American physicians and dual loyalty obligations in the "war on terror"

BACKGROUND

Post-September 11, 2001, the U.S. government has labeled thousands of Afghan war detainees "unlawful combatants". This label effectively deprives these detainees of the protection they would receive as "prisoners of war" under international humanitarian law. Reports have emerged that indicate that thousands of detainees being held in secret military facilities outside the United States are being subjected to questionable "stress and duress" interrogation tactics by U.S. authorities. If true, American military physicians could be inadvertently becoming complicit in detainee abuse. Moreover, the American government's openly negative views towards such detainees could result in military physicians not wanting to provide reasonable care to detainees, despite it being their ethical duty to do so.

DISCUSSION

This paper assesses the physician's obligations to treat war detainees in the light of relevant instruments of international humanitarian law and medical ethics. It briefly outlines how detainee abuse flourished in apartheid South Africa when state physicians became morally detached from the interests of their detainee patients. I caution U.S physicians not to let the same mindset befall them. I urge the U.S. medical community to advocate for detainee rights in the U.S, regardless of the political culture the detainee emerged from. I offer recommendations to U.S physicians facing dual loyalty conflicts of interest in the "war on terror".

SUMMARY

If U.S. physicians are faced with a conflict of interest between following national policies or international principles of humanitarian law and medical ethics, they should opt to adhere to the latter when treating war detainees. It is important for the U.S. medical community to speak out against possible detainee abuse by the U.S. government.

Dilemmas in military medical ethics since 9/11

The attack on the United States by terrorists on 9/11 and the war with Iraq have raised new ethical questions for the military and for military physicians (Herman 2002; Elshtain 2003). How and when attacks may occur now is less predictable. Planes have been hijacked, and persons dressed as civilians may carry bombs to blow themselves and others up. These dangers pose an increased threat, and, thus, there is a need for new defensive measures. How far these measures should go is, however, greatly open to debate. One of the most difficult ethical question raised for the military and military doctors by these developments is what interrogation methods are permissable when questioning captured terrorists. The licitness of different interrogation practices is, however, only one of the ethical problems potentially encountered by military physicians now having to treat terrorists and POWs. The following discussion presents the major concerns regarding this and other issues.

The Steve Biko Affair: A Case Study in Medical Ethics

Steve Biko died in detention in South Africa in 1977. Critical ethical issues are raised both by the conduct of the doctors responsible for Biko's care and by the subsequent response of the medical profession as a whole. Because those issues are relevant to all healthcare professionals everywhere, the Biko affair provides a useful case study in medical ethics. We discuss the case in this article, describing how we use it in our teaching.

Co-operation despite disagreement: from politics to healthcare

Political interaction among citizens who hold opposing moral views commonly requires reaching beyond toleration, toward actual co-operation with policies one opposes. On the more personal level, however, regarding (e.g.) interactions between healthcare providers and patients, several authors emphasize the importance of preserving integrity. But those who oppose any 'complicity in evil' often wrongly conflate instances in which the other's position is (and should be) totally rejected with instances of legitimate, although deep, disagreement. Starting with a striking example from the context of a particular tradition, I argue generally that in the latter sort of disagreements, talk of 'complicity' should be largely replaced with a more co-operative moral stance, grounded in a pluralistic framework. Co-operation Despite Disagreement (CDD) should be sought either for institutional reasons--akin to the political--or for relational reasons. CDD involves sharing another's perspective and sometimes calls for adopting another's moral judgements in preference to one's own. I seek to identify some of the conditions and circumstances that would justify such a shift, particularly in scenarios involving assistance, such as physician-assisted suicide (PAS) or the role of an anaesthesiologist in abortion. This discussion is meant to provide examples of the kind of second-order reasons appropriate for determining the terms for CDD-- in distinction from first-order considerations (e.g., the much-contested 'active/passive' distinction) which are likely to be the subject of the initial disagreement and hence cannot serve to resolve it.

Exploitation in biomedical research

This essay analyzes exploitation in biomedical research in terms of three basic elements: harm, disrespect, or injustice. There are also degrees of exploitation, ranging from highly exploitative to minimally exploitative. Although exploitation is prima facie wrongful, some exploitative research studies are morally justified, all things considered. The reason an exploitative study can still be ethical is that other moral considerations, such as the autonomy of the research subject or the social benefits of research, may sometimes justify studies that are minimally exploitative. Calling a research project exploitative does not end the debate about the merits of the study but invites one to ask additional questions about how the study is exploitative, and whether the study is justifiable nevertheless.

Contrasting role morality and professional morality: implications for practice

The notion of role morality suggests individuals may adopt a different morality depending on the roles they undertake. Investigating role morality is important, since the mentality of role morality may allow agents to believe they can abdicate moral responsibility when acting in a role. This is particularly significant in the literature dealing with professional morality where professionals, because of their special status, may find themselves at odds with their best moral judgments. Here I tell four stories and draw out some distinctions. I conclude that role morality is a genuine and useful distinction. However, I suggest that the purported distinction between role morality and professional morality is over-determined. Therefore, alleged conflicts between the demands of role and profession (such as the different pressures on Pinto designers as employees and as engineers) are not conflicts between different kinds of demands, but rather conflicts arising from divergent roles that most workers will encounter regularly. Another analytical perspective is to look at moral choices at work in terms of power and the ability to bring about change. Finally, I draw the implication that we should stress moral awareness at a fairly abstract level for all employees and reinforce the moral primacy of individual choice.

The limits of conscientious objection to abortion in the developing world

The South African Choice on Termination of Pregnancy Act 92 of 1996 gives women the right to voluntary abortion on request. The reality factor, however, is that five years later there are still more 'technically illegal' abortions than legal ones. Amongst other factors, one of the main obstacles to access to this constitutionally enshrined human right is the right to conscientious objection/refusal. Although the right to conscientious objection is also a basic human right, the case of refusal to provide abortion services on conscientious objection grounds should not be seen as absolute and inalienable, at least in the developing world. In the developed world, where referral to another service provider is for the most part accessible, a conscientious objector to abortion does not really put the abortion seeker's life at risk. The same cannot be said in developing countries even when abortion is decriminalised. This is because referral procedures are fraught with major obstacles. Therefore, it is argued that the right to conscientious objection to abortion should be limited by the circumstances in which the request for abortion arises.

Benefiting from 'evil': an incipient moral problem in human stem cell research

When does benefiting from others' wrongdoing effectively make one a moral accomplice in their evil deeds? If stem cell research lives up to its therapeutic promise, this question (which has previously cropped up in debates over fetal tissue research or the use of Nazi research data) is likely to become a central one for opponents of embryo destruction. I argue that benefiting from wrongdoing is prima facie morally wrong under any of three conditions: (1) when the wrongdoing is one's agent; (2) when acceptance of benefit directly encourages the repetition of the wrongful deed (even though no agency relationship is involved); and (3) when acceptance of a benefit legitimates a wrongful practice. I conclude by showing that, because of the ways in which most embryonic stem cell lines come into being, people who oppose embryo destruction may use human embryonic stem cells without incurring moral blame.

Vocabularies of motive for illicit steroid use among bodybuilders

Illicit steroid use, for purposes of performance and physique enhancement, is widely deemed unnecessary, wrong and dangerous. Such activity would appear especially foolhardy when engaged in by non-professional athletes who otherwise adhere to 'healthy' exercise regimens. Here a gap exists between many illicit steroid users' actions and societal expectations. Using qualitative data generated in South Wales, this paper explores bodybuilders' vocabularies of motive for illicit steroid use. These accounts which justified, rather than excused, steroid use were predominant during question situations between the participant observer and the researched. In supporting the fundamental tenets of their drug subculture, and as part of the underlying negotiation of self-identity, respondents espoused three main justifications for their own and/or other bodybuilders' illicit steroid use; namely: self-fulfilment accounts, condemnation of condemners and a denial of injury. Here steroid use was rationalised as a legitimate means to an end, observers passing negative judgements were rejected and it was claimed steroids do not (seriously) harm the user's health or threaten society more generally. These vocabularies of motive, acquired and honoured within bodybuilding settings, comprise a complex of subjective meanings which seem to the actor to be an adequate ground for the conduct in question. Similar to other sociological studies, this paper states that it is imperative to explore the social meanings which illicit drug users attach to their 'risk' practices. Without these understandings, researchers and health promoters may struggle to appreciate fully why illicit drug users behave as they do.

The ethics of human stem cell research

The medical and clinical promise of stem cell research is widely heralded, but moral judgments about it collide. This article takes general stock of such judgments and offers one specific resolution. It canvasses a spectrum of value judgments on sources, complicity, adult stem cells, and public and private contexts. It then examines how debates about abortion and stem cell research converge and diverge. Finally, it proposes to extend the principle of "nothing is lost" to current debates. This extension links historical discussions of the ethics of direct killing with unprecedented possibilities that in vitro fertilization procedures yield. A definite normative region to inhabit is located, within a larger range of rival value judgments. The creation of embryos for research purposes only should be resisted, yet research on "excess' embryos is permissible by virtue of an appeal to the "nothing is lost" principle.

Ethics seminars: physician complicity in the Holocaust: historical review and reflections on emergency medicine in the 21st century, part II

Part I of this seminar in ethics reviewed the participation of German physicians and the German medical establishment in carrying out Nazi policies and listed eight moral failures that could be attributed to doctors during the dark period of history known as the Holocaust. The collective acts that occurred during this period have, arguably, become a benchmark for abject ethical collapse on the part of mankind. Part II contemplates a variety of contemporary issues through the prism of the Holocaust. This article reviews and categorizes ethical pitfalls encountered by physicians during the Nazi era and examines them in relationship to several current issues. It also focuses on ethical concerns and challenges that confront contemporary emergency practitioners, some of which have parallels, though certainly not direct comparators, in the Nazi era.

Ethics seminars: physician complicity in the Holocaust: historical review and reflections on emergency medicine in the 21st century, part I

Individual physicians as well as the medical establishment were complicit in a wide range of activities carried out by the Nazis during the period that encompassed the Holocaust. This article examines these activities and lists eight moral failures attributable to physicians of this era. The accompanying article reviews the ethical pitfalls encountered by German physicians during the Nazi era and examines them in relationship to current issues. It also explores the role of professionalism then and now. In particular, ethical issues presently confronting emergency physicians are examined through this prism.

Seeing through the face of deception

We have developed a high-definition thermal-imaging technique that can detect attempted deceit by recording the thermal patterns from people's faces. This technique has an accuracy comparable to that of polygraph examination by experts and has potential for application in remote and rapid security screening, without the need for skilled staff or physical contact.

Responsibilities for poverty-related ill health

In a democratic society, the social rules are imposed by all upon each. As “recipients” of the rules, we tend to think that they should be designed to engender the best attainable distribution of goods and ills or quality of life. We are inclined to assess social institutions by how they affect their participants. But there is another, oft-neglected perspective which the topic of health equity raises with special clarity: As imposers of the rules, we are inclined to think that harms we inflict through the rules have greater moral weight than like harms we merely fail to prevent or to mitigate. What matters morally is not merely how we affect people, but how we treat them through the rules we impose. While current (consequentialist and Rawlsian) theorizing is dominated by the first perspective and thus supports purely recipient-oriented moral conceptions, an adequate approach to social justice requires a balancing of both. Such balancing results in a relational conception of justice, which distinguishes various ways in which an institutional scheme may causally affect the quality of life of its participants.

This essay argues that the strength of our moral reason to prevent or mitigate particular medical conditions depends not only on what one might call distributional factors, such as how badly off the people affected by these conditions are in absolute and relative terms, how costly prevention or treatment would be, and how much patients would benefit from given treatment. Rather, it depends also on relational factors, that is, on how we are related to the medical conditions they suffer. It then discusses some implications of this view for understanding responsibilities for international health outcomes.