With their allegiance to both the Hippocratic oath and military guidelines
sometimes in conflict, how do combat doctors decide whom to treat?
The ethics behind whom American combat doctors should treat in a war zone is
complicated. At its most challenging, it can leave physicians like myself and
other military medical personnel feeling they're serving two masters:
Hippocrates and Uncle Sam. The one calls for treating whomever needs our help;
the other, through the agency of the armed forces, has restrictions on whom we
can and cannot take under our care. In the end, I believe the battlefield doctor
has a duty to a third master: him- or herself. For in the complex circumstances
of a combat zone, decisions of how best to resolve this dichotomy between
care-for-all and care-for-some should ultimately rest with each doctor.
In my 20-plus years as a doctor in the military, I have served field units in
the first Gulf War, the Balkans, and Turkey, and in February 2003 I deployed to
the Gulf with the 10th Combat Support Hospital (CSH). It was during and after
this deployment that the true intricacies of combat medical ethics really came
home to me.
Rules of engagement
As could have been the case with my own career, few military nurses, and fewer
physicians, ever deploy to a combat environment. The vast majority of my
colleagues serve either an obligation of a few years or sometimes an entire
career safe at home in comfortable, state-of-the-art medical facilities. Some
have not ventured from the medical centers in which they trained. Instead they
provide care to stateside active-duty soldiers, sailors, airmen, and marines
and their dependents. Foremost among their patients are retired servicemen and
their spouses. Very few expect ever to stand at the gates of a CSH or MASH
(Mobile Army Surgical Hospital) determining who is or is not eligible for care.
Nor should they.
Some do, however, and they quickly come to understand the inherent
difficulties. Iraq, for instance, is a nation of 25 million. It has never been
a consideration that mobile U.S. military medical units would or could provide
sufficient personnel, equipment, or facilities to care for Iraqis in lieu of
their own, albeit hobbled, civil medical establishment. Rather, CSHs
necessarily prioritize care to American and coalition forces first. In accord
with Geneva Convention protocols, we understand and accept that we must attend
Iraqi Enemy Prisoners of War as well. Lastly, we provide care to Iraqi
civilians, giving priority to those injured by Allied fire over those
presenting with acute or chronic medical problems not related to Allied action.
Overriding these levels of priority is an understanding that any
individual—friend or foe, civilian or military—who is at risk
of losing life, limb, or eyesight will receive emergency care as best we can
supply it.
Alas, "best" in a war zone is a lot different than "best" in the States.
When I was in the Gulf last spring, our resources were meager, our supplies
finite. Our grasp of future events and future demands was as uncertain and
muddled as everyone else's. But we were physicians—medical officers who
took the same Hippocratic oath as all our civilian colleagues. In the early
days after their deployment to Iraq, American medics were relieved of the
mission they feared—wards full of American wounded—but they
suddenly faced long lines of Iraqi sick and injured. Some were recently
wounded. Some had injuries sustained in the Iran-Iraq war of the 1980s. Some
had chronic medical illnesses such as diabetes, kidney failure, or heart
disease. And some were civilians who had sustained injuries from burns and
accidents occurring at home.
"Mixed agency"
American combat doctors could not care for all of them, and in many cases this
was not for lack of willingness. The reason is that these doctors'
responsibilities to their patients—any patient in need of
care—compete with their responsibility to husband resources so as to be
able to care for the American serviceman. Military ethicists refer to this tug
of allegiance as "mixed agency." I've heard that one of the physicians featured
in the NOVA film declined to accept the role of gatekeeper at the 21st CSH,
saying in effect that "if I go out I will accept whatever patient is there."
This is the moral imperative of the physician trumping the military
imperative.
The dilemma is a profound one, one that ethicists have wrestled with but not
agreed upon. The United States, though a signatory to the larger Geneva Accords
of 1949, balked at signing additional protocols in 1977 that would have
obligated it to provide all medical support as necessary to an occupied state.
Recognizing that it was not equipped to assume what could easily become an
open-ended and monumental undertaking, the U.S. did not sign these protocols.
Military physicians were therefore not legally bound to accept any and all
cases outside of the priorities described above.
In fact, deployed medical units were by and large free to determine for
themselves whom they would accept for treatment and how they would deliver
care, always with the expectation that they would remain mission-capable and
ready to care for American wounded. In the current conflict, I am not aware of
anyone in Medical Command going further to define how any one unit is to accept
or deny care to Iraqis.
Degrees of care
For admitted patients, CSH doctors expend every effort to provide the same
in-house care to Iraqis as to Americans, though after leaving the CSH prospects
for Americans and for Iraqis are radically different. Once stabilized by
emergency resuscitation and surgery, Americans are air-evacuated out of Iraq to
medical centers in the U.S. via our large, fully equipped medical facility in
Germany. Iraqis remain in Iraq, dependent for a short time on the best
Americans can provide and then upon the limited resources of the surviving
civilian medical infrastructure. Neither of these systems can provide long-term
intensive burn care or complex subspecialty surgical intervention and intensive
care. Lives are lost as a result.
Doesn't the CSH doctor have a moral obligation to consider? Is not the military
physician and surgeon as obligated as his or her civilian counterpart to
provide care to all those who seek comfort? American military medical
commanders are largely free to set their own standards and parcel care as they
deem prudent. When I was stationed in the Gulf last year, once the issue of a
shifting role for U.S. medical assets became clear, I had a conversation with
Col. John Powell, commander of the 10th CSH, on how we would set priorities.
Powell was adamant that if need be, the 10th CSH's role would be largely a
humanitarian one. This happened with the 28th CSH, which assumed a major role
in humanitarian relief, providing orthopedic, surgical, and medical care to
hundreds of Iraqis.
To thine own self
There are solutions to the dilemmas posed by mixed agency. The physician's
responsibility to treat all who present to him can be codified. That is, the
U.S. could decide to become a signatory to the 1977 Geneva Protocols (I and
II), thus obligating itself to provide this care.
Alternatively, some would argue—naïvely and wrongly in my
opinion—that military medicine is an oxymoron. They would claim that
no physician can ever don a military uniform and willingly claim to
serve at once both patient and country. Rather than military doctors, these
ethicists presumably imagine a civilian corps of volunteers untrained in and
unprepared for the vicissitudes of the modern war zone and the unique nature of
battlefield trauma.
In the end, combat physicians assume their own responsibility, willingly or
not. They must set their own priorities and act accordingly, accepting the
outcome of their decisions. This could be satisfaction with selfless service at
the (unlikely) cost of judicial action. Or it could be living with personal
demons born of care denied and patients turned away.
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Despite having taken an oath to treat anyone who needs their care, doctors at American Combat Support Hospitals like the 21st (above) regularly have to turn away certain non-American patients who don't meet military guidelines for treatment.
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His father beside him, Ala, an Iraqi soldier
recuperating at the 21st from serious leg wounds sustained in battle, met one
of the U.S. Army requirements for admission to the CSH: he was injured by
American forces.
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In the final analysis, combat doctors
owe it to themselves, Lounsbury feels, to make their own decisions about whom
to treat.
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