Military Medical Ethics

From a lecture to the Family Practice Residents, Ft. Benning, Spring 1998

I'm still working on formatting this page--for the PowerPoint version of this lecture, e-mail me:

tgarigan@clds.net

Scruton

"All the Athenians and foreigners who lived there spent their time doing nothing but talking about and listening to the latest ideas."

Acts 17:21

• Ethical Consciousness
• Ethical Competency
• Ethical Commitment
• Ethical Courage

Metaphysical suppositions/postulates/first truths

Methodology

Epistemology- how one knows what one knows

Interpretation of Truth and Value

Principles (Ethics)

Morality (Practice)

Theism

Belief in the existence of a personal God as creator and ruler of the world.

The American Heritage® Dictionary of the English Language, Third Edition copyright © 1992 by Houghton Mifflin Company. Electronic version licensed from INSO Corporation. All rights reserved.

Deism

The belief, based solely on reason, in a God who created the universe and then abandoned it, assuming no control over life, exerting no influence on natural phenomena, and giving no supernatural revelation.

The American Heritage® Dictionary of the English Language, Third Edition copyright © 1992 by Houghton Mifflin Company. Electronic version licensed from INSO Corporation. All rights reserved.

Pantheism

Belief in and worship of all gods.

The American Heritage® Dictionary of the English Language, Third Edition copyright © 1992 by Houghton Mifflin Company. Electronic version licensed from INSO Corporation. All rights reserved.

Scientism

The theory that investigational methods used in the natural sciences should be applied in all fields of inquiry.

Rationalism

The theory that the exercise of reason, rather than the acceptance of empiricism, authority, or spiritual revelation, provides the only valid basis for action or belief and that reason is the prime source of knowledge and of spiritual truth.

Existentialism

A philosophy that emphasizes the uniqueness and isolation of the individual experience in a hostile or indifferent universe, regards human existence as unexplainable, and stresses freedom of choice and responsibility for the consequences of one's acts.

Humanism

1. A system of thought that centers on human beings and their values, capacities, and worth.

2. Concern with the interests, needs, and welfare of human beings

Utilitarianism

The ethical theory that all action should be directed toward achieving the greatest happiness for the greatest number of people.

The American Heritage® Dictionary of the English Language, Third Edition copyright © 1992 by Houghton Mifflin Company. Electronic version licensed from INSO Corporation. All rights reserved.

Nihilism

A doctrine holding that all values are baseless and that nothing can be known or communicated.

Rejection of all distinctions in moral or religious value and a willingness to repudiate all previous theories of morality or religious belief.

The American Heritage® Dictionary of the English Language, Third Edition copyright © 1992 by Houghton Mifflin Company. Electronic version licensed from INSO Corporation. All rights reserved.

First Period: Hippocratic Tradition

• amalgam of moral principles
• The Oath
• Deontologic books
• Close relation to philosophy
• Later removal of evidence of pagan influence,
• mingling with Judeo-Christian teaching
• adding of concept of noblesse oblige

Hippocratic Oath

• Beneficence
• Nonmaleficence
• Confidentiality
• Prohibitions against:
• abortion & euthanasia
• sex with patients and families

Deontologic books:

• "Etiquette"
• rules of dress, deportment, cleanliness, truthtelling, consultation
• Later: focus on virtues
• duty, compassion, doctor-patient relationship
• courage, temperance, justice

2nd Period: Mid 1960's

Influences:

• better educated public
• communication and transportation technology
• formation of groups from dispersed individuals
• changes in values
• changes in medicine

Changes in Values:

• distrust of authority and institutions
• decline in shared values
• consumerism
• individualism
• moral relativism

Changes in Medicine:

• complexity
• specializaiton
• fragmentation
• depersonalization
• institutionalization
• increasing number & complexity of ethical issues:
• esp. beginning and end of life issues.

AMA Code (1947)- stressed behavior and etiquette

AMA Codes (1957, 1980) increasingly stressed responsibility to patient

Doubts about the traditional moral grounding of society & medicine

Demand for alternative models of teaching and practicing ethics

3rd Period:

Period of Principlism

• elucidation of principles
• allow a "work-up" of a problem
• no particular faith system required
• derived from well-established principles
• Agreement on the most fundamental issues difficult to obtain in a pluralistic society:
• Avoided debate on specific issues
• guidance sought from judiciary and legislatures

The "Newer" Principles:

Autonomy

• derived from individualism
• individual vs. physician:
  • perspective
  • values
  • decision

Justice

• derived from egalitarianism
• access
• outcomes

How to Apply Principles?

• Best balance of right over wrong:
  • begs questions
    • Moral objective must be "realistic"
    • No morally preferable alternative
    • Least infringement on a principle

4th Period: Antiprinciplism

• Principles are "mid-level"
• Lack of unifying moral theory
• Too abstract/ too rationalistic
• Require "Moral Wisdom"
• Require theologic grounding
• Need to rank order the principles
• Need an ethic based on virtue, caring, etc.

• The Principles Approach
• Virtue-Based Theories
• The Case Approach
• "Casuistry"
• Conversation Approach
• The Ethics of Caring

• Benifecence
• Nonmalifecence
• Autonomy
• Confidentiality
• Truth-telling
• Informed Consent
• Ethical Approach
• Legal Approach
• Justice
• Micro-allocation
• Macro-allocation

The Principles Approach

• Who's principles?
• How did we get these principles?
• Inviolable or Modifiable?
• At what Level are these principles?

Virtue-Based Theories

• Emphasizes the character and integrity of the individual, not just how we reach a decision
• Pitfalls:

• Unlikelihood of a consensus
• Too private
• Too prone to individual definitions

The Ethics of Caring

• Feminist origin
• Based on belief that women are more caring than men when approaching ethical decisions
• Pitfalls:
  • = imprecise moral psychology,
  • not an ethical principle

Casuistry

• The reasoned application of principles to specific cases
• Benefit: a practical tool for working through problems
• Pitfalls: tends to become situational:

• moves the boundaries of what is acceptable
• not a guide to moral theory or practice

Casuistic methodology:

#1: Define indications for medical intervention

goals

potential of treatment

medical prognosis

#2: Determine patient preference

#3: Evaluate quality of life of patient

• Someone who knows best wishes of patient
• The more documentation, the more believable

#4: Weigh external factors:

(family wishes, impact on others, costs to society, etc.)

Conversational Approach

• Typified by Hospital Ethics Committees
• Variety of backgrounds and perspectives to balance individual and intraprofessional biases and prejudices
• Must be a constructive discussion

Elements of a Constructive Conversational Approach

• Participants from a variety of backgrounds
• Facts are discussed and agreed upon first
• Morally relevant issues are listed
• Each issue addressed fully
• The bases for disagreements are defined
• Course of action chosen that is supported by largest set of weightiest moral arguments.

Compare to: The Ethical Decision Making Plan:

DOD Directive on Ethics

• Define the problem
• Identify the goal
• List applicable laws or regulations
• List ethical values at stake
• Name all the stakeholders
• Gather additional information
• State all feasible solutions
• Eliminate unethical options
• Rank remaining solutions
• Commit to & implement the best ethical solution

Some common pitfalls

• Emphasis on "Process"
• Utilitarian
• Situational
• Tend to push the boundaries
• Individual Centered

Professional

• Duty
• Honor
• Integrity
• Country
• Loyalty
• Selfless Service

Personal

• Courage
• Candor
• Competence
• Commitment

Code of Ethics for Government Service

• Loyalty to principles and country
• Uphold the Constitution, laws, regulations
• Give a full day of earnest effort
• Seek efficiency and improvement
• Never discriminate
• Engage in no business with the Gov't inconsistent with duties
• Expose corruption
• Never use information gained for private profit

• Escalation

• "Defining deviancy down"

• Bad rules

• "That's just the way it is."

• Rationalizing

• Sense of entitlement

• Avoidance of conflict
• Pressure to:

• conform
• produce results

Ethical Decision Making

• Personal attributes
• Formal laws, regulations, guidance
• Basic national values
• Traditional Army values
• Organizational values
• Personal values
• Institutional pressures

When deciding, weigh:

• Impact
• Public Trust
• Example
• Personal Gain
• Prudence

"Which of Two Masters"

• Military
• Medical
• Business
• Community
• Individual
• Religious Beliefs
• Family

Cultural Trends in America

• Radical individualism
• Radical egalitarianism

The Medical Zeitgeist

• Relativity of all things
• Individual-centered

War and Peace

The conscientious objector model:

(insert image here)

Challenges to Integrity in the Military

• Ambition
• Loyalty
• Image

Some Possible Military Medical Values

• Force Protection
• Preventive Medicine
• Prophylactic Measures
• Preserve the Fighting Strength
• Maintain Unit Cohesion
• Support the Commander's Intent
• Candor
• Service to Country

"The educated man, particularly the educated leader, copes with the fact that life is not fair. The way to deal with failure is not to invent scapegoats or to lash out at followers."

-Stockdale

Our ethics are expressed in our actions, which is why they are usually clearer to others than to ourselves.

Sir Adrian Cadbury

Quartermaster Corps

• Water purification and supply
• MRE's

Military Police

• Traffic Laws

Engineers

• Sewage management
• Plumbing
• Housing/Heating/Cooling

Medical Corps

There is no right way

to do a wrong thing.

There is no pillow as soft as a clear conscience.

Ask:

Is it Legal?

• Civil law
• Organizational policy

Is it Balanced?

• Fair to all concerned in short and long term
• Promotes win-win relationships

How will it make me feel about myself?

• Pride
• If my family knew
• If the public knew

If everyone did what I am about to do, what would be the consequences?

If all my respected colleagues knew what I am about to do, would I still do it?

Estimating the "Moral Distance" between Physician and Questionable Activity

• Is the action good, wrong, or indifferent morally?
• To what degree does the physician share the purpose of others' wrong-doing?
• How essential is the physician's cooperation to the attainment of the harmful purposes?
• What is the causal relationship between the good the physician intends and the harm that occurs?
• Is there a proportionately good reason to permit cooperation?
• Is the act in question consistent with the ethical purposes of the medical relationship?

The most difficult aspect of being ethical is doing what is right, not deciding what is right.

The toughest ethical problems provide the biggest opportunity for growth.

Working without a moral compass is like running the race while looking at the clock and not on the track

Establish a high standard

Guard it jealously

Be willing to face difficulties and sacrifice in order to maintain your standard

The 5 P's of Ethical Power

• Purpose
• Pride
• Patience
• Persistence
• Perspective

Threats to Integrity

• Ethical Relativism
• Exaggerated Loyalty Syndrome
• Obsession with Image
• Ambition: The Drive for Success

Challenges to Integrity

• Ambition
• Loyalty
• Image

Some Pitfalls

• Integrity in Reporting
• Avoiding Blame
• Expedience: Illegal or Immoral Orders
• Situational Ethics
• Money Management
• Concern for Property

Informal Code of Ethics

• History
• Professional Solidarity
• Indoctrination

Duty

• Commissioning Oath
• Duty to:
• Country
• Constitution
• Unit
• Commander
• Subordinates
• "Moral Responsibility ... to enhance the security of the country..."

Hays SH, Thomas WN: Taking Command 1967 Stackpole Books

• Courage
• Obedience
• Initiative
• Loyalty to Man

Honor

• Integrity
• Reputation
• Authority
• Justice

Country

• Loyalty
• Civil-Military Relationship
• Support of Policy

Values

First Order:

• Productivity
• Efficiency
• etc..

Second Order:

• Trust
• Honor
• Integrity
• Dignity

Code of Ethics for Government Service

• Put loyalty to the highest moral principles and to country above loyalty to persons, party, or Government department.
• Uphold the Constitution, laws, and regulations of the US and of all governments therein, and never be a party to their evasion.
• Give a full day's labor for a full day's pay; giving earnest effor and best thought to the performance of duties.
• Seek to find and employ more efficient and economical ways of getting tasks accomplished.
• Never discriminate unfairly by the dispensing of special favors or privileges to anyone, whether for renumeration or not, and never accept, for himself or for family members, favors or benefits under circumstances which might be construed by reasonable persons as influencing the performance of government duties.
• Make no private promises of any kind binding upon the duties of office, since a Government employee has o private word which can be binding on public duty.
• Engage in no business with the Government, either directly or indirectly, which is consistent with the conscientious performance of governmental duties.
• Never use any information gained confidentially in the performance of governmental duties as a means of making profit.
• Expose corruption wherever discovered.
• Uphold these principles, ever conscious that public office is public trust.

• Using office supplies
• Running personal errands on duty time.
• Using position for personal gain.

Personal Gain:

• Escalation
• Rationalization
• Misprioritization
• Pressure to produce results

Rationalization

• Everyone does it.
• It helps me to do my job better.
• It helps the organization.
• I did it for a good cause
• I sacrifice in so many other ways.
• Nobody will notice.
• It won't hurt anybody.
• I'll do it just this once
• At least I'm not as bad as....
• Someone made me do it.
• I had no choice

Pressure to produce results- stems from:

• False expectations
• Vague or conflicting organizational goals and values
• Mixed signals- imply approval or noncommittal to a serious question
• Unstated preferences of superiors- avoidance of declaring position clearly
• Short-sightedness
• Slogans and exhortations
• Zero tolerance for mistakes
• Obsession with results
• Setting impossible goals
• Loyalty up but not down.

Pressure to produce results- results in:

• Fear
• Fudging/cooking the books with misleading figures
• Cover-ups
• "Yes" men
• Legalisms
• Malicious compliance
• Withholding information
• Lack of enthusiasm
• Reduced cooperation

Ethical Problems

Laws, Orders, Regulations

Basic National Values

Traditional Army Values

Organizational Values

Personal Values

Institutional Pressures

What is Ethics?

Questions to ask

• Impact

• to national security or safety of troops?

• Public Trust
• Example
• Personal Gain
• Prudence

• would a prudent person do the same thing?

Set high standards by your actions.

Confront unethical behavior.

Report violations

"A different habit, with worse effect, was the way that ambitious officers, when they came in sight of promotion to the general's list, would decide that they would bottle up their thoughts and ideas, as a safety precaution, until they reached the top and could put these ideas into practice....... Unfortunately the usual result, after years of such self-repression for the sake of their ambition, was that when the bottle was eventually uncorked, the contents had evaporated." B. H. Liddell Hart

"Whenever the tissue of life is woven of legalistic relationships, this creates an atmosphere of spiritual mediocrity that paralyzes [a person's] noblest impulses."

Solshenitsyn

Harvard Commencement Address, 1978

Preamble

"...a physician must recognize responsibility not only to patients, but also to society, to other health professionals, and to self. The following Principles are not laws, but standards of conduct which define the essentials of honorable behavior for the physician."

Principle #1

A physician shall be dedicated to providing competent medical service with compassion and respect for human dignity.

Principle #2

A physician shall deal honestly with patients and colleagues, and strive to expose those physicians deficient in character or competence, or who engage in fraud or deception.

Principle #3

A physician shall respect the law and also recognize a responsibility to seek changes in those requirements which are contrary to the best interests of the patient.

Principle #4

A physician shall respect the rights of patients, of colleagues, and of other health professionals, and shall safeguard patient confidences within the constraints of the law.

Principle #5

A physician shall continue to study, apply and advance scientific knowledge, make relevant information available to patients, colleagues, and the public, obtain consultation, and use the talents of other health professionals when indicated.

Principle #6

A physician shall, in the provision of appropriate patient care, except in emergencies, be free to choose whom to serve, with whom to associate, and the environment in which to provide medical services.

Principle #7

A physician shall recognize a responsibility to participate in activities contributing to an improved community.

Summary of Principles

• competency
• compassion
• respect human dignity
• honesty
• respect the law
• recognize responsibility to:
• seek changes in laws contrary to patient's interest
• participate in activities that help the community
• study, advance knowledge, share knowledge
• remain free to choose whom to serve, work with, and where to serve

• soldier-physician, or
• physician-soldier, or
• physician in uniform?

The Military vs. Medical Ethic

• "Divided Loyalty"
• "Mixed Agency"
• "Moral Complicity"
• morally heinous
• morally problematic

Moral Complicity

• morally heinous
• torture
• reviving of torture victims so torture continues
• interrogation via psychopharmacology
• covering up evidence of torture
• morally problematic cases
• penal, psychiatric, military , institutional medicine

Military Medical Ethical Conflicts

• Ethical conduct vs. unethical
• independent

Military Medical Ethics

• Problems of Dual Loyalty
• Problems of Communication
• Problems of Professional and Social Responsibility

Issues in Military Medical Ethics

• Physician contract with the Organization
• mission accomplishment
• Responsibility to all members of the organization at all times
• Responsibility to the country
• as commissioned officer
• Patients also are expected to share commitment to organization and country

Other issues of Military Medicine

• Medical training by civilian method
• Ethic varies as mission varies:

• Peacetime medical care
• Mobilization
• War
• National emergency

• Final authority for determining physician's role= The organization

Other principles of Military Medicine

• The physician in non-clinical roles:

• commander
• advisor
• manager

• Value systems of military and the medical profession are both valid

• Society has a right to wage war

• yet war can be immoral

Taxonomy of Outpatient Clinical Ethical Problems

• Problems of Dual Loyalty
• Problems of Communication
• Problems of Professional and Social Responsibility

Problems of Dual Loyalty

• Financial conflict of interest
• Legal obligations
• Demanding families
• Referral and consultation
• Physician as employee
• Personal time

Problems of Communication

• Psychologic factors
• Difficult patients
• Noncompliance
• Treatment refusals
• Lifestyle interventions
• Alternative health care
• Competency
• Advance directives
• Suicide, euthanasia

Problems of professional and social responsibility

• Ambulatory education
• Pharmaceutical representatives
• For-profit care and research
• Impaired colleagues
• Community health

Ethical Decision Making Plan

• Define the problem
• Identify the goal
• List applicable laws or regulations
• List ethical values at stake
• Name all the stakeholders
• Gather additional information
• State all feasible solutions
• Eliminate unethical options
• Rank remaining solutions
• Commit to and implement the best ethical solution

Risks of Moral Complicity:

How Military Medicine May Drift

• Unquestioning Loyalty to the Command
• Failure to study the ethical tradition of the medical profession
• Loss of focus on the sanctity of life
• Loss of focus on the individual's dignity
• Failure to participate in establishing high ethical standards for the entire military
• Unquestioning loyalty to the command
• Use of medical means for military purposes

Potential Dual Loyalties for Physicians

• Military
• Family
• Religion
• Financial conflict of interest
• Employer
• Legal
• Peers/Co-workers

Nature of conficts

• High Ethical standard vs. Low Ethical Standard
• Ethical absolutism vs. Ethical relativism
• Different prioritization of values and principles
• Profession vs. Profession
• Peer-Peer
• Supervisor vs. subordinate
• Official vs. unofficial

Ethical dangers to the military physician

Situational Factors:

• Unprepared to make triage decisions
• Isolation
• Separation from accountability- family, church, stable chain of command
• Overwork
• Fatigue
• Horrors of battle
• Resentment-Feelings of being treated unfairly
• Lack of stateside support
• Lack of ethical mentoring
• Poor leadership
• Poor unit morale
• Short-timer attitudes
• Political meddling
• Loss of sense of purpose

Battle factors affecting clinical decisions

• Number of casualties
• Weather
• Advance vs. Retreat
• Air superiority
• Supply
• Enemy proximity
• Medical Personnel Status

Is Military Medicine simply mission-expedient?

Yes:

• The military medical system subordinates the individual's interests to that of the organization
• Physicians in military have (by oath) duty to serve the whole military, creating a conflict with their duty to the individual patient
• Military medicine simply returns soldiers to battle where they are at more risk.
• Triage is designed to focus on who can be returned to duty, not who can be saved.

No:

• Health care management makes decisions to sustain the health care system, and governments make decisions for the whole community that may hurt an individual patient
• Serving the military also serves its members
• Not sustaining the force places the entire force at risk.
• Triage by medical units is clinical, not military.

Are military and medical ethics inherently in conflict?

Yes:

• Military physicians are told by commanders to do unethical things.
• Commanders are dedicated to mission over personnel
• Military operations destroy life; medicine is to enhance life
• Military physicians don't use the same values when providing medical care in military operations

No:

• Unethical orders does not represent a military-medical conflict- it is an ethical conflict between right and wrong.
• Commanders are dedicated to personnel including their health; Personnel are mission-essential
• Military operations are to destroy threats to our lives. Military medical operations are to sustain lives of those who are preserving all of our lives.
• Military operations have unique characteristics that require different prioritization of same values

Do military physicians abrogate their responsibility to the individual?

Yes: The Civilian Medical Ethic:

• Individual-centered
• Contract with the patient
• Accommodation of individual values
• Taking care of the patient's interests now

No: The Military Medical View

• Community-centered
• Contract with all patients simultaneously
• Expectation and upholding of common values among all organization members
• Maximize unit effectiveness and survival long-term and in any contingency
• When the same situation occurs in civilian setting, the same principles apply

Is participation by physicians in military operations unethical?

Yes:

• War is unethical; participation to facilitate operations in war is unethical
• Physician planning for war increases the likelihood a nation will go to war
• All cultures are equal; our country has no justification to go to war to maintain pre-eminence of our way of life
• The military conducts hostile and aggressive operations

No:

• War is not intrinsically unethical; there are just reasons to go to war
• Plenty of examples that show nations engage in war without adequate medical support
• If going to war for our way of life is unethical, then our way of life is unethical. All of us bear a responsibility for the ethical quality of our society, not just the military
• An effective military deters aggression
• Military operations are an instrument of national policy

Individual Factors:

• Lack of solid foundation in values and morals
• Misattribution of an individual's ethical standards as that of the organization
• Concerns for image
• Ambition/Careerism
• Excessive use of authority
• Rationalization
• Excessive loyalty

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