War dilemmas put medical ethics under fire

Most physicians will never have to make split-second decisions about how to ethically care for prisoners at Guantanamo Bay or choose whether the health of one terrorist patient outweighs the potential well-being of many citizens.

However, a group of Internal Medicine 2008 attendees, led by doctors who have been close to such dilemmas, enthusiastically debated the ethics of these and other aspects of military medicine during a session on “Ethical Challenges: Confronting Dual Loyalties When Seeing Patients on Behalf of a Third Party.”

During the session, sponsored by the College's Ethics, Professionalism and Human Rights Committee, Walter J. Coyle, FACP, and Vincent E. Herrin, MD, role-played hypothetical ethical challenges faced by physicians caring for enemy detainees. Dr. Coyle served in the military for 22 years and Dr. Herrin was deployed at Guantanamo while in the U.S. Navy.

Moderator Frederick E. Turton, FACP, got the program started with a case involving prisoners throwing feces and body fluids at their guards. The guards asked the detainees' physician to provide a list of the prisoners' diseases so they could know what they were at risk of catching.

When the physician refused, based on his duty to protect patients' privacy, his colleagues pressured him to prioritize military over medical ethics. “You're on our side, right?” asked Dr. Herrin, in the role of the sergeant on the cell block.

The desire to help one's buddies, and one's country, can create some of the toughest dilemmas, noted Dr. Coyle. “You're part of the organization. You want to be part of the team. He's saying, ‘Do it for my guys.’ It's very hard to see what the clear decision is,” he said.

Other military physicians in the audience seconded his assessment. “Telling him no is tougher than telling your wife no,” one said about denying the sergeant's request.

The presenters and the audience agreed, however, that the physician's primary duty is to his relationship with the patient. “If you want to take the best care of detainees that you can, you have to establish trust,” said Dr. Herrin. “If you're going to prevent death or illness there, then they have to trust you, tell you when they're sick, take the medicines you prescribe for them.”

The ethical pressures on these hypothetical physicians only increased with the second case study. In this situation, a new detainee reported a history of heart attack and current chest pain but his EKG and labs were normal. Security officials asked the physician to clear the detainee for interrogation, and to monitor and examine him during the questioning.

Any involvement at all in the interrogation process would destroy the detainees' trust in the physician, said Dr. Coyle. “You're now just one of the bad guys, not looking out for their health.”

But not clearing the detainee for interrogation could pose larger-scale problems. “The pattern you'll see over the next several weeks is that any detainee who doesn't like what's going on suddenly has chest pain. Is that your concern at all as a doctor?” asked Dr. Herrin.

The scenario also raised the question of how involved physicians have to be in defining the politically gray area between interrogation and torture. Although the guidelines requiring physicians to have nothing to do with torture are very clear, the actual situations are not always so clear-cut, said Dr. Coyle.

He cited Abu Ghraib, for example, where patients came to physicians with injuries that were explained as self-induced or caused by other prisoners. “You're not sure if there was actually harsh treatment. So if you patch the patient up and send them back and there are more injuries, are you facilitating torture indirectly?” he asked.

And how much responsibility do physicians have for the ethics of the entire detention system? One audience member argued that simply practicing medicine in Guantanamo was an unethical action, potentially comparable to those of Nazi physicians tried at Nuremberg for war crimes.

Drs. Coyle and Herrin disagreed. “If every physician refused to ever go down there, and these guys were getting no medical care, is that ethical? I'm not so sure,” said Dr. Coyle.

Dr. Herrin noted that he diagnosed a malignancy and arranged for a prisoner to receive life-saving therapy while at Guantanamo. “If I go there, and I make it my goal to be part of this separate process to ensure that the detainees get good medical care in an ethical way, in my opinion, I'm fulfilling my ethical obligation,” he said.

Third-party conflicts, while perhaps less dramatic, are no less common in civilian medical practice, the session attendees noted. In determining disability for social security or worker's compensation or deciding whether an athlete is ready to return to play, physicians routinely are asked to serve interests other than their patients'.

Insurance and cost issues also can pose such conflicts, for example if a physician works for an HMO that offers fecal occult blood screening instead of colonoscopies. “They can't give the patient true informed consent. Your organization is saying financially it is better for us to do this versus what is actually the best test for the patient sitting in front of you? That's a dual loyalty that I think we see all the time,” said Dr. Coyle.

The dilemma can get even more personal, said Dr. Turton, noting that he was recently encouraged to order more CT scans to increase group profits. “I didn't have any trouble making a decision, but those who saw their loyalty being to the group were influenced,” he said.

Despite the complexity of the issues raised during the session, his solution to resolving them was very simple. “Remember who's first—the patient.”