Foundation, the workshop was held at the National Academies building in Washington, DC. Seventy-three registered participants, representing diverse perspectives from academic, military, business, human rights, and health professions, contributed to the discussion.

The workshop was not intended to generate firm rules or a prescription for change; rather, it was intended to serve as a forum for discussion of the ethical challenges for physicians and other health professionals serving in the military—ethical challenges that sometimes arise from conflicts between their responsibilities to patients and their duties as military officers. A planning committee of 10 members, assisted by IOM staff, designed the workshop to that end. The committee’s role was limited to determining the format, setting the agenda, and choosing speakers, session moderators, topics, background readings, and two case studies to be used in the discussion. This report was prepared by the rapporteurs as a factual summary of the workshop discussion; it consolidates the views of the individual participants but is not intended to reflect a consensus of those attending.

Background materials provided for the workshop defined dual loyalty situations (also termed mixed agency) as those in which health professionals are obligated to fulfill multiple roles, sometimes resulting in ethical tensions between the roles (Beam and Sparacino, 2003; Appendix A).

The workshop focused on two specific situations in which military health professionals may face ethical conflicts because of dual loyalties—decisions regarding returning servicemembers to duty following an injury or health concern and decisions regarding the care of hunger strikers. The military is only one of many environments that involve dual loyalties. Selected others include

  • occupational health, where a physician serves both patients and employers;

  • infectious disease or mental health practice, where a clinician may have to balance the patient’s interests and demands against those of the patient’s family, sexual partners, or other individuals at potential risk of harm by the patient (Johnson et al., 2006);

  • sports medicine, where a physician or athletic trainer serves both the athlete and a sports organization or team;

  • forensic medicine, where a physician consultant serves the court but also has some responsibilities to the individual being examined (Strasburger et al., 1997); and



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