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Military Medical Ethics: Issues Regarding Dual Loyalties - Workshop Summary
MILITARY MEDICAL ETHICS
ISSUES REGARDING DUAL LOYALTIES
Workshop Summary
Neil E. Weisfeld, Victoria D. Weisfeld, and Catharyn T. Liverman, Rapporteurs
Board on Health Sciences Policy
INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES
THE NATIONAL ACADEMIES PRESS
Washington, D.C.
www.nap.edu
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Military Medical Ethics: Issues Regarding Dual Loyalties - Workshop Summary
THE NATIONAL ACADEMIES PRESS
500 Fifth Street, N.W. Washington, DC 20001
NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance.
This project was supported by Award No. W81XWH-07-F-0541 between the National Academy of Sciences and the U.S. Department of Defense through Experient, Inc., and by a grant from The Greenwall Foundation.
The views presented in this publication are those of the editors and attributing authors and do not necessarily reflect the view of the organizations or agencies that provided support for this project.
International Standard Book Number-13: 978-0-309-12663-2
International Standard Book Number-10: 0-309-12663-0
Additional copies of this report are available from the
National Academies Press,
500 Fifth Street, N.W., Lockbox 285, Washington, DC 20055; (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area); Internet, http://www.nap.edu.
For more information about the Institute of Medicine, visit the IOM home page at: www.iom.edu.
Copyright 2009 by the National Academy of Sciences. All rights reserved.
Printed in the United States of America
Suggested citation: IOM (Institute of Medicine). 2009. Military medical ethics: Issues regarding dual loyalties: Workshop summary. Washington, DC: The National Academies Press.
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Military Medical Ethics: Issues Regarding Dual Loyalties - Workshop Summary
“Knowing is not enough; we must apply.
Willing is not enough; we must do.”
—Goethe
INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES
Advising the Nation. Improving Health.
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Military Medical Ethics: Issues Regarding Dual Loyalties - Workshop Summary
THE NATIONAL ACADEMIES
Advisers to the Nation on Science, Engineering, and Medicine
The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences.
The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Charles M. Vest is president of the National Academy of Engineering.
The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine.
The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. Charles M. Vest are chair and vice chair, respectively, of the National Research Council.
www.national-academies.org
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Military Medical Ethics: Issues Regarding Dual Loyalties - Workshop Summary
WORKSHOP ON MILITARY MEDICAL ETHICS PLANNING COMMITTEE*
JAMES F. CHILDRESS (Chair),
University of Virginia
SCOTT A. ALLEN,
Brown University Medical School
PAUL S. APPELBAUM,
Columbia University Medical Center
THOMAS E. BEAM,
COL (retired), MC, U.S. Army
RICHARD J. BONNIE,
University of Virginia
LONNIE BRISTOW,
American Medical Association (retired)
LINDA EMANUEL,
Northwestern University
EDMUND HOWE,
Uniformed Services University of the Health Sciences
SANDRAL HULLETT,
Cooper Green Hospital
M. E. BONNIE ROGERS,
University of North Carolina, School of Public Health, Chapel Hill
Adviser to the Planning Committee
ELENA O. NIGHTINGALE, IOM Scholar-in-Residence
Study Staff
CATHARYN T. LIVERMAN, Study Director
FRANKLIN BRANCH, Research Associate
JUDY ESTEP, Program Associate
ANDREW M. POPE, Director,
Board on Health Sciences Policy
FREDERICK ERDTMANN, Director,
Board on Military and Veterans Health
CAROL CORILLON, Director,
Committee on Human Rights
*
IOM planning committees are solely responsible for organizing the workshop, identifying topics, and choosing speakers. The responsibility for the published workshop summary rests with the workshop rapporteurs and the institution.
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Military Medical Ethics: Issues Regarding Dual Loyalties - Workshop Summary
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Military Medical Ethics: Issues Regarding Dual Loyalties - Workshop Summary
Independent Report Reviewers
This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report:
George J. Annas, Department of Health Law, Bioethics and Human Rights, Boston University School of Public Health
Thomas E. Beam, U.S. Army (retired)
Lonnie R. Bristow, American Medical Association
Frederick M. Burkle, Harvard Humanitarian Initiative, Harvard University and Schools of Public Health and Medicine, Johns Hopkins University Medical Institutions, and U.S. Navy (retired)
Thomas C. Jefferson, Department of Clinical Investigation, Brooke Army Medical Center, U.S. Army
Elspeth Cameron Ritchie, Strategic Communication Directorate, Army Medical Department
Stephen Olufemi Sodeke, Tuskegee University National Center for Bioethics in Research & Health Care
Although the reviewers listed above have provided many constructive comments and suggestions, they did not see the final draft of
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Military Medical Ethics: Issues Regarding Dual Loyalties - Workshop Summary
the report before its release. The review of this report was overseen by Christine K. Cassel, American Board of Internal Medicine. Appointed by the Institute of Medicine, she was responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution.
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Military Medical Ethics: Issues Regarding Dual Loyalties - Workshop Summary
Preface
In finding common ground on the ethics of health care, the discussions held during this workshop highlighted the fact that military health professionals are not alone in facing dual loyalties—responsibilities to two or more entities. Corporate occupational health professionals deal with the push and pull of employers, workers, and unions. Sports medicine professionals from trainers to team physicians face questions and quandaries posed by players, parents, coaches, and administrators. Health professionals in correctional facilities work on matters of concern to the inmates and to management. As the workshop participants examined these issues and addressed them in light of two case studies specific to military health professionals, the similarities and differences with situations in the civilian sector pointed to the need for greater sharing of ideas across sectors as well as for increased transparency to the extent feasible consistent with national security concerns.
Although the ethical issues faced by the military in situations in Abu Ghraib and Guantanamo were a backdrop of this workshop, these discussions looked forward at ways to continue to improve military training, policy, and structure to better support ethical decisions by military health professionals.
Throughout the exchange of diverse perspectives and expertise, it became clear that the military experience can inform and be informed by ethical dilemmas faced in other health care settings. What was striking was the breath and depth of common ground. The paramount value of the patient–provider relationship was recognized, but many questions remain about how best to address other responsibilities as well as the realities of different organizational structures and cultures.
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Military Medical Ethics: Issues Regarding Dual Loyalties - Workshop Summary
It was a privilege to chair this Institute of Medicine workshop. Planning committee members and workshop speakers were diligent in their thorough preparation, thoughtful presentations, and considered comments. In addition, workshop participants raised insightful questions and provided further information that added to the open dialogue.
The groundwork for this workshop was provided through the insightful discussions of the National Academies’ Committee on Human Rights, the IOM Board on Military and Veterans Health, and the IOM Board on Health Sciences Policy.
The military services, as with other organizations, will continue to benefit from ongoing discourse about common and distinctive ethical quandaries.
James F. Childress, Chair
Planning Committee
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Military Medical Ethics: Issues Regarding Dual Loyalties - Workshop Summary
Contents
SUMMARY
1
INTRODUCTION
4
TOWARD A FRAMEWORK FOR RESOLVING DUAL LOYALTIES
6
ETHICAL DECISION MAKING: RETURN TO DUTY
7
Military Considerations,
9
Occupational Health Parallels,
10
Sports Medicine Parallels,
11
Discussion,
13
ETHICAL DECISION MAKING: TREATMENT OF DETAINEES
15
International Perspectives,
16
Military Policy,
17
Correctional Facility Parallels,
19
Human Rights Perspectives,
20
Cultural and Religious Issues,
21
Discussion,
22
INITIAL AFTERNOON DISCUSSION
23
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Military Medical Ethics: Issues Regarding Dual Loyalties - Workshop Summary
ETHICS TRAINING
24
Training of Military Medical Students,
24
Ethics Training in the Field and Continuing Education,
25
Improving the Teaching of Ethics,
27
Discussion,
28
INSTILLING ETHICAL VALUES: ORGANIZATIONAL STRUCTURE AND CULTURE
29
Nurturing a Just Culture,
29
Leadership and Vertical Integration,
31
Learning and Accountability in Organizational Structures,
31
Discussion,
32
CONCLUSIONS AND NEXT STEPS
33
APPENDIXES
A
References
37
B
Workshop Agenda
39
C
Workshop Participants List
43
D
Biographical Sketches of Workshop Speakers and Planning Committee Members
49
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