SUMMARY1

This report summarizes the proceedings of a one-day workshop, “Military Medical Ethics: Issues Regarding Dual Loyalties,” convened by the Institute of Medicine on September 8, 2008. The purpose of the workshop was to examine ethical challenges for physicians and other health professionals serving in the military that arise from conflicts between their responsibilities to patients and their duties as military officers. Dual loyalties exist in many medical fields, from occupational health to public health. Military health professionals, as all health professionals, are ethically responsible for their patients’ well-being. In some situations, however, military health professionals can face ethical tensions between responsibilities to individual patients and responsibilities to military operations.

Indeed, everyone has conflicting allegiances, partly as a matter of choice and partly as a matter of chance. Because dual loyalties involve multiple responsibilities that are not usually laid out in parallel or made to reinforce each other, moments of tension arise between them. The workshop proceeded from the premise that such conflicts are best brought to light and discussed by military and civilian leaders rather than relegated to individuals to cope with them alone in situations of stress.

1

The planning committee’s role was limited to planning the workshop, and the workshop summary has been prepared by the workshop rapporteurs as a factual summary of what occurred at the workshop.



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SUMMARY1 This report summarizes the proceedings of a one-day workshop, “Military Medical Ethics: Issues Regarding Dual Loyalties,” convened by the Institute of Medicine on September 8, 2008. The purpose of the workshop was to examine ethical challenges for physicians and other health professionals serving in the military that arise from conflicts be- tween their responsibilities to patients and their duties as military offi- cers. Dual loyalties exist in many medical fields, from occupational health to public health. Military health professionals, as all health profes- sionals, are ethically responsible for their patients’ well-being. In some situations, however, military health professionals can face ethical ten- sions between responsibilities to individual patients and responsibilities to military operations. Indeed, everyone has conflicting allegiances, partly as a matter of choice and partly as a matter of chance. Because dual loyalties involve multiple responsibilities that are not usually laid out in parallel or made to reinforce each other, moments of tension arise between them. The workshop proceeded from the premise that such conflicts are best brought to light and discussed by military and civilian leaders rather than relegated to individuals to cope with them alone in situations of stress. 1 The planning committee’s role was limited to planning the workshop, and the work- shop summary has been prepared by the workshop rapporteurs as a factual summary of what occurred at the workshop. 1

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2 MILITARY MEDICAL ETHICS: ISSUES REGARDING DUAL LOYALTIES To illustrate how dual loyalties can influence decisions of U.S. mili- tary health care providers, two case studies were presented based on cir- cumstances that a provider might encounter in the military setting. Decisions regarding whether to return an injured servicemember to duty after a closed head injury, despite the risk of greater harm, offered the situations for the first case study. Return-to-duty decisions are replete with unintended consequences, ranging from impacts on a soldier’s (or disabled veteran’s) compensation to effects on the morale and overall performance of the individual and the fighting unit. One consideration in these decisions is that there are opportunities in military service to return a servicemember to duty on a trial basis with the potential for change of duty or evacuation as needed. Dual loyalty situations, with some relevant similarities, exist in oc- cupational medicine and sports medicine. In occupational medicine, par- ticularly in small corporations, where the physician or nurse reports directly to corporate executives, an injured employee’s desire to return to work in order to obtain full benefits may conflict with corporate produc- tivity goals. In sports medicine, a triad of decision makers—physician, coach, and athlete—typically make a joint decision, based on a full as- sessment of risks and benefits offered by the physician. Treating detainees in ethically charged circumstances, such as a hun- ger strike, provided the situations for the second case study. International declarations require physicians to respect the autonomy of hunger strik- ers, who may have no other recourse to protest conditions of confine- ment. The U.S. Department of Defense (DoD) policy of beneficence would permit force-feeding to save a prisoner’s life. In the civilian world, physicians working in correctional facilities have found it impor- tant to earn prisoners’ trust and to use that trust to defuse potential crises by seeking alternatives, such as transferring the striking prisoner to an- other health facility. The hunger strike case study showed that two factors are fundamen- tally important in ethical decision making: the presence of organizational resources to help physicians manage ethical quandaries without having to resort to heroic tactics, and the recognition of the particular and often distinctive circumstances of each case. At times there is a cultural com- ponent to ethical issues involving hunger strikers. For example, Islamic scholars have advised that hunger-striking to the point of impending death is not a valid action in their faith, so long as detainees are allowed to perform their religious duties.

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3 WORKSHOP SUMMARY Addressing the need for training in medical ethics can involve a range of approaches. At the Uniformed Services University of the Health Sciences, medical ethics is an essential element of the core curriculum and encompasses varied teaching methods, including inviting speakers to discuss their experiences, case study discussions, and field practice exer- cises. Continuing education of health professionals offers ongoing oppor- tunities to learn from interdisciplinary perspectives. Training outside the classroom in a real-world situation, such as aboard a naval hospital ship on a humanitarian mission, offers teachable moments for addressing ethical dilemmas. Innovative approaches for enhancing ethics training are being tried in various contexts. For example, at Northwestern Univer- sity, training in ethical issues in palliative medicine includes interdisci- plinary hospital rounds, interactions with patients in nonclinical settings, and instruction focused on real patients and their life experiences— sometimes presented through videotaped interviews. Organizational values and behavior strongly influence adherence to ethical principles. In the military, the commander sets the tone, as does his or her counterpart in civilian senior management. A just organization exhibits ethical awareness, judgment, and motivation and implements ethical standards. A step that organizations can take to strengthen their ethical infrastructure is to establish an ombudsperson’s office to investi- gate individual complaints and report findings in the aggregate, without personal identifiers. Ensuring that organizations act ethically requires involving staff at many levels, along with organizational feedback, delib- eration, organized advocacy, and appropriate checks and balances, some of which may be external to the organization. Within the military services, primary responsibility to the patient should prevail in nearly all circumstances. This workshop focused on situations in which ethical conflicts arise because of dual loyalties. Workshop participants emphasized several points: • Dual loyalty situations can occur in military medicine, although in most routine aspects of health care, military medicine is simi- lar to civilian medicine. • Models used in occupational medicine, sports medicine, and prison medicine, among others, can be informative in consider- ing ways to address ethical issues in military medicine. • Some important differences exist between international declara- tions and DoD health policies regarding hunger strikes. The two views cannot easily be reconciled in the abstract, but, in many

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4 MILITARY MEDICAL ETHICS: ISSUES REGARDING DUAL LOYALTIES situations, consideration of individual circumstances could lead to the same result under either approach. • Ethical considerations relevant to military medicine include par- ity, elasticity, and primum non nocere. 2 Transparency of policies and practices should be paramount, except in those situations when legitimate security concerns require setting limits on the disclosure of information. • Patient trust in health care professionals is vital for a productive provider–patient relationship, yet sometimes difficult to engen- der in circumstances of dual loyalty. • Ethical decision making requires more than prioritizing separate principles, such as autonomy and beneficence. The ethical prin- ciples must be recognized, specified, and balanced in practical ways that build trust and preserve the dignity of each person. INTRODUCTION • Are there situations in which military medical ethics differ from the ethics of a civilian medical practice? If so, how do the obli- gations of a military officer and a military health professional differ? • What other models could be used to examine these conflicts (e.g., occupational health)? • How do existing national and international standards of medical ethics apply to military physicians, and what is their relationship to national and international law? • What are the ethical principles that guide medical practice for military physicians? Do these principles differ from those of the broader medical community? These four central questions were the starting point for discussion at an all-day workshop, “Military Medical Ethics: Issues Regarding Dual Loyalties,” conducted by the Institute of Medicine (IOM) of the National Academies on September 8, 2008. Jointly sponsored by the Office of the Assistant Secretary of Defense for Health Affairs and the Greenwall 2 In this context, parity refers to equality in treating patients, elasticity refers to flexibil- ity in implementing policies, and primum non nocere is the historic principle of “first, do no harm.”

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5 WORKSHOP SUMMARY 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 prescrip- tion 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 lim- ited to determining the format, setting the agenda, and choosing speak- ers, session moderators, topics, background readings, and two case studies to be used in the discussion. This report was prepared by the rap- porteurs 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 loy- alty situations (also termed mixed agency) as those in which health pro- fessionals 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 loyal- ties—decisions regarding returning servicemembers to duty following an injury or health concern and decisions regarding the care of hunger strik- ers. 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 exam- ined (Strasburger et al., 1997); and

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6 MILITARY MEDICAL ETHICS: ISSUES REGARDING DUAL LOYALTIES • public health practice, where a community’s interest in immuni- zations or quarantine may conflict with an individual’s interest, religious conviction, or preference. It is difficult for ethical arbiters and instructors to articulate the pre- cise ethical obligations of physicians in such varied, complex, and pres- sured situations. However, once articulated in the abstract, these obli- gations also must be effectively imparted to, and internalized by, current and future physicians likely to face such dilemmas. Educational models for medical ethics exist in several settings, such as military medical edu- cation, training in end-of-life care, and preparation of medical ombuds- persons. TOWARD A FRAMEWORK FOR RESOLVING DUAL LOYALTIES The workshop discussion commenced with a description of its con- text. The immediate and vital task in resolving dual loyalties is to lay out the difficulties. IOM President Harvey Fineberg observed, “Every one of us in our lives takes on different roles, some of them by chance, and some by choice.” Legal contracts, moral compacts, and other allegiances affect these relationships and responsibilities. Volunteers in the U.S. military service accept profound responsibilities—on oath 3 —but often these responsibilities are not clearly laid out in parallel or made to rein- force each other. As a result, said Fineberg, “moments of tension” arise, morally and in other ways. He offered as an “underlying premise” of the workshop the belief that these difficult issues do not benefit from being ignored or secretly managed or considered to be implicit. Rather, discus- sions such as those conducted during this workshop “can provide an op- portunity for reconciliation, for clarity, for decision making that will be based on ethical principles and guided by the realities” in carrying out the dual roles of health professional and military officer. 3 The oath of office of military officers is similar to oaths taken by civilian officials: “I . . . do solemnly swear (or affirm) that I will support and defend the Constitution of the United States against all enemies, foreign or domestic; that I will bear true faith and alle- giance to the same; that I take this obligation freely, without any mental reservations or purpose of evasion; and that I will well and faithfully discharge the duties of the office upon which I am about to enter, so help me God” (U.S. Army, 2004).

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7 WORKSHOP SUMMARY Negotiating ethical issues in military medicine is not simply a matter of implementing previously agreed-upon principles. Applying these prin- ciples in real-world situations involves health professionals making prac- tical judgments in complex circumstances. Joseph Kelley, Deputy Assistant Secretary of Defense for Clinical and Program Policy, observed that issues of medical ethics in the military often correspond to conten- tious issues in civilian medical practice. For example, the military deci- sion about return to duty is similar to the decision in sports medicine about keeping a player in a game, and the military physician’s need to recognize organizational interests is similar to the pressure exerted on the managed care physician to deny expensive medical procedures that are not cost-effective. Opportunities exist to improve the training of both military and civilian health professionals in working through these com- plex issues. Facing dual loyalties is nothing new for physicians and other health professionals; these issues have a history in military and other contexts and have often evoked vigorous and even heated discussion. Workshop Planning Committee Chair James F. Childress, Director of the University of Virginia Institute for Practical Ethics and Public Life, observed that the workshop discussion is designed to bring varied perspectives together to focus on opportunities for improving policy, practice, training, and individual and organizational decision making relevant to these types of ethical dilemmas. Childress noted that the intent of the workshop is not to investigate past allegations. In addressing dual loyalty, Childress said, the workshop will discuss which ethical principles are involved, whether these principles must be prioritized, what guidance exists and what needs to be developed, and who the ultimate decision makers are as well as how the training and other support they need will be provided. Ethically defining and balancing multiple role responsibilities and divided loyalties are the challenges for the discussion and for future action. ETHICAL DECISION MAKING: RETURN TO DUTY The participants in the first panel discussion considered a case study of ethical challenges to physicians charged with recommending whether to return a sick or injured servicemember to combat (or other fields of duty) (Box 1). The case study, involving a traumatic brain injury and risk of posttraumatic stress disorder (PTSD), included two situations that dif- fered in whether the soldier wished to return to combat.

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8 MILITARY MEDICAL ETHICS: ISSUES REGARDING DUAL LOYALTIES BOX 1 Case Study 1 Return to Duty: Ethical Issues for Military Health Professionals A U.S. soldier suffers injuries from the explosion of an improvised explosive device. Injuries include closed-head injury resulting in loss of conscious- ness. After six weeks of treatment, the soldier is medically stable and func- tional, though he continues to complain of fatigue, disturbed sleep, and daily headaches. It is likely that he would be at higher risk for more severe impairment and PTSD if he were to suffer another similar explosion result- ing in further traumatic brain injury. Situation 1: The soldier is eager to return to the front lines and even when provided with the information on potential detrimental health consequences is willing to take his chances and return to his unit. The soldier is very insis- tent that he understands the risks and feels that the best way to resume his life is to return to his unit. His commanding officers express the strong need for his expertise and experience but do not exert any pressure to return the soldier to his former patrolling duties. Situation 2: The soldier does not want to return to his patrolling duties and asks for reassignment. The physician suspects that the soldier may be exaggerating the symptoms that he is experiencing, though clearly consid- erable residual effects remain. However, personnel levels are low, with re- placements several months down the road. Soldiers with his level of experi- ence are desperately needed for upcoming missions, and there is strong pressure from the chain of command on the treating physician to sign off and return the soldier to his patrolling duties. Considerations: • What principles are in conflict? • What guides the clinician in approaching each situation? • What about the setting makes this situation different from civilian set- tings? Are the differences enough to warrant a separate rule? • Who is the ultimate decision maker regarding decisions on return to the battlefront? • What mechanisms or resources would help the health professional in resolving this conflict?

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9 WORKSHOP SUMMARY Military Considerations The concept of fitness for duty incorporates the health of the individ- ual and the overall health of the force. Even the health of the individual involves a multifaceted set of ethical factors. Colonel Elspeth Cameron Ritchie, Medical Director for Strategic Communication in the Army Medical Department, noted an increased emphasis in military medicine in recent years on patient education, prevention, and early diagnosis. The commander has the final call regarding return to duty, said Ritchie, but usually relies on physician recommendations, particularly when there is a recommendation for a medical evaluation board. Data on decisions regarding return to duty are difficult to obtain be- cause most communication has occurred through a paper medical profile that conveys health status and treatment information from the physician to the commander. As electronic medical records become more wide- spread, these data will become more accessible. As a psychiatrist, Ritchie focused on behavioral health while noting similar issues for other medical fields. She outlined several key factors taken into account in return-to-duty decisions. In 2006 the DoD Office of Health Affairs developed standards for all military services requiring that deployed servicemembers meet military retention standards in order to be deployed and requiring a pattern of stability for three months for spe- cific behavioral health diagnoses. A waiver process is available. Ritchie said that to date, 88 waivers have been requested with 22 of those disap- proved. Determining the level of impairment for some psychiatric condi- tions can be challenging, given the potential impact of working in the operational theater. Decisions regarding acceptable medications for de- ployment (DoD, 2006a) have been made more complex by use of newer medications for some psychiatric conditions that may provide greater long-term stability when used in low doses. Although servicemembers on permanent antipsychotic regimens have been prohibited by policy from being returned to duty, newer medications, such as quetiapine, may pro- vide long-term stability when used in low doses for treatment of symp- toms associated with psychiatric conditions. Other factors that affect return-to-duty decisions include access to treatment. Improved access to more sophisticated health care services now exists for PTSD and other mental health problems in mature theaters of operations, such as parts of Iraq. Further, return-to-duty decisions can include returning the servicemember to duty on a trial basis, with the po- tential for change of duty or evacuation as needed. Ritchie noted that the

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10 MILITARY MEDICAL ETHICS: ISSUES REGARDING DUAL LOYALTIES number of psychiatric casualties suffered by U.S. troops has not gone down and that there have been 20 to 40 evacuations per month for psy- chiatric reasons throughout the course of the war. Return-to-duty decisions are fraught with the potential for unin- tended consequences. For example, a decision not to return a service- member to duty can, in some cases, result in an administrative separation without disability compensation. And, for some patients, isolation from the soldier’s usual environment can prove harmful emotionally. A deci- sion to remove a soldier from harm’s way for mental health reasons can potentially stigmatize the soldier. In addressing the two situations of the case study, Ritchie com- mented that motivated soldiers who use the resources available for as- sessment and treatment have options available to return to duty at the pace needed or on a trial basis. Working with an unmotivated service- member involves discussions between the commander and the physician with the possibility of temporary changes in job duty station or trial duty options. Occupational Health Parallels Occupational health professionals face ethical conflicts that may be instructive to their military counterparts. Several professional associa- tions, including the American College of Occupational and Environ- mental Medicine and the International Commission on Occupational Health, have addressed dual loyalties—to the patient and to the em- ployer—and call for putting responsibility to the patient first (ACOEM, 2008; ICOH, 2002). Large firms and other organizations usually try to return employees to work promptly, even if in another capacity. Myron C. Harrison, Senior Health Adviser at ExxonMobil Corporation, sug- gested that, by contrast, small organizations may need the employee in the same job and may not have the flexibility to assign individuals to new roles. Another difference is that in large organizations occupational medicine physicians typically report to another physician and therefore are somewhat insulated from business priorities, whereas their counter- parts in smaller organizations often report to executives with bottom-line responsibilities who may be less tolerant of medical excuses. In smaller corporations, Harrison noted that the occupational health professional may also be more isolated. Occupational health often involves triaging and referring patients to specialists in the community. This involves early

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11 WORKSHOP SUMMARY case management by working with the patient, family, and supervisor or management. External referrals are also used to assess the worker’s abil- ity to return to work, thus providing transparency and a greater measure of independence. Harrison described ethical conflicts that typically involve competing “rights.” Some matters, such as protections of employee confidentiality, are now prescribed by law and are dealt with through legal approaches. On ethical issues without legal mandates, Harrison noted that there are few if any algorithmic-type answers. As a touchstone, Harrison sug- gested that an act that deceives someone, whether the individual or the employer, probably is unethical. If no one—employee, manager, or labor union—is being deceived, then the matter probably is being handled transparently and on an ethical track. Harrison highlighted that safety- sensitive situations are managed very tightly with limitations on em- ployee autonomy when third-party and plant safety is a concern. Similar to medical profiles in the military (used for communicating medical treatment issues relevant to duty status between military physi- cians and commanders), communications by occupational health profes- sionals to the worker’s supervisor focus on conveying the limitations dictated by the patient’s health status. Regarding the case study, Harrison observed that the accuracy of the individual’s description of symptoms often is doubted in cases such as those described in the second situation, when the individual does not wish to return to work, but is almost never doubted in the first situation, when the individual wishes to return. In a scenario similar to that of the motivated soldier, some occupational physicians would practice paternal- ism and would write a restriction from work, Harrison stated; relevant considerations include the magnitude of the risk and imminence of harm to the patient. In the situation of the unmotivated soldier, Harrison dis- cussed temporarily placing the patient in a noncombat role while taking time to observe any progress. Sports Medicine Parallels Sports medicine offers other possible ethical parallels with military medicine. In competitive professional or interscholastic sports, a decision to return a sick or injured player to the field or court usually involves a triad of decision makers: the coach, the player, and the physician. Kurt P. Spindler, Professor of Orthopaedics and Rehabilitation at the Vanderbilt

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26 MILITARY MEDICAL ETHICS: ISSUES REGARDING DUAL LOYALTIES The instruction occurred during transits between ports, as those were the teachable moments when personnel were on board and no one was actively treating patients. In providing care quickly overseas to thousands of victims of natural disasters or epidemics, these health care workers and volunteers must balance the health of individual patients with the health of the population. The ethics course was case-based and included structured discussion; this format elicited a great deal of discussion about personal experiences. The training also adapted a human rights impact assessment tool for public health interventions and policies (Box 3). Schor noted the dearth of peer-reviewed literature on the ethics of hu- manitarian assistance as well as the need for ethical considerations to “seep” into the planning, implementation, and assessment phases of hu- manitarian assistance missions. BOX 3 Adapted Human Rights Impact Assessment Tool for Public Health Interventions and Policies 1. Is there a clearly defined compelling and justified public health purpose? 2. Is the program/policy appropriate and likely to be efficient and effective? 3. Is the intervention well-targeted (neither overly inclusive nor under- inclusive)? 4. Are any civil, political, social, economic, or cultural rights being infringed upon or any ethical principles being violated? 5. Are there alternative interventions that are less intrusive/invasive or that have fewer ethical encumbrances? 6. Is the intervention likely to avert significant harm? 7. Are there procedural safeguards in place to ensure equity, fairness, and accountability? 8. Are the decision-making and intervention processes transparent to all concerned? SOURCE: Adapted from Gostin and Mann (1994).

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27 WORKSHOP SUMMARY Scenarios presented in the onboard training exercises included • conflict between the opinions of health professionals and force protection rules—for example, when surgical complications arise and overnight care for the patient could compromise the medical team’s safety; • the impact on the host nations—for example, the impact of the mission on the livelihood of local physicians and other health professionals; • questions about whose standard of care should prevail when U.S. health professionals practice in another country; • resource allocation decisions and public communication needs when more patients arrive to be treated than can be cared for; and • the importance of being knowledgeable about and respecting cul- tural traditions in the host country. Improving the Teaching of Ethics Experiences in teaching medical ethics in palliative care and geriat- rics—disciplines that concentrate on the whole person rather than on dis- ease processes—could inform training in medical ethics in a range of contexts. Joshua Hauser, Assistant Director of the Northwestern Univer- sity Buehler Center on Aging, Health & Society, noted that ethical issues in palliative care include medical futility, informed consent, assisted sui- cide, autonomy, and team responsibility. Efforts to improve education in palliative care are led by the Educa- tion in Palliative and End-of-life Care Project, which has included a fo- cus on ethics education. Students have complained that ethics training can be too abstract or boring. The following are some basic principles found to improve the teaching of ethics to health professionals: • Make it real—use real patients and real situations. • Make it novel—challenge the students’ assumptions and use new approaches to connect the patient and student. • Make it engaging. • Make it convenient. • Make it relevant.

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28 MILITARY MEDICAL ETHICS: ISSUES REGARDING DUAL LOYALTIES Hauser has found the greatest success in teaching ethics by engaging students directly in both structured and unstructured situations and apply- ing novel education methods, such as multiprofessional conversations (sometimes termed “Schwartz Center Rounds” 8 ), role play, videotaped interviews with patients, and community settings. (For illustrative pur- poses, he played a videotape excerpt of an interview with a terminally ill lung cancer patient discussing her interactions with comfort caregivers.) Videos allow the instructor to bring out different aspects of the patient’s care and specific ethical issues while focusing on the realities of the situation. Opportunities for ethics training exist throughout the training proc- ess. For example, in the first two years of medical school, students can follow patients longitudinally under close faculty supervision. During clinical years, students can interact with patients in different contexts and will encounter broader issues through interactions with family members and others involved in the care of the patient. Discussion Howe, who moderated the session, asked whether more patient- centered videos should be produced to serve as a core method of teaching medical ethics and, if so, when they should be shown and to whom. Schor answered that they should be shown at the start of medical mis- sions and commented that in the onboard exercises, participants such as military physicians and Project HOPE volunteers enjoyed learning each other’s perspectives. Emerging information technologies offer exciting opportunities for disseminating and sharing information, opinions, and experiences regarding ethical challenges. Developing ethics training that is real, practical, and timely requires choosing material that relates to the learning objectives. Policy issues can be perceived from the top down, such as who decides, or from the bot- tom up, such as how to deal with uncertainties. Problems that arise in medical practice often can be identified by asking students to recount an experience when they were not sure of the right action to take. While 8 Schwartz Center Rounds engage physicians, nurses, social workers, students, and other health professionals in interdisciplinary rounds in the hospital or other health care setting. Named for an attorney in Massachusetts who felt that his professional caregivers needed to improve their communications with each other, the Kenneth B. Schwartz Cen- ter funds these efforts around the country (Kenneth B. Schwartz Center, 2008).

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29 WORKSHOP SUMMARY preserving the productive and important tension between commanders and military health professionals, continuing education provides a means for discerning the two groups’ mutual interests and learning practical ways of realizing them. INSTILLING ETHICAL VALUES: ORGANIZATIONAL STRUCTURE AND CULTURE The participants in the fourth panel discussion considered how or- ganizational structure and culture can affect, nurture, and sustain ethical values. Organizations are living systems that have moral capacity and that are accountable to stakeholders for their standards of purpose and value. Session moderator Linda Emanuel, Director of the Northwestern University Buehler Center on Aging, Health & Society, explained that such standards determine an organization’s culture, structure, processes, and outcomes. Emanuel said that the present discourse between the medical profession and the military should lead to standards that would apply across sectors and disciplines—which have interdependent and balanced roles—and could evolve through continuous learning. Nurturing a Just Culture What is a just organization? David T. Ozar, Professor of Philosophy at Loyola University of Chicago, posited that a just organization affirms the role it assigns to its members to make complex ethics-laden deci- sions. Further, it supports these decisions by providing necessary com- munications, education, and other organizational processes. A just organization communicates openly about decisions after the fact to effect improvements, and it commends rather than punishes individuals for bringing ethical issues to light. At all levels, Ozar suggested, a just or- ganization demonstrates adherence to its professed values. Organizations can influence ethical conduct, according to Ozar, through positive impact on their members’ ethical awareness, judgment, motivation, and implementation. A just organization, he said, • fosters a rich awareness of, and sensibility for, its stated values and ideals, not just in generalities but in ways linked to actual decisions “on the ground,” rather than leaving individuals to

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30 MILITARY MEDICAL ETHICS: ISSUES REGARDING DUAL LOYALTIES their own devices, and it tests its structures and processes to en- sure that they are producing ethical results; • emphasizes the complexity of ethical decisions and the difficult judgments they require, provides resources to support individu- als’ ethical reflection and judgment, and commends individuals for displaying such reflection and judgment (e.g., in the military context, neither commanders in theater nor superiors within the medical hierarchy should expect physicians to act in isolation or blame them for ethical decisions not anticipated by rules and regulations); • supports the positive motivations of its members by focusing its systems on positive values rather than using coercion and fear to attain results, and responds to ethical lapses first of all as organ- izational issues rather than personal aberrations; and • actively assists its members to implement ethics consistently by identifing barriers to ethical conduct, developing a repertoire of interventions to assist individuals in making ethical decisions, and establishing a communication system for promoting ethical decision making before, during, and after an event. In this con- nection, most lapses in implementation can be attributed either to psychological barriers, such as fear and hopelessness, or practi- cal barriers, in which the individual does not know how to decide or where to turn for consultation. To illustrate the importance of dialogue about these components of ethical conduct with members of an organization at all levels, Ozar re- counted the changes at one hospital that occurred through asking em- ployees about impediments to realizing the hospital’s core values. After hearing a patient transport assistant’s concern about having to leave pa- tients isolated on gurneys without a way for them to summon assistance, the hospital responded by reconfiguring the units so that waiting patients could see and be seen by a receptionist. Respectful and serious conversa- tions with people on the ground can lead to important systems and organ- izational changes that can markedly increase the chances that the organization’s values and ethical standards will be actualized in its mem- bers’ judgments and conduct.

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31 WORKSHOP SUMMARY Leadership and Vertical Integration No substitute exists for leadership that is explicitly, materially (through the dedication of resources), and passionately committed to the ethical pursuit of an organization’s mission. Daniel D. Federman, Profes- sor of Medicine and Medical Education at Harvard Medical School, said that the commander sets the tone and that, ideally, the highest levels of leadership communicate their commitment to ethics with the same em- phasis as other goals. Federman stressed the need to review allegations of ethical infractions quickly and as publicly as possible. An ombudsperson function was added at Harvard Medical School over 17 years ago to hear and investigate, confidentially, complaints about administrative malfunctions—or, more broadly, any institution- related concerns. An ombudsperson is, in large measure, a listener, with access to many sources of information and the responsibility to report on anonymous complaints. The Harvard ombudsperson issues a broadly dis- seminated annual report that reveals patterns and trends; in this way, an individual’s confidential complaint carries weight as part of aggregated information. For example, frequently expressed complaints have led to improvements, or at least heightened sensitivity, in the areas of sexual harassment, research integrity, and intellectual property at the medical school. Reports are provided by the ombudsperson’s office in many set- tings to get the messages to multiple key audiences in the medical school, including the administration, faculty, new employees, managers, mentors, and the human relations office. The cumulative impact of the ombuds function is to hold up a mirror, allowing the institution to re- shape itself if it does not like what it sees, said Federman. Learning and Accountability in Organizational Structures What are next steps in making organizations more ethically attuned? Emanuel discussed building learning and layered accountability into or- ganizations. Ensuring that organizations act ethically requires layered stages of professional voices, including an external voice, she said, as well as organizational feedback, deliberation, organized advocacy, and disobedience when necessary. Conflicts of interest provide an example of an ethical problem that can be addressed through a set of approaches appropriate to the level of ethical concern. Under current rules in force in most settings, some con-

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32 MILITARY MEDICAL ETHICS: ISSUES REGARDING DUAL LOYALTIES flicts are flatly prohibited, some are limited, and some are merely dis- closed, depending on a variety of factors, namely, the sum of money at stake, the proximity of the conflict to patient care, and the values in- volved. Checks and balances within an organizational structure are not necessarily sufficient to prevent undue conflicts of interest from arising. For example, at the American Medical Association (AMA), accountabil- ity appeared to translate well into the structure. However, in 1997 AMA entered into a marketing agreement with the Sunbeam Corporation 9 that violated the organization’s ethical principles. In addressing this situation, AMA found that the problem had resulted from a lack of transparency coupled with poor decision making. The challenge after a major lapse is to learn from the mistakes and work to restore positive culture and lead- ership, Emanuel said. Structural mechanisms useful for promoting medical ethics within a health care organization include • peer review; • advisory boards; • institutional review boards, for investigative research; • systems engineering and continuous learning and improvement (in the patient safety area, for example, effective approaches in- corporate teamwork and opportunities for speaking against the authority gradient and for both anonymous and compulsory re- porting of lapses); and • involvement of multiple professions, such as clergy, educators, and social workers. As the military continues in its efforts as a learning organization, it is important to identify, refine, and institutionalize mechanisms for contin- ued deliberation on issues in military medical ethics. Discussion The panel members had an opportunity for discussion followed by general discussion with the workshop participants. One barrier to organi- zation-wide ethical behavior is the “myth of enough good people,” Ozar 9 The marketing agreement allowed Sunbeam to display the AMA logo on packages of its products, regardless of whether the product provided a demonstrated health benefit.

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33 WORKSHOP SUMMARY remarked. According to this myth, if we just recruit enough good peo- ple—the best and the brightest—into our organization, we will not have any ethical problems. Lieutenant General Eric Schoomaker, U.S. Army Surgeon General, commented that the discussion in the workshop had recognized that the ethical issues faced by military health professionals are a microcosm of ethical issues faced by the larger medical community in the United States. Some ethical conflicts arise from situations in which there is a misunderstanding about servicemember’s rights, such as the right of the individual, under ordinary circumstances, to refuse treatment. Further efforts are needed to continue to examine competing ethical principles and to explore the concerns about security to ensure the highest level of transparency that is feasible. Several participants noted that there are a number of organizational structures in place in the military that support whistle-blowing, including ombudsperson offices and ethics experts who are outside the normal chain of command. Although these structures appear to be transparent and known by military health professionals, they are apparently less fa- miliar to their civilian counterparts. CONCLUSIONS AND NEXT STEPS The workshop concluded with James Childress summarizing the day’s discussions, Joseph Kelley providing his thoughts on next steps, and workshop participants presenting final thoughts. Childress summarized the presentations and discussions during the workshop in the following 10 points: 1. The need for transparency in policies and processes related to military ethics was affirmed, as were the challenges in further achieving it both internally and externally. 2. Military medical ethics discussions benefit from a wide range of public and professional perspectives. 3. In addressing medical ethics issues, we need to attend— imaginatively and thoughtfully—to diverse social and cultural views, beliefs, and practices. 4. Organizational structures, systems, training, and procedures need to be in place so that individual actors do not have to act hero- ically to ensure ethically proper decisions.

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34 MILITARY MEDICAL ETHICS: ISSUES REGARDING DUAL LOYALTIES 5. International and domestic laws supporting medical ethics are essential but do not obviate the need for ethical analysis. 6. Codes of ethics help to guide ethical behavior by physicians and other health professionals but are not specific enough to address each individual ethical issue that comes up in clinical practice. 7. Similarities and differences between dual loyalties in the military and dual loyalties in other fields, such as occupational and sports medicine, are illuminating and instructive. 8. Patient trust in health care professionals is vital, yet difficult to engender in circumstances of dual loyalty. 9. Ethical dilemmas can be either intra-agent—reflecting situations when different moral principles conflict—or inter-agent, such as between a military commander and a physician. 10. Ethical decision making requires more than prioritizing separate principles, such as autonomy and beneficence. The principles must be made concrete and ways found to be as specific as pos- sible about how to apply them in practice. Childress emphasized this last point by stating that ethical principles alone may not provide enough practical guidance. Ongoing efforts fo- cused on defining specific ethical responsibilities are needed in certain settings. Kelley began his summary of the workshop by highlighting the con- cept of the triad—patient, physician, commander—and emphasizing the need for communication. Although the workshop focused primarily on the policy perspective, it will be important for future discussions, Kelley noted, to focus on the perspective of the practitioner. Kelley stressed that the military is not monolithic but has provisions in place for military health professionals to exercise their right of conscience, including sup- port for health professionals who have ethical concerns and are seeking to determine ethical courses of action. This right applies to physicians who are dealing with situations such as hunger strikes. He noted, too, that the organization is what makes the individual effective while realiz- ing that national security concerns must be addressed. Opportunities for ethics training can draw from the models presented in the workshop. Kelley emphasized the need for as much transparency as possible. He encouraged allegations of situations of concern to be shared with available information so that they can be investigated. Further, he em- phasized the need for continued dialogue on ethical issues between the military and civilian medical communities.

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35 WORKSHOP SUMMARY In the discussion that followed, participants raised several points, in- cluding • The hunger strike case study demonstrates the need for further development of ethical guidelines for military health profession- als as well as further discussions to more fully understand the na- ture of ethical concerns and the extent of opportunities for professional autonomy by military health professionals. • The military is not monolithic, and military physicians have sub- stantial professional autonomy, so similar dilemmas can produce different results. • Further discussions are needed on the structures or systems that the military has (or could have) in place to assist not only physi- cians but also other health professionals, such as psychologists, in situations where they are serving as behavioral science con- sultants. • The military has provided greatly increased guidance on medical ethics since 2006, including a substantial body of policy and standard operating procedures at the operational level. The DoD continues to be a learning organization on issues raised by de- tainee treatment—including hunger strikes, forensic roles, and training—and dual loyalty. • Increased attention to ensuring the transparency of DoD policy, guidelines, and protocols is an ongoing need with the under- standing that national security issues will be addressed. There is strong interest in continuing to find common ground and in dis- cussing ethical issues integral to hunger strike management, in- terrogation policies, and other related issues. Discussion also focused on additional next steps for open dialogue, including the formation of advisory committees to DoD through either the National Academies or other entities. These types of committees can review events involving challenging ethical components and recommend policy improvements, a mechanism that has been used by other national security–related agencies. Recent and ongoing changes in the Defense Health Board in this direction were noted, and appreciation was ex- pressed for the opportunity in this workshop to have open and reasoned dialogue with individuals with a wide range of expertise and interest. Several participants noted that interrogation issues have been controver-

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36 MILITARY MEDICAL ETHICS: ISSUES REGARDING DUAL LOYALTIES sial, and it was suggested that a forum specifically exploring these issues might be useful.