Military medical personnel should adhere to the highest military and medical moral standards. This adherence is critical in all of medicine, of course, in the interest of providing optimal patient care. But it is particularly important in the military for several additional reasons. One of these is that service men and women often look to military doctors for moral guidance and view them, more generally, as role models.
At the Uniformed Services University of the Health Sciences (USUHS) all students are required to study medical ethics and have been since the first class came to USUHS more than 30 years ago. In their second year, all take a course in medical ethics that includes discussion of topics specific to the military. I have been director of this course since its inception.
Since the school began, every student has addressed many of the same core military medical issues [1,2]: the duty to treat captured enemy soldiers as they would members of their own U.S. forces, the obligation to bring suspected ethical and legal misconduct to the attention of command, and the need to treat civilian patients in occupied territory as ends in themselves, rather than exploiting their vulnerability in the hope of winning over their "hearts and minds" in an effort to further U.S. military or political ends [3,4].
In recent years and especially since the attacks of September 11, 2001, new topics have joined the core military ethics curriculum [5-11]: What approaches should interrogators be permitted to use during interrogations of suspected terrorists? To what extent, if any, should military care providers be involved in interrogations? What should military doctors do if and when prisoners go on a hunger strike? In discussing these new topics we remind students that military physicians must maintain the confidentiality of detainees they treat at places like Guantanamo, just as all military physicians must maintain the confidentiality of their own service persons whom they see as patients.
Each year I bring in people who have faced difficult moral decisions in the military to discuss how they responded to them. We hope that, after hearing from military doctors who have faced and made these decisions, students will appreciate more fully that they, too, can achieve the exemplary moral standards that they see modeled for them by the medical officers who come to speak.
For more than a decade now, students have heard from Gordon Livingston, MD. Dr. Livingston graduated from West Point and then went to Vietnam. While there, he experienced several military practices he viewed as unethical. These included one officer's suggestion that an enemy soldier be left to die after he had been interrogated and another's suggestion that Dr. Livingston give a prisoner succinylcholine to induce him to disclose important information, in the hope that this would result in lives saved. Succinylcholine paralyzes the respiratory muscles so that the prisoner feels as though he is suffocating. Livingston refused.
Since the present war in Iraq began, military physicians who have recently served in that region have spoken to the class. One described improving Iraqi prisoners' living conditions, telling students in detail how he expressed his ideas to his superior officer and how these were passed up the chain of command. He succeeded. Another military doctor who worked on a Navy "medical ship" explained how she and other military medical personnel explored whether enemy prisoners whom they were treating could be placed in more comfortable restraints. Again, by taking the question up the chain of command, they succeeded in this initiative.
Students have also heard from a physician who refused to serve in the military on the grounds of moral conscience and, this fall, will hear from an attorney who represents detainees at Guantanamo.
Another important area of military medical ethics relates to military doctors' treatment of their own service persons . The potential problem here is "mixed loyalties" [13,14]. In some contexts military doctors may have duties to their patients and to the military that conflict or are even mutually exclusive. Such conflicts can arise, for instance, when service personnel tell military physicians that they are gay or that they recently have used marijuana.
Students learn that, in general, military doctors' two major roles are to maintain the health of each service person and to be able to give their commanders accurate information regarding the unit's health. Accordingly, in most cases, they should give priority to meeting their patients' needs, because doing so will enable them to fulfill both tasks to the greatest extent. To that end, when they have doubts as to whether they are acting primarily in their role as physicians or as military officers, they can take the initiative to clarify this ambiguity by explaining their dual role to their patients and telling them specifically which role will have priority before they begin to treat them. This approach best furthers their service patients' autonomy, and, thus, most respects them as persons .
Members of the military are often viewed as a likely group for participating as "subjects" in military medical research, so students are taught that it is absolutely critical to protect service personnel from coercion, real or implied, to participate in research. This protection is particularly important because people in the service may perceive that they have a duty to participate in military medical research and, as a result, might not feel free to decline.
In general, the primary goals of the medical ethics course (and of many other ethical discussions students have during their four years at USUHS), are to help them identify ethical problems, recognize their personal value biases, and understand the most basic ethical factors, values, and arguments on "both sides" of present and emerging major military medical ethical issues. It is anticipated that, as a result of this knowledge, USUHS students will make better ethical decisions throughout their military careers.
It is important for students to understand the difference between situations in which they may exercise their discretion in making moral choices and situations in which they may not, as in the cases that Dr. Livingston describes each year. They must treat enemy prisoners/patients as they would treat their own and not do such things as give prisoners succinylcholine or any other drug (e.g., intravenous sodium amytal or "truth serum") for a purpose other than beneficial medical care. These decisions are not matters of personal discretion. But when they are in doubt or in situations for which military medical ethics has not prepared them, they should follow their moral conscience and refuse to do anything that they believe is unethical or illegal. This, they are told, is, in addition, what military law requires.
To highlight and emphasize the importance of the last point, we have invited an historian from the Holocaust Museum in Washington, D.C., to present the final lecture in this course for the past several years. She presents a film that shows some of the horrors perpetrated by Nazi doctors during and right before World War II [16-18]. The point of this presentation is that the doctors who committed these atrocities had other choices; they didn't have to do what they did.
This historical example is intended to make USUHS students aware that, like all other present and future physicians, they now are and always will be at risk for acting in ways that are morally suboptimal and even unconscionable. They are urged to consider, therefore, how their best protection against behaving in these ways may, indeed, be themselves.
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