Officer first, doctor second?

[IgD]

I guess I just don't see much in the way of ethical dilemmas here. In fact, I would argue that the privacy restrictions in place in the civilian world present many more problems for physicians: the domestic abuse or rape victim who doesn't want to report the attack; the HIV positive and herpes patients who won't tell their sexual partners; the people with medical conditions that make them a danger on the job; etc etc etc.

Military physicians face a dual agency dilemma every day. You work for the patient but also the government. Like was said above most of the time what is best for the patient is best for the government but there are plenty of times when the needs conflict.

I don't think the HIV example is a good one. That's a public health issue and mandated reporting in most states as far as I know.

---

Members don't see this ad.

 

[IgD]

Dual agency is not a dillema...

I think some of the statements you've made are indefensible. Dual agency is a reason why doctors don't date patients and doctors don't self-prescribe or self-treat.

 

[IgD]

Another poster requested examples of when being a physician and medical officer conflict so I've been trying to come up with some.

The example you posted with the command auditory hallucinations is a great example. Service members aren't fit to serve with schizophrenia. As a medical officer you have a duty to report that. From the prospective of a physician making a diagnosis of schizophrenia is a watershed moment. Any action that might jeopardize a patient's trust could discourage them from ever seeking help again. You could argue that in some ways you are protecting the patient by taking them out of the unit but in other ways you might be harming the patient.

What I'm trying to say is that in military medicine you have to find the sweet spot between balancing a patient's privacy against the command's right to know. You have to always be sensitive to this and never let your guard down. I've seen many cases where errors were made in either direction.

 

[SirGecko]

You could argue that in some ways you are protecting the patient by taking them out of the unit but in other ways you might be harming the patient.

What I'm trying to say is that in military medicine you have to find the sweet spot between balancing a patient's privacy against the command's right to know. You have to always be sensitive to this and never let your guard down. I've seen many cases where errors were made in either direction.

In the military your priority goes like this: Constitution, Mission, Service, Unit, Shipmate (or fellow soldier), Self. I'd say that the command's right to know supersedes the patient's privacy. The commanding officer is responsible for the mission and has a right to know anything that might affect his unit's ability to resolve the mission. You really don't have a right to hide anything that would hinder your performance from the CoC. Doesn't mean people don't still try to do it but ethically you are bound to report this type of thing.

 

[Gastrapathy]

In the military your priority goes like this: Constitution, Mission, Service, Unit, Shipmate (or fellow soldier), Self. I'd say that the command's right to know supersedes the patient's privacy. The commanding officer is responsible for the mission and has a right to know anything that might affect his unit's ability to resolve the mission. You really don't have a right to hide anything that would hinder your performance from the CoC. Doesn't mean people don't still try to do it but ethically you are bound to report this type of thing.

You don't have the legal right to "hide" anything but you are expected to use your discretion deciding what your CO needs to know. I'd recommend the following conversation to any GMO. "Sir/Ma'am, I'm not going to bore you with every medical detail. I'll let you know about the stuff you need to know. Are there specific issues that you always want to know about?" Then, go from there.

In general, I think this question of officer versus doctor is overblown. For most fitness for duty questions, you have to protect the group as well as the patient. This really isn't any different than civilian aviation physicals, reporting the drug use of a school bus driver, etc. For the examples where it was suggested that you involve yourself in interrogation, that is a clear violation of the Geneva conventions, so man up and say so. One interesting issue is force feeding of prisoners in GITMO. I think those doctors could have risked their licenses by participating in that. I don't think I could have done that but, thankfully, was never put in that position.

http://www.wma.net/e/policy/h31.htm

 

[pgg]

For the examples where it was suggested that you involve yourself in interrogation, that is a clear violation of the Geneva conventions, so man up and say so. One interesting issue is force feeding of prisoners in GITMO. I think those doctors could have risked their licenses by participating in that. I don't think I could have done that but, thankfully, was never put in that position.

I would have refused the force feeding on ethical grounds also. I know some other physicians who would disagree, however - and I don't think this is a black/white issue.

I will point out, however, at the risk of inviting flames, that the Geneva Conventions clearly and specifically do not apply to the Gitmo detainees, as they fail to meet even one of the four criteria laid out in Article 4.1.2 of the Third Convention. The Convention specifically excludes them, deliberately, and for good reason, because their chosen mode of conflict places civilians at increased and unnecessary risk.

(I think Gitmo should be closed for strategic and PR reasons, not because of the absolutely irrelevant Geneva Conventions.)

I'll also note for the record that during my limited time as the GMO physician for a small detention center in Iraq, my interaction and contact with prisoners was strictly doctor-patient ... not just because that's the way I chose to run things, but because that's the way the commanders wanted it. I was never asked (either directly or wink-nudged) to assist with or facilitate interrogation or information gathering. The Marines treated them very well ... can't say the same for the Iraqi Army. (Abu Ghraib's got nothing on what the IA did to prisoners in the time between capture and dropping them off with us.)