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, WinsladeClinical 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

sustained trans-cranial (TC) high velocity GSW

• Plain films demonstrated TC nature with fragments

• Significant extrusion of brain tissue/large exit wound defect

• Agonal breathing Unstable BP/GCS 3

• Intubated / supported• Discussions among

all surgeons, regional neurosurgeon, family

• Decision to treat expectantly and keep patient locally- Fard Kifaya, Kafan

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

Justice

Dignity

Truthfulness and Honesty

MedicalIndications

Patient Preferences

QOLContextual

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)• Corpsman wanted to

begin intubating patients after they were pronounced dead to improve skills

• Supported by claims of standard practice in US

• Religious concerns brought forward in Iraqi patients

• Subsequent to discussions, practice performed only on Americans

• Chief of Professional 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

Conclusions

• Can achieve CIV obj• Avenue for anyone• Ethical decisions from

multidisciplinary team seem to have greater legitimacy

• Greater unit cohesion• Allows changing

policies in a changing environment

• Conflicts with COC and eliminates higher authority (HA)– Decision is non-binding– Time & distance can preclude

meaningful decision from HA– Alternative is individual decision

with varying degrees of disclosure

• Too slow for EXP MED– Doesn’t slow down CIV med

Pro Con

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