AMA Journal of Ethics^®

As an active duty military medical officer who has been deployed several times, I wish to infuse the debate over the dual role of military physicians with a sense of the military physician's ethical responsibility to society as a whole. To do so, I summarize the concept of dual agency and raise the topic of duty. Then I develop an argument for what I consider an ethically superior, but seldom discussed, moral position: the obligation of physicians to perform military medical service in the United States. In advancing this concept, I am aware of the contradiction inherent in the notion of mandatory service in a free society. I am also aware that the American military itself generally disagrees with this opinion.

Dual Agency

Dual, or mixed, agency refers to the conflicts and potential for unethical breaches of the fiduciary relationship between a provider of services and a consumer of those services. Although I believe the relationship between a physician and a patient is special (perhaps even sacred), I find the fiduciary aspect of that relationship no more unusual or distinctive than that of any other professional faced with decisions that weigh the benefits and risks of his or her client (usually an individual) against the purported benefits for an organization or society.

Indeed, dual agency concerns can be found in almost any human interaction where fiduciary relationships exist-in law, finance, real estate, medicine, guardianship, commerce, education, and essentially every other endeavor that is considered a profession. Whenever someone represents another and agrees to consider that person's interests paramount, a fiduciary relationship is created and, with it, some potential for moral discord should a claim arise that conflicts with the client's interests.

In military medicine, dual agency is addressed conceptually and in many real-world scenarios by Edmund Howe in the Textbooks of Military Medicine. His chapter on mixed agency in military medicine convincingly discusses and provides an ethical framework for an analysis that will produce the best results over time [1].

There is a concept, however, that I believe supersedes and overarches concerns about mixed agency, a concept by virtue of which mixed agency conflicts occur. That concept is duty. When one assumes more than one professional duty, the moral dilemma of dual agency arises, and those who are willing to bear this mantle of responsibility must be well prepared if they are to avoid moral pitfalls. It would be difficult to defend the argument that it is morally better to avoid the responsibilities that engender potential dual agency than to accept those responsibilities and prepare oneself to deal with ethical conflicts should they arise.

Duty

What is a duty, then, and how can medical service to the military be considered one? The definition of duty available in an online dictionary of philosophical terms derives from philosophers Immanuel Kant and W. D. Ross. A duty is "what we ought to do; an action that people are required to perform; the practical content of a moral obligation" [2].

The "definition" I tend to favor, though, is one that hangs in the gymnasium of the U.S. Naval Academy: "If not you, who? If not now, when?" I like this rendering of the definition because it implies the self-evident truth that, when there is something that needs to be done for the benefit of all, if every individual were to leave this duty to someone else, it would go undone. I believe most people fail either to understand or to accept this truism when it comes to military service in general and military medical service in particular. Indeed, I believe a pervasive and severe misunderstanding about the nature of service in the United States threatens most efforts at improving our society and perhaps even the persistence of our nation.

Importantly, the degree and manner in which military force is used as an instrument of foreign policy should not be confused with the moral weight and clarity of the concept of military defense. In this regard, I remind readers that the United States recognized just this distinction after World War II when it reorganized the Departments of War and the Navy into the newly named Department of Defense. The need for a system of collective defense seems to be an unfortunate, indeed tragic, part of human existence. From antiquity through today, it appears self-evident that "those who wish for peace must prepare for war" [3].

One argument that questions the morality of military service in general (including medical military service) suggests that somehow, by maintaining military force, one invites attack. Another argument implies that the fiduciary relationship between doctor and patient is sacrosanct and therefore precludes any assumption of dual agency. Other arguments are raised and countered in the Textbooks of Military Medicine.

In my view, whatever the argument, an eschewing of military service boils down to a willingness to allow others to take on a duty that is necessary to the maintenance of the infrastructure of civil society.

Duty is not discussed much in modern Western culture, having been supplanted by more palatable arguments for and dissertations on individual rights. Even when rights are discussed in terms of concomitant responsibilities, the responsibilities part of the equation is generally mild, if not passive, in nature: pay taxes, vote.

Discussion of the morality of military medicine and the consequent moral dilemmas faced by military medical service providers should be an essential part of the dialogue about duty and service in the United States. Mandatory service should fall under the definition of duty, and duty should be of relevance in the wider realm of ethics in general: "If not you, who? If not now, when?"