Managing dual loyalties
In practice… health professionals often have obligations to other parties besides their patients… that may conflict with undivided devotion to the patient.
What are dual loyalties?
‘Dual loyalties’, or ‘dual obligations’, refer to the conflicting demands placed on doctors who have direct obligations to their patients as well as to a third party. Doctors in the armed forces can at times be required to balance conflicting, and sometimes irreconcilable, obligations or loyalties.
Doctors’ professional and ethical duties require them to preserve life, care for the sick and wounded, and reduce suffering. As military personnel, part of their role is to support those non-medical military colleagues whose function involves attacking and inflicting harm on the enemy. Circumstances can therefore arise where doctors come under pressure to prioritise their obligations or loyalties to the military over their ethical duties.
How can conflicting loyalties be managed?
In the BMA’s view, adherence to the guiding principles in this tool kit is vital if doctors are to address the conflicting obligations they are likely to face while serving in the armed forces. The medical role is further protected by international humanitarian law, which reinforces the ethical obligations of doctors practising in the military context during active conflict. Outside of armed conflict, human rights law and elements of domestic law apply.
Doctors are never absolved of their overriding responsibilities but they may at times feel pressure to subordinate or reinterpret their ethical duties where these duties appear to conflict with their broader loyalties to the military, their colleagues or friends. Military commanders are required to support doctors in the fulfilment of their ethical duties, and will expect doctors to act in accordance with their professional obligations.
However, circumstances, such as those outlined in the examples below, can place doctors under huge pressure. Guidance on how doctors in the armed forces can manage their dual loyalties in response to particular ethical dilemmas is given throughout this tool kit. Recognising where such tensions arise, and how they may influence decision-making, are important steps in ensuring that the doctor’s own principles are not eroded.
Key provisions under international humanitarian law
The Geneva Conventions are founded on the idea of respect for the individual and his or her dignity. People who are not directly involved in hostilities and those put out of action through sickness, injury, captivity or any other cause must be respected and protected against the effects of war. Those who suffer must be aided and cared for without discrimination.
- the wounded and sick must be respected and protected in all circumstances
- they must be treated humanely and must receive, to the fullest extent practicable and with the least possible delay, the medical care and attention required by their condition
- there must be no distinction in the treatment of the wounded and sick on anything other than clinical grounds
- forces must care for the wounded and sick of enemy forces taken prisoner as they would care for their own; and
- no one shall be compelled to perform acts contrary to the rules of medical ethics or to refrain from action which is required by those rules.
- Doctors in the armed forces have direct obligations to their patients as well as to the military.
- Doctors are never absolved of their overriding medical ethical responsibilities.
- Human rights law, domestic law and, in the context of active conflict, international humanitarian law reinforce and protect the ethical obligations of doctors practising in the armed forces.
- Adherence to core ethical principles can help doctors to address the conflicting obligations and loyalties they are likely to face while serving in the armed forces.
Examples of dual loyalties in practice
Triaging enemy, civilian, coalition and UK casualties
At the British field hospital in Afghanistan, casualties are treated solely on the basis of their clinical need. Injured suspected insurgents are, for example, treated ahead of British casualties if their condition is more urgent. The principles of triage are clear.
Doctors may nevertheless find themselves under moral pressure from colleagues, or their own sense of loyalty, to prioritise the treatment of their friends and colleagues over civilians and the enemy. These feelings are of course entirely natural but, if allowed to prevail, they could lead to objectively unethical decisions. Only by recognising and acknowledging such feelings can doctors hope to set them aside where it becomes necessary to do so.
Duty of care under fire
The principle of care under fire may require medical military personnel to use their weapons alongside non-medical colleagues, in order to meet their responsibility to protect their patients. Ministry of Defence doctrine, in line with the Geneva Conventions, states that medical personnel may be armed with light individual weapons for use in their own defence or in defence of the wounded and sick in their charge. Medical personnel must never use weapons offensively.
Once a doctor has used a weapon in defence, it is possible that he or she will be required to treat the individuals against whom the defensive action was taken. Considerable moral pressure is likely to emerge out of such situations and, as with the triage scenario above, doctors should be alert to the potential effects of such pressure on their clinical decision-making.