How can psychiatrists apply current ethical principles to war?
PSYCHIATRIC VIEWS ON THE DAILY NEWS
Once upon a time, back on July 1, 1975, I was welcomed as Major Moffic to Ft. McClellan in Anniston, Alabama. At first, we did not even know where this was located. I had just finished my residency training in psychiatry. We drove down to the deep south with our young daughter and fish. The Vietnam war had also just wound down, and the highest ranking military officer on the base told us this:
“There is not a question of another war. It is not if, but when. Therefore, we are also going to teach all you Docs the basics of being a soldier, including how to shoot a weapon.”
And they did. I was not a very good shot. And there have been more wars. It is human nature.
However, I do not recall anything they covered about medical ethics as applied to war, including if you were a physician in the Armed Forces in times of war, or even an outside physician observer.
The military does have some unique ethical considerations if one is in service as a “physician soldier.”1 Confidentiality is less well protected as you have an allegiance to the military command as well as the patients. In combat, there is the task to determine whether a soldier can return to combat, even if one has been traumatized already and not recovered. At that time, there was also controversy about discharging—even dishonorably—soldiers who were homosexual as it was still a diagnosable disorder (if you as a psychiatrist were willing to make that diagnosis).
However, even though we have been in some sort of war many of the years since 1975, there has been minimal discussion of how we psychiatrists might ethically serve, other than the astute analysis of leaders requested by the government of Jerrold Post, MD, an exception to the Goldwater ethical prohibition about analyzing public figures.
Somewhat in the invasion of Ukraine, but even more so in the new Middle East war, discussion of wartime ethics has become prominent in the media. What are the general ethical guidelines for soldiers, especially toward civilians?
Veteran’s Day is tomorrow. I am continually very grateful that I did serve, though left with a little bit of ambivalence and guilt that it was not during wartime. Fortunately, there may also be ways to serve without actually being in the Armed Forces.
These current wars got me wondering about if—and how—psychiatrists can apply our current ethical principles to these current wars. Here is what I came up with. It is Section 7 of our Principles of Medical Ethics, with Annotations Especially Applicable to Psychiatry, 2013 Edition, which says:
“A physician shall recognize a responsibility to participate in activities contributing to the improvement of the community and the betterment of public health.”
The most relevant annotations seem to be:
1. “. . . Psychiatrists are encouraged to serve society by advising and consulting with the executive, legislative, and judiciary branches of the government.”
2. “Psychiatrists may interpret and share with the public their expertise in the various psychosocial issues that may affect mental health and illness.”
3. “Psychiatrists shall not participate in torture.”
The torture principle received prominence in the Iraqi war after 9/11/01. Psychiatry, but not psychology, came quickly to a resolution of not participating in torture. As fanciful as it may be, perhaps the most important contribution psychiatry could ever make is if we contributed to peace and the prevention of unnecessary wars.
In the meanwhile, for the current wars in Ukraine and Middle East, which the United States is not directly responsible for, we may perhaps best serve as watchdogs. Because revenge is so common after humiliation and cruelty, there is always a chance of excessive retaliation and traumatic moral injury in the process. In addition, whenever it is possible to contribute to treating traumatized citizens, either live and via Zoom, that would be an ethical way to take.
Dr Moffic is an award-winning psychiatrist who specialized in the cultural and ethical aspects of psychiatry, and is now in retirement and refirement as a private pro bono community psychiatrist. A prolific writer and speaker, he has done a weekday column titled “Psychiatric Views on the Daily News” and a weekly video, “Psychiatry & Society,” since the COVID-19 pandemic emerged. He was chosen to receive the 2024 Abraham Halpern Humanitarian Award from the American Association for Social Psychiatry. Previously, he received the Administrative Award in 2016 from the American Psychiatric Association, the one-time designation of being a Hero of Public Psychiatry from the Speaker of the Assembly of the APA in 2002, and the Exemplary Psychiatrist Award from the National Alliance for the Mentally Ill in 1991. He is an advocate and activist for mental health issues related to climate instability, physician burnout, and xenophobia. He is now editing the final book in a 4-volume series on religions and psychiatry for Springer: Islamophobia, anti-Semitism, Christianity, and now The Eastern Religions, and Spirituality. He serves on the Editorial Board of Psychiatric Times.
1. Quinn M, Wilkes S. Military medical ethics: privacy, military necessity, and the dual roles of military psychiatrists. The American Journal of Psychiatry Residents’ Journal. 2020;15(4):12-13.