Magazine article Clinical Psychiatry News

Ethical Ambiguity in Times of War

Magazine article Clinical Psychiatry News

Ethical Ambiguity in Times of War

Article excerpt

Psychiatry and the war in Iraq have been in the news recently. Such commentary has piqued the interest of many psychiatrists. After all, issues related to the military pose special ethical challenges for our specialty.

My Own Disclosure

Some self-disclosure seems appropriate here to put my comments into perspective--as well as to give those who have never served in the military a sense of what that may be like.

The military's influence on psychiatric practice became clear to me many years ago when I started my career in medicine. That was 1967, during the Vietnam War, a war some liken to the current conflict in Iraq.

The military draft was in place, and I soon had the option of risking being drafted before the end of all my training, trying to become a conscientious objector (CO), or seeking to defer deployment under the Barry Plan, which would have allowed me to finish my specialty training in exchange for 2 years of service in the military.

Literally, at the midnight deadline for a postmark, I decided against taking the CO route and eventually got into the Barry Plan. Through my struggle, I concluded that as much as I was ambivalent about the Vietnam War, if the country needed me as a psychiatrist at such a critical time, I might have to serve.

Among the first words all physicians heard from the military base commander was, "It's not if we fight another war, but when." We also took an oath to obey our supervisors and commander in chief.

The key was this: The needs of the military would supersede any freedom that I had regarding whom I should care for and what I thought I was competent to do. That meant I had to serve on sick call and in the emergency room as a general physician--despite my deficient skills in those areas.

Soon, the pressure was on to diagnose certain people in a way that would expedite their discharge from the service.

During the recent years of the Iraq War, many situations seem similar to my military experience, and others seem different.

Ethics From the Inside

According to "Military Medical Ethics, Volume 1" (Bethesda, Md.: Uniformed Services University of the Health Sciences, 2003), at the same time that the armed forces have continued to support military psychiatrists to provide competent care for military patients and their families, military psychiatrists continue to be subject to special military ethical constraints.

In particular, section VI of the American Medical Association's "Principles of Medical Ethics," published in 2006, did not seem to apply, at least while one was in the military:

"A physician shall, in the provision of appropriate patient care, except in emergencies, be free to choose whom to serve, with whom to associate, and the environment in which to provide medical care."

Once in the military, the psychiatrist is subject to a command structure. Although the 1999 Military Whistleblower Act accords some protection for limited protest, repercussions for doing so are unclear.

Psychiatric Ethics in War

For those military psychiatrists involved in a war, increased societal needs further challenge putting the patient first and foremost. After all, the presumed security and well-being of the nation can be at stake, and societal responsibilities are indeed part of the AMA's ethical principles. Therefore, the military psychiatrist can be under increased pressure--and orders--to participate in interrogation or even torture of detainees thought to be at risk to the country. Although these individuals may not strictly be considered patients, such processes may surely adversely affect their physical and mental status.

Military psychiatrists may also feel more pressure to quickly treat psychiatric symptoms so that troops can continue to function in a war zone. Posttraumatic stress disorder (PTSD) would be the most common challenge. …

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