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Military Medical Ethics: Is there a conflict? Walter J. Coyle, FACP Governor, Navy Chapter American College of Physicians.

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Presentation on theme: "Military Medical Ethics: Is there a conflict? Walter J. Coyle, FACP Governor, Navy Chapter American College of Physicians."— Presentation transcript:

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 article Retraction Falsify records? Must wait for the full report – The investigative ball is rolling '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 apologizes

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

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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; 5 th 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:

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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 – 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: – 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

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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

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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 Free download on web --Free copies by mail

53 The Borden Institute mil/textbook.htm mil/textbook.htm 1.Military Medical Ethics 2.Free 2-volume set 3.Worth reading 4.Order on website.

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56 The Line Officers guide…

57 The lawyers guide…

58 ACP Ethics Manual th 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…)


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