6.1 Introduction

Physicians joined the Nazi party in greater numbers than any other professional group. By the end of the war, over 38,000 physicians were members of the Nazi Party—representing almost half of all German physicians (Proctor 1988). Physicians were also overrepresented in the Nazi Schutzstaffel (SS). Compared to <0.5% of the general population, 7% of all physicians were members of SS with significant responsibilities at the concentration camps (Proctor 1988). The ideas of National Socialism and later Nazi ideology were both informed by and enthusiastically embraced by the medical profession. Framed as “applied biology,” National Socialism became the political mechanism through which eugenic science was implemented as social policy (Proctor 1988). In accordance with the work of the international eugenics conference, National Socialism advocated that commitment to race betterment was an obligation held by those in government to their citizens (Kevles 2007). It was a government intent on improving the so-called health of the German people by excising those populations that were deemed as inferior. Physicians were instrumental to the policies and practices of World War II Germany. They were involved in many of the atrocities committed during the Holocaust including: forced sterilization, institutionalized killing (Child Euthanasia, Aktion T4 Program, Wild Euthanasia, Operation 14f13, The Final Solution), and Medical Experimentation (Lifton 1986).

When examining bioethics and the Holocaust, the role of physicians is often surprising to students of history. As a society, we expect more of physicians. How did caregivers and healers become killers? How did physicians end up so intimately involved in war time atrocities? But the involvement of physicians in war atrocities is not unique to the Holocaust. Throughout history, medical professionals operating together with and in the name of the governing power and particularly the military, have played key roles in the most horrible human-made calamities: genocides, wars, and human rights violations.Footnote 1 Since the specifics of physician involvement in the Holocaust are explored in detail other chapters, this chapter will explore the ethics of physician participation in war more generally. We will focus on the foundational and recurring issue known as “the problem of dual loyalty,” which is when a single moral agent has loyalty to two competing interests or sets of moral obligations. The underlying assumptions of this examination is that, first, both the professions of medicine and the military involve a set of professional moral obligations, and, second, that these obligations sometimes conflict. We will further describe the concept of “dual loyalty” through historical examples, which will provide breadth and depth of understanding to the moral tensions that undergird it.

6.2 The Military Physician

When physicians were clearly non-combatants in a civilian culture, tending to the sick and wounded of belligerent, armed combatants, regardless of country of origin, protecting and preserving the integrity of the healing arts was less complicated. Today physicians wear the uniforms of their countries, travel imbedded with the fighting forces to intervene and to provide care and treatment to the sick or wounded soldier as quickly as possible with the best expectation of survival (Allhoff 2008, 39).

Physicians and other caregivers have long played an important role in armed conflict and other military operations. Their involvement is critical to ensure both that the war wounded receive proper care and that the able-bodied stay that way—healthy and able to fight. Medical treatment is also essential to military morale. Soldiers will run towards battle when they know that military physicians are ready to treat them if they are injured. However, the existence of caregivers on the battlefield has always been complicated. Their role is highly valued and specialized granting the profession unique status and warranting specific protections—but sometimes these protections and status fall away, and they act in service of the state, rather than in service of the patient.

The physicians who provide care to war’s wounded have not always been part of the military itself. Throughout history, civilian doctors have been mobilized in times of war to provide medical care (Gillett 1981). However, using a civilian medical force without battlefield training often led to a steep learning curve, lost lives, and compromised missions (Cowdrey 1987). Civilian physicians also lacked the cultural knowledge and rank to influence military operations (Gillett 1981). In response to these limitations, military physicians have become increasingly embedded within professional militaries. Now physicians hold high ranks and serve in command roles. They can also be attached to specific units to serve a limited and specialized patient pool (such as flight surgeons). They are trained to use weapons and deploy to combat zones; they wear the same patch as the soldiers around them to symbolize their belonging. Despite their special status, they are now fully integrated in the military, and are in many ways separated from civilian medicine. However, embedding medical professionals within the military not only ensures the necessary training to provide adequate medical care, but it also confers two sets of obligations on a single moral agent and ushers in a foundational ethical tension: are these moral agents doctors? Soldiers? Both? And if both, which role is primary?

6.3 The Problem of Dual Loyalty

The dual loyalty problem refers to dilemmas that challenge military physicians to prioritize the obligations of one of their professional roles over those of the other (Chamberlin 2013; Howe 2003) These physicians find themselves confronted with situations where military protocol, orders, or strategy requires them to behave in a way that is contrary to norms of medical ethics in civilian and peacetime medical practice.

Of course, military medicine has always differed greatly from civilian medicine. Generally, these differences were manifested in scale and scope: military physicians, unlike their civilian counterparts, were responsible for the health of large numbers of soldiers in crowded environments such as camps and transports (Gillett 1981). By contrast, private practice physicians were largely unfamiliar with the unique medical issues of large populations in crowded environments or in the battlespace (Gillett 1981). However, scope and scale are not the only differences between these two groups of medical doctors. Beginning in the First World War, military physicians and outside critics began to discuss a perceived ethical dilemma inherent in physician participation in the military and in war (Byerly 2005). Private-practice, or civilian, physicians were obligated to serve the individual patient, having sworn the Hippocratic Oath and made a public promise to uphold the fiduciary relationship between them and their patients. However military physicians had also sworn another oath—making the public promise to serve their country. During times of war, this meant preparing men to be deployed into war zones that could result in mass deaths (Byerly 2005). Military physicians were also subject to military hierarchy, where they were often outranked by men with no medical training and had to adopt an almost utilitarian framework in order to “maintain the fighting force.”Footnote 2 Although this language was not yet used, the issue of focus was the problem of dual loyalty.

According to the normative conception of modern western medicine, physicians have intrinsic moral obligations that engender responsibility first and foremost towards their individual patients. Many scholars have argued that the medical profession carries its own set of natural ethical maxims (Troug 2011). Edmund Pellegrino, Howard Brody and Franklin G. Miller, for example, have argued that the moral obligation of physicians is grounded in an internal morality of medicine (Pellegrino 2001; Miller and Brody 2001). These authors argue that the internal morality of medicine is internal because it is derived from the nature of medical practice (Pellegrino 2001; Miller and Brody 2001). Edmund Pellegrino and David Thomasma specifically argue that the individual patient encounter is the central defining moral phenomenon of medicine (Pellegrino and Thomasma 1998). They contend that it is this relationship that shapes the foundation for the moral obligations assumed by the physician when she offers to “heal, help, care for, or comfort a sick person” (Pellegrino and Thomasma 1998, 115).

Even those who are not swayed by the argument of an internal morality of the profession of medicine generally agree that there are additional moral obligations that arise due to the special status of the medical professional. This special status confers obligations that, in turn, warrant the public trust and cultural authority granted to members of the medical profession. Longstanding conceptions of medical ethics obligate physicians to prioritize the good of the patient and avoid doing harm. Further, the concept of an internal morality of medicine grounds the physician-soldier’s obligation to her patient in the relationship, locating, at the very least, a prima facie priority where a physician is obligated to care for an often vulnerable, ill patient who requires help. However, in some situations, military health professionals face circumstances and scenarios in which this prima facie priority towards their patients seemingly breaks down. Within the military context, occasions may arise that present ethical tensions between the responsibilities felt towards the individual patient and those felt (and enforced) towards the military mission (Lederman 2013; Gross 2006; Chamberlin 2013).

This ethical conflict is the problem of dual loyalty. This issue arises throughout military medicine, with dilemmas ranging from the common and mundane to the extreme. As a practical matter, the unique issues of military medicine are rarely experienced in garrison. When soldiers receive care in military hospitals at home, it is seldom different from civilian medical care. However, the battlespace is unique. Military hierarchy and the exigencies of war change everything from the experiences of the patient and the provider to the foundational patient-provider relationship. The military itself, usually as represented by the mission or command, enters into this relationship. Beyond that, the physicians’ focus is reoriented away from patient-centred beneficence to the military’s objectives and the mission’s success. In the deployed setting, the military mission is paramount and aggregate concerns are prioritized, this is especially true of combat deployments. Thus, the physician-soldier’s participation in war extends beyond patient care to include other activities perceived as critical to mission success. These activities may even limit or obfuscate patient care completely.

In the following section, the philosophical concept of dual loyalty will be examined through historical examples that offer illustrative case studies arising from physician participation in war.

6.3.1 Historical Examples

Human Experimentation in Concentration Camps

The full extent of physician complicity and participation in the Holocaust is examined throughout this book, so we will not delve into significant detail here. Simply put, the medical community’s involvement was instrumental to everything from early sterilization laws to the Final Solution. While these practices were not limited to military physicians, those working in the concentration camps were uniformed military officers (generally members of the SS). In concentration camps, physicians had many responsibilities and roles, including the development and implementation of inhumane medical experiments. Many of these experiments were military in nature, with the aim of addressing real-life issues facing the German military. This type of wartime research typifies the rationale that national security and military necessity permit normally unethical practices. In prioritizing the mission of the Nazis, these physicians not only failed to protect the vulnerable, but they actively abused and harmed them. Further, their use of prisoners of war highlights the problematic othering that can occur when enemies are not seen as patients, research subjects, or even people. We will briefly describe three experiments with clear military application: High-altitude decompression, wound care/infection, and hypothermia/re-warming.

High-altitude decompression: WWII was the first time that a significant portion of warfare happened in the sky. As a result, prior to the Second World War, aviation medicine did not exist and our comprehension of flight’s effect on the human body was nascent. Militaries were anxious to understand the effects of high altitude and the limits of their pilots. To address this, SS physicians developed and conducted high-altitude experiments on prisoners at the Dachau concentration camp. A pressure chamber was constructed to simulate altitudes as high as 68,000 ft (Caplan 1992). Prisoners were then placed in low-pressure chambers where physicians monitored their physiological response as they lost consciousness and died. These victims were then either dissected of vivisected. Of the reported 200 people subjected to these experiments, 80 died during the experiment and the remainder were either executed or dissected alive (Caplan 1992).

Wound care/infection: In a similar vein, the Nazi doctors conducted many experiments on the treatment of wounds with the hopes that their findings would benefit the German Army. As in prior wars, battle wound infection continued to have significant impact on the health and readiness of troops. For example, German soldiers suffered greatly from gas gangrene in both WWI and WWII. To explore best practices, doctors performed studies to test the effectiveness of sulphanilamide and other drugs in curbing such infections. These experiments involved the intentional infliction of wounds on victims to mimic those of combat. These non-consenting prisoners were first either shot, stabbed, or otherwise mutilated; the wound was then infiltrated with bacteria such as streptococcus, tetanus, and gas gangrene and aggravated by rubbing ground glass and wood shavings into the wound. On occasion, healthcare professionals even tied off blood vessels on either side of the injury to simulate what would happen to an actual war wound. A variety of ointments, salves, and sulfa drugs were then applied to the festering wound. Victims suffered intense agony and serious injury, and some of them died as a result.

Hypothermia/re-warming: Among the most infamous experiments were the hypothermia experiments conducted at Dachau. Again, these experiments were designed to address a pressing issue facing the German military. German pilots were becoming hypothermic after ejecting into the cold ocean and facing extreme exposure on the Russian front. Without any best practices in treatment, experiments were designed to determine the most effective means of treating hypothermia in German soldiers. Dr. Sigmund Rascher and others conducted freezing experiments at Dachau. For up to five hours at a time, victims were placed into vats of icy water, or strapped down outside (Caplan 1992). Victims were either dressed in aviator suits or naked. Physicians were involved in all aspects of the study. They measured changes in the patients’ heart rate, body temperature, muscle reflexes, and other factors. When a prisoner's internal body temperature fell to 79.7 °F, the doctors tried re-warming him using hot sleeping bags, scalding baths, and they even forced naked women to copulate with the victim (Caplan 1992). Victims of these experiments were said to have writhed in pain, foamed at the mouth, and lost consciousness, with many dying in the chamber itself. According to records, roughly 80–100 patients perished during these experiments (Caplan 1992).

These experiments are unethical on every level: the participants had no choice and did not consent, the experiments themselves were torturous, and often the desired outcome was death and dissection. The integral role of doctors highlights the danger of unreflectively applying medical knowledge to military goals. While this research was intended to serve a military mission—albeit a clearly immoral one aimed at genocide and domination—it accomplished these goals by harming patients. This abuse was made possible through a reorientation of medical ethics to serve the Volk and to support the Nazi war effort. Physicians used their medical knowledge and expert skill to design and implement research that was not in keeping with any conception of professional medical morality.

Physician Complicity in Torture: CIA

Half a century later, clinicians once again used their expertise for purposes that ran counter to their professional ethos. Physicians, psychologists, physician assistants, and medics were intimately involved with the “enhanced interrogation” techniques used as part of the Global War on Terror, which in many cases constituted tortureFootnote 3 (Senate Select Committe on Intelligence 2014). In fact, medicine was built into the torture system by way of institutional policy. Steven Miles has argued that tactics constituting torture depended on the participation of medical professionals. According to Miles, “In 2002, Defense Department attorney Diane Beaver crafted Guantanamo’s request for harsh interrogation, arguing that such techniques were legally permissible ‘with appropriate medical monitoring” (Miles, Oath Betrayed: Torture, Medical Complicity and the War on Terror 2009: xiii). Thus, non-clinician commanders and policymakers saw the use of medical professionals as being a more humane approach to the issue of enhanced interrogation. Similarly, Secretary of Defense Donald Rumsfeld included physicians in his harsh interrogation plans for Abu Ghraib and Afghanistan (Miles, Oath Betrayed: Torture, Medical Complicity and the War on Terror 2009).

According to Miles, military medical officers and psychologists played three important roles in the enhanced interrogation system: (1) vetting patients to ensure that they could withstand torture, (2) monitoring patients during interrogations, (3) personalizing enhanced interrogation plans according to medical indicators (S. H. Miles, Oath Betrayed: Torture, Medical Complicity and the War on Terror 2009). The third role, which involved the personalization of the plan, was performed by a group of psychologists and psychiatrists known as Behavioral Science Consultation Teams (BSCTs). These teams were responsible for creating harsh interrogation plans that exploited medical weakness and were informed by psychological knowledge and theory.Footnote 4

According to the Senate report on the CIA detention and interrogation program, detainees underwent inhumane and cruel abuses that included: slaps, “walling” (slamming against a wall), sleep deprivation, loud music, extreme temperatures, prolonged stress positions, waterboarding, and “rectal rehydration” or rectal feeding (Senate Select Committe on Intelligence 2014, 3–4). Physicians for Human Rights (PHR) issued a report summarizing the more lengthy CIA document. Their report elaborates on the roles of medical officers mentioned by Miles (Physicians for Human Rights 2014).

According to their report, medical professionals:

  1. 1.

    Designed, directed and profited from the torture program.

  2. 2.

    Intentionally inflicted harm on detainees.

  3. 3.

    Enabled the legitimization of interrogation practices.

  4. 4.

    Engaged in human subject research to provide legal cover for torture.

  5. 5.

    Monitored interrogations.

  6. 6.

    Evaluated and approved detainees for torture.

  7. 7.

    Conditioned medical care on cooperation.

  8. 8.

    Failed to document physical or psychological evidence of torture.

Importantly, the senate report does not actually corroborate all the claims raised by the PHR’s report. For example, there is no evidence of human experimentation by medical officers in the CIA report. Further, if we exclude psychologists from the category of medical professionals (see footnote 1), the senate report does not provide any evidence for medical professionals designing or directing interrogations

A few abuses intrinsically required active medical officer participation, and were even justified medically, providing a prime example of the “medicalization” of war and torture. For instance, rectal rehydration was used by interrogators as an instrument of torture, while CIA medical officers also justified it medically. One medical officer wrote: “(sic) [w]hile IV infusion is safe and effective, we were impressed with the ancillary effectiveness of rectal rehydration on ending the water refusal…” In June 2013, the CIA even claimed that rectal rehydration was a “well acknowledged medical technique” (Senate Select Committe on Intelligence 2014, 100. footnote 584).

In his testimony to the US senate, CIA director Michael Hayden claimed: “Health care has always been administered based upon detainee needs. It’s neither policy nor practice to link medical care to any other aspect of the detainee program.” In light of the many narratives reported by the senate report, one may conclude that Hayden's testimony was false. The senate report explicitly states that, “[t]his testimony was incongruent with CIA records (Senate Select Committe on Intelligence 2014, 113, 449 (footnote 665)).

Importantly, the ethical dilemma of dual loyalty was addressed at an institutional level by positioning the military as the physician’s client, rather than the individual patient. According to Defense Department Deputy Assistant Secretary for Health, Dr. David Tomberg, there was “no doctor-patient relationships for interrogatees.” This reorientation of moral obligations attempts to relieve the physician-soldier from their medical obligation to the health and welfare of individual patients by rhetorically redefining the doctor-patient relationship through policy. This conceptual understanding of the physician-soldier’s role was reinforced by specific policy: “Under Guantanamo’s 2002 policy, medical personnel were obliged to give non-medical personnel, including members of the BSCT, medical information relative to the ‘national security mission’ upon request.” (Miles, Oath Betrayed: Torture, Medical Complicity and the War on Terror 2009, 54).

Interestingly, others in powerful positions within the U.S. government made statements that directly contradicted these policies. While rejecting the allegations that physicians were involved in these harsh interrogation programs, Assistant Secretary of Defense for Health, Dr. William Winkenwerder Jr., stated, “…we always expected a physician to behave ethically in any circumstance” (Miles, Oath Betrayed: Torture, Medical Complicity and the War on Terror 2009, 63). This highlights the military’s institutional failure to address adequately and coherently the role of the physician-soldier, while simultaneously compounding the problem with mixed institutional messages.

Doctor-Patient Confidentiality

Another significant issue related to the problem of dual loyalty is the violation of patient confidentiality under military order or in support of the military mission. Generally, these cases exist along a continuum and ethicists such as Edmund Howe believe that physicians should breach confidentiality only in limited situations, such as when the demands of military necessity are stronger (Howe 2003). An illustrative example is that of the now-repealed American policy known as “don’t ask, don’t tell” that was abolished by President Barack Obama. This policy had banned openly gay citizens from active military duty. The policy placed psychiatrists in a position that exemplified the problem of dual loyalty. If a patient were to confide in them about their homosexuality, military psychiatrists had an obligation to report the individual to their commanding officer, as his or her sexuality violated regulation. This regulatory obligation was problematic to psychiatrists because they felt that medical ethics called for doctor-patient confidentiality, which was breached by this policy. There may be other occasions in which physicians can be compelled to breach confidentiality—such as reporting diseases and illnesses that affect mission readiness or a soldier’s ability to fulfil his or her obligations/duties. However there needs to be a clearly justifiable medical need to violate this fundamental tenet of bioethics.

6.4 An Ethical Analysis of Military Medicine

Various authors have grappled with the problem of dual loyalty presented in these and other cases. Philosopher John Moskop explains that military physicians assume a set of obligations as physicians (which he characterizes as a fiduciary relationship grounded in the four principles of Tom Beauchamp and James Childress) and another as soldiers, as framed by the institution of the military itself.Footnote 5 Moskop acknowledges that these obligations may come into conflict and seeks to highlight the important moral decision a physician faces when joining the military. Standing in contrast to other authors who posit the supremacy of one of the physician-soldiers’ twin roles, Moskop recognizes both as having prima facie legitimacy (Moskop 1998). While acknowledging the moral difficulties of the physician-soldier, Moskop leaves it to the individual to decide his or her own ethical and professional path. According to Moskop, “a physician’s decision to enter military service is thus a morally weighty one that bears reflection on the practices of the military service to which one is pledging obedience” (Moskop 1998, 163).

Some have argued that a military physician is a moral impossibility. According to this line of thought, the dual loyalties are not just conflicting but incompatible. Put another way, the use of physicians by the military and involvement of physicians in military activity is morally objectionable on the grounds of medical morality (Siden and Levy 2003). In the textbook titled, Military Medical Ethics, Victor Sidel and Barry Levy argue that it is unacceptable for physicians to serve as both physician and soldier (Sidel and Levy 2003). The authors ground their position in the belief that the “overriding ethical principles” of each of these professions are incompatible with the other. Sidel and Levy define the overriding ethical principles of medical practice as (1) concern for the welfare of the patient and (2) to primarily do no harm (Sidel and Levy 2003). These principles are rooted in the ethical codes of professional organizations, and further codified in the Geneva conventions and similar international documents. On the other hand, the overriding principles of military service are defined as concerning (1) maintaining the effective function of the fighting force and (2) obedience to the command structure. These are seen as incompatible because medical morality is understood as necessitating prioritization of the patient above military concerns. Due to this incompatibility, Sidel and Levy believe that the role of the physician-soldier is an inherent moral impossibility (Sidel and Levy 2003).

As a response to the arguments of Sidel and Levy, other scholars have gone so far as to posit that there is in fact no problem of dual loyalties for the physician-soldier (Madden and Carter 2003). William Madden and Brian S. Carter have argued that the values are not that different when one explores the essence or ethos of the profession’s moral world (Madden and Carter 2003). According to Madden and Carter, the ethos of each profession is characterized by the values that define the profession and the professionals, establishing their collective rights and responsibilities (Madden and Carter 2003). According to these authors, both professions seek protection of the vulnerable, rendering the dual loyalties inherently compatible.

Madden and Carter ground the ethos of medicine in its professional oaths (such as the Hippocratic Oath and AMA code of ethics), which have historically existed to prevent medical professionals from becoming “agents of death” (Madden and Carter, 271). Their understanding of professional medical morality is further grounded in social and political policy, which have used “professional, civil, and criminal sanctions to prevent members of the medical profession from becoming involved in activities that led to the deaths of members of their society” (Madden and Carter 2003, 271). This professional medical morality is discussed in conversation with the morality of the profession of arms, which Madden and Carter characterize as being, “tasked with defending members of that society by becoming directly involved in activities that lead to the wounding or death of others” (Madden and Carter 2003, 271).

These authors refute the arguments of Levy and Sidel by appealing to medical necessity and a long history of physicians’ involvement in war. Their involvement is necessary because of the very nature and context of war. The unsanitary and overcrowded conditions of war lead to rampant illness and infectious disease, which warrants medical attention. Beyond these conditions, the ability to maintain or conserve the fighting force is paramount to military success, necessitating the skills of a medical doctor.

Importantly, Madden and Carter recognize the physician’s role in the military system in a way other authors fail to. Madden and Carter acknowledge that physicians have become part of the formal military system, joining in the initiation rites by swearing the same oath as non-medical officers and wearing the same uniform. These physicians are not just individuals doctoring in the context of war, they are doctoring within the military profession and that institution. Drawing on the work of Samuel Huntington, Madden and Carter enrich the understanding of the profession of arms as one of the historically recognized professions: namely, divinity, law, medicine, and the military (Madden and Carter 2003).

Madden and Carter define the goals of medicine as “prevention whenever possible; curative treatment when prevention fails; and healing, the relief of pain and suffering, when specific treatment will not benefit the patient” (Madden and Carter 2003, 275). The goal of the military profession is defined as security. Madden and Carter argue that men and women are “drawn to the profession of arms both by their desire to serve society and by the inherent attraction of the ultimate means of the profession—war” (Madden and Carter 2003, 279). The authors then trace the professional similarities between medicine and the military. They argue that medicine aims at aiding individuals in maintaining and restoring health or working to ease the patient’s suffering if a cure is not possible. This goal serves society because society benefits from having healthy citizens. The goal of the military also seeks to benefit society by protecting it and dissuading others from attacking it. Madden and Carter offer the argument that societies need both professions, as they both serve it in preserving its future.

By appealing to the ethos of these professions Madden and Carter appeal to a normative conception of professional morality. In shaping the conception of military morality in this way and understanding the profession of arms as beneficently protecting society, Madden and Carter are able to frame military morality in a more positive way as compared to Sidel and Levy. This distinction highlights the importance of maintaining both normative theories and descriptive realities in any dialogue of professional morality.

The morality of the military profession depends on the morality of the military mission and how that mission is carried out. Since the military institution is built on the foundational values of obedience and loyalty, soldiers are trained to uphold the mission and follow orders regardless of whether they agree with the mission or not.Footnote 6 While some military missions, programs and operations do aim to protect society and uphold important values, there have been historical examples where the goal was not protection but rather colonization or imperialism. This is especially true of WWII, where the goals of Nazi genocide and domination have been universally condemned. The mission was immoral and thus anything done in support of this mission was also morally wrong.

Similarly, the morality of the medical profession depends on the morality of the medical mission. In this case, the mission is arguably always the same- caring for individual patients. Consider however the role of individual healthcare workers in research, or as officers of public health—only recently authors of an introductory book in bioethics have explicitly argued that physicians should consider public health implications in their care of individual patients (Herbert and Rosen 2020). Some form of the dual loyalty problem is thus not limited to the military.

6.5 Dual Loyalty in Non-military Settings

Analogies are often drawn between those examples just discussed and the conflicting loyalties that occur in the civilian sector. The editors of the Institute of Medicine’s published workshop summary entitled Military Medical Ethics: Issues Regarding Dual Loyalties acknowledge that this type of dual loyalties problem exists outside of the military sphere, having many civilian analogies:

In occupational medicine, particularly in small corporations, where the physician or nurse reports directly to corporate executives, an injured employee’s desire to return to work in order to obtain full benefits may conflict with corporate productivity goals. In sports medicine, a triad of decision makers—physician, coach, and athlete—typically make a joint decision, based on a full assessment of risks and benefits offered by the physician (Institute of Medicine 2009, 2).

The military physician certainly differs from the above-mentioned professionals in terms of moral obligations and professional status. Howe points out that “the conflicting obligations military physicians face generally are greater in both magnitude and frequency than those faced by their civilian counterparts” (Howe 2003, 334). According to this argument, the main difference is the fact that the stakes in the military are substantially higher. Military physicians practice medicine in the context of war, a context seen as unparalleled in civilian medicine. Due to this fact it is possible that medical decisions could lead to the loss of the war, potentially resulting in many millions of deaths and great harm. Occasions such as that may be rare but are nonetheless real. The context of war coupled with the high stakes accompanying such an endeavour differentiates military problems of dual loyalty from those of the civilian sphere. This difference highlights the ethical dilemmas unique to military physicians.

Practitioners of sport and occupational medicine for instance may be placed in situations that challenge their obligation to care for an individual patient, but their other allegiances are not to professions in the same sense as medicine and the military. These physicians have not made a public promise as a member of two distinct professions, entering into specific relationships with inherent moral obligations in the same way as a military physician. The act of profession, of publicly promising to become a member of a specific profession, with everything that entails, is a foundational component of professional morality (Pellegrino and Thomasma 1998). Practitioners of sports medicine, or occupational medicine have only joined the profession of medicine; they have not taken an oath to the non-medical institution they serve. This oath confers both a moral and a legal obligation to follow orders that support the military mission. Beyond that, their second, non-medical roles generally lack the established professional morality of medicine, making medical obligations easier to prioritize over other, non-medical goals. Although other concerns may enter their decision-making process, including job security and pleasing their employer and patient, the second role of an occupational or sports medicine physician does not carry the same moral and legal obligations as those in the military.

Healthcare workers working in public health or research may come closer to the dilemma faced by the military healthcare worker. While they have sworn only one oath, aimed at their individual patients, they have obligations towards the public which they serve and to science—i.e. to produce generalizable knowledge. Arguably, not only public health officers hold duties towards the public but all healthcare workers, who must report cases of certain infectious diseases for instance, whether it serves the individual patient or not. While the dilemma of the clinician-researcher has been discussed ad nauseum, the dual loyalty of the clinician who is also a public health practitioner seems to rely on the unchallenged assumption that the two loyalties are and should be separated. Maybe time is due to challenge this assumption, especially as the tensions that arose during the Covid-19 pandemic revealed that a conflict of interests exists between public health and fiduciary focus on individual patients. In other words, the practical and conceptual separation between the clinician and public health is probably overstated and morally questionable.

Despite the existence of these conflicting identities outside of the military, the austerity and intensity of war raise the stakes for military physicians. But more than that, times of crisis have a tendency of shifting societal values for all, not just those in the military. Under threat of death or the prospect of mission failure, people can suspend their moral values. Those physicians who were integral to and complicit in the atrocities of the Holocaust were not all in uniform. The proliferation and power of the Nazi ideology within the professional community meant that the majority of physicians tolerated the expulsion of their Jewish colleagues and accepted discriminatory policies. The complicity of German medicine during the Holocaust, must recognize the communal nature of this support, as well as its widespread proliferation within the broader medical culture.

6.6 Conclusion

The problem of dual loyalty ushers in a professional identity crisis for the military physician. Research has shown that military physicians self-identify along a spectrum, and that this spectrum informs their understanding of their role (Chamberlin 2013). Some see themselves as physicians who simply work for the military and others see themselves as inhabiting a unique role as both or as a “military physician.” Still others (and many in command) see this group as no different from other categories of soldiers with unique skillsets of operational relevance. While each of these moral identities brings with it challenges and issues, it is this last view that is most problematic. Viewing military physicians as soldiers with military relevant skills ignores the professional moralities outlined above and enables the instrumentalization of medicine for military purposes. According to this line of thought, military physicians are no different from airplane mechanics or combat gunners. Their skillset does not come with professional moral obligations and thus can be used as needed by the military. A soldier’s only obligation is to the military and its mission. The danger of instrumentalizing medicine for military purposes is evident across history. When professional medical obligations are cast aside and military goals are prioritized, we have seen physicians involved or complicit in significant harms against the ill, disabled, and vulnerable (their would-be patients).