Military doctors and nurses, working neither as pure soldiers nor as merely doctors or nurses, may face a ‘role conflict between the clinical professional duties to a patient and obligations, express or implied, real or perceived, to the interests of a third party such as an employer, an insurer, the state, or in this context, military command’. This conflict is commonly called dual loyalty. This chapter gives an overview of the military and the medical ethic and of the resulting dual (...) loyalty problem for medical personnel working in the military. It considers how dual loyalties relate to being a professional, something medical personnel are the paradigmatic examples of, but also something military personnel claim to be. Against that background, the chapter elaborates on the medical rules of eligibility used in Afghanistan, and on the policies concerning military involvement in local healthcare, to see what the existing rules and policies are, and whose interests they serve. (shrink)

BackgroundFrench military doctors are currently deployed in the Sahel to support the armed forces of Operation Barkhane, in medical or surgical units. As well as supporting French soldiers, their other missions are diverse and complex: medical assistance to civilians and persons under control (PUC), advice to commanding officers. These tasks can create ethical dilemmas when decisions are forced upon doctors that may be in conflict with medical values or fundamental principles. Little is known about the specific dilemmas experienced by French (...) military doctors in overseas operations. We therefore conducted a qualitative study among doctors and surgeons recently deployed to the Sahel to explore and better understand this question.MethodSemi-structured, face-to-face interviews were conducted with 20 French military doctors or surgeons deployed since January 2016 in medical or surgical facilities in Mali and Chad.ResultsAll interviewed doctors reported having faced several ethical dilemmas during missions. All reported dilemmas involved the treatment of civilians (while delivering community medical assistance) or of PUC. The dilemmas involved choices as to which patients to treat, the use of care as a means to an end by military authorities, and the level of care attainable in the absence of any possible hospital follow-up. Questions of delivering care at the risk of their own safety or the mission’s and of treating openly hostile patients were also brought up. Several dilemmas stemmed from the dual loyalty problem, namely the conflict between military doctors’ duty of care to patients and to the military institution, but this was not the only factor involved. Contextual factors (restricted resources and security constraints) and psychological factors (especially hostility towards the enemy) were also associated with many of the reported dilemmas.ConclusionThis is the first reported study focusing on the ethical dilemmas encountered by French military doctors in overseas operations. It provides unique insights into their ethical experiences and should prove useful in improving operational training for healthcare personnel deployed on overseas missions. (shrink)

Using a three-dimensional ethical role-specific model, this article considers the dual loyalty conflict between following military orders and professional codes of practice in an operational military environment when a patient soldier refuses life-saving medical treatment and where their legal capacity is questionable. The article suggests that although every competent patient has the right to refuse medical treatment even though they may die as a consequence. Ordinarily, it is unethical to exert any undue influence on a patient to accept medical treatment, (...) in a military operational environment where attack from the enemy is likely, it may be reasonable and understandable to exert undue influence over a patient when they lack legal capacity. (shrink)

The principle that physicians should always act in the best interests of the present patient is widely endorsed. At the same time, and often within the same document, it is recognised that there are appropriate exceptions to this principle. Unfortunately, little, if any, guidance is provided regarding which exceptions are appropriate and how they should be handled. These circumstances might be tenable if the appropriate exceptions were rare. Yet, evaluation of the literature reveals that there are numerous exceptions, several of (...) which pervade clinical medicine. This situation leaves physicians without adequate guidance on when to allow exceptions and how to address them, increasing the chances for unfairness in practice. The present article considers the range of exceptions, illustrates how the lack of guidance poses ethical concern and describes an alternative account of physician obligations to address this concern. (shrink)

Religious considerations and language do not typically belong in the professional advice rendered by a doctor to a patient. Among the rationales mounted by Greenblum and Hubbard in support of that conclusion is that religious considerations and language are incompatible with the role of doctors as public officials.1 Much as I agree with their conclusion, I take issue with this particular aspect of their analysis. It seems based on a mischaracterisation of what societal role doctors fulfil, qua doctors. What obliges (...) doctors to communicate by means of content that is expressed in public reason-based language is not that they are public officials. Doctors as doctors are not necessarily public officials. Rather, doctors have such obligations, because they are professionals. Unlike public officials doctors are part of a profession that is to a significant extent self-governing. This holds true for all professions. The …. (shrink)

Military physicians are often perceived to be in a position of ‘dual loyalty’ because they have responsibilities towards their patients but also towards their employer, the military institution. Further, they have to ascribe to and are bound by two distinct codes of ethics, each with its own set of values and duties, that could at first glance be considered to be very different or even incompatible. How, then, can military physicians reconcile these two codes of ethics and their distinct professional/institutional (...) values, and assume their responsibilities towards both their patients and the military institution? To clarify this situation, and to show how such a reconciliation might be possible, we compared the history and content of two national professional codes of ethics: the Defence Ethics of the Canadian Armed Forces and the Code of Ethics of the Canadian Medical Association. Interestingly, even if the medical code is more focused on duties and responsibility while the military code is more focused on core values and is supported by a comprehensive ethical training program, they also have many elements in common. Further, both are based on the same core values of loyalty and integrity, and they are broad in scope but are relatively flexible in application. While there are still important sources of tension between and limits within these two codes of ethics, there are fewer differences than may appear at first glance because the core values and principles of military and medical ethics are not so different. (shrink)

This chapter attempts to identify some ethical concerns evoked by military engagement in healthcare reconstruction. By bringing empirical evidence to the ongoing debate in military and development communities we aim to shed some light on the central question if and how, from a military ethical point of view, military should be involved in healthcare reconstruction during stabilization and reconstruction operations in Uruzgan.

Global debates in approaches to HIV/AIDS control have recently moved away from a uniformly strong human rights-based focus. Public health utilitarianism has become increasingly important in shaping national and international policies. However, potentially contradictory imperatives may require reconciliation of individual reproductive and other human rights with public health objectives. Current reproductive health guidelines remain largely nonprescriptive on the advisability of pregnancy amongst HIV-positive couples, mainly relying on effective counselling to enable autonomous decision-making by clients. Yet, health care provider values and (...) attitudes may substantially impact on the effectiveness of nonprescriptive guidelines, particularly where social norms and stereotypes regarding childbearing are powerful, and where providers are subjected to dual loyalty pressures, with potentially adverse impacts on rights of service users. Data from a study of user experiences and perceptions of reproductive and HIV/AIDS services are used to illustrate a rights analysis of how reproductive health policy should integrate a rights perspective into the way services engage with HIV-positive persons and their reproductive choices. The analysis draws on recognised tools developed to evaluate health policies for their human rights impacts and on a model developed for health equity research in South Africa to argue for greater recognition of agency on the part of persons affected by HIV/AIDS in the development and content of policies on reproductive choices. We conclude by proposing strategies that are based upon a synergy between human rights and public health approaches to policy on reproductive health choices for persons with HIV/AIDS. (shrink)

A widely accepted framework governs biomedical research and the practice of medicine in the civilian sector, but no such framework exists to guide the military in how it should treat its own personnel. Civilian bioethical principles are unsuitable because of fundamental differences between civilian and military core values. This paper proposes a framework for military bioethics. It begins by describing core military values, articulating how they differ from civilian goals and values, and explaining how these differences limit the ability of (...) civilian bioethical principles to govern military biomedicine. The paper then puts forward a set of more appropriate principles for the military and discusses how these principles apply in three main areas of controversy within military bioethics: the use of military personnel as research subjects; the deployment use of biomedical agents; and the obligations of military physicians toward their own troops. (shrink)

This paper argues that bioethics as a field should broaden its scope to include the ethics of war, focusing on war’s public health effects. The “Introduction” section describes the bioethics literature on war, which emphasizes clinical and research topics while omitting public health. The section, “War as a public health crisis” demonstrates the need for a public health ethics approach by framing war as a public health crisis. The section, “Bioethics principles for war and public health” proposes six bioethics principles (...) for war that address its public health dimensions: health justice, accountability, dignified lives, public health sustainability, nonmaleficence, and public health maximization. The section, “Justifying and applying bioethical principles” shows how these principles inform ethical analysis, including just war theory and military ethics. The section, “From principles to practice” envisions ways in which bioethicists can promote these principles in practice through research, teaching, and service. The “Conclusion” section urges bioethicists to engage with war as a public health crisis, including calling attention to war’s impact on civilians, especially women, children, and other vulnerable groups. (shrink)

This commentary examines the incursion on the neutrality of medical personnel now taking place as part of the human rights crises in Bahrain and Syria, and the ethical dilemmas which these incursions place not only in front of physicians practicing in those nations, but in front of the international community as a whole.In Bahrain, physicians have recently received harsh prison terms, apparently for treating demonstrators who clashed with government forces. In Syria, physicians are under the same political pressure to avoid (...) treating political demonstrators or to act as informants against their own patients, turning them in to government authorities. This pressure has been severe, to the point that some physicians have become complicit in the abuse of patients who were also political demonstrators.This paper posits that physicians in certain countries in the Middle East during the “Arab Spring,” specifically Syria and Bahrain, are being used as both political pawns and political weapons in clear violation of Geneva Convention and World Medical Association guidelines, and that this puts them into the most extreme sort of “dual loyalty” dilemma. They are being forced to choose between their own safety and well-being and that of their patients – a negative sum scenario wherein there is no optimal choice. As such, an international call for a United Nations inquiry must be made in order to protect the neutrality of medical care and personnel during times of armed conflict. (shrink)

This paper explores ethical questions arising from the work of health practitioners in immigration detention centres in Australia. It raises questions about the roles of professional disciplines and the ways in which they confront dual loyalty issues. The exploration is guided by interviews conducted with health professionals who have worked in asylum seeker detention and an examination of the outsider advocacy role undertaken by the social work profession. The paper discusses the stance taken by individuals and professional associations on participation (...) in controlled settings, including as participant, bystander and advocate, and asks when the provision of care becomes collusion with oppression. (shrink)

Immigration medicine and the work carried out by Panel Physicians within the Canadian immigration system give rise to ethically troublesome practices and consequences. In this analysis in three parts, we explore the context of the immigration medical examination, characterize the observed and potential burdens and harms for immigrant and refugee applicants with HIV, and critically assess the possibilities for transforming immigration medical practices and policy to reduce inequities. We use the Code of Ethics of the Canadian Medical Association and the (...) Medical Ethics Manual of the World Medical Association to analyse six practices that fail to meet ethical expectations. This analysis opens up new lines of inquiry into the medico-administrative practices regulating immigration to Canada. It also extends knowledge about the functioning of immigration medical policy and the collection and uses of HIV-related health information. We argue that to reduce burdens and harms to prospective immigrants and refugees to Canada with HIV, changes must occur in how Citizenship and Immigration Canada asks Panel Physicians to work with these applicants. This argument is empirically informed by institutional ethnographic research results of the Canadian immigration system and its treatment of applicants with HIV. (shrink)