Medicine in the military

Military medicine, in many regards, is unlike the other branches of medicine that we have discussed so far in class. Coming into this class, I had a vague idea that doctors on active military duty would see horrific injuries and have to make harrowing triage decisions. I also knew from various emails sent through the PLME listserv and a couple of physicians I know who are in the Army that the Army generously pays for their doctors’ education and gives them all the privileges of being a member of the Armed Forces. However, after the readings, and the insightful presentation by Dr. Hayda, I have come to realize that military medicine is much more complex, and yet also simpler, than I had imagined.

The patients that military doctors must treat usually have more severe injuries, of a traumatic sort rather than chronic diseases—unfortunately, they also tend to be younger, and otherwise healthy. It was interesting to note that military doctors don’t seem to have to triage on a regular basis like ER doctors, but employ a “damage control” model that allows them to treat multiple patients in steps. The use of leaner mobile units reflects an overall revised strategy in the military, and their use will continue to grow. I think that our discussion about the role of biotechnology in medicine last week ties nicely into the NYT article on the use of new technologies like QuikClot that aim to improve mortality rates from traumatic battlefield injuries. It is apparent that in addition to public health agencies and private companies, the military also has a stake in developing new medical technologies, for the purposes of sustaining its soldiers—however, this military technology may also become available to the civilian population.

I was struck by the NEJM’s account of military officials’ insistence that becoming a physician is “not a sacramental vow” and that the military doctor “is a combatant, not a physician”—this goes against the other works we have read which portray medicine as a calling, as a noble lifestyle rather than vocation. The conflict of interest that arises then is interesting. Does the doctor follow Hippocratic/civilian protocols of do no harm, and are they beyond the chain of military command? Or does the doctor obey orders and carry out the wishes of higher-ups? As the authors suggest, the answer lies somewhere in-between: they imply that a doctor should follow commands insofar as they do not cause harm to another human being. With this conclusion, it was disturbing to read evidence that doctors willingly participated in the abuses at Abu Ghraib by helping to design interrogation techniques and sharing detainee information with interrogators. As Atul Gawande writes, civilian physician codes of conduct are often inadequate for military doctors, who face sometimes very different challenges, and it is evident that greater attention needs to be paid to creating effective, ethical military medical guidelines.

I was horrified by soldiers’ accounts of shoddy treatment and profound bureaucratic unhelpfulness at Walter Reed. However, their complaints do not surprise me, as they echo those of people with disabilities all across America that I have learned about in Pathology to Power (a class on people with disabilities). In general, there is a weak and vague structure of compensation and rehabilitation that is exacerbated by bureaucratic demands—brutal overhaul of the system is necessary. The public is also somewhat to blame for this sorry state, though, since there are many people who claim to support the troops and applaud enlisted men and women, but also become infuriated by the idea of these same men and women receiving governmental aid for injury/disability paid for through taxes.