Divided loyalties of health professionals.

• Author: Ascheim, Deborah D.
• Position: Divided Loyalties: Professional Standards and Military Duty

1. INTRODUCTION II. CASE STUDY: TORTURE IN THE WAR ON TERROR IV. CONCLUSION I. INTRODUCTION

   Health professionals, in routine practice, often have obligations to other parties beside their primary patients. Such divided loyalties between professional duties to the patient and obligations to the interests of a third party, whether express or implied, real or perceived, are not uncommon. And for some medical specialties, such divided loyalties are inescapable. For example, organ transplant physicians are obligated both to their individual patients, as well as to the larger community of those listed and waiting for an organ. (1) And obstetricians are obligated to both mother and fetus. (2) Thus, when either the mother or fetus is medically compromised, the practitioner must balance the conflicting obligations to both patients. Such examples are well-worn and come with clear guidelines that have been developed over time, and are often adopted by professional societies to assist practitioners in managing the opposing concerns. (3)

   Medical professionals working on behalf of the state may also grapple with divided loyalties--those to their patient, profession, employer, country, and personal values. These loyalties are negotiated in various ways, and there are situations where individual or professional loyalties are made subservient to state interests or broader policy goals. Common examples include breaching confidentiality in order to protect others from harm, or reporting requirements for communicable diseases. (4) Military health professionals face unique conflicts. They are required to navigate between very different and sometimes antagonistic or irreconcilable goals; their obligation as health professional, to preserve life and reduce suffering, is in conflict with their obligation as a military officer or soldier, to support killing and inflicting harm on the enemy. (5) A more recent and highly contested arena in which divided loyalties play out is the use of torture in U.S. detention centers. Instead of having the luxury of clearly defined rules for dividing a medical professional's allegiance between the patient and the state, as in the more common situations facing physicians today, the new torture regime raises difficult questions of how medical professionals should navigate competing loyalties. In an era where medical professionals are becoming involved in torture to varying degrees, (6) we must use a workable standard for professionals who find they must negotiate divided interests. Such a standard must be based on fairness, transparency, and a respect for human rights. In difficult complicated situations such as those presented by the war on terror, the frameworks of bioethics and human rights law are essential to ethical decision-making.

   The international human rights framework grants legal obligations to states, and medical professionals in the military, as agents of the state, should operate under these obligations. The involvement of medical professionals in torture raises significant human rights...