AMA Journal of Ethics^®

Case

Three months of the first year of medical school had passed, and, in addition to the fields of anatomy and histology, Amanda was beginning to learn more about her classmates. She'd been pleased to discover that she had quite a bit in common with many of the students she'd met; like her, they not only had a fascination with human biology and pathophysiology but were also motivated to help others and to prevent or alleviate suffering.

When an e-mail went out to the first-year class announcing an upcoming visit by a military recruiter, Amanda assumed that her friends would agree that the military had no place in an academic institution dedicated to the promotion of health and the safety of individuals and communities. She was shocked to hear her lab partner say, "Actually, I'm in the Health Professions Scholarship Program. My husband and I have a young child, and putting us into debt for my education just wasn't an option. So, I'll do some military service after my residency, and the Army will cover the entire cost of med school. I don't see any conflict in being a military doctor. I'll make a huge difference by giving care to people who are working to keep us all safe and secure."

Commentary 1

This case provides a snapshot of the diverse feelings people attach to the U.S. military and its methods of recruitment. Amanda and her friend undoubtedly have different perceptions of the military, its actions and influence, and its potential impact on the practice of medicine. Amanda might be against a military recruiter presence on campus because she assumes that military demands compromise the ethical behavior of physicians in some way; thus her concern for her classmate. Conversely, Amanda's friend might assume that practicing medicine in the military will allow her the same freedoms in professional conduct that any civilian physician has. Both assumptions contain some truth.

Since the topic of recruitment on campus can provoke heated discussions, let's elucidate what makes concern about military presence at a medical school disconcerting for Amanda. After all, it is less likely she would be so upset if other governmental agencies that provide loan forgiveness in exchange for service, such as the U.S. Public Health Service Corps or the Global Health Fellows Program of the U.S. Agency for International Development (USAID), were to recruit at her campus. What concerns attached to the military's presence might shape her views?

My comments on the ethical issues raised with military recruitment (i.e., Health Professions Scholarship Program) at medical institutions, posit that it is ethically permissible in theory for the military to recruit medical students as long as baseline military ethical and professional guidelines satisfy universal ethical standards of the medical profession at large. At the same time, I suggest that prudential concerns that have ethical implications might cause specific individuals to justifiably deny, protest, or hesitate in allowing active recruitment on campus.

Guidance for Decision Making: Ethical and Prudential Concerns

There are two baseline ethical guidelines that, I believe, we must consider in evaluating how the military interfaces with medical students and the medical profession. They are: (1) how military medical ethics compares, in general, with universal declarations of medical ethics, and (2) where military ethics stands on specific issues such as physician involvement in interrogation and violations of medical neutrality (e.g., not providing medical care on the basis of need and urgency, which are normative values in medical ethics). To make a case for allowing military recruitment of medical students, it is essential that the core ethical values of medical neutrality in the provision of medical care and adherence to the ethical standards of the practice of medicine be met.

Students for or against active military recruitment on campus, however, may understandably bring prudential arguments to bear on the topic, including (1) general attitudes towards the military that stem from widespread opposition to, for example, the current war policy in Iraq and the possibility that a physician might be part of a military unit in which violation of human rights is practiced; (2) the impact of the financial incentives to accept recruitment among an economically vulnerable population of students, given the underfunded state of medical education; and (3) objection to the current administration's influence on the military's behavior on the battle field or at home, as evidenced by labeling prisoners at Guantanamo Bay as unlawful enemy combatants and limiting their human rights; and by the controversial "don't ask, don't tell" policy towards homosexual men and women serving in the military-a policy with human rights implications that has been rejected by other militaries (e.g., the United Kingdom) that allow homosexuals to serve openly [1]. Prudential concerns such as these certainly have ethical implications, but they arguably do not proscribe recruitment or physician involvement in the military on an ethical basis as long as they do not entail physician violation of established human rights and ethical mandates of the profession.

Examining Core Military Medical Ethics

At the nexus of an ethical examination of military recruitment at a medical school campus lies the question of how well military medical ethics aligns with wider professional mandates in medical ethics-that is, the possibility that physicians' obligations to the military might conflict with their obligations to the medical profession. This is often called the problem of "dual loyalty," and it exists in other domains of medicine outside military medicine as well [2]. There are two levels to the dual loyalty inquiry: (1) what official military ethics documents and guidelines dictate and (2) how military physicians and those in charge of them conduct themselves in the field. On core points such as medical neutrality in provision of medical care in conflict situations, official U.S. military medical ethics (according to the Textbooks of Military Medicine, Military Medical Ethics [3]) stand largely in line with those of the wider profession, although their guidelines are not always stated as clearly and straightforwardly as they are in nonmilitary professional manuals such as the American Medical Association's Code of Medical Ethics, World Medical Association's Medical Ethics Manual, and the Geneva Conventions of the United Nations.

Physicians for Human Rights (PHR) maintains a library of human rights statements related to medicine practiced in military and humanitarian group settings [4]. PHR monitors the actions of militaries and other groups around the world and government policies pertinent to human rights. A simple query of its search engine displays numerous articles and statements concerning actions that hold negative implications for human rights. Unfortunately, many of these briefs have been created in response to U.S. military, congressional, and executive branch policies. While few military physicians have been implicated in unethical medical behavior, their presence in a military where unethical treatment of people sometimes occurs should be disconcerting to anyone.

In respect to the second aspect of the dual loyalties conflict-what military physicians do in the field-recent years have brought concerns and allegations of physician and health professional participation in interrogation, torture, and prisoner force-feeding in places such as Iraq and Guantanamo Bay. To be clear, if military physicians violate entrenched ethical mandates that proscribe participation in torture and interrogation, either of their own volition or because of orders from military superiors, then medical institutions have a strong case for prohibiting military recruiting on campus. Indeed, their banning of recruiting could be construed a duty imposed by the need for change in the practice of military medicine.

Others have argued elsewhere, as have I, that physicians have a fiduciary duty to practice medical neutrality in all contexts. Conflict situations viewed as public health problems can be likened to an epidemic of disease. Physicians should conceive of conflict situations as destructive, fatal epidemics and respond accordingly [5,6]. Medical professionalism and the ethical integrity of medicine practiced in its diverse societal domains, including military medicine, should be of the utmost concern to all physicians because the values of the profession are at stake. As Wynia et al. have explained, attitudes of the medical profession reveal much about a society's well-being and its respect for the rights of its citizens and those of other nations [7]. Given current concerns about certain practices in the U.S. military, Amanda's reservations are understandable. Medical institutions can play an important role in monitoring and influencing the ethical behavior of other organizations where physicians practice. Permitting or prohibiting military recruitment on campus might be one way for the profession to make its views known.

Concluding Thoughts

Amanda's opinions about the military's presence and recruitment of medical students might arise in part from a sense of "guilt by association," given accusations of unethical behavior (e.g., force-feeding, unethical interrogation practices, and prisoner abuse) on the part of service members or military health professionals. On this view, if some military personnel violate human rights and health care standards, all military physicians are implicated due to their affiliation-and, one has to suspect, by their failure to speak out about the violations-whether or not they are directly involved. (That physicians should speak out against violations of human rights raises a separate issue that cannot be examined here [5]). The guilt-by-association allegation is, of course, unfair to many outstanding and ethical military physicians. Recently, some physicians abstained from the unethical behavior of force-feeding of prisoners at Guantanamo Bay, while others, unfortunately, reportedly participated [8,9]. In response to Amanda's hypothetical concern, one can make the counterargument that physicians, especially those knowledgeable in the field of medical ethics, are needed more than ever in today's military and society.

Having looked at statements of military ethics and the conduct of physicians in the military separately, we can return to the question at hand: Is there an ethical argument that justifies a ban on military recruiters at medical school campuses? Based on the criteria I have laid out, the answer appears to be "no," if we are convinced that normative ethical values dictate the military physician's practice, despite any military instruction that he or she receives to the contrary. Given the military's involvement in wars that might not meet the ethical criteria of a "just war" and possible violations of human rights, there are strong prudential arguments-that perhaps gain the status of a duty-for limiting recruitment activities, even if military physicians themselves are not involved in unethical or ethically dubious situations.

Banning military recruiting from campus does not prevent students from seeking out HPSP opportunities if they choose to do so, again, on the proviso that the military satisfies universal medical ethics guidelines. There are many ways to serve U.S. citizens and others around the globe; a career of medical service to the men and women of the armed forces and civilians in combat settings is one example. Amanda, like many who are concerned with the actions of military, possibly recognizes the need to provide exceptional medical ethics education and uphold the rigorous ethical standards of professionalism. Her friend in the vignette holds the same values. In order to continue strengthening and protecting the ethical integrity of the medical profession, medical students, physicians, and the public should settle for nothing less in the military's relationship with physicians. In raising concerns and civil discussions on these issues, the values of transparency and accountability in the medical profession are more important than ever.