WRNMMC, Bethesda, Md.  –   “If you see someone suffering to the point that even the morphine being given is not totaling relieving this and you, as the care provider, is just lingering on with that individual, then you may want to do something that is beneficence. So, maybe the next injection of morphine you give the person has a slightly higher dose than the standard would call for, and that person passes away peacefully. You can sleep at night because you caused, ‘a good death,’ but are you sleeping well, or did you murder that individual?”

This was just one of the questions posed by Joseph Procaccino, Jr., to those who attended the Healthcare Ethics Symposium hosted by Walter Reed on Oct. 26. Procaccino serves as a legal advisor for the Department of Defense Medical Ethics Center (DMEC) and as an adjunct assistant professor in the Department of Preventive Medicine and Biostatistics at the Uniformed Services University (USU).

Procaccino, and other speakers at the symposium discussed a variety of ethical issues, including healthcare ethics consultations, moral injury, military medical ethics and dilemmas in contemporary armed conflict, and lessons learned regarding ethics at USU, the former National Naval Medical Center (NNMC) and Walter Reed National Military Medical Center (WRNMMC) over the past four decades. Speakers also presented case scenarios involving ethical issues and challenges for participants to consider and discuss, including one involving the trials of labor [and delivery] focused on embracing informed consent and patient autonomy.

Case scenarios

Another case Procaccino discussed that occurred in 1978 involved an individual diagnosed with bone cancer and needing a donor for a bone marrow transplant. “The family was checked for donorship, and one family member, a first cousin, showed up as being highly compatible, but the cousin said, ‘No.’ The patient then went to a judge seeking a court order to compel the cousin to submit to the bone marrow transplant.
“If you were the judge, would you have signed the court order?” Procaccino asked those attending the symposium. Only a few people raised their hands.

Procaccino then presented another scenario, this one involving the military.

“You’re in the battlefield in the hospital tent. A Marine is brought in with blood gushing out of his stomach. He needs a blood transfusion to be stabilized and survive. A few minutes earlier, an enemy Soldier was brought into the tent with two broken legs. When you look at the Marine’s identification, you find out he has O-negative blood. Someone who frisked the enemy Soldier and took out his wallet noticed on his driver’s license indicated that he has O-negative blood, too. The medical team asks the enemy Soldier to donate blood to save the Marine, and the enemy Soldier refuses. The commanding officer comes in and says, ‘Transfuse him [anyway].’ How many of you would follow that order and transfuse the enemy Soldier to save that Marine?” Procaccino asked the attendees. A few more hands were raised.

“Reverse the situation,” Procaccino added. “Now, it’s the enemy Soldier who needs blood and it’s the Marine who has the broken legs? Add to this is we really need to save the enemy Soldier because he has important information about an upcoming attack on our installation, and if we can get him stabilized, we might be able to get that information. But the Marine refuses the transfusion. [Do you transfuse the Marine anyway]?” Some attendees raised their hands “yes.”

In another scenario, Procaccino explained a severely injured is Soldier brought into the hospital tent for care. The Soldier’s legs have been blown off, as well as one of his arms. The surgeon explains to the Soldier, who is competent and has capacity, that despite the severity of his injuries, he can be saved. The Soldier says, “I’ve seen my body. My girlfriend just left me. My parents are elderly and poor. We live in a rural area in the middle of the country. You’re just going to send me back to where they’re going to put me in a wheelchair and what type of life will I lead? Just let me go.”

“Now if this was a civilian environment with an adult, would you not respect his autonomy to refuse treatment?” Procaccino continued. “But then [because it’s military], the Soldier’s commanding officer comes in and says, ‘Look, this Soldier speaks three dialects of a language in this area which are critical for us to be able to [accomplish the mission]. Second, what message are you sending to our other Soldiers around here if you just let him die as to how much we’re going to take care of our people?’ Does the mission supersede the individual’s autonomy of the patient?” Procaccino asked.

Autonomy vs. Beneficence

The autonomy of patients at times conflict with the beneficence of providers, said Procaccino. “What you believe is in the best interest of the patient may not necessarily be what the patient believes is in the best interest of the patient. [As an example] the Jehovah Witness who comes into the ER with blood gushing out of his stomach and will be dead within minutes without a transfusion. You tell him this, but he still says, ‘No, because if you transfuse me, I will be denied life everlasting according to the tenants of my faith.’ If this person is cogent, has capacity, and is an adult, you may have to sacrifice your beneficence and watch that person die in front of you because the pendulum has swung toward autonomy.”

Procaccino explained DOD established the DMEC to provide the health care force a foundation to analyze and determine the best course of action when facing medical ethics questions fundamental to both saving lives and maintaining the military medical readiness of the Military Health System. He added DOD established the center in the wake of a Navy nurse’s refusal for force-feed Guantanamo detainees who refused to eat as a means of protest to their institutional treatment and proclamation of their innocence. The nurse contended the force-feeding was prohibited not only by medical ethics, but also under international law and went against the first obligation of medical professionals – “to do no harm.”

Healthcare Ethics Consultation

Brigid Herrick, chief experience officer at Walter Reed and Hospital Ethics Committee co-chair, along with Army Chaplain (Maj.) Vincent Bain, ethics advisor for Walter Reed as well as the co-chair of the Hospital Ethics Committee, explained the purpose of healthcare ethics consultation is “to improve the quality of health care through the identification, analysis and resolution of ethical questions or concerns.”

They said the consultation should include the following elements: clarification of the ethical issues needing to be addressed; gathering of relevant information; clarification of relevant concepts; ensuring all parties are heard; assisting in clarifying values; help in identifying a range of ethically acceptable options; identifying and supporting ethically appropriate decision makers; and applying mediation or resolution techniques, if relevant.

“Healthcare ethics consultations recommendations are advisory only,” Herrick stressed. “Treatment decision-making authority remains with the patient/surrogate and the clinical team on the same basis as before the consultation.”

Dr. Paul Fowler, a physician and attorney at Walter Reed who attended the symposium, has served as the chief risk officer for the U.S. Public Health Service, Department of Health and Human Services based in Washington D.C. He previously served as the legal-medicine officer to the Surgeon General of the Army.

“In my career of defending medical malpractice cases for the military, I believe that where there is an involvement of ethics consultation, it has decreased medical malpractice claims filed against installations,” Fowler shared.

The Trials of Labor

Army Capt. (Dr.) Alexa Vercelli, a resident in the Gynecologic Surgery and Obstetrics Program at Walter Reed, earned her medical degree in osteopathic medicine and her doctorate in healthcare ethics. She discussed informed consent and patient autonomy in relation to the complexities of obstetric care. She said obstetric care is “the only specialty with two patients in one entity, which often makes it “a highly litigious field. Even with best practice recommendations and best intentions, there are difficult outcomes that can occur.”

Vercelli explained that meeting the ethical obligations of informed consent requires that the OB-GYN and the medical team give the patient and family adequate, accurate and understandable information, and the patient and family have the ability to understand and reason through this information to ask questions and make an intentional and voluntary choice, which can include refusal of care or treatment.

Moral Injury

Navy Lt. Cmdr. Antony Kaniaru, USU brigade chaplain, discussed moral injury and stress, defining moral injury as “the intense psycho-spiritual distress individuals may feel when they experience a potentially harmful event which they or another person perpetrates, witnesses or learns about, or which they or another personal fails to prevent. Moral injury is a violation of one’s moral agreement with one’s own inner moral world.” He added there has been increased focus on both moral injury and stress because of their effects on combat Soldiers and health care workers.
Dr. Edmund Howe, also a lawyer and professor of psychiatry, professor of medicine, and director of Programs in Medical Ethics at USU, said in 1977, when he first arrived at USU, there were only about 10 medical schools out of 100 plus in the United States that had classes focused on ethics. “It wasn’t there,” he said.

He added that a lesson since that time is the need to “think globally” when it comes to ethical issues. He cites as examples the care of enemy prisoners, COVID vaccination mandates, and care of patients in the wake of the global pandemic.

Howe also stressed the importance of avoiding ambiguity and validating the concerns and feelings of patients and their families when doing ethics consult. “Don’t abandon but walk out [of consultations] hand in hand. Make explicit that you will support [decisions by patients and families], even if you disagree. And validate, even if there is anger [by the patient and family].”

The Ethics Consult Line at Walter Reed is available at 301-547-1136.