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Military Medical Ethics: Is there a conflict?

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Military Medical Ethics: Is there a conflict? Walter J. Coyle, FACP Governor, Navy Chapter ... 560-582. www.annals.org * * Beat Army It is an Army problem! – PowerPoint PPT presentation

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Title: Military Medical Ethics: Is there a conflict?


1
Military Medical EthicsIs there a conflict?
  • Walter J. Coyle, FACP
  • Governor, Navy Chapter
  • American College of Physicians

2
Military Medical Ethics
  • Difficult subject
  • Ambiguous situations
  • Soul-searching
  • My first reaction to seeing the Abu Ghraib
    picture.

3
Abu Ghraib
  • Disgust
  • Embarrassment
  • Disappointment
  • Are we are no better than the enemy?

4
Military Medical Ethics
  • One of my reactions to the Abu Ghraib situation
  • Parochial
  • Immature
  • Based on old prejudice

5
GO NAVY!
Beat Army
It is an Army problem!
6
But then came the stories about Cuba
  • Not only questions of legality at GTMO
  • Medical complicity?
  • Breech of trust?
  • Medical support of interrogations?

7
Questions to Address
  • Why are we in this predicament?
  • What is in place to guide physicians?
  • What is unique about military physicians?
  • What is in place to guide us?
  • What can we do to better prepare physicians for
    ethical quagmires?

8
Why are we in this predicament?
  • United States Higher moral authority
  • Believe we are just and right
  • Just war, just cause
  • Open society free press
  • We air our dirty laundry
  • Usually come to the right answer
  • Allegation of medical complicity
  • World-wide press

9
Dont always believe what you read!
'Newsweek' retracts Koran desecration story By
Bill Nichols, USA TODAY WASHINGTON Newsweek
magazine formally retracted on Monday a story
published last week that said U.S. interrogators
of Muslim prisoners at Guantanamo Bay desecrated
the Koran. "Based on what we know now, we are
retracting our original story," Editor Mark
Whitaker said in a statement. Whitaker had
written in the magazine's latest issue that the
May 9 report might not be true but had stopped
short of a retraction. (Video Newsweek
apologizes)
  • Newsweek article
  • Retraction
  • Falsify records?
  • Must wait for the full report
  • The investigative ball is rolling

10
What I do know about GTMO?
  • Receiving top notch medical care
  • Better care than prisoners in US
  • Access to physicians including mental health
  • Nutrition and appropriate medications
  • Detainee with pancreatic mass
  • Detainee with cardiac disease

11
(No Transcript)
12
What is in place to guide all physicians?
--Hippocratic Oath --System of Medical
Ethics --ACP Ethics Manual --Geneva Conventions
13
Hippocratic Oath
  • Original (ancient version)
  • Modern version
  • Most medical schools in U.S. still give some form
    of this oath at graduation

14
Hippocratic Oath
  • exercise my art solely
  • for the cure of patients,
  • and will give no drug,
  • perform no operation for
  • a criminal purpose, even
  • if solicited

15
Framework of Ethics
  • Respect for autonomy
  • Beneficence
  • An obligation to act for the benefit of others
  • Intentionally take positive steps to help others.
  • Non-maleficence
  • An obligation not to inflict harm on others
  • Intentionally refrain from actions that cause
    harm
  • Justice

16
Framework for Ethical Research
  • Respect for Persons
  • Beneficence
  • Justice

The Belmont Report, 1979
17
ACP Ethics Manual 2005 5th Edition
Relation of the Physician to Government Physicians
must not be a party to and must speak
out against torture or other abuses of human
rights. Participation by physicians in the
execution of prisoners except to certify death is
unethical. Under no circumstances is it ethical
for a physician to be used as an instrument of
government to weaken the physical or mental
resistance of a human being, nor should a
physician participate in or tolerate cruel or
unusual punishment or disciplinary
activities beyond those permitted by the United
Nations Standard Minimum Rules for the Treatment
of Prisoners (90).  
Ann Intern Med. 2005142560-582. www.annals.org
18
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19
Geneva Conventions
  • Arose from the need to maintain some humanity
    during war in the 1800s
  • Prisoners, wounded
  • Civilians, displaced
  • Established definitions and codified conduct
  • Accepted throughout Europe and U.S.

20
Geneva Conventions
  • Major revision after each World War.
  • Most recent version signed by majority of world
    in 1949.
  • US ratified this convention in 1955
  • It applies within the US military for
  • all cases of declared war or of any other armed
    conflicteven if the state of war is not
    recognized by one of the parties to the
    conflict.

21
Geneva Conventions
22
Modern Four Conventions (1949)
Convention I For the Amelioration of the
Condition of the Wounded and Sick in Armed Forces
in the Field, Geneva, 12 August 1949 Sets forth
the protections for members of the armed forces
who become wounded or sick. Convention II   For
the Amelioration of the Condition of Wounded,
Sick and Shipwrecked Members of Armed Forces at
Sea,Geneva, 12 August 1949 Extends these
protections to wounded, sick and shipwrecked
members of naval forces. Convention III  Relative
to the Treatment of Prisoners of War, Geneva, 12
August 1949 lists the rights of prisoners of
war. Convention IV  Relative to the Protection of
Civilian Persons in Time of War, Geneva, 12
August 1949 Deals with the protection of the
civilian population in times of war.
23
The Two Protocols (1977)
Protocol I Additional to the Geneva Conventions
of 12 August 1949, and relating to the Protection
of Victims of International Armed Conflicts, 8
June 1977 Extends protection to victims of wars
against racist regimes, wars of self
determination, and against alien
oppression. Protocol II   Additional to the
Geneva Conventions of 12 August 1949, and
relating to the Protection of Victims of
Non-International Armed Conflicts, 8 June 1977
Extends protection to victims of internal
conflicts in which an armed opposition controls
enough territory to enable them to carry out
sustained military operations.
24
Protected Persons under the Conventions
  • Non-Combatants
  • Civilians
  • Medical Personnel
  • The Wounded, Sick, or Dead
  • Enemy Prisoners of War
  • Parachutists Escaping Craft
  • Chaplains
  • Shipwrecked sailors

25
Civilians
  • Treat Civilians Humanely
  • Respect their customs and religion
  • Do not use them as hostages or shields
  • Protect Civilians from
  • Violence and Insult
  • Sexual Assault
  • Pillage or reprisals
  • No displacement
  • except in extreme cases and for protection

GC Article 8, Article 54, and others
26
Medical Personnel
  • Article 10 General Protection of Medical Duties

Under no circumstances shall any person be
punished for carrying out medical duties
compatible with medical ethics, regardless of the
person benefiting therefrom.
Geneva Conventions
27
Geneva Convention Emblems
  • Red Cross on
    White Background
  • Red Crescent onWhite background
  • Red Star of David on White Background

28
International Committee of the Red Cross ( ICRC
)
  • The ICRC is an international humanitarian
    organization based in Switzerland whose role is
    formally recognized within the Geneva
    Conventions.
  • The ICRC must be permitted to visit EPWs to
    monitor their treatment.

Geneva Conventions
29
Duties Owed to Enemy Prisoners of War (EPWs)
  • Duty to Respect
  • Do not attack, kill, mistreat, or in any way harm
    a fallen and unarmed combatant.
  • Duty to Protect
  • Render care as the combatants condition
    requires.
  • Duty to provide humane treatment
  • Treat fallen combatants as ones own wounded.
  • There should be no adverse distinctions
  • based on factors of gender, race, nationality,
    religion, or political opinions.

30
Obligations for humane treatment of EPWs
  • Removal from combat zone
  • Allow surrender
  • Do not kill and do safeguard from harm
  • No coercion
  • Provide medical care
  • Dont take personal property
  • Allow religious practice
  • Do not force EPWs to perform dangerous,
    humiliating, or war-related labor.

31
The core of obligations for all armed conflict
  • Common Article 3
  • Regarding treatment of Prisoners of War
  • The following acts are and shall remain
    prohibited at any time and in any place
    whatsoever
  • Violence to life and person, in particular murder
    of all kinds
  • Mutilation
  • Cruel treatment and torture
  • Outrages upon personal dignity
  • In particular, humiliating and degrading
    treatment

32
Detainee Medical Care
  • EPWs
  • We must provide medical and dental care
  • Retained Personnel
  • We must provide medical and dental care
  • Civilian Internees
  • We must provide medical and dental care
  • Civilian Internees will, if possible, be moved to
    a civilian hospital, where treatment must be as
    good as that provided to the general population

Based on Geneva Conventions
33
Detainee Medical Care
  • EPWs
  • We must provide medical and dental care
  • Retained Personnel
  • We must provide medical and dental care
  • Civilian Internees
  • We must provide medical and dental care
  • Civilian Internees will, if possible, be moved to
    a civilian hospital, where treatment must be as
    good as that provided to the general population

Geneva Conventions
34
Commander and Chief
I hereby reaffirm the order previously issued by
the Secretary of Defense to the United States
Armed Forces requiring that the detainees be
treated humanely and, to the extent appropriate
and consistent with the military necessity, in a
manner consistent with the principles of Geneva.
White House Memorandum, Washington, DC, 7 Feb
2002
35
Article 17
  • No physical or mental torture, nor any other form
    of coercion, may be inflicted on prisoners of war
    to secure from them information of any kind
    whatsoever
  • Prisoners who refuse to answer questions may not
    be threatened, insulted, or exposed to any
    unpleasant or disadvantageous treatment of any
    kind.

36
Torture
The deliberate, systematic, or wanton infliction
of physical or mental suffering by one or more
persons acting alone or on the orders of any
authority, to force another person to yield
information, to make a confession, or for any
other reason.
Tokyo Declaration, 1985 World Medical Association
37
Investigation of Detainee Deaths and Injuries
  • A camp or hospital commander must appoint an
    officer to investigate and report each death or
    serious injury caused, or suspected to be caused,
    by guards or sentries, another civilian
    internee, or any other person.

Geneva Conventions
38
What is unique about military physicians?
  • Dual loyalty
  • Conflict resolution?
  • New guidelines from Health Affairs

39
Military Medical Ethics
  • Dual Loyalty
  • Medical Oath
  • Military Oath
  • State-employed physicians
  • Occupational Health
  • Prisons
  • Comrades in Arms
  • National security

Insert picture
40
DUAL LOYALTY
When physicians have responsibilities and are
accountable both to their patients and to a third
party and when these responsibilities
and accountabilities are incompatible,they find
themselves in a situation of dual loyalty .
WMA Ethics Manual, 2005
41
http//www.phrusa.org/healthrights/dual_loyalty.ht
ml
42
Dual Loyalty Working Group
  • Military health professionals should refrain
    from direct, indirect, and administrative forms
    of cooperation in cruel, inhuman, and degrading
    treatment and punishment at all times, including
    in wartime and during interrogation of
    prisoners.
  • A health professional passively participates by
    permitting his or her clinical findings or
    treatment to be used by authorities to aid in the
    process of torture.

43
A health professional
  • should not authorize, approve, or participate
    in punishment in any form, in any way, including
    being present when such procedures are being used
    or threatened.
  • Indirect participation includes examinations to
    declare an individual fit for caning, shackles,
    solitary confinement, or any other kind of abuse
    or dietary restriction.

Dual Loyalty Working Group
44
If a health provider experiences a conflict of
interest between the duty to care for, and
protect, an arguably legally unprotected
"unlawful combatant" against abusive treatment,
and the patriotic duty to protect and serve the
interests of one's country, he or she should
consider it their legal and ethical obligation to
report or actively protest against such treatment
to appropriate authorities.
Dual Loyalty Working Group
45
(No Transcript)
46
ASD-HA Principles
1.Health care personnel charged with the medical
care of detainees have a duty to protect their
physical and mental health and provide
appropriate treatment for disease. To the extent
practicable, treatment of detainees should be
guided by professional judgment and standards
similar to those that would be applied to
personnel of the US Armed Forces. 2. All
health care personnel have a duty in all matters
affecting the physical and mental health of
detainees to perform, encourage, and support,
directly and indirectly, actions to uphold the
humane treatment of detainees. 3. It is a
contravention of DoD policy for health care
personnel to be involved in any profession al
provider-patient treatment relationship with
detainees the purpose of which is not solely to
evaluate, protect, or improve their physical and
mental health.
47
ASD-HA Principles
  • It is a contravention of DoD policy for health
    care personnel (a) To apply their knowledge and
    skills in order to assist in the interrogation of
    detainees in a manner that is not in accordance
    with applicable law (b) To certify, or to
    participate in the certification of, the fitness
    of detainees for any form of treatment or
    punishment that is not in accordance with
    applicable law, or to participate in any way in
    the infliction of any such treatment or
    punishment. 5.  It is a contravention of DoD
    policy for health care personnel to participate
    in any procedure for applying physical restraints
    to the person of a detainee unless such a
    procedure is determined in accordance with
    medical criteria as being necessary for the
    protection of the physical or mental health of
    the safety of the detainee himself or herself, or
    is determined to be necessary for the protection
    of his or her guardians or fellow detainees, and
    is determined to present no serious hazard to his
    or her physical or mental health.

48
ASD-HA Principles
  • 1. Medical Records Accurate and complete medical
    records on all detainees shall be created and
    maintained in accordance with reference (b).
  • 2. Treatment Purpose  Health care personnel
    engaged in a professional provider-patient
    treatment relationship with detainees shall not
    undertake detainee-related activities for
    purposes other than health care purposes.  Such
    health care personnel shall not actively solicit
    information from detainees for purposes other
    than health care purposes.  Health care personnel
    engaged in non-treatment activities, such as
    forensic psychology or psychiatry, behavioral
    science consultation, forensic pathology, or
    similar disciplines, shall not also engage in any
    professional provider-patient treatment
    relationship with detainees.

49
What can we do to better prepare physicians for
ethical quagmires?
50
Preparation
  • Read
  • Be Informed
  • Plan scenarios
  • EPWs, civilians, refugees, etc
  • Discuss issues with other physicians
  • Discuss issues with non-physicians
  • Chaplains
  • Commanding Officer / XO

51
World Medical Association
  • Established in 1947 response to WWII
  • Independent organization
  • Over eighty member organizations
  • AMA, BMA, etc
  • Created to ensure the independence of physicians
  • Work for the highest possible standards of
    ethical behavior and care by physicians

52
World Medical Association
--Published in 2005 --Free download on web --Free
copies by mail
http//www.wma.net/e/ethicsunit/resources.htm
53
The Borden Institute
  1. Military Medical Ethics
  2. Free 2-volume set
  3. Worth reading
  4. Order on website.

http//das.cs.amedd.army.mil/textbook.htm
54
(No Transcript)
55
http//www.phrusa.org/healthrights/dual_loyalty.ht
ml
56
The Line Officers guide
57
The lawyers guide
58
ACP Ethics Manual 2005 5th Edition
Ann Intern Med. 2005142 560-582. www.annals.org
59
Up and coming
  • Web-based teaching on ethics
  • More rigorous ethical curriculum at USUHS
  • More exposure to Military Medical Ethics in OIS

60
Summary
  • Military medical ethics
  • Longstanding problem
  • Tougher than good medical care
  • Know the guidelines
  • Do your homework
  • Seek advice
  • Do the right thing (if not sure, advise what is
    best for the patient, detainee, EPW, etc)
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