Ethics Committees
Have a Role in
Expeditionary
Military Medicine
Peter F Roberts, MD, FACS
Commander, MC, USN
Naval Medical Center, Portsmouth,
Virginia
NATO Medical Conference 2009
Estoril, Portugal
Disclaimer
The views expressed in
this article are those of
the author(s) and do not
reflect the official policy
or position of the
Department of the Navy,
Department of Defense,
or the United States
Government.
Ethics Committees Have a Role in
Expeditionary Military Medicine
Pretext
Despite technology, science [or
practice venue],
medicine is an encounter between
human beings.
It must be undertaken in a moral context.
Jonsen, Siegler, Winslade
Clinical Ethics, 2006
Ethics Committees Have a Role in
Expeditionary Military Medicine
Introduction
• Role of ethics committees (EC) are well
established in civilian/peacetime medicine
–
–
–
–
Education
Policy Development
Case Consultation
(Dispute Resolution)
• Benefits/Effectiveness have not been confirmed
by rigorous studies but,
– The Joint Commission requires them
– Few hospitals are without one-COMMUNICATION
Ethics Committees Have a Role in
Expeditionary Military Medicine
Introduction
• Membership-Physicians, nurses,
therapists, clergy, administrators,
representatives from community, an
individual with more formal ethics training
• Caresse JA, Sugarman J: The inescapable
relevance of bioethics for the practice of
medicine. Chest 2006; 130: 1864-72.
Ethics Committees Have a Role in
Expeditionary Military Medicine
Introduction
• Volumes have been written on military medical ethics
– Physician-Soldier, “Physician First, Last, Always,” NEJM, 2008
– Prisoner care, psychotropic drugs to retain soldiers and other
complex issues
• Paradigm– Education-Standards for Accreditation of Medical Education Programs
Leading to the M.D. Degree. Washington, DC, AAMC, 2007
– Training-Accreditation Council for Graduate Medical Education:
Program Director Guide to the Common Program Requirements, 2007,
– JIT -Geneva Conventions, LOAC, likely scenarios
– DEPLOY-You’re on your own.
Though the environment is austere,
the goal of ethical medicine should
be the same.
The tools may have to be tailored.
Ethics Committees Have a Role in
Expeditionary Military Medicine
Methods
• Level II Surgical Shock Trauma Platoon
– Operation Iraqi Freedom 06-08.2
– Approx 100 personnel, 7 surgeons (mobile)
• Established EC by local SOPs; consults
avail to all; documented and forwarded
• Membership-Nurse, physician, chaplain,
enlisted member, (translator)
Ethics Committees Have a Role in
Expeditionary Military Medicine
•
•
•
•
Results (Case #1)
20 year old Iraqi male
• Intubated / supported
sustained trans-cranial
• Discussions among
(TC) high velocity GSW
all surgeons, regional
Plain films demonstrated
neurosurgeon, family
TC nature with fragments
• Decision to treat
Significant extrusion of
brain tissue/large exit
expectantly and keep
wound defect
patient locally- Fard
Agonal breathing
Kifaya, Kafan
Unstable BP/GCS 3
Ethics Committees Have a Role in
Expeditionary Military Medicine
Results (Case #1)
Bedside nurse felt uncomfortable with decision.
Rumors that the treatment was tailored due to ethnicity began circulating.
The nurse requested an ethics consultation.
Autonomy
Beneficence
Nonmaleficence
Medical
Indications
Patient
Preferences
Justice
Dignity
Truthfulness and Honesty
QOL
Contextual
Features
Ethics Committees Have a Role in
Expeditionary Military Medicine
Results (Case #1)
• EC found patient met “physiologic futility”
and that contextual factors and
family/wishes were appropriately
considered
• EC briefed concerned staff, discussed
findings, science and what to expect
• Multidisciplinary group succeeded where
others had failed
FUNCTION: Case consultation, education
Ethics Committees Have a Role in
Expeditionary Military Medicine
Results (Case #2)
• Religious concerns
• Corpsman wanted to
brought forward in
begin intubating
Iraqi patients
patients after they
• Subsequent to
were pronounced
discussions, practice
dead to improve skills
performed only on
• Supported by claims
Americans
of standard practice in • Chief of Professional
US
Services requested
EC consultation
Ethics Committees Have a Role in
Expeditionary Military Medicine
Results (Case #2)
• Despite Iraqi participation, consensus on
how practice would be accepted culturally
could not be reached
• Based principles of “justice” and
inequitable distribution of a “burden,”
practice was discontinued on all and policy
written
• Program to allow direct supervision of
corpsman in operating room established
FUNCTION: Policy setting
Ethics Committees Have a Role in
Expeditionary Military Medicine
Pro
Conclusions
Con
• Can achieve CIV obj • Conflicts with COC and
eliminates higher authority
• Avenue for anyone
(HA)
• Ethical decisions from
– Decision is non-binding
multidisciplinary team
– Time & distance can preclude
seem to have greater
meaningful decision from HA
legitimacy
– Alternative is individual decision
with varying degrees of
• Greater unit cohesion
disclosure
• Allows changing
• Too slow for EXP MED
policies in a changing
– Doesn’t slow down CIV med
environment
Ethics Committees Have a Role in
Expeditionary Military Medicine
Conclusions/Recommendations
• Formally establish existence of tailored
EXP ECs
• Designate leader prior to deployment and
provide additional training
• Establish mechanism for forwarding
activity to HA for theater lessons learned
“The only thing
harder than getting
a new idea into a
military mind is
getting an old one
out.”
-Basil Liddell Hart, 1943