DHB-16-recommendations

Defense Health Board – Federal Advisory
Committee to the Secretary of Defense
The Defense Health Board (DHB) is a Federal Advisory Committee to the
Secretary of Defense that provides independent advice / recommendations
on matters relating to operational programs, health policy development, health
research programs, and requirements for the treatment and prevention of
disease and injury, promotion of health and the delivery of health care to
Department of Defense (DoD) beneficiaries.
Mission
The mission of the DHB is to provide independent authoritative advice to
maximize the health, safety, and effectiveness of the United States Armed Forces.
Defense Health Board
Ethical Guidelines and Practices for
U.S. Military Medical Professionals
February 11, 2015
Recommendation 1: Department of Defense (DoD) should further develop and expand
the infrastructure needed to promote DoD-wide medical ethics knowledge and an ethical
culture among military health care professionals, to include: a code of ethics; education
and training programs; consultative and online services; ethics experts; and an office
dedicated to ethics leadership, policy, and oversight. To achieve these goals, DoD should
form a tri-Service working group with appropriate representation to formulate policy
recommendations on medical ethics. This should include development of a DoD
Instruction to guide development of the infrastructure needed to support the ethical
conduct of health care professionals. In addition, this working group should consider
the best ways to implement the recommendations in this report
Recommendation 2: Throughout its policies, guidance, and instructions, DoD must
ensure that the military health care professional’s first ethical obligation is to the patient
Recommendation 3: DoD leadership, particularly the line commands, should excuse
health care professionals from performing medical procedures that violate their
professional code of ethics, State medical board standards of conduct, or the core tenets
of their religious or moral beliefs. However, to maintain morale and discipline, this
excusal should not result in an individual being relieved from participating in hardship
duty. Additionally, health care professionals should not be excused from military
operations for which they have ethical reservations when their primary role is to care for
the military members participating in those operations.
Recommendation 4: DoD should formulate an overarching code of military medical
ethics based on accepted codes from various health care professions to serve as a
guidepost to promote ethical leadership and set a standard for the cultural ethos of the
MHS. To inform this process, the ethics codes of relevant health care professional
organizations should be reviewed regularly and updates should be made to the military
medical ethics code as appropriate.
Recommendation 5: To provide formal ethics guidance, direction, and support to the
MHS and its components, DoD and the Military Departments should:
a) Publish directives/instructions regarding the organization, composition,
training and operation of medical ethics committees and medical ethics
consultation services within the MHS. DoD should review best practices at
leading civilian institutions in formulating this guidance.
b) Ensure military treatment facilities have access to consistent, high-quality,
ethical consultation services, including designation of a responsible medical
ethics expert for each location. For those facilities/locations without onsite
medical ethics support, DoD should ensure remote consultation is available.
c) Provide a “reach back” mechanism for deployed health care professionals to
contact an appropriately qualified individual to assist in resolving an ethical
concern that has not been resolved through their chain of command.
d) Develop a small cadre of clinicians with graduate level training in bioethics to
serve as senior military medical ethics consultants.
e) Ensure that health care professionals are knowledgeable about their rights and
available procedures for obtaining ethics consultation, expressing dissent or
requesting recusal from certain objectionable procedures or activities.
f) Review compliance with ethics directives and instructions as part of recurring
health service inspections.
Recommendation 6: DoD should develop clear guidance on what private health
information can be communicated by health care professionals to leadership, and the
justifications for exceptions to the rule for reasons of military necessity.
Recommendation 7: DoD should provide military health care professionals with
privileges similar to those of Chaplains and Judge Advocates regarding their
independence and obligation to protect privacy and confidentiality while meeting the
requirements of line commanders.
Recommendation 8: DoD should provide specific education and training for health care
professionals designated to serve as medical mentors or health care providers in foreign
health care facilities or in support of humanitarian assistance or disaster relief operations.
Such education and training should cover cultural differences, potential ethical issues,
rules of engagement, and actions that might be taken to avert, report, and address
unethical, criminal, or negligent behavior or practices.
Recommendation 9: DoD should create an online medical ethics portal. At a minimum,
it should include links to relevant policies, guidance, laws, education, training,
professional codes, and military consultants in medical ethics.
Recommendation 10: DoD should include in professional military education courses
information on the legal and ethical limitations on health care professionals regarding
patient care actions they may or may not take in supporting military operations and
patient information they may and may not communicate to line leadership.
Recommendation 11: DoD should ensure that systems and processes are in
place for debriefing health care professionals to help them transition home
following deployment. Debriefing should occur as a team when possible. Not only could
this help mitigate potential moral injury in health care professionals, but it may also
provide lessons learned and case studies for inclusion in ongoing training programs.
Recommendation 12: To create an environment that promotes ethical conduct and
minimizes conflicts of dual loyalty, DoD leadership should emphasize that senior military
health care professionals are full members of the Commander’s staff as an advisor on
medical ethics as it relates to military readiness.
Recommendation 13: To minimize isolation of health care professionals, the Military
Departments should make every effort to ensure personnel who are deploying to the same
location train together as a team prior to deployment. Establishing relationships prior to
deployment may enable better communication and trust among line command and health
care professionals in the deployed setting.
Recommendation 14: DoD should issue a directive or instruction designating minimum
requirements for basic and continuing education and training in military medical ethics
for all health care professionals in all components and indicate the appropriate times in
career progression that these should occur.
Recommendation 15: To enhance ethics training for military health care professionals
and the line command, DoD should:
a) Ensure pre-deployment and periodic field training includes challenging
medical ethics scenarios and reminders of available resources and contact
information to prepare both health care professionals and line personnel.
Curricula should include simulations and case studies in addition to didactics.
b) Provide a mechanism to ensure scenarios and training curricula are
continually updated to reflect specific challenges and lessons learned through
debriefing from real-world deployments and garrison operations.
c) Ensure key personnel returning from deployment who have faced significant
challenges provide feedback to assist personnel preparing for deployment
Recommendation 16: To enhance health care practices in the military operational
environment, DoD should:
a) Update the Joint Knowledge Online Medical Ethics and Detainee Health Care
Operations courses to improve the efficiency with which the information is
communicated and maintain currency of the material.
b) Create a medical ethics course to cover key principles, ethical codes, and case
studies applicable to both garrison and deployed environments, in addition to
providing resources and appropriate steps to take when assistance is needed in
resolving complex ethical issues. This course should be required for all health
care professionals.