Dual Loyalty Cecil Wilson

August 17, 2019
Declaration of Geneva
“I will apply, for the benefit of the sick, all measures
which are required, avoiding those twin traps of
overtreatment and therapeutic nihilism.”
Primum non nocere (“first, do no harm”)
Oath of Commissioned Officers
“I, _____, having been appointed an officer in the
Navy of the United States, as indicated above in the
grade of ____ do solemnly swear (or affirm) that I will
support and defend the Constitution of the United
States against all enemies, foreign and domestic; that
I will bear true faith and allegiance to the same; that I
take this obligation freely, without any mental
reservation or purpose of evasion; and that I will well
and faithfully discharge the duties of the office upon
which I am about to enter; So help me God.”
“Medical ethics in times of armed conflicts is identical to
medical ethics in times of peace.” World Medical Association
“Respect human life and the dignity of every individual.
Refrain from supporting or committing crimes against humanity
and condemn any such acts.
Treat the sick and injured with competence and compassion
and without prejudice.”
AMA Declarations of Professional Responsibility
Dual Loyalty
Clinical role conflict between professional
duties to a patient and obligations, expressed
or implied, real or perceived, to the interest of
a third party such as an employer, an insurer
or the state (military) that can violate patient’s
rights.
Primary Care Physician
A young female primary care physician deployed
in Afghanistan was directed to perform physicals
on male detainees prior to their interrogations.
Female physical exams performed on male
muslims are considered highly embarrassing. She
refused and was threatened with courts martial.
She subsequently did the physicals, fearing the risk
of a court martial and serving a two-year jail term
this doctor has a young daughter and did not want
to miss time with the daughter
Team Physician
The team physician for critical care transport
(flying ICU) stationed outside the US is directed
to transport four critically ill civilians to another
hospital. The team physician on boarding the
plane determines that the facilities of the
newer hospital are not able to provide care and
the civilians will die. He directs the aircraft pilot
to return the plane. The pilot refuses – he has
different orders. There is potentially a court
martial.
Navy Nurse
A Navy nurse who refused to force-feed Guantánamo
prisoners. he refused to manage tube feedings of prison hunger
strikers. He was removed from his duties treating captive
patients.
He was described as an 18 year active duty sailor, a one-time
submariner who, at the Navy’s, urging became a nurse and
commissioned officer who had only three years before retiring.
At one point he was threatened with court-martial for
insubordination. But the personnel board will not face a court
martial and he is being returned to regular duties.
Instead, the nurse “is going to be able to go back to work,” and
have every reason to believe, finish up his honorable service in
the U.S. Navy.”
JANUARY 29, 2013
Under Secretary of Defense for Personnel and
Readiness request the Defense Health Board to
review the unique challenges faced by military
medical professionals in their dual-hatted
positions as a military officer and a medical
provider
Defense Health Board
The Defense Health Board is an appointed
civilian body known as a Federal Advisory
Committee to the Secretary of Defense that
provides independent
advice/recommendations on matters
pertaining to military health.
Question 1
How can military professionals most
appropriately balance their obligations to their
patients against their obligations as military
officers to help commanders maintain military
readiness?
Question 2
How much latitude should military medical
professionals be given to refuse participation in
medical procedures or request excusal from
military operations with which they have
ethical reservations or disagreement?
WMA Policies
International Code of Medical Ethics
Statement on the Protection and Integrity of Medical Personnel
in Armed Conflicts and Other Situations of Violence
Regulations in Times of Armed Conflict
Declaration of Tokyo – Guidelines for Physicians Concerning
Torture and other Cruel, Inhuman or Degrading Treatment or
Punishment in Relation to Detention and Imprisonment
February 11, 2015
Ethical Guidelines and Practices
for United States Military
Professionals
Recommendation 1
DoD should further develop and expand the infrastructure needed to
promote DoD-wide medical ethics knowledge and an ethical culture
among military health care professionals, to include: a code of ethics;
education and training programs; consultative and online services;
ethics experts; and an office dedicated to ethics leadership, policy,
and oversight. To achieve these goals, DoD should form a tri-Service
working group with appropriate representation to formulate policy
recommendations on medical ethics. This should include
development of a DoD Instruction to guide development of the
infrastructure needed to support the ethical conduct of health care
professionals. In addition, this working group should consider the
best ways to implement the recommendations in this report. .
Recommendation 2
Throughout its policies, guidance, and instructions,
DoD must ensure that the military health care
professional’s first ethical obligation is to the patient.
Recommendation 3
DoD leadership, particularly the line commands,
should excuse health care professionals from
performing medical procedures that violate their
professional code of ethics, State medical board
standards of conduct, or the core tenets of their
religious or moral beliefs. However, to maintain
morale and discipline, this excusal should not result in
an individual being relieved from participating in
hardship duty.
Recommendation 4
DoD should formulate an overarching code of military
medical ethics based on accepted codes from various
health care professions to serve as a guidepost to
promote ethical leadership and set a standard for the
cultural ethos of the MHS (military health services).
Recommendation 5
To provide formal ethics guidance, direction, and
support to the MHS and its components, DoD and the
Military Departments should:
Publish directions/instructions
Ensure military treatment facilities have access to
high-quality ethical services
Provide a reach back mechanism
Develop a cadre of physicians with graduate training
Ensure health professionals are knowledgeable
Review compliance with ethics directives
Recommendation 6
DoD should develop clear guidance on what
private health information can be
communicated by health care professionals to
leadership, and the justifications for exceptions
to the rule for reasons of military necessity
Recommendation 7
DoD should provide military health care
professionals with privileges similar to those of
Chaplains and Judge Advocates regarding their
independence and obligation to protect privacy
and confidentiality while meeting the
requirements of line commanders.
Recommendation 8
DoD should provide specific education and training for
health care professionals designated to serve as
medical mentors or health care providers in foreign
health care facilities or in support of humanitarian
assistance or disaster relief operations. Such
education and training should cover cultural
differences, potential ethical issues, rules of
engagement, and actions that might be taken to avert,
report, and address unethical, criminal, or negligent
behavior or practices.
Recommendation 9
DoD should create an online medical ethics
portal. At a minimum, it should include links to
relevant policies, guidance, laws, education,
training, professional codes, and military
consultants in medical ethics.
Recommendation 10
• DoD should include in professional military
education courses information on the legal
and ethical limitations on health care
professionals regarding patient care actions
they may or may not take in supporting
military operations and patient information
they may and may not communicate to line
leadership.
Recommendation 11
DoD should ensure that systems and processes
are in place for debriefing health care
professionals to help them transition home
following deployment. Debriefing should occur
as a team when possible. Not only could this
help mitigate potential moral injury in health
care professionals, but it may also provide
lessons learned and case studies for inclusion in
ongoing training programs.
Recommendation 12
To create an environment that promotes ethical
conduct and minimizes conflicts of dual loyalty,
DoD leadership should emphasize that senior
military health care professionals are full
members of the Commander’s staff as an
advisor on medical ethics as it relates to
military readiness.
Recommendation 13
To minimize isolation of health care
professionals, the Military Departments should
make every effort to ensure personnel who are
deploying to the same location train together
as a team prior to deployment. Establishing
relationships prior to deployment may enable
better communication and trust among line
command and health care professionals in the
deployed setting.
Recommendation 14
DoD should issue a directive or instruction
designating minimum requirements for basic
and continuing education and training in
military medical ethics for all health care
professionals in all components and indicate
the appropriate times in career progression
that these should occur
Recommendation 15
To enhance ethics training for military health care professionals and
the line command, DoD should:
a) Ensure pre-deployment and periodic field training includes
challenging medical ethics scenarios and reminders of available
resources and contact information to prepare both health care
professionals and line personnel. Curricula should include
simulations and case studies in addition to didactics.
b) Provide a mechanism to ensure scenarios and training curricula
are continually updated to reflect specific challenges and lessons
learned through debriefing from real-world deployments and
garrison operations.
c) Ensure key personnel returning from deployment who have faced
significant challenges provide feedback to assist personnel preparing
for deployment.
Recommendation 16
To enhance health care practices in the military operational
environment, DoD should:
a) Update the Joint Knowledge Online Medical Ethics and
Detainee Health Care Operations courses to improve the
efficiency with which the information is communicated and
maintain currency of the material.
b) Create a medical ethics course to cover key principles,
ethical codes, and case studies applicable to both garrison
and deployed environments, in addition to providing
resources and appropriate steps to take when assistance is
needed in resolving complex ethical issues. This course
should be required for all health care professionals
MARCH 3, 2015
The Defense Health Board submitted its report to the
Secretary of Defense on “Ethical Guidelines and
Practices for U.S. Miitary Medical Professionals
Department of Defense”.
It was considered favorably
Department of Defense Medical Ethics Center
(DMEC) Vision
Establish the Department of Defense (DoD) Medical
Ethics Program Office at the Uniformed Services
University (USU), known as the DoD Medical Ethics
Center (DMEC), to facilitate a common cultural ethos
throughout the Military Health System (MHS), and
serve as a knowledge repository and consultancy
resource for all military health professionals
DoD Medical Ethics Center (1)
1. Health care personnel will adhere to principles of
medical ethics
2. Baseline and periodic updates in medical ethics
education and training
3. Systematic and integrated DoD Medical Ethics Program
4. Consultation by fully trained experts in medical ethics
5. Medical ethics leadership composed of senior medical
ethics in military ethics will promote ethics conduct
and culture across the MHS and DoD
DoD Medical Ethics Center (2)
6. Health care personnel must protect their patients
privacy
7. Medical Heath Service leaders must:
a. Unless it could have an adverse impact on military
readiness, unit cohesion, and good order and
discipline, the Armed Forces will accommodate
individual expressions of belief of a member of the
armed forces reflecting the sincerely held conscience
or moral principles of the member.
DoD Medical Ethics Center (3)
b. In so far as practicable, the Armed Forces may not use
such expression of belief as the basis of any adverse
personnel action, discrimination, or denial of promotion,
schooling, training, or assignment.
c. This paragraph is applicable to individual expressions of
belief of a health care professional reflecting the sincerely
held conscience or moral principles of the individual that
are grounded in an applicable professional ethics code.
d. Nothing in this paragraph precludes disciplinary or
administrative action for conduct that is proscribed by the
Uniform Code of Military Justice, including actions and
speech that threatens good order and discipline.
Current Medical Ethics Landscape (1)
• Societal and media perceptions of military medical
practice
• Varying influences on ethical thought/practices
dependent on age, cultural & economic
background, and religious beliefs of providers, both
military and civilian
• Advances in medical technology
• Determining the roles of patient’s providers in
decision making
Current Medical Ethics Landscape (2)
• Potential conflicts between autonomy and
beneficence
• Ethical practices in deployed environment
• Appropriate parameters of patient and heathcare
workers
• Confidentiality and disclosure of Personnel Health
Information
• Military mission/chain of command influence and
potential conflict of interest
Brief to the Defense Health Board 4-23-18
• Initial operating capacity Fall of 2018
• Functional operating capacity Spring 2019
• Housed in the Uniformed Services University
• Six senior staff plus additional personnel staff and
ethics consultants
• Ethics resources from within the military, and from
outside civilian medical ethics programs and centers
• Formulate medical ethics curriculum
• Establish medical ethics portal presence
Principles of Medical Ethics
Military Health System
The MHS embraces the principles of
professional ethics of America’s health care
professions whose members are represented in
the Military Services. Codes of ethics
developed by health care professional
organizations recognize responsibility to
patients first and foremost and to society. The
MHS views the responsibilities of health care
personnel and military professionals as
mutually reinforcing.
Principles of Medical Ethics (1)
Members of the Military Health System (MHS) will
• Provide competent health care
• Uphold the standards of professionalism
• Advocate for the best possible health interest of
patients
• Respect the rights of patients , colleagues and other
health care personnel
• Complete appropriate education and training
Principles of Medical Ethics (2)
• Support patient-centered decision-making
• Use expertise of the health professions
• Consider the context of local culture
• Uphold the responsibilities under the law In caring
for enemy combatants
• Regard responsibility to the patient as a primary
responsibility
From 2001 and the 9 Eleven
catastrophe to the present
Nelson Mandela
Dual Loyalty
Military Medicine