Reference solution

Moral Questions

1. Is it morally justifiable for the doctor to declare the soldier fit for normal duty?
2. Is it morally justifiable for the chain of command
to send a soldier back on patrol knowing that s/he has not fully recovered from a previous injury?

Final Actions

Prohibited

• It is ethically unacceptable for the doctor to declare the soldier fit for normal duty, given the obvious health risks associated with his condition.
• It is ethically unacceptable for the chain of command to send the soldier back on patrol while he has not sufficiently recovered and there is a subsequent risk to his comrades if he cannot do his job properly.

Maybe allowed

• It may be ethically acceptable to return the soldier to lighter duties where he or she is not exposed to potentially re-trauma-tizing events, but can be slowly reintegrated.

Permissible

• If the injured soldier poses an immediate danger to others, it is ethically required to temporarily remove him from duty.
• It is ethically permissible for the physician to protect the soldier's health by ensuring that he receives the necessary treatment/rehabilitation and time to recover.
• It is ethically permissible to explore other job opportunities for the soldier within the armed forces until his condition allows him to return to his normal duties.

Further reflections

Main ethical issues

The most important questions of this scenario is (1) what kind of criteria should from an ethical perspective influence the decision if someone is declared fit for duty and (2) who should take this decision. Since the doctor in the scenario is employed by the military, s/he also faces the issue of dual loyalty.

Dual Loyalty of the doctor

Dual loyalty conflicts of military doctors occur when they may not be able to fulfil their obligations towards a patient as a doctor because military (and, thus, non-medical) reasons demand to be respected as well. The question of whether a wounded soldier is fit for duty again is a typical example in which dual loyalties can occur. If and to what extent they play a role also depends on the context, for example if the soldier is really needed to return or if others can easily replace him or her.

• Read more on dual loyalty in our introductory chapter in the MME Scenario Collection

Individual's health

Obviously, the health of the individual in question should from a medical ethics perspective the most important point to consider. Considerations should include both the current condition of the individual as well as preventive measures such as avoiding and exposure to obvious risks (related to the current medical condition).
On the other hand, not returning someone to duty can also have adverse effects on the individual's health or have unintended side effects such as stigmatization, administrative separation without compensation etc. These have to be taken into account as well.

• See discussion at p.8 ff. in the Report of a Dual Loyalty Workshop

Risk for others

Another aspect to consider are risks associated with the health condition of the individual but that would ultimately affect others. For example, if the soldier in our scenario would be expected to freeze and be unable to act in case he is again exposed to an IED situation, such a behaviour would then clearly put comrades at risk and would speak against declaring the soldier fit for duty again.

Alternatives

In cases like the one presented in the scenario it seems important to not only consider extreme solutions, but to rather treat the question of being fit for duty as continuum. Reintegration can for example be part-time, exclude certain aspects of the job for some time, etc. Doctors may play a helpful role for command decisions if they give hints regarding what kind of duty someone may already be fit for. Patient confidentiality must however be respected and the patient's consent be sought if information about medical diagnoses are shared.

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