Military Medical Conflicts of Interest Including Treating One’s Military “Family”
The very recent attack on a military dining facility in Mosul and the resulting deaths followed by the prompt mobilization of medical treatment for the numbers of wounded brought to me a revisiting of my thoughts about the profession of the military physician. I have been writing throughout this blog about conflicts of interest in the profession of medicine and I find this topic certainly applies to doctors in the military. It seems obvious that their conflicts of interest would be qualitatively quite different than those affecting physicians in civilian life.
One clear conflict is that of the physician’s allegedly primary duty to the military. This aspect is well described by John C. Moskop, Ph.D. whose article can be found in the Ethics and Healthcare newsletter of The Bioethics Center, University Health Systems of Eastern Carolina
Department of Medical Humanities, The Brody School of Medicine at East Carolina University Volume 7:Number 1 Spring 2004 under the title Ethics and Military Medicine: New Developments & Perennial Questions
The following is an excerpt of the Conclusion of the article:
What, then, is the underlying moral difference between military and civilian medical practice? It is, I believe, the fact that the military demands a more nearly total commitment to its goals and practices than other employers and, as a result, military physicians have less individual freedom to make their own moral choices. Some military goals, such as the protection of citizens and their way of life, are highly desirable; other possible goals, such as aggression against other nations, are highly morally suspect. Some military practices and procedures, such as strict discipline and rigorous training, are necessary and defensible means to achieving military goals; others, such as torture, genocide, and mistreatment of one’s own soldiers, prisoners of war, or civilians, are highly morally problematic. Upon entering military service, physicians assume obligations to pursue military goals and abide by military procedures, with only limited options to resist these on medical or other grounds. Thus, the decision to enter military service is a morally weighty one which demands careful reflection on the practices and regulations of the military service to which one is pledging obedience.
I have a theory that there is another conflict of interest, not described in the article, which though perhaps subtle represents a relationship with the traumatized patient, particularly during a war, which physicians in civilian life are not encouraged to encounter. It is reasonable to say that the military physician, especially during the immediate distress of battle and most especially for those physicians near the “front line”, the patients for whom the physician is responsible is part of a closely knit team of which the physician is an important part and partner. Together, they are all working to defeat the enemy. I have a feeling that the military physician might reasonably look at the team, emotionally, as his/her “family” of service people. And, if so, the physician could be in a way treating the severely injured of his/her “family”. In civilian life, physicians are discouraged from treating their own family members, certainly a severely traumatized one, because of the psychological-emotional effects which might affect proper medical judgment. And yet, this very act of treating one’s military "family member" is what is demanded of the military physician. And it is this responsibility which could be the basis for the subtle conflict of interest and its effect on professional judgment.
I really don’t have any data or other information to confirm my concerns. I don't know if military physicians look at their team emotionally as "family". I don’t know if there are more mistakes in clinical decision-making up front in Iraq or even at the military hospital in Germany than let’s say in a civilian hospital emergency room. And, if there were more mistakes on the “front-line” would other factors such as the psychological effect of potential of injury or death of the physicians or limited resources there be the important factors. This could all be my expounding an unrealistic personal idea. Do you think that there is any merit to my theory and worthy of further investigation? Let me know. ..Maurice.
posted by Maurice Bernstein, M.D. @ 4:49:00 PM
4 comments
4 Comments:
I think there's something to your comments. There are differing "strata" of attachment for the military physician to his/her patients. Many of the medical personnel overseas are part of field hospital units and, as such, probably don't know their patients personally; in that setting, the feeling of "family" is somewhat abstract, although the common bond of wearing the uniform is definitely there.
The type of doctor you're thinking of is the physician who is directly attached to a particular combat unit as their medical officer. I was a flight surgeon with a carrier air wing during Operation Enduring Freedom. As a member of a squadron, wearing their insignia on my flight suit and going flying with the guys when clinical duties permitted, I did encounter a dilemma on occasion: my patients were often my close friends. Only rarely was it a significant issue, but the potential was there.
Thanks for noting your first hand experience. Did you ever have to make decisions as to whether the patient was ready for return to duty and was this difficult? ..Maurice.
The problem faced by a military flight surgeon is deciding when an aviator who has been grounded due to illness or injury is ready to fly again. Since the aviators are your immediate peers (usually), and getting to fly with them is the major perk of being a flight surgeon, there is a potential conflict every time you "up" someone...patients will inevitably downplay their symptoms and degree of disability in order to fly sooner.
A flight surgeon who "ups" pilots sooner rather than later is considered a good guy, rewarded by his peer group; more conservative physicians may face some social censure. (Once you've built up some social standing in the squadrons, this becomes less of an issue as your opinion and judgement become more valued, but this takes time.) There's a fair bit of politics involved. In the end, though, military groups tend to respect professionalism. Aviators, like trained monkeys or small children, will complain when you don't always give them what they want, but they'll respect you more in the end.
I was never confronted with treating a seriously injured friend, thankfully. The more seriously injured or ill patients I treated were (at best) acquaintances. My colleagues who've been on the ground in Iraq could tell a different story, I'm sure. Atul Gawande wrote about one such case in the December 9, 2004, issue of NEJM:
"One surgeon deserves particular recognition. Dr. Mark Taylor began his Army service in 2001, to fulfill the terms of his military scholarship to attend medical school several years before. He, like many, was deployed twice to Iraq — first from February through May 2003 and then from August 2003 through the following winter. On March 20, 2004, outside Fallujah, four days from returning home to Stockton, California, the 41-year-old surgeon was hit in a rocket-propelled–grenade attack while making a telephone call outside his barracks. Despite his team's efforts, he could not be revived. None among us have paid a greater price."
Your description of the social/professional relationships and problems of a military physician is very educational for those of us who have never served and had the opportunity to experience what you did. Thanks. ..Maurice.
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