When Doctors Go to War
http://www.100md.com
《新英格兰医药杂志》
To the Editor: Like Bloche and Marks in their Perspective article on doctors in combat (Jan. 6 issue),1 the American Medical Association (AMA) applauds the outstanding work of military physicians in treating wounded soldiers under extremely challenging circumstances.2 Physicians are defined by their common calling to prevent harm and treat people who are ill or injured and by their universal commitment to uphold recognized principles of medical ethics whenever patients rely on their care, irrespective of the setting. Any involvement in torture is fundamentally incompatible with the physician's role as healer and contrary to the policy set forth in the AMA Code of Medical Ethics.3
As a professional association of physicians, the AMA works with all U.S. physicians, both civilian and military, to promote professionalism. Appropriate guidelines and education are important tools of this work. The AMA stands ready to serve our country by contributing to the development of ethical guidelines and training materials regarding the appropriate roles of physicians who care for military detainees.
John C. Nelson, M.D., M.P.H.
American Medical Association
Chicago, IL 60610
president@ama-assn.org
References
Bloche MG, Marks JH. When doctors go to war. N Engl J Med 2005;352:3-6.
Gawande A. Casualties of war -- military care for the wounded from Iraq and Afghanistan. N Engl J Med 2004;351:2471-2475. [Free Full Text]
Opinion 2.067: torture. In: Council on Ethical and Judicial Affairs, American Medical Association. Code of medical ethics: current opinions with annotations. Chicago: American Medical Association, 2004.
To the Editor: Bloche and Marks report that Dr. Tornberg seeks to justify the "intelligence gathering responsibilities" of U.S. military physicians by arguing that since these physicians have no doctor–patient relationship with detainees, they are absolved from the normal requirements of ethical biomedical behavior. As further justification, military physicians point to "civilian parallels" — situations in which "the medical profession sometimes serves purposes at odds with patient welfare." Occupational health is given as an example.
A moment's thought will reveal that these are fallacious arguments. Patients who visit an occupational health clinic do so voluntarily. They must give their consent to the process and be told of the consequences of giving or withholding consent. Detainees have no such rights. Furthermore, physicians who practice occupational medicine — in the United Kingdom, at least — have an "ethical duty to put the interests of the patients first."1
It is not surprising that those involved in the activities described in the article by Bloche and Marks would use spurious arguments to try to justify the unjustifiable. It is unacceptable that the article's authors characterize the arguments as persuasive.
Christopher C. Harling, F.F.O.M.
Faculty of Occupational Medicine of the Royal College of Physicians
London NW1 4LB, United Kingdom
References
Guidance on ethics for occupational physicians. 5th ed. London: Faculty of Occupational Medicine of the Royal College of Physicians, 1999.
To the Editor: The commentary on ethics in military medicine by Bloche and Marks highlights the wider problem of dual loyalty1,2 that manifested in role conflicts between professional duties to a patient and obligations to third-party interests that may lead to complicity in violations of human rights.3 Because reliance on traditional ethical codes alone appears to be insufficient for the management of such conflicts, an international working group has developed guidelines for health professionals facing situations of dual loyalty.4 These include specific guidelines for military settings that aim to resolve conflicts in situations in which alleged security concerns may intrude on the clinical relationship. The commentary on guideline 2 emphasizes that military health care professionals are subject to the same ethical and human-rights standards as civilian professionals and that exceptions for essential military purposes must be subject to regular review by boards that include civilian health care professionals who are skilled in addressing ethical issues. Similarly, divulging confidential information simply in the interests of the command structure is not legitimate. We urge further discussion of these guidelines.
Leslie London, M.D.
University of Cape Town
Cape Town 7925, South Africa
ll@cormack.uct.ac.za
Laurel Baldwin-Ragaven, M.D.C.M.
Trinity College
Hartford, CT 06107
References
Singh JA. Military tribunals at Guantanamo Bay: dual loyalty conflicts. Lancet 2003;362:573-573.
Singh JA. American physicians and dual loyalty obligations in the "war on terror." BMC Med Ethics 2003;4:E4-E4.
Miles SH. Abu Ghraib: its legacy for military medicine. Lancet 2004;364:725-729.
Physicians for Human Rights, University of Cape Town Health Sciences Faculty. Dual loyalty and human rights in health professional practice: proposed guidelines and institutional standards. (Accessed March 9, 2005, at http://www.phrusa.org/healthrights/dual_loyalty.html.)
Drs. Bloche and Marks reply: We would welcome a robust response by the AMA to the challenges posed by medical complicity in the abuse of detainees at Guantanamo Bay, Abu Ghraib, and elsewhere. The letter by AMA president Nelson falls far short in this regard. Nelson writes that physicians make a "universal commitment to uphold recognized principles of medical ethics whenever patients rely on their care, irrespective of the setting." But what of the claim, made by some at the Department of Defense, that physicians who assist interrogators or otherwise use their clinical skills for nontherapeutic purposes do not act as physicians and are therefore not subject to medical ethics?1 At best, Nelson fails to address this claim. At worst, his call for physicians to abide by medical ethics "whenever patients rely on their care" tacitly accepts it.
The notion that physicians are not bound by medical ethics when they put their medical know-how to nontherapeutic use is unpersuasive to us for reasons we have set out elsewhere.1,2 We agree with Harling in this regard. But military doctors make a fair point (this is the argument we characterize as persuasive)1 when they note that the Hippocratic ideal of undivided loyalty to patients does not reflect all of medicine's social roles.2 Physicians routinely perform evaluations for forensic and other nontherapeutic purposes. Medical ethics and the law permit this when these purposes are legitimate.
We share the view of London and Baldwin-Ragaven that more must be done to clarify professional obligations when duties to the state (or other third parties) and to patients (or other clinical subjects) conflict. The working group they mention (for which one of us raised funds and was a consultant) represents a good start. But there is no ambiguity about the ethics — or the illegality — of physicians' assistance in the design and execution of interrogation practices that violate the Geneva Conventions or other international legal norms. We wish that Nelson, on the AMA's behalf, had spoken clearly on this point. There is still time for the AMA to do so. Should it falter in this regard, future historians of the profession are not likely to look on its performance admiringly.
M. Gregg Bloche, M.D., J.D.
Jonathan H. Marks, M.A., B.C.L.
Georgetown University Law Center
Washington, DC 20001
As a professional association of physicians, the AMA works with all U.S. physicians, both civilian and military, to promote professionalism. Appropriate guidelines and education are important tools of this work. The AMA stands ready to serve our country by contributing to the development of ethical guidelines and training materials regarding the appropriate roles of physicians who care for military detainees.
John C. Nelson, M.D., M.P.H.
American Medical Association
Chicago, IL 60610
president@ama-assn.org
References
Bloche MG, Marks JH. When doctors go to war. N Engl J Med 2005;352:3-6.
Gawande A. Casualties of war -- military care for the wounded from Iraq and Afghanistan. N Engl J Med 2004;351:2471-2475. [Free Full Text]
Opinion 2.067: torture. In: Council on Ethical and Judicial Affairs, American Medical Association. Code of medical ethics: current opinions with annotations. Chicago: American Medical Association, 2004.
To the Editor: Bloche and Marks report that Dr. Tornberg seeks to justify the "intelligence gathering responsibilities" of U.S. military physicians by arguing that since these physicians have no doctor–patient relationship with detainees, they are absolved from the normal requirements of ethical biomedical behavior. As further justification, military physicians point to "civilian parallels" — situations in which "the medical profession sometimes serves purposes at odds with patient welfare." Occupational health is given as an example.
A moment's thought will reveal that these are fallacious arguments. Patients who visit an occupational health clinic do so voluntarily. They must give their consent to the process and be told of the consequences of giving or withholding consent. Detainees have no such rights. Furthermore, physicians who practice occupational medicine — in the United Kingdom, at least — have an "ethical duty to put the interests of the patients first."1
It is not surprising that those involved in the activities described in the article by Bloche and Marks would use spurious arguments to try to justify the unjustifiable. It is unacceptable that the article's authors characterize the arguments as persuasive.
Christopher C. Harling, F.F.O.M.
Faculty of Occupational Medicine of the Royal College of Physicians
London NW1 4LB, United Kingdom
References
Guidance on ethics for occupational physicians. 5th ed. London: Faculty of Occupational Medicine of the Royal College of Physicians, 1999.
To the Editor: The commentary on ethics in military medicine by Bloche and Marks highlights the wider problem of dual loyalty1,2 that manifested in role conflicts between professional duties to a patient and obligations to third-party interests that may lead to complicity in violations of human rights.3 Because reliance on traditional ethical codes alone appears to be insufficient for the management of such conflicts, an international working group has developed guidelines for health professionals facing situations of dual loyalty.4 These include specific guidelines for military settings that aim to resolve conflicts in situations in which alleged security concerns may intrude on the clinical relationship. The commentary on guideline 2 emphasizes that military health care professionals are subject to the same ethical and human-rights standards as civilian professionals and that exceptions for essential military purposes must be subject to regular review by boards that include civilian health care professionals who are skilled in addressing ethical issues. Similarly, divulging confidential information simply in the interests of the command structure is not legitimate. We urge further discussion of these guidelines.
Leslie London, M.D.
University of Cape Town
Cape Town 7925, South Africa
ll@cormack.uct.ac.za
Laurel Baldwin-Ragaven, M.D.C.M.
Trinity College
Hartford, CT 06107
References
Singh JA. Military tribunals at Guantanamo Bay: dual loyalty conflicts. Lancet 2003;362:573-573.
Singh JA. American physicians and dual loyalty obligations in the "war on terror." BMC Med Ethics 2003;4:E4-E4.
Miles SH. Abu Ghraib: its legacy for military medicine. Lancet 2004;364:725-729.
Physicians for Human Rights, University of Cape Town Health Sciences Faculty. Dual loyalty and human rights in health professional practice: proposed guidelines and institutional standards. (Accessed March 9, 2005, at http://www.phrusa.org/healthrights/dual_loyalty.html.)
Drs. Bloche and Marks reply: We would welcome a robust response by the AMA to the challenges posed by medical complicity in the abuse of detainees at Guantanamo Bay, Abu Ghraib, and elsewhere. The letter by AMA president Nelson falls far short in this regard. Nelson writes that physicians make a "universal commitment to uphold recognized principles of medical ethics whenever patients rely on their care, irrespective of the setting." But what of the claim, made by some at the Department of Defense, that physicians who assist interrogators or otherwise use their clinical skills for nontherapeutic purposes do not act as physicians and are therefore not subject to medical ethics?1 At best, Nelson fails to address this claim. At worst, his call for physicians to abide by medical ethics "whenever patients rely on their care" tacitly accepts it.
The notion that physicians are not bound by medical ethics when they put their medical know-how to nontherapeutic use is unpersuasive to us for reasons we have set out elsewhere.1,2 We agree with Harling in this regard. But military doctors make a fair point (this is the argument we characterize as persuasive)1 when they note that the Hippocratic ideal of undivided loyalty to patients does not reflect all of medicine's social roles.2 Physicians routinely perform evaluations for forensic and other nontherapeutic purposes. Medical ethics and the law permit this when these purposes are legitimate.
We share the view of London and Baldwin-Ragaven that more must be done to clarify professional obligations when duties to the state (or other third parties) and to patients (or other clinical subjects) conflict. The working group they mention (for which one of us raised funds and was a consultant) represents a good start. But there is no ambiguity about the ethics — or the illegality — of physicians' assistance in the design and execution of interrogation practices that violate the Geneva Conventions or other international legal norms. We wish that Nelson, on the AMA's behalf, had spoken clearly on this point. There is still time for the AMA to do so. Should it falter in this regard, future historians of the profession are not likely to look on its performance admiringly.
M. Gregg Bloche, M.D., J.D.
Jonathan H. Marks, M.A., B.C.L.
Georgetown University Law Center
Washington, DC 20001