INSTITUTE OF MEDICINE

National Academy of Sciences

Workshop on Military Medical Ethics: Issues Regarding Dual Loyalties

Monday, September 8, 2008

National Academy of Sciences

Lecture Room

2100 C Street, NW

Washington, D.C.

Case Study 1

Return to Duty: Ethical Issues for Military Health Professionals

A U.S. soldier suffers injuries from the explosion of an improvised explosive device (IED). Injuries include closed head injury resulting in loss of consciousness. After six weeks of treatment, the soldier is medically stable and functional, though he continues to complain of fatigue, disturbed sleep, and daily headaches. It is likely that he would be at higher risk for more severe impairment and PTSD if he were to suffer another similar explosion resulting in further traumatic brain injury.

Situation 1: The soldier is eager to return to the front lines and even when provided with the information on potential detrimental health consequences is willing to take his chances and return to his unit. The soldier is very insistent that he understands the risks and feels that the best way to resume his life is to return to his unit. His commanding officers express the strong need for his expertise and experience but do not exert any pressure to return the soldier to his former patrolling duties.

Situation 2: The soldier does not want to return to his patrolling duties and asks for reassignment. The physician suspects that the soldier may be exaggerating the symptoms that he is experiencing, though clearly considerable residual effects remain. However, personnel levels are low with replacements several months down the road. Soldiers with his level of experience are desperately needed for upcoming missions and there is strong pressure from the chain of command on the treating physician to sign off and return the soldier to his patrolling duties.

Questions:

• What principles are in conflict?
• What guides the clinician in approaching each situation?
• What about the setting makes this situation different from civilian settings?  Are the differences enough to warrant a separate rule?
• 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?

Case Study 2

Treatment of Detainees: Role of Military Health Professionals

10 detainees in a national security facility have gone on a hunger strike to protest the conditions of their confinement.

Part 1: The strike has gone on for 3 days and the detainees are taking only water and vitamins.  The camp commander declares the strike a threat to security and order and directs the doctor to evaluate the medical condition of the detainees and to "do whatever is necessary to bring this to an end".  The doctor examines the detainees and finds no immediate threat to the health of any individual detainee at this point in the strike.

Part 2:  The hunger strike has continued for 45 days.  One striker has lost 30% of his initial body weight and is felt to be at risk of irreversible harm or even death.  He has previously said to the physician that he does not intend to die, but is willing to die if there is no resolution to his grievances.

Questions:

• What principles are in conflict?
• What guides the clinician in approaching this conflict?
• What about the setting makes this situation different from civilian settings?  Are the differences enough to warrant a separate rule? What comparisons are there to civilian settings such as jails and prisons?
• Who is the ultimate decision maker regarding a clinical intervention?
• What mechanisms or resources would help the health professional in resolving this conflict?