Military Medical Ethics
http://www.100md.com
《新英格兰医药杂志》
A military physician at Abu Ghraib prison in Iraq is asked to treat wounds caused by prisoner abuse; a soldier is ordered by a military physician to receive an investigational vaccine; a military physician is ordered to treat wounded soldiers who can return to combat quickly before treating others; a military psychiatrist is asked to order a psychologically traumatized soldier to return to combat; a military psychiatrist is ordered to breach the confidentiality of his soldier-patients for the good of the soldiers' unit; a military physician is ordered to evaluate a prisoner before the prisoner undergoes aggressive interrogation; a military physician remains at a mobile hospital on the battlefield after her unit is forced to retreat and the hospital comes under hostile fire. These are just a few of the many challenging moral dilemmas that could confront physicians in the military.
(Figure)
Flashlight Surgery, Saipan, by Robert Benney.
Courtesy of Army Art Collection, U.S. Army Center of Military History, Washington, D.C.
Until now, there has been no single repository of scholarly discourse to help guide military physicians who face ethical quandaries. The former surgeon general of the U.S. Army, General James B. Peake, accurately states in the foreword to Military Medical Ethics: "These two volumes of the Textbooks of Military Medicine address medical ethics within a military context, a heretofore essentially unexplored field." These are the 15th and 16th volumes in the Textbooks of Military Medicine series, begun in 1989, and are the most comprehensive and scholarly books of their kind. We agree with General Peake that they should be studied by "all military medical officers, commanders, and others involved in ethical decision-making in medicine." We would go further and encourage a wide readership among civilian physicians and bioethicists as well, because the role of physicians in the military in particular and the problem of dual loyalty in general are issues that society must understand and help to resolve.
One of the editors of these two volumes correctly describes the fundamental tension involved in military medical ethics: "The core enigma underlying many ethical questions posed by the military is whether the military physician should adopt a military role-specific ethic, which favors military interests exclusively; exercise independent discretion . . . ; or assume a medical role-specific ethic, which favors patients' medical interests exclusively." Is the military physician a physician first and a military officer second? More specifically, when there is a conflict between the best interests of the patient and the success of the military mission, which interest must the military physician serve? Some of the ethical dilemmas faced by physicians in military medicine are different from those encountered in civilian life and directly relate to combat and the fact that the military physician cannot escape the situation by resigning his post.
Of the 27 chapters in these two volumes, 4 are devoted to medical ethics, 5 to military ethics, and 14 to specific historical and contemporary issues related to medical ethics in the military (including Nazi medicine, Japan's biologic and chemical warfare experiments during World War II, radiation experiments by the U.S. military, the Geneva Conventions, humanitarian missions, and the development of new weapons systems). All these chapters are worth reading, but four specifically address the core ethical conflict of the physician-officer and how to resolve it, and these are the most challenging and novel. William Madden and Brian S. Carter, both of whom are physicians and former colonels in the Army Medical Corps, argue that the similarities between civilian and military physicians overwhelm any differences and that the ethic of the conservation of life is central to both; they conclude bluntly, "There is no ethical conflict in being both physician and soldier."
In contrast, public health physicians Victor W. Sidel and Barry Levy, former military medical officers, argue that fidelity to the military mission is often sufficiently incompatible with doing what is best for the patient that "the ethical principles of medicine make medical practice under conditions of military control fundamentally dysfunctional and unethical." These authors provide specific examples of failed record keeping, forced vaccinations, and triage that is determined by the military mission rather than the best medical interests of the soldiers. But their strongest arguments, perhaps, are that (in both wartime and peacetime) a military physician almost always outranks the soldier-patient, reinforcing traditional medical paternalism — with the soldier's requirement to follow orders — and that in wartime, the physician in uniform will naturally "bond" with his or her fellow soldiers, seeing the enemy as "them" versus "us," and will be unable to live up to the neutrality required of physicians by the Geneva Conventions.
Sidel and Levy propose that a dialogue be opened on the issues they address, and they specifically recommend either that the military medical service be restructured to permit physicians "to be moral agents" or that physicians be allowed to choose an alternative form of service in the event that doctors are drafted. Their arguments, as seen by the editors (who are to be commended for including this chapter), are so powerful that their chapter is the only one in the two volumes preceded by a note explaining why it is included and the only one followed by specific commentaries. The commentators concede some of the points made by Sidel and Levy but totally reject their conclusions.
One of the commentators, who is also the author and a coauthor of the two other chapters that attempt a role at reconciliation, is Edmund G. Howe, director of ethics at the Uniformed Services University of the Health Sciences and a former military physician. Aside from his continual flat defense of the decision on the part of the U.S. military to force troops to use an investigational drug and an investigational vaccine during the Gulf War (a decision we opposed at the time, one that neither of the commanding generals now justifies and that in response to which Congress changed the applicable law), Howe's analysis is generally balanced and insightful. He reviews, for example, a series of cases in which conflicts in the roles of military physicians are similar to those confronted by civilian physicians, and he argues that in almost all of these conflicts, military physicians have as much discretion as do civilian physicians in following medical ethics. Almost all questions about medical ethics that are unique to the military arise in wartime, when the military mission or "exigencies" require physicians to perform actions that they would not perform otherwise. In these cases, Howe insists, the ultimate decision (e.g., whom to treat first or how to go about triage) will be made not by the physician but by the unit's commanding officer. In this circumstance, the military physician must follow orders. Howe believes that this is as it should be, because in war, "we need military physicians who can and do identify as closely as possible with the military so that they, too, can carry out the vital part they play in meeting the needs of the mission."
In the concluding chapter of the book, Howe and Colonel Thomas E. Beam (retired), one of the editors, reiterate that issues of "mixed agency" and "conflicting loyalty" are common in civilian as well as in military life, and they cite sports medicine, penal institutions, and even managed care as examples. They also believe that civilian physicians make military-like decisions, although the only example they can cite is that of quarantine, which has not been used on a large scale for almost a century in the United States. Military necessity, on the other hand, like national security, is almost routinely used as a justification for action. Howe and Beam's ultimate conclusion is uncontroversial: military medical ethics should reflect the fact that "the military physician is a physician first and usually can continue to place his patient's interests first." The debate is over what exceptions exist to this "usual" rule.
Howe and Beam posit that military necessity provides the primary exception. However, they argue, military necessity only rarely conflicts with medical ethics, and these rare conflicts, which are usually combat-related, occur when civilian authority has made a prior determination — usually by applying a version of "just war" theory — that military action is necessary to preserve the nation. Under such circumstances, Howe and other authors argue, active participation on the part of military physicians in the defense of the nation is both honorable and ethical. Of course, even under the most extreme circumstances, there are still some nonnegotiable prohibitions, such as those against murder and torture, as well as the obligations of physicians to abide by international humanitarian law, most notably as enumerated in the Geneva Conventions.
These two volumes provide the foundation for a military medical ethic. The next phase will require an open dialogue, followed by explicit and accessible guidelines, manuals, education, and training. If it is acknowledged that war is and will continue to be a tragic but likely reality in the foreseeable future, Military Medical Ethics could serve as a watershed in the history of both medical ethics and military medicine.
Michael A. Grodin, M.D.
George J. Annas, J.D., M.P.H.
Boston University
Boston, MA 02118
grodin@bu.edu(Thomas E. Beam and Linett)
(Figure)
Flashlight Surgery, Saipan, by Robert Benney.
Courtesy of Army Art Collection, U.S. Army Center of Military History, Washington, D.C.
Until now, there has been no single repository of scholarly discourse to help guide military physicians who face ethical quandaries. The former surgeon general of the U.S. Army, General James B. Peake, accurately states in the foreword to Military Medical Ethics: "These two volumes of the Textbooks of Military Medicine address medical ethics within a military context, a heretofore essentially unexplored field." These are the 15th and 16th volumes in the Textbooks of Military Medicine series, begun in 1989, and are the most comprehensive and scholarly books of their kind. We agree with General Peake that they should be studied by "all military medical officers, commanders, and others involved in ethical decision-making in medicine." We would go further and encourage a wide readership among civilian physicians and bioethicists as well, because the role of physicians in the military in particular and the problem of dual loyalty in general are issues that society must understand and help to resolve.
One of the editors of these two volumes correctly describes the fundamental tension involved in military medical ethics: "The core enigma underlying many ethical questions posed by the military is whether the military physician should adopt a military role-specific ethic, which favors military interests exclusively; exercise independent discretion . . . ; or assume a medical role-specific ethic, which favors patients' medical interests exclusively." Is the military physician a physician first and a military officer second? More specifically, when there is a conflict between the best interests of the patient and the success of the military mission, which interest must the military physician serve? Some of the ethical dilemmas faced by physicians in military medicine are different from those encountered in civilian life and directly relate to combat and the fact that the military physician cannot escape the situation by resigning his post.
Of the 27 chapters in these two volumes, 4 are devoted to medical ethics, 5 to military ethics, and 14 to specific historical and contemporary issues related to medical ethics in the military (including Nazi medicine, Japan's biologic and chemical warfare experiments during World War II, radiation experiments by the U.S. military, the Geneva Conventions, humanitarian missions, and the development of new weapons systems). All these chapters are worth reading, but four specifically address the core ethical conflict of the physician-officer and how to resolve it, and these are the most challenging and novel. William Madden and Brian S. Carter, both of whom are physicians and former colonels in the Army Medical Corps, argue that the similarities between civilian and military physicians overwhelm any differences and that the ethic of the conservation of life is central to both; they conclude bluntly, "There is no ethical conflict in being both physician and soldier."
In contrast, public health physicians Victor W. Sidel and Barry Levy, former military medical officers, argue that fidelity to the military mission is often sufficiently incompatible with doing what is best for the patient that "the ethical principles of medicine make medical practice under conditions of military control fundamentally dysfunctional and unethical." These authors provide specific examples of failed record keeping, forced vaccinations, and triage that is determined by the military mission rather than the best medical interests of the soldiers. But their strongest arguments, perhaps, are that (in both wartime and peacetime) a military physician almost always outranks the soldier-patient, reinforcing traditional medical paternalism — with the soldier's requirement to follow orders — and that in wartime, the physician in uniform will naturally "bond" with his or her fellow soldiers, seeing the enemy as "them" versus "us," and will be unable to live up to the neutrality required of physicians by the Geneva Conventions.
Sidel and Levy propose that a dialogue be opened on the issues they address, and they specifically recommend either that the military medical service be restructured to permit physicians "to be moral agents" or that physicians be allowed to choose an alternative form of service in the event that doctors are drafted. Their arguments, as seen by the editors (who are to be commended for including this chapter), are so powerful that their chapter is the only one in the two volumes preceded by a note explaining why it is included and the only one followed by specific commentaries. The commentators concede some of the points made by Sidel and Levy but totally reject their conclusions.
One of the commentators, who is also the author and a coauthor of the two other chapters that attempt a role at reconciliation, is Edmund G. Howe, director of ethics at the Uniformed Services University of the Health Sciences and a former military physician. Aside from his continual flat defense of the decision on the part of the U.S. military to force troops to use an investigational drug and an investigational vaccine during the Gulf War (a decision we opposed at the time, one that neither of the commanding generals now justifies and that in response to which Congress changed the applicable law), Howe's analysis is generally balanced and insightful. He reviews, for example, a series of cases in which conflicts in the roles of military physicians are similar to those confronted by civilian physicians, and he argues that in almost all of these conflicts, military physicians have as much discretion as do civilian physicians in following medical ethics. Almost all questions about medical ethics that are unique to the military arise in wartime, when the military mission or "exigencies" require physicians to perform actions that they would not perform otherwise. In these cases, Howe insists, the ultimate decision (e.g., whom to treat first or how to go about triage) will be made not by the physician but by the unit's commanding officer. In this circumstance, the military physician must follow orders. Howe believes that this is as it should be, because in war, "we need military physicians who can and do identify as closely as possible with the military so that they, too, can carry out the vital part they play in meeting the needs of the mission."
In the concluding chapter of the book, Howe and Colonel Thomas E. Beam (retired), one of the editors, reiterate that issues of "mixed agency" and "conflicting loyalty" are common in civilian as well as in military life, and they cite sports medicine, penal institutions, and even managed care as examples. They also believe that civilian physicians make military-like decisions, although the only example they can cite is that of quarantine, which has not been used on a large scale for almost a century in the United States. Military necessity, on the other hand, like national security, is almost routinely used as a justification for action. Howe and Beam's ultimate conclusion is uncontroversial: military medical ethics should reflect the fact that "the military physician is a physician first and usually can continue to place his patient's interests first." The debate is over what exceptions exist to this "usual" rule.
Howe and Beam posit that military necessity provides the primary exception. However, they argue, military necessity only rarely conflicts with medical ethics, and these rare conflicts, which are usually combat-related, occur when civilian authority has made a prior determination — usually by applying a version of "just war" theory — that military action is necessary to preserve the nation. Under such circumstances, Howe and other authors argue, active participation on the part of military physicians in the defense of the nation is both honorable and ethical. Of course, even under the most extreme circumstances, there are still some nonnegotiable prohibitions, such as those against murder and torture, as well as the obligations of physicians to abide by international humanitarian law, most notably as enumerated in the Geneva Conventions.
These two volumes provide the foundation for a military medical ethic. The next phase will require an open dialogue, followed by explicit and accessible guidelines, manuals, education, and training. If it is acknowledged that war is and will continue to be a tragic but likely reality in the foreseeable future, Military Medical Ethics could serve as a watershed in the history of both medical ethics and military medicine.
Michael A. Grodin, M.D.
George J. Annas, J.D., M.P.H.
Boston University
Boston, MA 02118
grodin@bu.edu(Thomas E. Beam and Linett)