Ethics Committees Have a Role in Expeditionary Military Medicine

1. 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

2. 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.

3. Ethics Committees Have a Role in Expeditionary Military MedicinePretext 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

4. Ethics Committees Have a Role in Expeditionary Military MedicineIntroduction • 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

5. Ethics Committees Have a Role in Expeditionary Military MedicineIntroduction • 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.

6. Ethics Committees Have a Role in Expeditionary Military MedicineIntroduction • 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.

7. Though the environment is austere, the goal of ethical medicine should be the same. The tools may have to be tailored.

8. Ethics Committees Have a Role in Expeditionary Military MedicineMethods • 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)

9. 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 MedicineResults (Case #1)

10. Medical Indications Patient Preferences Contextual Features QOL Ethics Committees Have a Role in Expeditionary Military MedicineResults (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

11. Ethics Committees Have a Role in Expeditionary Military MedicineResults (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

12. 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 MedicineResults (Case #2)

13. Ethics Committees Have a Role in Expeditionary Military MedicineResults (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

14. 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 Ethics Committees Have a Role in Expeditionary Military MedicineConclusions Con Pro

15. Ethics Committees Have a Role in Expeditionary Military MedicineConclusions/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

16. “The only thing harder than getting a new idea into a military mind is getting an old one out.” -Basil Liddell Hart, 1943