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

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Neil E. Weisfeld, Victoria D. Weisfeld, and Catharyn T. Liverman, Rapporteurs Board on Health Sciences Policy

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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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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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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. v

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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 pub- lished report as sound as possible and to ensure that the report meets in- stitutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confi- dential 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 Univer- sity and Schools of Public Health and Medicine, Johns Hopkins Uni- versity 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 Bio- ethics in Research & Health Care Although the reviewers listed above have provided many construc- tive comments and suggestions, they did not see the final draft of vii

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viii INDEPENDENT REPORT REVIEWERS 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 care- fully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution.

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Preface In finding common ground on the ethics of health care, the discus- sions 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 medi- cine 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 situa- tions 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 discus- sions 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. ix

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x PREFACE It was a privilege to chair this Institute of Medicine workshop. Plan- ning committee members and workshop speakers were diligent in their thorough preparation, thoughtful presentations, and considered com- ments. 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 insight- ful 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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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 xi

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xii CONTENTS 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