Page 154 - JSOM Winter 2018

An Ongoing Series

Moral, Legal, and Ethical Considerations for
Operational Medicine in the Austere Environment

An Introduction

Michael R. Hetzler

s a series for the JSOM, we continually try to brief our Clearly, MLE issues can have great ambiguity, and few will
intention and processes to audiences and medical direc- likely agree with findings and opinions of situational chal-
Ators to ensure clarity and understanding, as well as to lenges in our realm, but that should not dissuade us from en-
develop opportunities for further contribution. While doing so gaging these questions as a community. Unlike evidence-based
last spring, two offices requested that we consider addressing medicine with rigorous process and methodology, MLE issues
moral, legal, and ethical (MLE) concerns for operational med- have natural uncertainty in interpretation and exercise and
icine in the austere environment. can be very philosophical in consideration and psychological
in effect. This is not a disciplined course of study – there is no
MLE medical issues have pertinent and important value to the prospective approach, no sensitivity and specificity, only dis-
profession. Considering the many additional challenges in the cussions and debates for the best advice we can give to those
operational environment, ethics may often lack the timely at- most likely to wrestle with the questions.
tention they require. Ethical questions in the austere can also
be more difficult to understand, let alone manage. MLE challenges in combat, humanitarian relief, or the austere
are often questions of conscience, and these issues can have
The medical profession has relied on the following four basic a human impact. Conflict with our own actions and values
principles as a start point when performing ethical delibera- will have cost to the care provider. While that cost is argu-
tion in a civilian context: ably based on the situation and interpretation of the individ-
ual, these challenges should be professionally discussed and
• Autonomy – A patient must be fully informed, free of co- addressed. Common and routine discussions would be healthy
ercion, and understanding of all considerations and pro- to our community to both familiarize the complexities of MLE
cedures when making decisions for their own healthcare challenges and deepen understanding.
• Nonmaleficence – That procedures do no harm to the
patient or society in exercise By not engaging these subjects, MLE concerns could be left
• Beneficence – Requires that medicine must be applied open to misunderstanding, assumption, and outdated aspects.
with the intent of benefit to the patient Issues in the operational environment are also not specific to
• Justice – That the burdens and benefits of new or exper- either military or civilian, and these challenges are often fur-
imental treatments must be distributed equally among ther complicated by the ethics and cultures of other nations
all groups in society and that procedures uphold exist- and regions in which we operate.
ing laws and are fair to all players involved. Providers
just further evaluate additional areas of fair distribution The future will likely be more difficult than the past. So, too
of scarce resources, competing needs, right and obliga- will the MLE task. The challenges of peer adversaries, large-
tions, and potential conflicts with established legislation scale warfare, and the blurring of lines in traditional military
when evaluating justice conflict mean that we will see suffering in uncommon and un-
expected ways that differ greatly from our present. Whether
These “Big Four” are further understood to be nonhierarchi- physician or medic, civilian or military, these challenges are
cal, meaning that no single principle raises above the others part of our work, and for our community, we should be en-
in priority in deliberation or practice. Additionally, other con- gaged beforehand.
cepts and findings, from the Hippocratic Oath to the Nurem-
burg Code, lend guidance, precedence, and cultural values to It is hoped that these MLE works will raise the subject and
the medical community overall. Although these principles of- awareness in our community, provide further perspective
ten serve the efforts between clinical medicine and scientific and understanding, and promote interaction, discussion and
research, it could be argued that the ethical challenges existing debate.
in our environments can be more complicated and volatile.
Correspondence to michael.hetzler@JSOMonline.org

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