To illustrate how dual loyalties can influence decisions of U.S. military health care providers, two case studies were presented based on circumstances 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 occupational medicine and sports medicine. In occupational medicine, particularly 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 productivity goals. In sports medicine, a triad of decision makers—physician, coach, and athlete—typically make a joint decision, based on a full assessment of risks and benefits offered by the physician.

Treating detainees in ethically charged circumstances, such as a hunger strike, provided the situations for the second case study. International declarations require physicians to respect the autonomy of hunger strikers, who may have no other recourse to protest conditions of confinement. 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 important to earn prisoners’ trust and to use that trust to defuse potential crises by seeking alternatives, such as transferring the striking prisoner to another health facility.

The hunger strike case study showed that two factors are fundamentally 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 component 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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