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The global war on terror has brought renewed attention to the question of whether physicians in the U.S. military are physicians first, soldiers first, or physician–soldiers. George Annas writes that it is not surprising that wars have produced battlefield situations in which suspending patient-centered medical ethics has seemed reasonable. The global war on terror has brought renewed attention to the question of whether physicians in the U.S. military are physicians first, soldiers first, or physician–soldiers, or whether some other formulation best describes their medical–ethical obligations. The chair of the President's Council on Bioethics, Edmund Pellegrino, has insisted that medical ethics are and must be the same for civilian and military physicians, “except in the most extreme contingencies.” 1 There is no special medical ethics for active-duty military physicians any more than there is for Veterans Affairs physicians, National Guard physicians, public health physicians, prison physicians, or managed care physicians. The . . .

In mid-October, Dr. Susan Okie was among a small group of visitors to Camp Delta. Dr. Okie discusses the complex ethical issues surrounding force-feeding the hunger strikers, the interrogation process, and care of the detainees. On a rainy afternoon in mid-October 2005, a white bus climbed the brush-covered hills near Guantanamo Bay, Cuba, carrying a group of visitors to Camp Delta, the desolate spot on the island's southern coast where the U.S. military holds more than 500 prisoners captured in the war on terror. It rolled through the detention camp's stockade-style gate and turned onto the dirt track inside the outermost of three high fences. Like others in the small group of civilian doctors, psychologists, and ethicists visiting that day, I peered through the bus's windows, eager for a glimpse of detainees. Since our arrival . . .

Dealing with ethical and forensic issues, this book is authored by active duty psychiatrists and psychologists from the Army, Navy, and Air Force, as well as civilians from within and outside of the Department of Defense.Ethical issues will refer to areas in which basic principles are in play: autonomy, justice, beneficence, and nonmaleficence.

Despite the advances of civilization, conflict remains in many areas around the world. Often psychiatry finds itself playing an essential role in dealing with the consequences of conflict or influencing the process. Along with this involvement comes great responsibility as well as many associated ethical dilemmas. Although bound by professional medical oaths, many physicians disregard fundamental medical ethical principles during times of conflict and situations of \"dual loyalty.\" The phenomenon should be addressed so that ethical awareness and sensitivity to these issues are nurtured. Important factors for psychiatrists during times of conflict to consider include their \"social contract\" with the community, dangers of boundary violations, the ethics of media contact, involvement in governmental and political activities and confidentiality. In addition, their role in conflict resolution and unique ethical considerations in the military should be considered. While as regular citizens, psychiatrists in their individual capacity may involve themselves in political activism, at an organizational level it should be discouraged. A physician's skills should only be exploited to save lives and provide comfort as entrusted by society, and any other pursuit, even in the name of the state, should be proscribed. Rather than engage in political activism, psychiatrists can promote the rights of patients, especially if these rights are limited during conflict. Responsibility and ethically-driven commitment needs to be primary for the psychiatrist who involves himself either directly or indirectly with patients during times of conflict. Trauma and its effects during conflict should be addressed without any unbalanced attention to pathological responses.

Jonathan Marks and Dr. M. Gregg Bloche write that the AMA and APA firmly oppose physicians' helping to devise interrogation plans for individual detainees. Yet documents recently provided by the U.S. Army make clear that the Department of Defense still wants doctors to be involved. In May 2006, the American Psychiatric Association (APA) adopted a position statement prohibiting psychiatrists from “direct participation” in the interrogation of any person in military or civilian detention — including “being present in the interrogation room, asking or suggesting questions, or advising authorities on the use of specific techniques of interrogation with particular detainees.” 1 A few weeks later, the Council on Ethical and Judicial Affairs of the American Medical Association (AMA) issued a similar opinion, stating that “physicians must neither conduct nor directly participate in an interrogation, because a role as physician–interrogator undermines the physician's role as healer.” 2 The opinion . . .

Although knowledge of torture and physical and psychological abuse was widespread at both the Guantanamo Bay detention facility and Abu Ghraib prison in Iraq, and known to medical personnel, there was no official report before the January 2004 Army investigation of military health personnel reporting abuse, degradation or signs of torture. Military medical personnel are placed in a position of a “dual loyalty” conflict. They have to balance the medical needs of their patients, who happen to be detainees, with their military duty to their employer. The United States military medical system failed to protect detainee's human rights, violated the basic principles of medical ethics and ignored the basic tenets of medical professionalism.

To the Editor: Regarding the Perspective articles by Annas 1 and by Marks and Bloche 2 (Sept. 11 issue) describing interrogation training of physicians by the military, participation in interrogations violates the duty of the physician to be a healer and undermines the public's trust that the physician will act in the best interest of his or her patients. It is for these reasons that the American Psychiatric Association and the American Medical Association oppose the participation of physicians in interrogations. Before adopting those official positions, we consulted with the Department of Defense and arrived at an agreement that physicians would not . . .

The U.S. military has long emphasized the principles of prevention and early intervention in preparing for and treating those afflicted by the psychological wounds of war. This article opens with lessons learned by the U.S. military through wartime during the past century. Current practice in the military's employment of stress control teams is reviewed. Updates in the military efforts in Operation Iraqi Freedom and Operation Enduring Freedom to prevent and to limit psychological casualties are stressed. Misconduct has occurred in this conflict; future steps to reduce aberrant behavior by soldiers are discussed. The challenges of reintegration at home, by both healthy and wounded soldiers, are highlighted.

Military psychologists and psychiatrists frequently face ethical quandaries involving boundary crossings, or extratherapy contact, and multiple relationships. A multiple relationship is defined as necessarily engaging psychotherapy patients in nonclinical roles, such as coworker, superior officer, neighbor, or friend. In contrast to their civilian counterparts, military mental health professionals must often engage patients in many different contexts and roles. In this article, we consider the distinctive features of mental health practice in the military and offer military providers several practice guidelines for avoiding harm to patients in military settings. This article is also designed to enhance sensitivity to multiple-role risks among nonpsychiatric providers.