Should Military Doctors Help Patients When Doing So Could Increase Risks to Others?

Abstract

THE CASE A military psychiatrist routinely visited a small forward medical aid station in Afghanistan every 2 months. During one of his visits, he was made aware that a member of the local Afghan National Security Force (ANSF) had developed symptoms of depression. The rules of engagement that military providers usually applied for deciding when they could give medical support to ANSF members involved primarily risks to “life, limb, and eyesight,” but at that time, U.S. military medical personnel were also authorized to use their own judgment to render care beyond these boundaries for a variety of reasons, which included the promotion of optimal relations with ANSF forces. During his initial evaluation, the psychiatrist could not determine whether this policeman was in imminent danger of harming himself but he did elicit a past history of attempted suicide. The story as relayed through an interpreter was that the patient had tried unsuccessfully to hang himself just 2 months before while visiting his mother’s house in Pakistan. The psychiatrist did not know this patient and had no way of verifying his trustworthiness. One possibility that must be ruled out in a wartime environment was that the patient was only feigning illness to obtain medication that he could use to harm U.S. or Afghan soldiers. It will be clear shortly how he might do this as others clandestinely working for the enemy have in fact done. I shall relate this subsequently. After his unsuccessful suicide, the patient obtained some medications from a pharmacist, which he showed to the psychiatrist. A Google search could only identify a few of them as herbal and folk remedies for libido and erectile problems. The man reported not having slept in weeks, looked very tired and demonstrated psychomotor slowing. He denied having had suicidal ideation but acknowledged his depressed mood. The psychiatrist had a small supply of travel medications, which included antidepressants and sleep medications. The sleep medications could help enable the patient to marshal his own resources to overcome his depression. The antidepressants would not be effective for some time and to have optimal positive results might have to be continued for several months. The psychiatrist provided a 2-week supply of sleep medications and learned later that this provided some improvement. The thought provoking ethical question which remained, however, was this: The psychiatrist later learned through intelligence channels that in a nearby province nine Afghan local police had been killed when a “rogue” policeman, an “insider,” put sedatives in their tea and then shot them as they slept. This event gave the psychiatrist new pause. He asked himself, should he have given this unknown and potentially unfriendly patient the sleep medications?