Military physicians' ethical experience and professional identity: a Canadian perspective.

Military physicians can experience ethical tensions and encounter important dilemmas when acting at the same time as healers, soldiers and humanitarians. In the literature, these are often presented as the result of pressures, real or perceived, from the military institution or role and obligation conflicts that can divert physicians from their primary duty towards their patients. In this article, I present the ethical experiences of 14 Canadian military physicians who participated in operational missions, particularly in Afghanistan. Interestingly, although some dilemmas discussed in the academic literature were raised by Canadian physicians, ethical tensions were less frequent and numerous than what might have been expected. Instead, what emerged were distinctions between the ethical experiences of physicians: generalists experienced more frequent and different ethical challenges than specialists, and these also varied by context, that is, garrison versus on deployment. The main dilemmas during deployment were similar to those encountered by humanitarian physicians and concerned inequalities in the provision of care between coalition soldiers and Afghans (soldiers and civilians), as well as the lack of resources. Surprisingly, participants were evenly divided with regards to how they perceived their professional identity: one group clearly prioritised the medical profession (ie, doctor first and foremost), while the other group identified themselves as military physicians, but without prioritising one profession over the other.

Ethical questions identified in a study of local and expatriate responders' perspectives of vulnerability in the 2010 Haiti earthquake.

BACKGROUND: Situations of disaster that prompt international humanitarian responses are rife with ethical tensions. The 2010 Haiti earthquake caused great destruction and prompted a massive humanitarian response. The widespread needs experienced by the population and the scale of the response inevitably rendered priority-setting difficult, and gave rise to ethical challenges. PURPOSE: This paper presents four ethical questions identified in the analysis of a study on vulnerability and equity in the humanitarian response to the 2010 Haiti earthquake. METHODS: Using interpretive description methodology, the interdisciplinary research team analysed 24 semi-structured in-depth interviews conducted with expatriate and Haitian health workers and decision-makers involved in the response. RESULTS: Ethical questions identified through the analysis were: (1) How should limited resources be allocated in situations of widespread vulnerability and elevated needs? (2) At what point does it become ethically problematic to expend (considerable) resources to sustain expatriate disaster responders? (3) How ought rapid and reactive interventions be balanced with more deliberated and coordinated approaches? (4) What trade-offs are justified when interventions to address acute needs could contribute to long-term vulnerabilities? DISCUSSION: The questions arise in light of an immense gap between available resources and widespread and elevated needs. This gap is likely unavoidable in large-scale crises and may be a source of ethical distress for both local and international responders. The analysis of ethical questions associated with crisis response can advance discussions about how relief efforts can best be designed and implemented to minimise ethical distress and improve assistance to local populations.

Understanding and Addressing Vulnerability Following the 2010 Haiti Earthquake: Applying a Feminist Lens to Examine Perspectives of Haitian and Expatriate Health Care Providers and Decision-Makers.

Vulnerability is a central concept in humanitarian aid. Discussions of vulnerability in disaster response literature and guidelines for humanitarian aid range from considerations of a universal human vulnerability, to more nuanced examinations of how particular characteristics render individuals more or less at risk. Despite its frequent use, there is a lack of clarity about how vulnerability is conceptualized and how it informs operational priorities in humanitarian assistance. Guided by interpretive description methodology, we draw on the feminist taxonomy of vulnerability presented by Mackenzie, Rogers and Dodds (2014) to examine perspectives of 24 expatriate and Haitian decision-makers and health professionals interviewed between May 2012 and March 2013. The analysis explores concepts of vulnerability and equity in relation to the humanitarian response following the 2010 earthquake in Haiti. Participants' conceptualizations of vulnerability included consideration for inherent vulnerabilities related to individual characteristics (e.g. being a woman or disabled) and situational vulnerabilities related to particular circumstances such as having less access to health care resources or basic necessities. Participants recognized that vulnerabilities could be exacerbated by socio-political structures but felt ill-equipped to address these. The use of the taxonomy and a set of questions inspired by Hurst's (2008) approach to identifying and reducing vulnerability can guide the analysis of varied sources of vulnerability and open discussions about how and by whom vulnerabilities should be addressed in humanitarian responses. More research is required to inform how humanitarian responders could balance addressing acute vulnerability with consideration of systemic and pre-existing circumstances that underlie much of the vulnerability experienced following an acute disaster.

Are Military and Medical Ethics Necessarily Incompatible? A Canadian Case Study.

Military physicians are often perceived to be in a position of 'dual loyalty' because they have responsibilities towards their patients but also towards their employer, the military institution. Further, they have to ascribe to and are bound by two distinct codes of ethics (i.e., medical and military), each with its own set of values and duties, that could at first glance be considered to be very different or even incompatible. How, then, can military physicians reconcile these two codes of ethics and their distinct professional/institutional values, and assume their responsibilities towards both their patients and the military institution? To clarify this situation, and to show how such a reconciliation might be possible, we compared the history and content of two national professional codes of ethics: the Defence Ethics of the Canadian Armed Forces and the Code of Ethics of the Canadian Medical Association. Interestingly, even if the medical code is more focused on duties and responsibility while the military code is more focused on core values and is supported by a comprehensive ethical training program, they also have many elements in common. Further, both are based on the same core values of loyalty and integrity, and they are broad in scope but are relatively flexible in application. While there are still important sources of tension between and limits within these two codes of ethics, there are fewer differences than may appear at first glance because the core values and principles of military and medical ethics are not so different.