be transient into permanent psychiatric illness. Since the symptoms of this reaction and its optimal treatment are well established, the risk of misdiagnosis of this syndrome may be much smaller than some would imagine.

Still, even if a soldier has this reaction but wants to get out of battle, can it be said that his intention is no longer genuine because he has combat fatigue? Stated differently, if he has combat fatigue, is he no longer competent to make this request and to take responsibility for possible consequences such as court martial?

Cases 9 and 10 involve dilemmas which could arise on the battlefield during triage after mass casualties have occurred. Under international law, captured enemy soldiers should be treated on a par with one's own soldiers, but injured civilians may be given second priority. Can you identify the reason that the equity present in civilian situations differs during combat?

These cases also raise issues similar to those in the first three cases: all involve situations in which military physicians' legal obligation is clear but in which they could experience pressure to violate the law. In the first three cases, for example, the possibility was raised that during combat military physicians could experience pressure to give captured enemy soldiers less than optimal treatment so that these soldiers could be interrogated. Similarly, when mass casualties occur during combat, military physicians could experience pressure to treat their own soldiers first. Cases 9 and 10 are based on situations which actually occurred. In responding to them, you will have an opportunity to pursue ethical analysis and to anticipate what you could encounter during combat.

Case 11 involves the question whether military physicians have a duty to speak out when they believe that patients' lives might be endangered if they have attempted to achieve a remedy through formal channels but it hasn't achieved satisfactory results. This situation could include military physicians' learning of or suspecting atrocities during wartime or observing a surgeon's operating negligently during peacetime. These criteria would be pertinent: the probability of harm to a patient,its magnitude, and the degree of your certainty concerning this. What else?

A final question not raised in the cases provided for discussion is whether active euthanasia is justifiable during combat. Examples of euthanasia have occurred. John Masters, in "The Road Past Mandalay", describes a situation in which soldiers had been wounded and could not be moved without endangering the entire unit. Since the enemy likely would have captured and tortured these soldiers, they were killed. Howard Brody, in "Ethical Decisions in Medicine", gives a second hypothetical example of this dilemma: A Green Beret is wounded and cannot be moved; probably he will be captured and tortured for information. Would "euthanasia" be justified? Why or why not?

Compare this dilemma with cancer patients experiencing severe pain. There is a distinction between giving morphine to relieve pain which might kill a patient and giving morphine for the primary purpose of killing a patient. If you believe that civilian physicians should never kill a patient, are there relevant moral considerations which distinguish the combat situation?

Steven Swann, a graduate of USUHS, wrote a paper which was published in Military Medicine (December 1987) in which he develops criteria to attempt to justify a military physician's performing euthanasia. His paper won the Bioethics Essay Contest open each year to USUHS students. One Army physician who has read this paper considers Swann's argument dangerous and disagrees strongly. If you wish to inform your own opinion, it is the fourteenth recommended reading on reserve.

Session III - Cases for Discussion

September 8,1998

Case 1

A captured enemy soldier is brought to you by members of your own troops who are specialists in interrogation. They tell you that this man knows vital information which could prevent an entire unit's being destroyed. "It is absolutely necessary that he give this information." The interrogators want you to give this soldier succinyl choline to transiently paralyze his respiratory muscles so that he will remain alert but unable to breathe to induce him to talk.

What do you do?

Assume you refuse. You are asked instead to give him intravenous sodium amytal (truth serum) to attempt to get him to talk by "loosening his inhibitions." This drug will not cause pain, but will produce an effect similar to the moderate intoxication which occurs after one takes several drinks.

What do you do?

Case 2

During intense combat, a captured enemy soldier is brought to you with his arm hanging by his side, injured by a missile. He appears to be in mild pain. Before you can assess the damage, your own soldiers tell you that this captured soldier has information that could save the lives of several of your own soldiers. They want to question him immediately and add that if they offer him treatment only on the condition that he gives them this information, this might make the difference between his talking or not talking and save several soldiers' lives.

What do you do?

Case 3

You are treating your own and enemy soldiers during intense combat. You have heard stories that on occasion captured soldiers who have vital information and will not talk are taken up in helicopters and if they continue to be silent are thrown off.

You are now treating an injured enemy soldier for a superficial flesh wound. Your paramedic comes into you and states that he overheard interrogators waiting in another room saying that the patient you are now treating has vital information. They are considering taking him up in a helicopter and throwing him out if he won't talk after you finish treating him.

What do you do?

Case 4

Captain Levy, a physician, arrived at Fort Jackson, South Carolina, in July 1965 to take over as Chief of the Dermatology Clinic. The aidmen he was to train would work as medics with the Special Forces (Green Berets) in Vietnam, providing them with dermatological skills that would be used, among other things, to win support of local residents for the American cause.

By October 1966 Captain Levy had reached the conclusion that he must refuse to train the Special Forces in dermatology. According to the brief filed in his defense, Captain Levy maintained that the medical training being given to the Special Forces Aidmen was prostituting medicine for political and military purposes. He quoted Colonel Richard Coppedge, former Chief Surgeon for the Special Forces' Warfare Center who had originated the aidmen program, as calling it a "political use of medicine; certainly its effects are political...the motives of those who engage in it may differ."

The Staff Judge Advocate, summarizing Colonel Coppedge's testimony at the Army court martial, said:

... With the advent of the Vietnam War the mission of the Special Forces changed somewhat; there were more counterguerrilla forces than there guerrilla forces. it became recognized that the struggle was in many respects a social war in which social instruments such as medicine would have to be utilized. So "we sought to use medicine as a means of approaching the enemy and imposing our will on his." The one great "in that you have is this medic because people are short on doctors and trained medical personnel in there; the thing to do is sort of push a medic up there in front and let him get the confidence of these people by treatment them.... this lays the way open now for the rest of the team to come in and organize them in their primary mission....

Captain Levy argued that the order was illegal because it forced him, as a physician, to violate medical ethics.

One authority cited was Dr. Jean Mayer, a nutritionist and professor: "I would say that the whole thrust of progress has been to separate the functions of the doctor and his auxiliary from...the destruction of life and property...It is an ethical judgment and it is one which is based on the whole thrust of what professional men have (tried to make medicine) for the past twenty-five hundred years."

(From Veatch, Recommended Reading #2)

Should military physicians treat civilians in occupied territory in part for political or military gain?

Does it matter if the treatment given is designed primarily to meet the population's needs, e.g., providing nutrition or treating infectious disease or is designed primarily for its "dramatic effect", e.e., cosmetic surgery?

To what extent, if any, does this answer depend on whether the military is attempting only to gain the population's favor or is using treatment to attempt to gain specific information from patients, such as information from spouses of enemy troops useful in locating their husbands?

Would it matter how this information is obtained? Would it make a difference, for example, if patients were asked to give information voluntarily after being treated as opposed to being treated only on the condition that they give information or is the concept "voluntary" a misnomer in this instance because these patients are in an inherently coercive situation--that is, they are not truly free to choose because they have pressing medical needs?

(From Veatch, Recommended Reading #2)

Case 5

A 20-year-old female member of the military police comes to see you for frequent headaches of recent onset. In taking a history you ask her if she has experienced any recent upsets. She states that indeed her headaches began shortly after she broke up a relationship with a friend. Attempting to give her the opportunity to ventilate her feelings of loss, you invite her to tell you what happened in this relationship. She states that she would rather not, but you insist that, in your opinion, it would be beneficial for her to talk about it. As she describes her relationship it becomes clear that she has been having a relationship with another woman.

You have heard that the commanding officer of the MPs believes that no one who practices homosexuality in any way, shape, or form should remain in the military. This patient has been screened for HTLV-III related illness and is negative. It is possible that if you inform her commander of her homosexual conduct, her commander will bring action to have her administratively discharged. She wants strongly to remain on active duty.

Do you inform the MPs commanding officer? Why or why not?

Case 6

A 35-year-old Air Force Major comes to the Emergency Room complaining of 48 hours of abdominal cramps and diarrhea. You notice on the Emergency Room record that he has a mildly elevated blood pressure. He says that this always happens when he sees a physician for the first time but on subsequent visits it always reverts to normal. Because of this, he asks that you not note it in his record, because he is a pilot and this would result in his temporarily being taken off flying status until he could get it officially straightened out. he is concerned that this might cause him to miss an important mission and harm his career. What do you do?

(This case was given to you in the Human Context Course last year.)

Case 7

You are seeing a soldier in whose unit several soldiers have been killed. He was referred to you by his Sergeant who noted that he was agitated and talked exceptionally fast. In response to questioning him about his response to his fellow soldiers' deaths, he states that is part of war and he can't wait to get back into battle to "kill the bastards that did it." He holds up an imaginary rifle and demonstrates what he would do.

He knows that you could retain him at least transiently for observation and pleads with you to send him back to his unit immediately so that he will not lose "credibility" with his fellow soldiers.

What do you do?

_____________________________
Adapted from Colbach EM Ethical Issues in Combat Psychiatry. Military Medicine 150:256-265, 1985

Case 8

During combat you see a soldier who has recently seen many of his unit killed. He tells you that he wants to get out of combat and will accept whatever consequences would result from his refusing to go back to duty. He appears entirely calm and rational. You believe that he is probably reacting to his experience in combat and manifesting a stress response which would be best treated by sending him back to his unit after a brief treatment but are not certain.

What do you do?

_____________________________
Adopted from Veatch RM Case Studies in Medical Ethics, pp. 245-250. Harvard University Press, Cambridge, Mass., 1977

Case 9

During combat you are one among a few other military surgeons who are overwhelmed by injured soldiers, enemy soldiers and civilians of the country in which battle is occurring. The most seriously injured persons are about to be evacuated by helicopter. You observe, however, that those about to be evacuated consist only of your own soldiers and some of them might do satisfactorily if not evacuated, whereas a number of enemy soldiers will die if they are not promptly evacuated. You report this to your commanding officer. He says, "Keep those enemy soldiers alive so that we can question them. After that they can die, it doesn't matter to me."

What do you do?

_____________________________
Adopted from Livingston GS. "Medicine and Military" in Humanistic Perspectives in Medical Ethics (Edited by Visscher MB, pp. 268, Prometheus Books, Buffalo, 1972.

Case 10

You, a military surgeon are overwhelmed by combat casualties. You are attempting to treat first those patients most severely injured who might survive as a result of your treatment. After evaluating patients just brought in consisting of your own soldiers and civilians, you begin to treat a civilian. Your superior officer says "Leave those civilians alone; there are dying marines all around you. I'll court martial you if you touch a wounded civilian."

What do you do?

_____________________________
Adopted from Parrish J 12, 20 and 5 A Doctor's Year in Vietnam. E.P. Dutton and Co., Inc., New York, 1962, pp. 213-264.

Case 11

Assume that you are a physician at Naval Regional Medical Center in Oakland and believe that patients have died because of a shortage of staff. After attempting to remedy this situation by going to the proper authorities, you believe that your options of working with the system are closed.

What would you do? Why?

_____________________________
Adopted from Probers Called to See "Needless" Death. Logan, The Washington Post August 16, 1977.

FACILITATORS' GUIDELINES FOR DISCUSSING CASES

SESSION III - September 8,1998

Cases 1 and 2 - These cases involve military physicians being asked to treat enemy soldiers less than optimally for the purpose of saving their own soldiers' lives. They are presented in a sequence to provide situations in which military physicians are progressively less directly involved.

The cases begin with the physician giving succinyl choline to terrify enemy soldiers and they go on to their giving intravenous sodium amytal (truth serum), and then to their withholding treatment, which is an act of omission.

The students might be asked whether they see a morally relevant difference between the physician's inflicting pain (terror) or not inflicting pain (truth serum) and acting passively as opposed to actively in the last situation. In a later session they will consider the active/passive distinction in another context. They will also be asked whether or not there is a morally relevant difference between killing terminally ill patients by giving them an overdose of medication and discontinuing nutrition and hydration. More generally, they might also be asked whether or not they believe a physician would betray his professional medical identity by "colluding" in any or all of these acts.

Case 3 - raises the question whether military physicians have a moral obligation to attempt to remedy illegal or immoral acts which occur outside the treatment setting during combat and have come to their attention. On one hand, a military physician might be morally as well as legally obligated to oppose any possible violation of international law. Yet, on the other hand, if military physicians take this approach and do all they can to attempt to stop these acts, as a practical matter, among other consequences, they could find themselves isolated or cut off from acquiring further information and, as a result, be less able to affect other legally ambiguous practices on subsequent occasions.

If students assert that in all three cases the military physician should do what is legal, three challenges might be posed: First, it is sometimes not clear whether an act is illegal; what does the military physician do then? Second, what if permitting even an illegal act would cause only "minor" harm to an enemy soldier (such as allowing him mild pain for a short length of time by withholding analgesics to induce him to "talk"), but his "talking" could save thousands of soldiers' lives. Would the physician's withholding analgesics then be warranted?

This is, of course, the situation given in Case 2, but it can be altered from saving several soldiers' lives to saving thousands. Would the physician never be justified in withholding analgesics?

Third, what if the enemy unconscionably violated international law and would not only kill one's own country's soldiers, but torture those they captured. Is there some point at which, as Winston Churchill claimed when trying to initiate research on germ warfare during World War II, "I do not see why we should always have all the disadvantages of being the gentleman while they have all the advantages of being the cad."

The students will address a related question when they consider whether or not there are kinds of research (such as biological and chemical) in which military physicians should not participate. One of the relevant aspects of this question they will consider is the possibility that other nations could be conducting this research.

Case 4 - The issues in this case involve military physicians treating civilians in occupied territory in part for military gain. They are discussed in the article I wrote in the student packet. The students, at a minimum, should be aware that if they use their medical skills in part for a political purpose, whether this is justifiable or not, ethically, they are exploiting these patients' vulnerability (due to illness) and, to some extent using these patients as means to others' ends (as opposed to treating these patients as ends in themselves). They should also recognize that there are degrees of exploitation which range from merely gaining patients' favor as an indirect by product of providing them medical care, on one hand, to providing care only on the condition that patients give them specific information, on the other. The latter exploits these patients' inherently coercive situation, of course, to a far greater extent. There are also morally relevant differences between the kinds of medical care military physicians might provide in this situation. They might, for example, provide care which is designed primarily to meet these patients' medical needs, such as by supplementing their nutrition and treating their infections or parasites. Alternatively, they might provide care designed primarily for its dramatic effect, such as cosmetic surgery. The latter, obviously, is ethically more problematic.

Again, if students consider exploitation of any degree so morally reprehensible that it should not be carried out, facilitators might ask them to consider for comparison how medicine is practiced in other contexts. They might, for example, be asked whether research on subjects who are physically ill exploits them to some extent for future patients' interests. That is, patients normally see clinicians who provide treatment on an other than random basis; if clinicians have even slight anecdotal data suggesting that one treatment is preferable to another, they are likely to give it. Physicians in private practice, as a second example, can be seen as exploiting patients' illness to earn a salary.

Finally, the students should consider that even if medical care is used as an "offensive weapon", care provides benefit, not destruction. Facilitators might ask students whether they think this consideration should "count" or whether it is primarily a rationalization of what cannot be ethically justified and is disingenuous. They will consider this possible use (or abuse) of ethical argumentation previously when they considered the Willowbrook case. Here, researchers argued that it was justified to use institutionalized retarded children as research subjects because if these children participated in hepatitis experiments, they would receive better housing and have less likelihood of developing more severe hepatitis later on.

Case 5 - This case raises questions whether or not military physicians should report a serviceperson/patient's homosexuality and, by implication, other illegal behaviors as well which come to their attention. If they report all, they would be following a "role specific" ethic; otherwise, they must decide on a case by case basis. Case 5 exemplifies situations in which the service would gain least from a physician's reporting a serviceperson/patient's illegal behavior and the patient would lose most. Accordingly, this provides the "strongest case" for the physician to decide on a case-by-case basis or to decide not to report. Students who would do neither should recognize fully the kind of prices they must be willing to pay.

Case 6 - Case 6 represents a more "pure" example of military physicians' conflict between their obligations to the mission and to patients. In this situation the patient is clearly aware of the military physician's obligation to the military. The students might be asked what weight they would give this particular consideration. Also, in this case, unlike Case 5, the physician may have "intermediate" options, such as retaking the patient's blood pressure after a few hours. The students might be asked whether the military physician has an obligation to attempt to find such "intermediate" options, and if so, its extent.

Cases 7 and 8 - Both cases pose situations during combat in which the patient's interests may be seen as conflicting with the military's. In both situations, diagnosis is uncertain, and, taken together, these cases illustrate that military physicians' ethical conflicts during battle can occur when the serviceperson/patient wants to remain at the front or when he wants out of combat.

In Case 8, however, the conflict between the military's and patient's interest may be, at least to some extent, illusory. That is, sending the patient back to duty after treating him temporarily may help not only the military, but the patient by preventing the patient from developing permanent psychiatric symptoms. This situation, as I noted in the student packet, is given in some ethics "texts" and is particularly prone to being misconstrued. For this reason, it is discussed in some detail in the student materials. The discussion of Case 8 should particularly bring out, however, that medical aspects of ethical conflicts during combat are sometimes complex; due to this complexity ethical dilemmas which appear to be straightforward may be more difficult than they appear.

Cases 9 and 10 - These cases are intended in part to expose the student to the kinds of situations they could encounter during combat in which the heat of their own and others' emotions makes what may appear legally and/or ethically clear in theory more problematic in practice. Legally, for instance, in Case 9 the enemy soldier should be evacuated and, in Case 10, the civilian should be left alone.

In both situations as they actually occur, however, it may be that military physicians' "moral character," as addressed in the first required reading by Colonel Wakin is decisive in determining the outcome. In situations similar to Case 10, for instance, it is a matter of judgment when one's own soldiers' and enemy soldiers' medical needs are sufficiently minor that civilians should be treated. The degree to which civilians' medical needs are met in this situation may depend, then, at least partially, on the degree to which a physician attempts to maximize civilians' care. The facilitator might point out as a historical note, that U.S. military physicians in the past have attempted to give civilian patients optimal care even when under international law they might have done otherwise.

Case 11 - This case may be difficult on the few facts given, but it raises an issue the students should consider. Namely, what if patient care in the military is inadequate and the military physician goes to proper military authorities, but these authorities do not respond? The students should specifically consider the degree, if any, to which they believe their allegiance to the military would require them to compromise patients' interests in such a situation. They might, for example, subordinate their views to those of persons higher up in the chain of command who are likely to know more about the situation. That is, should they ever compromise patients' interests in a military environment which they would not compromise in civilian settings because of their allegiance to the military?