The document discusses several ethical dilemmas that may arise for psychiatrists working in the military. It outlines scenarios involving issues like diagnosis and confidentiality when treating soldiers, obtaining informed consent, determining fitness for duty, and handling psychiatric casualties during combat. The document also examines more complex situations like battlefield euthanasia, participation in interrogations, and providing care during peacekeeping missions. Overall, it explores the challenges of balancing duties to individual patients with responsibilities to the military organization.

1. DUAL ROLE ETHICAL DILEMMA
IN MILITARY PSYCHIATRY
Col. Dr. Ehab Elbaz
Psychiatry hospital
Maadi military medical complex

2. CLINICAL SCENARIO (1)
• A 20 years old solider was referred by his unit
for psychiatric assessment due to anxiety
symptoms and inappropriate fear of the sound
of firearms . The psychiatrist decided to admit
the patient in the hospital for further
evaluation but the patient refused admission.
• What the right action for the military
psychiatrist to do ?

3. CLINICAL SCENARIO (2)
• During a psychiatric interview with a military
officer , he disclosed homosexual desires and
activities to his psychiatrist.
• What the psychiatrist should do ?

4. CLINICAL SCENARIO (3)
• A solider with moderate depression attending
the psychiatric clinic and refuses to take any
medication. The psychiatrist decide to give
him ECT against his will.
• Is it ethical ?

5. CLINICAL SCENARIO (4)
• A military officer with substance use disorder
during his follow up visit he disclosed to his
psychiatrist taking one tablet of tramadol few
days ago although his drug screen was
negative .
• Should the psychiatrist report this to the
higher authorities ?

6. WHAT IS ETHICS ?
• The discipline dealing with what is good and bad
and with moral duty and obligation.
• the principles of conduct governing an individual
or a professional group .
• A branch of moral philosophy .

7. MILITARY PSYCHIATRY
‫الوالء‬ ‫يمين‬
•"‫م‬‫م‬ ‫مون‬‫م‬‫أد‬ ‫أن‬ ‫ميبك‬‫م‬ ،‫ال‬ ‫ملع‬‫م‬‫هلل‬ ‫مب‬‫م‬‫أقس‬ً‫ل‬‫ي‬
‫ممممبك‬‫م‬‫هللي‬‫ص‬،‫ال‬ ‫ممممص‬‫م‬،‫م‬ ‫ممممب‬‫م‬‫وصي‬ ‫م‬ ‫ل‬ ً‫ل‬‫مممم‬‫م‬‫وفي‬
ً‫ل‬‫حلميم‬ ‫ل‬ ‫وسمهم‬ ‫مل‬ ‫أم‬ ‫علم‬ ً‫ل‬ ‫محلف‬
‫مممص‬‫م‬‫هللح‬‫ل‬‫وا‬ ‫مممص‬‫م‬‫هلل‬‫ل‬‫ا‬ ‫ممم‬‫م‬‫ف‬ ‫ممملك‬‫م‬ ‫ع‬ ً‫ل‬،‫ف‬ ‫ممم‬‫م‬‫وم‬
‫ممبك‬‫م‬‫وصي‬ ‫م‬ ‫ال‬ ‫مملصه‬ ‫و‬ ‫مما‬ ‫ا‬ ‫مموك‬ ‫وال‬
‫ممدصيب‬‫م‬‫ال،س‬ ‫ممص‬‫م‬‫لموام‬ ‫ممل‬‫م‬،‫مطي‬‫ك‬ً‫ا‬ ‫مم‬‫م‬‫ف‬ ‫وم‬
‫قل‬ ‫ألوامص‬‫سهح‬ ‫عل‬ ً‫ل‬ ‫ومحلف‬ ‫ك‬
‫وه‬ ‫ك‬ ‫الممو‬ ‫و‬ ‫أ‬ ‫م‬ ‫ح‬ ‫قط‬ ‫صده‬ ‫أ‬ ‫ال‬
‫ي‬ ‫ش‬ ‫أقوا‬ ‫مل‬ ‫عل‬"
‫هلللء‬‫ط‬‫األ‬ ‫قسب‬
•((‫فى‬ ‫هللا‬ ‫أراقب‬ ‫أن‬ ‫العظيم‬ ‫باهلل‬ ‫اقسم‬،‫هنتى‬
‫ىا‬‫ى‬ ‫وار‬ ‫أ‬ ‫ى‬‫ى‬‫ااف‬ ‫ى‬‫ى‬‫ف‬ ‫ىان‬‫ى‬‫اننس‬ ‫ىان‬‫ى‬‫اي‬ ‫ىون‬‫ى‬‫أص‬ ‫وأن‬
‫فى‬ ‫وسىع‬ ‫بىاوس‬ ‫واحاىوال‬ ‫الظىرو‬ ‫ال‬ ‫ف‬
‫ن‬ ‫ا‬ ‫استنقاو‬‫والقل‬ ‫واحلم‬ ‫رض‬ ‫وال‬ ‫الهالك‬‫ق‬
‫ىىورتهم‬ ‫واسىىتر‬ ‫تهم‬ ‫اىىرا‬ ‫ىاا‬‫ى‬‫للن‬ ‫اافىىظ‬ ‫وأن‬
‫م‬ ‫ىىر‬‫ى‬‫س‬ ‫ىىتم‬‫ى‬‫واا‬‫ىىن‬‫ى‬ ‫وام‬ ‫ىى‬‫ى‬‫ال‬ ‫ىى‬‫ى‬‫ل‬ ‫ىىون‬‫ى‬‫أا‬ ‫وان‬
‫ل‬ ‫الطبي‬ ،‫ايت‬ ‫ر‬ ‫باوس‬ ‫هللا‬ ‫را‬ ‫وسائل‬‫لقريب‬
‫والخاطئ‬ ‫للصالح‬ ‫والبعي‬‫وا‬ ‫يق‬ ‫والص‬‫و‬ ‫لعى‬
‫العلىىىم‬ ‫طلىىىب‬ ‫لىىى‬ ‫أثىىىابر‬ ‫وان‬‫لنفىىى‬ ‫أسىىىخرن‬
‫آلوان‬ ‫س‬ ‫اننسان‬‫لىم‬ ‫وا‬ ،‫ن‬ ‫ل‬ ‫ن‬ ‫أوقر‬ ‫وان‬
‫ى‬‫ى‬‫ف‬ ‫ىل‬‫ى‬‫ي‬ ‫ىل‬‫ى‬‫لا‬ ‫ىا‬‫ى‬‫أخ‬ ‫ىون‬‫ى‬‫وأا‬ ،‫ى،رن‬‫ى‬‫يص‬ ‫ىن‬‫ى‬
‫والت‬ ‫ىر‬‫ى‬‫الب‬ ‫ى‬‫ى‬‫ل‬ ‫ىاونين‬‫ى‬‫تع‬ ‫ى‬‫ى‬‫الطبي‬ ‫ى‬‫ى‬‫هن‬ ‫ال‬‫ىو‬‫ى‬‫ق‬
‫ىر‬‫ى‬‫س‬ ‫فى‬ ‫ىان‬ ‫اي‬ ‫اي‬ ‫صى‬ ‫ايىات‬ ‫تاىون‬ ‫وان‬
‫ور‬ ‫هللا‬ ‫ىان‬‫ى‬ ‫ت‬ ‫ىينها‬‫ى‬‫يت‬ ‫ىا‬‫ى‬ ‫ى‬‫ى‬‫نقي‬ ‫ى‬‫ى‬‫النيت‬ ‫و‬‫ىل‬‫ى‬‫س‬
‫تهي‬ ‫أقول‬ ‫ا‬ ‫ل‬ ‫وهللا‬ ‫نين‬ ‫ؤ‬ ‫وال‬)).

9. ETHICS IN PSYCHIATRY

10. ETHICS IN PSYCHIATRY

11. LAW vs. ETHICS

12. RELATIONSHIP BETWEEN LAW AND ETHICS
ETHICSLOW
LAW AND ETHICS
LAW
&
ETHICS

13. ETHICS VS. LAW
legal
illegal
unethical ethical

14. ETHICAL DILEMMA

15. PSYCHIATRY AND
THE MILITARY
• Psychiatrists have been serving in
uniform since World War I and
caring for service members in
times of war and peace.
• During the Vietnam War, the
psychiatric community began to
debate the appropriate role for
psychiatrists during time of war,
especially for those serving in the
military.
• At the root of this issue was the
question ‘‘For whom does the
psychiatrist work—the individual
service member-patient or the
military organization?’’

16. DUAL AGENCY
• As physicians, they attend directly to the needs of their patients,
maintain confidentiality, and protect the privacy of the information
conveyed to them in clinical settings.
• At the same time, military psychiatrists serve the organization in
ensuring that the unit is able to optimally perform its mission
without undue danger to service members or others.
• At times these overlapping roles, each with significant
responsibilities and duties, create a sense of ‘‘dual agency,’’ which in
turn can lead to real and perceived conflicts.

17. • The dictum, that a medical officer is a soldier
first and only then a medical man, is drilled
repeatedly into the minds at the officers’
academy of the army medical corps.
• A military psychiatrist becomes a soldier,
doctor and a psychiatrist all rolled in one. Each
role has potential to come in conflict with the
other.

19. 1- DIAGNOSIS
• In general medicine diagnosis of a disease is fairly straight forward in
nature. There is a moral and evaluative element in psychiatric diagnoses.
• Terms like “deterioration” and “disregard for the rights of others” are
included in the diagnostic criteria of some conditions. Conditions like
personality disorders do not meet the robust criteria of diagnosis.
• In psychiatry , diagnosis has implications for involuntary treatment,
insanity defense and loss of job in the military setting.
• It is the duty of the service psychiatrist to get relevant inputs from various
sources like the patient's comrades, commanding officer and family
members before making a diagnosis of personality disorder.

20. 2- CONFIDENTIALITY
• Military psychiatrists come into contact with service member-patients
through two general routes:
1- The most common route is self-referral
2- The second route is (a ‘‘command referral’’)
• Under conditions of self-referral, unit commanders are notified of service
member mental health conditions only under rare circumstances.
• Exceptions to this rule exist in some specialty communities, such as flight
crews and personnel in submarine service,. In those communities,
regulations may require that the unit command be notified whenever a
service member is treated with psychiatric medications.
• Service members are generally aware of this notification requirement and
its potential impact on the employment before self-referring.

21. • In command referral , commanders must
document the specific behaviors that have given
cause for such an evaluation.
• In the event of a command-directed evaluation, it
is clear to all parties that a fitness-for-return-to-
duty is evaluated .
• But what if the service member refuse to be
admitted ???

22. 3- INFORMED CONSENT
• limitations on medication choices because of impact
on service member-patient’s fitness for deployment or
continued service or involuntarily separation from the
military despite his or her desire to continue service.
• The element of voluntarism represents a potential
ethical vulnerability for a patient who may feel unable
to seek treatment or decline recommended treatment
because seeking care may negatively impact the
individuals career.
• Informed consent for ECT????

23. 4- FITNESS FOR DEPLOYMENT
• In 2006, the US department of defense laid down minimum
mental health standards for deployment.
• Mental health screening is incorporated into the pre-
deployment medical screening process.
• It is unethical to expose an incompetent soldier to the
combat environment putting him as well as his unit
members at risk .
• What if the solider has mild anxiety and does not want to
be deployed ?

24. 5- RETURN TO UNIT
• When confronted with a minimally injured person a physician may
experience internal conflict between a desire to protect the patient
from additional trauma and the duty to support the organization.
• A psychiatrist may face similar conflict in managing a patient with
combat stress reaction. In the guise of respecting a person's
autonomy he might evacuate the patient who is reluctant to go
back to unit or he may become paternalistic and give a serious
diagnosis to place the evacuation on sound footing.
• In the event of injury or death happening he might question if he
would have been better off facing court martial rather than carrying
guilt in his heart.

25. 6- BATTLE FIELD TRIAGE
• Psychiatrists are not required to be available in field
hospitals as focus is shifting towards primary care
rather than specialist care of psychiatric casualties.
• Psychiatrists will continue to remain involved in
consultation and training.
• In some circumstances, a soldier who has little chance
of recovery may not be treated or even evacuated. In
such events some may die who otherwise would have
survived if appropriate medical facilities were made
available.

26. 7- BATTLE FIELD EUTHANASIA
• Swann raised the question of euthanasia in an assumed scenario
where he could neither care for his patients nor evacuate them and
as the enemy is fast approaching he must retreat.
• The options could be three:
1- Kill them for mercy .
2- Leave them to the mercy of the enemy .
3- Disobey the order to retreat to another location and stay
with them and do what best can be done.
• All the options can be considered from the angles of autonomy,
beneficence, non-maleficence and justice. Swann argued that
euthanasia could be a viable option.

27. 8- INTERROGATION AND TORTURE
• A psychiatrist might be asked to help in
interrogating an injured detainee or a prisoner of
war who is under his care or he may be asked to
put his expertise at the disposal of the
interrogating team as consultant.
• The American Psychiatric Association and the
World Psychiatric Association expressly forbid
their members to participate in any sort of
interrogation mandated by the military or law
enforcing agencies.

28. 9- PEACE KEEPING
• Military medical officers deployed in peace keeping
operations encounter difficult decisions in regard to their
obligation to the local civil population, which may be under
resourced and vulnerable to abuse both by the peace
keepers and the warring factions.
• It is advisable for the medical contingents to work through
local authorities and community leaders. Due care should
be taken to identify local leaders, which in itself may turn
out to be a difficult task.
• In recent times psychiatrists are also being deployed with
the peace keeping contingents.

29. 10-BOUNDARIES
• When providers live and work in a small community, many complex issues related
to professional and personal role boundaries also arise. Military psychiatrists, more
than other physicians and military physicians, need to exercise great care in
establishing social relationships.
• As a service psychiatrist is a marked man, being a rare commodity he should take
great pains to compartmentalize his social and professional relationships because
some of his superior officers and subordinates might actually be under his care.
• Boundaries must be discussed clearly at the outset of treatment, separating the
treatment from the professional or personal relationship and establishing
expectations for both parties.
• At the beginning of treatment, the psychiatrist should discuss how both parties
will handle daily interactions, such as seeing each other at the dining facility, the
gym, or in the general living area.

30. 11- SEPARATION FROM THE MILITARY
• At times soldiers may have mental health conditions that do not
require a medical disability discharge but may make a soldier unfit
for duty.
• These conditions are defined in U.S. Army Regulation 635-200
(Enlisted Separations).
• Predominantly, military psychiatrists are involved with chapters 5-
13 (personality disorders) and 5-17 (other mental or physical
disorders).
• Both of these chapters require that the soldier not have a condition
that would require a medical discharge and disability evaluation,
such as bipolar disorder, posttraumatic stress disorder, or
schizophrenia

31. • Chapter 5-13 states that a soldier can be separated for personality
disorder if the condition severely impairs the soldier’s ability to function in
the military environment (ie, potentially jeopardizes the health and safety
of others and/or key operations of the military). The policy further states
that the disorder must be longstanding and deeply ingrained.
• This is particularly important when dealing with the post deployment
soldier who may have confounding posttraumatic stress issues, mild
traumatic brain injuries, or acute situational issues.
• It is expected that a military psychiatrist considering this separation has
documented a longstanding pattern of dysfunctional behavior that clearly
has impaired social and occupational relationships but is not the result of
military service.

32. • Chapter 5-17 deals with physical or mental issues not
covered under other areas of the separation regulations
that ‘‘potentially interfere with assignment to or
performance of duty.’’
• This includes conditions such as claustrophobia,
disturbances of perception, emotional control or behavior,
dyslexia, sleepwalking, or other disorders that may
significantly impair military duties.
• In recent years, the military has been accused of using
these separations to withhold disability benefits from
service members.

33. • At times, military psychiatrists may perceive
pressure to recommend use of these chapter
separations as opposed to a fitness-for-duty
and disability evaluation. This pressure often
comes from the patient, the unit, or both who
are primarily trying to expedite a rapid exit
from the military for varying reasons.

35. 1- APPROACH MODEL
• Johnson and Wilson (1993) identified three approaches to consider
in the military mental health system.
1- military manual approach, occurs when professionals
adhere strictly to military regulations without
consideration for the specific client’s needs.
2- stealth approach, occurs when there is strict adherence to
the mental health professionals’ code of ethics, regardless
of the legalities surrounding the circumstances.
3- best interest approach, maintains focus on the client’s best
interest while also adhering to the standards of the military.
• Although most professionals have deemed this approach the best
option, it also leads to the most ambiguity.

36. 2- STAGE MODEL
Barnett and Johnson (2008) proposed a 10-stage model to follow when
navigating an ethical dilemma.
1. Clearly define the situation.
2. Determine what parties could be affected.
3. Reference the ethical codes.
4. Reference the laws and regulations.
5. Reflect on personal thoughts and competencies on the issue.
6. Select knowledgeable colleagues with whom to consult.
7. Develop alternate courses of action.
8. Evaluate the impact on all parties involved.
9. Consult with professional organizations and colleagues.
10. Decide on a course of action.

37. A PROPOSED MILITARY MEDICAL
ETHIC ( BEAM AND HOWE, 2003)

38. PRINCIPLES OF PUBLIC HEALTH ETHICS AND ITS
ABLICABILITY IN MILITARY SETTINGS
 The effectiveness principle: requires evidence of the effectiveness of a
measure in improving public health if other moral considerations (such as
individual rights and freedoms) are to be violated.
 The proportionality principle: requires that a positive balance be achieved
between the potential benefits of a public health intervention and the
adverse effects of violating individual human rights.
 The necessity principle: requires that no other method of achieving the
required goals would have less conflict with other moral considerations.
 The harm principle: states that the only justification for restricting the
liberty of an individual or group is to prevent harm to others.

39.  The least restrictive means principle: requires that less
coercive means (e.g., education, facilitation, and
discussion) should first be tried before it is justified to
implement the full force of state authority.
 The reciprocity principle: requires the state to provide
assistance to individuals to facilitate their meeting their
public responsibility.
 The transparency principle: requires the public health
decision-making process to be as clear and accountable
as possible.

40. CONCLUSION
• Dual role in military psychiatry creating an ethical
dilemma regarding many aspects of the clinical practice
of psychiatry rather than the civilian environment.
• Sometimes , taking decisions which is legal and ethical
may not be straightforward .
• Teaching ethics to military psychiatrists and all the
military medical physicians help to identify and solve
many personal and professional problems they face in
their career life .