"A U.S. soldier suffers injuries from the explosion of an improvised explosive device. Injuries include closed-head injury resulting in loss of consciousness. After six weeks of treatment, the soldier is medically stable and functional, though he continues to complain of fatigue, disturbed sleep, and daily headaches. It is likely that he would be at higher risk for more severe impairment and PTSD if he were to suffer another similar explosion resulting in further traumatic brain injury.
Situation 1: The soldier is eager to return to the front lines and even when provided with the information on potential detrimental health consequences is willing to take his chances and return to his unit. The soldier is very insistent that he understands the risks and feels that the best way to resume his life is to return to his unit. His commanding officers express the strong need for his expertise and experience but do not exert any pressure to return the soldier to his former patrolling duties.
Situation 2: The soldier does not want to return to his patrolling duties and asks for reassignment. The physician suspects that the soldier may be exaggerating the symptoms that he is experiencing, though clearly considerable residual effects remain. However, personnel levels are low, with replacements several months down the road. Soldiers with his level of experience are desperately needed for upcoming missions, and there is strong pressure from the chain of command on the treating physician to sign off and return the soldier to his patrolling duties."
Source: IOM (Institute of Medicine). 2009. Military medical ethics: Issues regarding dual loyalties: Workshop summary. Washington, DC: The National Academies Press. Page 8.
What principles are in conflict?
What guides the clinician in approaching each situation?
What about the setting makes this situation different from civilian settings? Are the differences enough to warrant a separate rule?
Who is the ultimate decision maker regarding decisions on return to the battlefront?
What mechanisms or resources would help the health professional in resolving this conflict?