Report: S. M. Eagan Chamberlin, MPH PhD (United States of America)
The Warrior in a White Coat
Moral Dilemmas, the Physician-Soldier & the Problem of Dual Loyalty
Being a physician-soldier can be an ethically and morally complicated job. While the moral obligations of physicians are usually oriented towards the health and well being of their individual patients, military health professionals may encounter situations in which ethical tensions arise between their responsibilities to individual patients and those responsibilities held to the military mission. This seemingly conflicting set of obligations held by the physician-soldier is commonly referred to within the philosophical literature as ‘the problem of dual loyalty.' This paper examines the issue of dual loyalty, which is sometimes referred to 'mixed agency.'
The aim of this paper to is to examine the core of the ‘problem of dual loyalty’ and to argue that both the professions of medicine and the military have a morality inherent in them that sometimes conflict. While examples of this issue are often discussed, the core conflicting set of professional obligations is all too often left unmentioned, and when professional obligations are mentioned only the medical professional obligation is discussed. This failure to acknowledge the professional obligation of both medicine and military does not reflect the moral experience of the physician-soldier.
In this paper, both philosophical and sociological concepts and understandings of professions and professionals will come together to enrich the debate and expand our understanding of the moral obligations of professional physician-soldiers. To further illuminate the reality of this issue, the problem of dual loyalty will also be explored through a series of case studies ranging from doctor-patient confidentiality and treatment decisions to missions where medicine is used as a tool of strategy. Overall, this paper seeks to explore an ethical dilemma unique to military medicine that is under-represented in the training, policy and literature available to the physician-soldier and their commanders.
This paper will examine the problem of dual-loyalty in order to explore the moral realities of military medicine. While civilian medical ethics expects physician-soldiers always to act according to the moral obligations placed on them by the medical profession, this prioritization is complicated by their simultaneous membership in two professions. Medical ethics has not yet recognized the moral experience of these physicians who do not always or necessarily see themselves as a physician first and foremost; rather these physician-soldiers may see themselves as balancing twin-roles. Thus, this paper seeks to clarify the problem of dual loyalty that is institutionalized within military medicine, by examining the twin professional moralities of the physician-soldier.
The concept of professional morality is not new; the unique professional moralities of medicine, law and the clergy have been well developed and discussed in great depth. However, a great deal less has been said about the professional morality of soldiers. Despite the lack of development in this area, the moral obligations placed on professionals in the field of medicine, law and religion can be extended to the profession of arms; the same moral and sociological characteristics are present in all of these professional groups.
On a foundational level, the problem of dual loyalty is this: Military physicians hold two professional identities as members of both the medical profession and the profession of arms. Self-identifying as both a medical doctor and a soldier introduces the problem of dual loyalties by establishing obligations to two distinct professional moralities. As a society, we understand medical doctors to have an obligation to care for their individual patients and prioritize the individual patient above other constraints, acting as their advocates driven by patient centred consequentialism. As members of the armed forces, military physicians are also members of the military profession. As such they have certain obligations incumbent on them as soldiers: they are expected to prioritize the mission, recognizing aggregate level obligations, with an eye to the utilitarian greater good. Since medical morality prioritizes the individual and military morality prioritizes the aggregate we can see that these two professional moralities conflict, as the prioritization of the individual and the aggregate are mutually exclusive.
According to John Ladd, who first introduced the concept of internal professional morality, professional morality is designated by a body of norms, which binds professionals (be they physicians, soldiers, or another profession) together by virtue of their membership in that profession (Welie 2002). A professional sees him (or her) self, not just as a doctor, but also as a member of his/her profession (Welie 2002). In turn, society views them as such. In fact, communal or professional identity is a key factor the acquisition of public trust in these professionals. Put simply, when it comes to professionals it is less an issue of the individual, rather it is the professional identity which warrants public trust. Each member of that profession is understood as obligated to practice according to standards that apply to all members of the profession. Thus, we can walk into any doctor’s office and expect them to act a certain way, a way that we expect all doctors to act.
Within the philosophical literature, this public trust is intimately linked to the “act of the profession,” and other rituals and characteristics of professions (Pellegrino and Thomasma 1998). One of which we can better understand by exploring the etymology of the word profession. The Latin professio comes from a Greek verb meaning, “to declare publicly.” This public declaration happens in different ways for different professions. For physicians, in swearing the Hippocratic oath upon graduation, they are understood to be professing their intention publicly. Swearing the oath, and thus publicly acknowledging one’s expert knowledge and acceptance into the medical profession, creates an implicit obligation to treat one’s patient and practice medicine while abiding by professional morality (Pellegrino and Thomasma 1998). Within the military, a similar oath is taken publicly; thus a similar public promise is made, while the exact oath varies depending on the nation, it generally involves the promise to protect that nation and its citizens.
Besides the moral characteristics of professionals, there are also distinct sociological differences between professionals and non-professionals, conferring special status and obligations that, in turn, warrant public trust and cultural authority. These sociological characteristics, which separate professions from vocations, include expertise, corporateness and responsibility (Huntington 1981).
Expertise is conferred by way of specialized and restricted education. It is an important part of professional identity and corporateness. Corporateness refers to a sense of collective unity (Huntington 1981). For the military, uniforms and insignias of rank publicly symbolize the line between a soldier and the layman or civilian. Within medicine, this symbolic distinction is achieved in the wearing of a white coat. For both this distinction of corporateness is also apparent through the expert language used, which is often unknown to the non-professional. Another important professional characteristic is responsibility. It is this responsibility that distinguishes the professional from other experts, because a professional provides something understood to be of enormous value to the larger community (Huntington 1981). The profession of medicine helps members of the community achieve, or restore, health and well-being. Within the military context, the military officer has a responsibility to the society he serves, generally understood as security of the nation-state. Both health & security are highly valued. Thus, a physician-soldier, as a simultaneous member of two professions can be uniquely torn between these two professions, creating unique ethical dilemmas known as the problem of dual-loyalty.
Profession of Medicine
The medical profession is understood to have a very specific ethical code or set of moral obligations. As a society, we understand members of this profession to act a certain way. Physicians are expected to care for their individual patients, to do what is best for them, and to be motivated by a beneficent drive to care for these individuals. This type of patient centred consequentialism is at the basis of clinical ethics, wherein physicians are trusted to act in the best interest of their patients. These normative ethical ideas have been a part of the medical profession throughout its history. The Hippocratic oath is clear that physicians should do what is in the best interest of their patients, “I will follow that system or regimen which according to my ability and judgment I consider for the benefit of my patient and abstain from whatever is deleterious and mischievous” (Oath of Hippocrates 2014). Historical and contemporary codes of ethics reiterate these ideas of medical professional morality. In fact, physicians face sanctions and penalties should they fail to live up to the expectations of this communal identity (Ozar 2004).
Of course, it is not mere codes and policies that are of interest to this discussion. What is of significance is the notion that the professional moral obligations of physicians go beyond codes. They lie in the moral and sociological characteristics of what it means to be a professional and to possess that public trust. Ethicists and philosophers have proposed that there is something internal to medicine that determines its morality and shapes medical ethics. Ethicist, Dr. David C. Thomasma, has argued, “The internal morality of the profession emphasizes caring for the common good of patients” (Thomasma 1992). He and others argue for a medical morality that is internal to the practice of medicine itself. Proponents for an internal morality of medicine (IMM) include Edmund Pellegrino, Franklin Miller and Howard Brody, among others (E. D. Pellegrino 2001, Miller and Brody 2001). While this is a complex philosophical argument, proponents of IMM argue that the morality of medicine is derived from medicine itself. IMM is grounded in the clinical encounter and the relationship between the physician and the individual patient. Pellegrino specifically argues that this forms the central moral phenomenon in medicine (Pellegrino and Thomasma 1998). Thus, the importance of prioritizing the individual patient cannot be overstated.
Profession of Arms
As a society, we expect military professionals to “protect the innocent, abide by the just war theory, the laws of land warfare, and support the enduring values of American society” (Dyck 1989). The expectations of and moral obligations placed on soldiers vary greatly from those placed on physicians. As members of the profession of arms, soldiers are expected to exhibit the virtues of courage and loyalty, while prioritizing the mission and the nation over the individual.
While the discussion of the professional morality of military members is not as well developed, chivalry and other value-based codes have long shaped the practices of professional warriors. Since men and women first organized themselves for battle, there have been codes of conduct that have shaped their behaviour, specifically aimed at distinguishing honourable actions from dishonourable. Within many militaries around the world, despite the lack of any formalized document that is titled a “code of ethics,” there exist various policies, documents and publications whereby militaries attempt to ground the behaviour of its members in a specific morality (United States Army 2005, United States Army 1956). Within the United States Army, the “U.S. Army Values” are understood to be formative in teaching individual soldiers about appropriate behaviour within the military, and how to conduct themselves as soldiers. “…every day in everything they do — whether they’re on the job or off” (United States Army 2005).
The military prioritizes the mission and values of loyalty and obedience in its members in order to ensure a well-functioning institution. Without obedience to those in command, the military could not function properly, efficiently and effectively. Following orders is a critical component of military conduct because it promotes vertical cohesion and promotes the mission, avoiding the possibly dire consequences understood to be associated with mission failure. It is also undeniable that when the consequences are so significant and failure so ominous, the ethical conduct of the military is necessary to aid in its success.
The Problem of Dual-Loyalty
The professional morality of soldiers prioritizes aggregate level concerns, while that of the medical professional prioritizes the individual. The aggregate and the individual are at times mutually exclusive, and it is this conflict that creates the problem of dual loyalty. Each of these two professional groups holds special status, and both are understood to have specific obligations. Thus, it should not be surprising that when a single moral agent is conferred both sets of obligations that they find themselves in situations where they feel pulled in two directions. To further illuminate this issue, the following section will examine examples of the problem of dual loyalty in practice.
One of the most common examples of the problem of dual-loyalty is the violation of patient confidentiality under military order or in support of the military mission. There may be occasions in which physicians may be compelled to breach confidentiality, such as disease or illness that effect mission-readiness, this often includes infectious diseases, immunizations or injuries that could effect mission performance (although the degree of the breach of doctor-patient confidentiality required by military doctrine varies from country to country). Doctor-patient confidentiality is a core tenant of medical ethics, upon which much of the patient-provider trust relationship is built. However, mission readiness/performance and the possibility of endangering others pose challenges to this basic principle of medical morality.
Another significant issue of the problem of dual loyalty related to wartime or disaster military medicine is of “Treating to return to Duty.” At a general level, this refers to the act of returning an injured soldier to battle when he would normally (i.e. in civilian, peacetime medical practice) continue to receive treatment. This issue is particularly significant during times of intense combat when physicians must conserve the fighting strength. The ethical question arises in the fact that this treatment is not standard of care and places the physician squarely within a situation characteristic of the problem of dual loyalty. From a medical morality standpoint, physicians are to provide medical care that will benefit their individual patient, larger mission concerns should not factor into treatment decisions. However, within the military morality mission success and aggregate level concerns are paramount, rendering this type of treatment completely ethical. A form of this is often called “reverse triage.” A famous historical example took place in WWII in North Africa, when rationed penicillin was given to those with VD, instead of those with more substantial infections, because those with VD could return to duty sooner, and thus it was better for the military mission. This case has been hotly debated for some time.
A final example of the problem of dual-loyalty is medical civilian assistance programs, often known as humanitarian missions. This example of the problem of dual loyalty has not received as much attention as those discussed above, despite the fact that thousands of physicians have participated in these types of missions in many national militaries around the world(Eagan Chamberlin 2013). At a basic level, these programs/missions involve the deployment of uniformed military medical personnel to provide medical care to civilian populations as part of an official military mission or program. Very importantly, the goals of these programs are not simply medical (although medical or humanitarian is generally in their official title), rather the goals are both military and medical, often with military or strategic goals prioritized or emphasized over medical goals, which are often understood by program design or policy to be only secondary goals or even merely ancillary benefits. This prioritization of goals makes these programs unique and different from forms of disaster response and civilian programs and missions that may at first glance appear similar. The strategic intent of these programs is apparent in the doctrine that shapes/establishes them, reports from the missions, as well as the accounts of individual participants (Eagan Chamberlin 2013). According to these sources, medicine was understood as a tool of strategy and often-called a “non-lethal weapon,” with strategic goals including: “Winning Hearts and Minds,”pacification of civilian populations, intelligence gathering, training, and international relations (Eagan Chamberlin 2013).
However, using medicine as a tool of strategy has created a morally complicated space for the physician soldier. Often these missions prioritize military or strategic goals, which limits medical care and is detrimental to medical goals. Physicians express deep discontent with their limited ability to care for patients (Eagan Chamberlin 2013). Restrictions are placed on the providers by both their own military and government as well as the host nation. The restrictions can affect the supply of medications, access to patient population and program length. Program length is still a significant source of strife for military medical providers. Despite the fact that these missions are short-term, these doctors are confronted with populations suffering from endemic disease and poverty, lack of basic sanitation, potable water, and proper nutrition. They cannot begin to address these health problems, leaving providers feeling morally trapped. Military physicians have not been equipped to deal with such moral conundrums by military doctrine or professional training. Their dissatisfaction & frustration is apparent in the words of physician participants. One described the MEDCAPs of Vietnam as “the medical discipline being prostituted for a less worthy purpose” (Wilensky 2004). They were limited by time, supplies and military regulation, which impeded their ability to provide the care they felt that their patients needed. They expressed the knowledge that these programs were providing horrible medical care, but were, in fact, an excellent tool of strategy. In interviews they shared many ethical dilemmas and great moral turmoil.
There are many similarities between the professions of medicine and the military. These similarities have been explored in order to show the necessity of recognizing the internal professional morality of both professions, expanding on the one-sided debate that assumes internal morality of medicine, while ignoring the professional morality internal to the military.
It is this experience of identifying as both a soldier and a physician that creates the problem of dual loyalties. The internal morality of medicine emphasizes and prioritizes the health and healing of individual patients. Conversely, the internal morality of the military emphasizes service to and security of the state, an aggregate-level client. The contrast of medicine’s obligation to the individual and the military’s obligation to the many can leave military physicians morally confused. Thus, it is easy to imagine situations that could place these two obligations in competition. By combining the professions of medicine and the military and conferring both sets of obligation onto a single moral agent, the Army institutionalizes this ethical conflict. Although peacetime military medicine may pose fewer, if any, problems to medical morality, situations will arise when the two professional moralities conflict. This conflict is inherent in the different and divergent obligations of these two professions. Prioritization of the individual and the aggregate can be mutually exclusive, making it difficult to fulfill moral obligations to both.
The aim of this paper is to draw attention to the uniquely complicated moral space of military medicine, which is created both by the context of the man-made disaster of war and the institutionalization of the problem of dual-loyalties. These problems are not addressed within modern professional militaries; physicians are left in the dark to figure out how to balance their dual loyalties, and this needs to change. International militaries fail to recognize these dilemmas, nor do they adequately prepare their physician-soldiers through education, reflection or military training. Instead many militaries convey confusing and contradictory messages, urging these military physicians to be simultaneously both a ‘doctor-first’ and a ‘soldier-first’—this is a strangely schizophrenic message that is both inappropriate and impossible. These physician-soldiers must be prepared and taught to balance their two professional obligations.
Source: Medical Corps International Forum (4/14)