Introduction: Dual loyalty and mixed obligations

Author: Dr phil Daniel Messelken | ZH Center for Military Medical Ethics.

The problem of “dual loyalties” is not a new one and is, in fact, not restricted to the military context. It is sometimes also labelled “mixed agencies” or “divided loyalties” and can occur whenever the fulfilment of a professional role puts a person in between different role obligations.

According to Williams (2009: 9), physicians may encounter potential dual loyalty conflicts when obligations towards a patient on the one hand collide with obligations towards prison authorities or the police, the army, a hospital, an insurer, the employer, a sports team, or the public more generally. This shows the wide range of dual loyalty issues, which may however be said to lead to sharper tensions in the military, as typical situations of dual loyalty in the military context include orders that a military doctor is expected to follow. The BMA has described the military specifics of dual loyalties in their tool kit on “Ethical decision making for doctors in the armed forces” following way:

“Doctors’ professional and ethical duties require them to preserve life, care for the sick and wounded, and reduce suffering. As military personnel, part of their role is to support those non-medical military colleagues whose function involves attacking and inflicting harm on the enemy. Circumstances can therefore arise where doctors come under pressure to prioritise their obligations or loyalties to the military over their ethical duties.“ (BMA Medical Ethics Committee and Armed Forces Committee: 7)

Definition of “Dual Loyalties”

The problem of dual loyalty can be defined very generally as situations “in which health professionals are obligated to fulfill multiple roles, sometimes resulting in ethical tensions between the roles” (Weisfeld et al. 2009: 5) A more complex definition of dual loyalty, which is most often quoted and referred to has been given by an international working group on the issue and defines the problem as a

“clinical role conflict between professional duties to a patient and obligations, express or implied, real or perceived, to the interests of a third party such as an employer, an insurer or the state.” (International Dual-Loyalty Working Group 2008: 16)

As this definition shows, situations of dual loyalties are not restricted to the military context but can occur in a variety of settings. The authors of a workshop report on dual loyalties in the military context hint at the context where issues may arise for military doctors:

“Military health professionals, as all health professionals, are ethically responsible for their patients’ well-being. In some situations, however, military health professionals can face ethical tensions between responsibilities to individual patients and responsibilities to military operations.” (Weisfeld et al. 2009: 1)

Dual loyalty conflicts for military doctors, according to this statement, thus occur when a doctor may not be able to fulfil his or her obligations towards a patient as a doctor because military (and, thus, non-medical) reasons demand to be respected as well.

Situations of dual loyalty should not be confounded with a “conflict of interests”. The latter involves a personal interest, whereas “dual loyalties are conflicts between two external accountabilities that are incompatible.” (Williams 2009: 8) A conflict of interests could thus be resolved by giving one’s own interest less weight, whereas in situations of dual loyalties the interests of two external parties need to be weighed against each other.

Doctor’s primary obligation to medical ethics

According to their professional ethics, doctors are first and foremost bound to working for the (mental and physical) well-being of their patients. They are, as Annas put it, they are “Physician first, last, and always.” (Annas 2008: 1087) A formulation of this principle can be found in the Declaration of Geneva (the modern Hippocratic Oath) as well as in the document on “Ethical Principles of Health Care in Times of Armed Conflict and Other Emergencies”:

“THE HEALTH AND WELL-BEING OF MY PATIENT will be my first consideration;
I WILL RESPECT the autonomy and dignity of my patient;” (Declaration of Geneva)

“The primary task of health-care personnel is to preserve human physical and mental health and to alleviate suffering. They shall provide the necessary care with humanity, while respecting the dignity of the person concerned, with no discrimination of any kind […].  Health-care personnel act in the best interest of their patients and whenever possible with their explicit consent. If, in performing their professional duties, they have conflicting loyalties, their primary obligation, in terms of their ethical principles, is to their patients.” (Ethical Principles of Health Care…)

The validity of these principles even during armed conflict are restated and thus reinforced by International Humanitarian Law, which bounds medical personnel to act according to medical ethics and prohibits forcing them to act contrary to medical ethics (GC 1, Art. 12; AP 1, Art. 16; Customary IHL, Rule 26).

In reality however, practical constraints and difficult circumstances can nevertheless lead to situations during which doctors feel dual obligations when they act in different roles at the same time. As such situations cannot be completely avoided it is important to be aware of the issue in order to react adequately.

Example scenarios

Typical dual loyalty situations for doctors practicing in the armed forces arise in the contexts of “fit-for-duty” examinations, the treatment of detained persons, and when respect for medical ethics is missing (e.g. under duress). The MME Scenario Collection contains a number of cases to illustrate such situations, among them the following:

Return to duty

A first set of scenarios can be grouped under the heading “return to duty”. The scenario "Return to Duty: Ethical Issues for Military Health Professionals" is about the question whether a soldier should be sent or allowed back to duty after being injured in an IED event. It is an individual case with two different sub-scenarios in which the doctor must weigh the possible health consequences for the individual soldier with the needs of the army.

In "Ethical versus Military Imperatives", the question is about the independence of a medical commission (at home) from political interference. One of the questions here is to what extent and how medical services in the military can remain independent and prevent from being influenced by non-medical (e.g. political) arguments and interests.

Triage and Medical Rules of Eligibility

The second group of scenarios are about triage and medical rules of eligibility. A ‘classical’ case of triage is presented in the scenario “Only one equipment but two patients”. How do you choose who to treat in such situations and can you weigh medical impartiality with loyalty to comrades?

A different question of prioritized treatment is presented in “VIP treatment?”. Here, the question is whether non-medical arguments can override pure medical reasoning regarding the prioritization of patients.

An example for medical rules of eligibility can be found in “Treatment Eligibility (Ebola mission)” – an example taken from a humanitarian mission. The ethical issue here is whether and how loyalty to medical ethics on the one hand can be reconciled with loyalty to the overall aims of a difficult mission.

Treating detainees

A third set of examples for possible dual loyalty situations concerns the treatment of detained persons. In "Treatment of Detainees: Role of Military Health Professionals" (as in “Hunger strike to protest against detention”), doctors are ordered to treat detainees who are refusing to eat in order to avoid damage to their health and keep them alive by, ultimately, using means such as force-feeding.

The scenario "Reporting abuse" alludes to a different issue, namely mis-treatment of detainees and the question of loyalty to (failing) comrades or whistle-blowing the abuse.

Advancing military objectives

A last group of scenarios that illustrate dual loyalty issues is about doctors’ implication in advancing military objectives – the use of medicine for non-medical purposes.

The scenario “Dialysis for a Prisoner of War” provides an example in which medical treatment shall be provided to advance a military objective, mainly gaining information. Even though the treatment would benefit the patient, the doctor is confronted with a patient who is denying this life-prolonging treatment. Also, the motivation to offer the treatment does not rely on medical arguments (or humanity) but is clearly a military one.

Similarly, in "Estimating the age of captured persons", a dentist is asked to perform a medically unnecessary intervention and to provide an age-estimation of a captured young person. Not only might the doctor be instigated to perform a medical exam against the will of the patient, but he may also be complicit to an illegal act following his age-estimation.

More related scenarios can be found by going through the sub-categories of this section (use the navigation links on the left side).

Outlook

The comprehensive report on the workshop “Military Medical Ethics: Issues Regarding Dual Loyalties?” concludes that “these difficult issues do not benefit from being ignored or secretly managed or considered to be implicit.” (Weisfeld et al. 2009: 6) It is much more difficult for an individual doctor to find answers to dual loyalty issues when they find themselves in such challenging situations. An open debate in a larger context would thus be better both for the individual doctor and for probably for the outcome of the case as well. As the workshop report postulates, “such conflicts are best brought to light and discussed by military and civilian leaders rather than relegated to individuals to cope with them alone in situations of stress.” (Weisfeld et al. 2009: 1)

Awareness of potentially difficult situations is thus an important prerequisite of meeting them. Education about the ethical and legal obligations and adherence to the core principles of medical ethics can help (military) doctors to resolve conflicting obligations and situations of dual loyalties. An institutionalized opportunity to discuss and analyze such (and other) ethical issues in a larger group can help to avoid or reduce their recurrence and also lead the institution to formulate best practices for future situations.

Key points

• Military doctors have obligations (ethical and legal) to both their patients and to the military chain of command. This can provoke situations of so-called “dual loyalties”.
• Under no circumstances are (military) doctors absolved of their medical ethical responsibilities nor can they be forced to act against medical ethics.
• This obligation of (military) doctors to act according to medical ethics are reinforced and protected by human rights law and international humanitarian law.
• The primary ethical obligation of (military) doctors is thus to their patients.

Professional ethics and other relevant documents

Professional Ethics

• Ethical Principles of Health Care in Times of Armed Conflict and Other Emergencies
• WMA Declaration of Geneva
• WMA International Code of Medical Ethics

International Humanitarian Law

• Geneva Conventions, I/II, Art. 12
• Geneva Convention, Additional ProtocoI (1977), Art. 16
• Customary International Humanitarian Law, Rule 26.

References and further reading

• Annas, George J. (2008), 'Military Medical Ethics — Physician First, Last, Always', New England Journal of Medicine, 359 (11), 1087-90.
• Benatar, Solomon R. and Upshur, Ross E. G. (2008), 'Dual Loyalty of Physicians in the Military and in Civilian Life', American Journal of Public Health, 98 (12), 2161-67.
• BMA Medical Ethics Committee and Armed Forces Committee Ethical decision-making for doctors in the armed forces: a tool kit (London: BMA). [Link]
• Howe, Edmund G (2003), 'Mixed agency in military medicine: Ethical roles in conflict', in Thomas E. Beam and Linette R. Sparacino (eds.), Military Medical Ethics. Vol 1 (Washington D.C.: Office of The Surgeon General, United States Army), 331-65.
• International Dual-Loyalty Working Group (2008), 'Dual-Loyalty and Human Rights in Health Professional Practice: Proposed Guidelines and Institutional Mechanisms', in Fritz Allhoff (ed.), Physicians at War: The Dual-Loyalties Challenge (Dordrecht: Springer Netherlands), 15-38.
• Johnson, W Brad, et al. (2006), 'Multiple-role dilemmas for military mental health care providers', Military medicine, 171 (4), 311-15.
• London, Leslie (2005), 'Dual loyalties and the ethical and human rights obligations of occupational health professionals', American Journal of Industrial Medicine, 47 (4), 322-32.
• London, Leslie, et al. (2006), 'Dual Loyalty among Military Health Professionals: Human Rights and Ethics in Times of Armed Conflict', Cambridge Quarterly of Healthcare Ethics, 15 (4), 381-91.
• Singh, Jerome Amir (2003), 'American physicians and dual loyalty obligations in the" war on terror"', BMC medical ethics, 4 (1), 4.
• Weisfeld, Neil E, Weisfeld, Victoria D, and Liverman, Catharyn T (2009), 'Military Medical Ethics: Issues Regarding Dual Loyalties? Workshop Summary'.
• Williams, John R (2009), 'Dual loyalties: How to resolve ethical conflict', South African Journal of Bioethics and Law, 2 (1).
• Zupan, Daniel, et al. (2004), 'Dialysis for a prisoner of war', The Hastings Center Report, 34 (6), 11.