1. Military Medical Ethics: Is 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. Don’t 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

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. 2005;142:

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 conflict…even 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 on White 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 combatant’s condition requires.
Duty to provide humane treatment:
Treat fallen combatants as one’s 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
Don’t 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: Retained Personnel: Civilian Internees:
We must provide medical and dental care
Retained Personnel:
Civilian Internees:
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:
Civilian Internees:
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

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. Dual Loyalty Working Group
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.

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

53. The Borden Institute Military Medical Ethics Free 2-volume set
Worth reading
Order on website.

56. The Line Officers guide…

57. The lawyers guide…

58. ACP Ethics Manual 2005 5th Edition
Ann Intern Med. 2005;142:

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…)