The complicated life of a physician-soldier: Medical readiness training exercises & the problem of dual loyalties

doi:10.4236/jbise.2013.610A1002

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J. Biomedical Science and Engineering, 2013, 6, 8-18 JBiSE

http://dx.doi.org/10.4236/jbise.2013.610A1002 Published Online October 2013 (http://www.scirp.org/journal/jbise/)

The complicated life of a physician-soldier: Medical

readiness training exercises & the problem of dual loyalties

Sheena M. Eagan Chamberlin

Institute for the Medical Humanities, University of Texas Medical Branch, Galveston, USA

Email: Sechamberlin@me.com

Received 14 August 2013; revised 6 September 2013; accepted 12 September 2013

License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

While physicians are generally understood as owing

moral obligation to the health and well being of their

individual patients, military health professionals can

face ethical tensions between responsibilities to indi-

vidual patients and responsibilities to the military

mission. The conflicting obligations of the two roles

held by the physician-soldier are often referred to as

the problem of dual loyalties and have long been a

topic of debate. This paper seeks to enrich the dual-

loyalties debate by examining the embedded case

study of medical civilian assistance programs. These

programs represent the use of medicine within the

military for strategic goals. Thus, a physician is ex-

pected to meet his obligation to his role as a soldier

while also practicing medicine. These programs in-

volve obligations inherent in both roles of the physi-

cian-soldier and thusly they serve as excellent exem-

plars for the problem of dual loyalties at an institu-

tional level. This paper focuses on Medical Readiness

Training Exercises (MEDRETEs). These programs

are short-term, generally taking place in low-income

nations in order to accomplish strategic goals includ-

ing training opportunities for military medical pro-

fessionals that are not possible on the home front.

This form of temporary program raises ethical con-

cerns regarding the exploitation of vulnerable popu-

lations and the value of what is termed “parachute

medicine”. The short-term nature of these interven-

tions makes long-term treatment and follow-up im-

possible, begging the question as to whether this peak

and trough approach to foreign civilian aid is of any

use. Physicians are generally understood as having

obligations towards the well being of the patient,

which these programs do not necessarily prioritize.

Rather, the programmatic intent is military, with po-

litical and strategic aims of furthering international

relations, increasing US military global presence and

providing austere and tropical training opportunities

for military healthcare providers. This can be mor-

ally problematic for the physician-soldier.

Keywords: Military Medicine; Dual Loyalty; Medical

Ethics; History of Medicine; Military History; Military

Ethics; MEDRETEs; Civic Action

1. INTRODUCTION

Military physicians are simultaneously members of two

professions. Identifying as both soldiers and physicians

can occasionally create moral dilemmas that are unique

to military medicine. This complicated moral experience

has been called the “problem of dual-loyalties” or some-

times “mixed agency”, and has been understood as a

fundamental issue in military medical ethics. These mili-

tary medical professionals have historically found them-

selves confronted with situations where military protocol,

orders or strategy require them to act or behave in a way

that is contrary to norms of civilian medical ethics, occa-

sionally valuing the mission over the individual patient.

This creates a morally complicated space in which the

military physician must practice. Critical reflection and

inquiry are needed to understand this uniquely compli-

cated combination of professions and the moral dilem-

mas faced by these practitioners.

This paper will explore the problems faced by physi-

cian-soldiers in light of their dual-loyalty. Analysis will

use a case study design to examine the dual-loyalties

issue on an institutional level, offering an in-depth de-

scription of the dual-loyalties problem as experien ced by

military physicians as well as a broader understanding of

the medico-military intersection, where medicine and the

military strive, through a single program, for seemingly

disparate goals. The case study f ocuses on medical civil-

ian assistance programs, which include all formal, in-

formal and ad hoc missions during which uniformed per-

OPEN ACCESS

S. M. Eagan Chamberlin / J. Biomedical Science and Engineering 6 (2013) 8-18 9

sonnel provided medical care to civilian populations as

part of their military duties.

2. MEDICAL CIVILIAN ASSISTANCE &

THE PROBLEM OF DUAL-LOYALTY

The security policy has shifted towards stability opera-

tions that often prioritize medical operations su ch as this.

Stability operations, including Humanitarian and civic

assistance has become an important part of the military

mission. National policy has emphasized and prioritized

these types of missions within the American armed

forces. According to Department of Defense (DOD) In-

struction 3000.05 Military stability operations (MSOs)

are a “core US military mission”, that “shall be given

priority comparable to combat operations…” [1] This

shift signifies formal recognition of America’s role on

the international level, and new technique in achieving

American military goals.

The military institutionalizes the dual-loyalty problem

with missions such as medical civilian assistance pro-

grams by combining both military and medical goals in to

a single program or mission. Now that these programs

are being prioritized at the same level as combat mis-

sions they must be studied. This critical reflection and

analysis is the key to the formation of institutional

knowledge. However, little analysis has taken place. In

fact, there is little institutional memory and sparse record

keeping when it comes to key medical civilian assistance

programs, and even these records do not paint a full pic-

ture of these missions. This paper introduces oral history

data into this discussion. The stories shared by these

military physicians provide valuable insight into a

uniquely complicated profession. This paper will share

those stories providing in-depth historico-ethical analysis

of these programs, as well as the problem of dual loyal-

ties.

American military medical professionals have been

providing medical care to civilian populations since the

beginning of formalized Army medicine. In fact, evi-

dence of civilian medical assistance programs dates b ack

to the Revolutionary War when the American Army first

organized [2]. During that time, military medical per-

sonnel often provided care to civilians who lived in the

vicinity of Army camps and bases. This care was pro-

vided out of a motivation to better or maintain the health

of soldiers by improving hygiene and reducing epidemic

disease, rather than to improve the health of the civilian

population. This meant that civilian assistance had a de-

cidedly strategic purpose; imp roved civilian health meant

a reduction in epidemic disease, and thus a healthy and

disease-free army, which meant a higher likelihood of

mission success. The use of medicine to accomplish stra-

tegic goals would go on to form the foundation for medi-

cal civilian assistance programs, as the military recog-

nized a new tool in its strategic arsen al. Despite the long

history of medical civilian assistance programs, these

programs were not officially formalized and emphasized

by the American military until much later.

After the Second World War, the US began to shift

away from the isolationist tendencies that had shaped its

previous foreign policy [3]. In the period between 1949-

1960 US foreign policy began to emphasize assistance to

foreign nations that were sympathetic to western democ-

racy and opposed to communism. This period was fol-

lowed by an era of US policy that shifted toward a bal-

ance of military force and humanitarian assistance [3]. In

the post-Vietnam era, US national policy took interest in

South and Central America. Official history notes that

the US recognized a low-intensity threat in Latin Amer-

ica caused by regional violence and destabilization [4].

Journalist Juan Gonzalez has argued that US economic

and military interests played a role in destabilizing Latin

America, creating a relationship of migration and de-

pendence with the United States [5]. In response to this

instability, the US Southern Command (SOUTHCOM)

command surgeon’s staff developed The Regional Medi-

cal Strategy. This strategy sought to use medical initia-

tives in conjunction with military assets to assist Latin

American host governments address the health care

needs of their country. The hope was that in assisting the

host government augment host nation medical capabili-

ties, the US would successfully preempt the possibility

that the lack of health care would become an insurgent

issue [4]. The two countries of specific focus were El

Salvador and Honduras [6].

The development, stabilization, and security assistance

missions were in line with both US national policy and

DOD directives. DOD directive 5132.3 established mili-

tary policy for security and civic assistance missions

stating, “security assistance is an integral part of the

DOD mission” [7]. In fact, many senior military officials

believed that the Army should be involved with Latin

and South American countries, as a partner for develop-

ment [8]. The US was also interested in increasing its

sphere of influence to encompass South America due to

the area’s rich natural resources, such as oil [9].

These missions involved the use of non-violent mili-

tary means, which is generally understood to mean “the

provision of training, equipment, personnel or other pro-

grams utilizing military resources” [10]. Before stabili-

zation and development assistance became a focus of US

foreign policy, non violent military means had referred to

the ramping up and scaling back of support forces before

and after hostilities. Howeve r, as the US became engag ed

in this type of nation development and assistance, it rec-

ognized that the support forces (including medical) could

be used beyond simply augmen ting combat pow er. These

support forces could be utilized as a separate and distinct

S. M. Eagan Chamberlin / J. Biomedical Science and Engineering 6 (2013) 8-18

element of power [10]. This recognition was due partly

to the perceived success of Medical Civic Action Pro-

grams (MEDCAPs) and other medical civilian assistance

programs during the Vietnam War. Thus, medical civic

action became a prominent component of stabilization

and development efforts during the later part of the twen-

tieth century in Latin, Central and South America. The

use of medicine in Latin America was recognized as “the

least controversial, most cost effective and politically

acceptable” means of furthering American military in-

terests [11]. Still, much like the programs of Vietnam that

inspired them, published commentators critiqued these

programs as small, limited and tending to “concentrate

on high impact, short range projects” [12]. Similar to

their predecessor programs in Vietnam, the short term

and temporary nature of these missions lent themselves

to contextual challenges regarding medical goals, such as

limited patient care, education and follow-up.

The Central and Latin American programs began in

Honduras, a country that would go on to receive a great

deal of medical civilian assistance from all branches of

the US military. COL Zajtchuk, part of Joint Task Force

Bravo (JTF-Bravo) amended the MEDCAP model from

Vietnam to create the modern MEDRETE. JTF-Bravo

represented US Southern Command in Honduras, work-

ing with Host-Nation governments in their area of re-

sponsibility to organize various comprehensive humani-

tarian assistance programs, as a part of the stabilization

and development missions that were now a priority

within US national policy [13]. Zajtchuk held the belief

that humanitarian and civic assistance activities or HCAs

had “the potential of becoming the greatest promoter of

developing positive US policy in Central America” [14].

He also believed that these programs would be a good

way for him to occupy the time of his staff, improving

troop morale and preventing boredom [14].

One of his largest and most successful programs was

the MEDCAP. These MEDCAPs were modeled after

those conducted in Vietnam and said to be the “mirror-

image of their Vietnam-counterparts” [15]. However,

there were some substantial changes between the MED-

CAPs in Vietnam and those being carried out in Hondu-

ras. According to Zajtchuk, the intention behind this pro-

gram was “to take advantage of a unique opportunity and

provide US physicians, nurses, administrators, medics

and support personnel field training that are unavailable

elsewhere” [15].

In Vietnam, the main focus had been psychological

warfare; in Honduras the MEDCAP was now a training

mission with the specific purpo se of enhancing a military

medical professional’s ability to practice medicine in

austere conditions [16]. As it no longer prioritized the

same goals as the MEDCAP, this reorientation led to a

change in name. The program began operating under the

name Medical Readiness Training Exercise or ME-

DRETE [16]. The title better reflected the main purpose

of the program: the training of military medical person-

nel in environments that could not be accurately repli-

cated in the US. Low-income nations and the isolated

rural populations presented diseases and illness that phy-

sicians, nurses and medics rarely saw in the US. Beyond

that, the temporary clinical setting of the impoverished

rural village was far from the western hospital in which

they trained and worked. MEDRETEs provided many

training opportunities that the military saw as advanta-

geous for military readiness and mission success.

3. MEDICAL READINESS TRAINING

EXERCISES—MEDRETES

MEDRETEs have involved many different types of

medical care and a wide variety of medical specialties.

The most common is the general multi-medical special-

ties MEDRETE. This two-week MEDRETE provides

primary care to remote, often rural, locations in low-

income nations in conjunction with the host nation’s

government and ministry of health [17]. Generally, this

includes immunizations, basic clinical care and dental

activities [17]. Some MEDRETEs also prioritize preven-

tive medicine and civilian health education [17]. More

specialized MEDRETEs include those involving spe-

cialty surgical teams performing cleft lip and palate re-

pair, hand reconstruction, plastic surgery on burn patients,

orthopedics and urology [17]. DENTRETEs also repre-

sent a popular and common subspecialty of the ME-

DRETE program, during which dentists perform tooth

extractions, tend to dental emergencies, apply fluoride

and provide oral hygiene education [17].

3.1. MEDRETE—Programmatic Intent

Although there was little doctrine to inform the behav-

iour of individual soldiers engaged in these missions, the

official intent is clearly documented. Stabilization and

development missions, such as the MEDRETE, were

understood to fall under the umbrella of military civic

action or MCA. According to Field Manual 41 - 10,

MCA projects are:

… Designed and intended to win support of the lo-

cal population for government objectives and for

the military. Properly planned and executed MCA

projects result in popular support. MCA employs

predominately indigenous military forces as labor

and is planned as short-term projects [18].

This definition, with a decidedly strategic purpose,

serves to distinguish MCA from the civic action done by

the United States Agency for International Development

or USAID, which includes forces of humanitarian assis-

S. M. Eagan Chamberlin / J. Biomedical Science and Engineering 6 (2013) 8-18 11

tance such as disaster relief. DOD Instruction 2205.02

provides greater understanding of the military conception

of “Humanitarian and Civic Assistance Activities” or

HCAs [19]. This DOD instruction directs US Armed

Forces personnel to

Participate in HCA activities to create strategic, op-

erational, and/or tactical effects that support Com-

batant Commander objectives in theatre security

cooperation or designated contingency plans while

concurrently reinforcing skills required for the op-

erational readiness of the forces executing the HCA

mission... [19].

This doctrine is reiterated in an earlier in- struction,

2205.3: “Implementing Procedures for the Humanitarian

and Civic Assistance (HCA) Program”, which states

“HCA activities shall promote the foreign policy and

national security interests of the United States and the

Specific operational readiness skills of the US Armed

Forces who participate in the activities” [2 0]. The strate-

gic focus of these missions is also apparent in read- ing

the official website of Joint Task Force Bravo, who has

been and remains responsible for the majority of Army

MEDRETES in Honduras and other SOUTHCOM coun-

tries. According to their site,

There are several mission objectives to ME-

DRETES, to include providing US military per-

sonnel training in delivery of medical care in aus-

tere conditions, promoting diplomatic relations be-

tween the US and host nations in Central America,

and providing humanitarian and civic assistance via

a long-term proactive program. These exercises b rin g

together key members of the US and foreign mili-

taries, US Embassy Country Teams, US Non-Gov-

ernmental Organizations (NGO’s), Host Nation

(HN) government agencies and indigenous civilian

organizations [17].

This military doctrine is clearly strategic. The mis-

sions are not humanitarian in nature but rather seek to

fulfill military goals, and emphasize strategic aims in-

cluding training and international diplomacy. Medical

civic action programs, which were reoriented and re-

named medical readiness training exercises during this

period, fell under the umbrella of MCA and HCA doc-

trine. Thus, their primary motivation is military not

medical.

The strategic purpose of these programs was not lost

on participants. In a letter to the editor that was published

in the journal Military Medicine, one author who had

experience developing these programs wrote, “the pri-

mary missions of MEDRETES has never been to resolve

health problems of the people in the host-nation, but to

train our military service elements to be ready for war”

[21]. Importantly the author also described the many

benefits that these programs can have for the host nation

civilian populatio ns.

As training missions, MEDRETES have been in-

valuable and worth much more in skill learning,

time and money than the simulated domestic (US)

training of our active and reserve components. As

benefits for foreign host-nation recipients, ME-

DRETEs serve a limited but good, useful service,

including some preventive medicine teaching as

part of care [21].

Participants and commentators recognized the poten-

tial benefits and the potential pitfalls of these programs,

almost from their first implementation in the post-Viet-

nam era. These programs offered an inexpensive and

excellent opportunity for public relations and training

[22]. Although they were recognized as a significant and

powerful policy tool if they were conducted properly,

many believed that irresponsibly conducted medical ci-

vilian assistance could be counterproductive [23]. They

feared that if the Vietnam MEDCAP style was perpetu-

ated, where strategic concerns subverted medical goals

leading to the provision of subpar medical care, the mili-

tary interests could suffer from the distrust that this could

engender.

3.2. The Promise & Pitfalls of MEDRETEs

The recognition of both the potential positive benefits

and negative consequences of these programs is promi-

nent in the written and interview discussions with par-

ticipants who reflect on their own experiences on spe-

cific missions. Honduras was the recipient of a substan-

tial amount of medical civilian assistance during this

time period. The US was motivated to assist the Hondu-

rans in nation building and enhance the image of the US

while expanding its sphere of influence and providing

maximal training experience for its personnel [24]. Pro-

grams like MEDCAPs and MEDRETEs were often well

recieved in Honduras because of the state of medicine

there. Although there was an appearance of a local public

health system, it had many shortcommings that stymied

its success. These included staff shortages, with doctors

gathered in large city centers, leaving isolated rural areas

without medical care and severe budgetary constraints.

Thus, the US military decided to assist Honduras with its

medical care and infrastructure problems to ensure stabi-

lization and promote development. HCA in Honduras

was approached in a four tiered way: 1) hospital/clinics;

2) village outreach programs (transitory MEDRETEs); 3)

contingency response; and 4) quarterly visits from max-

illo-facial plastic surgery (Operation Smile-cleft lip and

palate repair) [24].

The MEDRETEs were usually set up in a village

S. M. Eagan Chamberlin / J. Biomedical Science and Engineering 6 (2013) 8-18

school or church [25]. The majority of their patients were

women and children, who are reported to have occasion-

ally created fictionalized complaints simply for the op-

portunity to see a western doctor [25,26]. Other patients

who were actually ill believed that the mere presence of

a western physician could cure them [25].

These missions involved many types of medical inter-

ventions including primary care and preventive medicine,

public health lectures deliv ered in Sp anish, den tistry, sur-

gery and even deworming [25]. Operation Smile is often

hailed as an enormous success due to the visual impact

of repairing a child’s cleft and lip palate [27]. A team of

plastic surgeons from William Beaumont Army Medical

Center in El Paso TX would travel to Honduras four

times a year and select patients for this surgery from pre-

determined villages [27]. Much like in Vietnam, the lo-

cation of MEDRETEs was determined by the US mili-

tary MEDRETE coordinator in consultation with Hon-

duran military and local civilian officials based on a

“particular need” [25]. Specific patient populations were

also chosen by US and Honduran military, civilian and

government officials, leading some physicians to express

discontent at the limitations being placed on them in the

clinical setting [25]. Rarely did MEDRETE teams revisit

the same village.

Many military physicians who had participated in

MEDRETEs expressed critiques of these programs. One

point of discontent was the constraints placed on medical

care by political and strategic requirements and necessity.

These critiques often focused on the constraints and limi-

tations placed on them by both the US military and the

host nation government. Often the ability of a ME-

DRETE team to return to a specific village was dictated

by the host nation government [28]. Thus, a physician or

planner could no t choose to return to a sp ecific village to

maintain continu ity of care; these decisions were dictated

by those higher up the chain of command in conversation

with the host nation themselves. One participant ex-

pressed the concern that he felt that they were making

villagers dependent on American military medical care

by introducing these people to western medicine, and

then never returning to provide follow up care [29]. This

presented him with a type of moral dile mma, identifying

chronic conditions for which he could do nothing. Other

constraints included the fact that the host nation often

dictated the patient population that could be seen, the

villages that could be visited, as well as what services

could be provided and what medications could be dis-

tributed [30].

Other constraints dealt with context and environment.

These included the lack of support services, language

barriers and being unfamiliar with the local culture, en-

demic diseases, the local health-care system, and stan-

dards of care [31]. There were also a large number of

patients to see in a short amount of time. Often patients

travelled from neighbouring villages for the opportunity

to see an American physician [32]. The short-term and

temporary nature of MEDRETEs were also a source of

constant critique and discontent for the military physi-

cian. Often called “parachute medicine” training opera-

tions because teams dropped in and provided care for a

short time and then left, this short-term model prevented

long-term and follow up care for patients with chronic

conditions [33]. Many participants recognized the need

for long-term projects, and re-occurring MEDRETEs

[34].

Discontent was not limited to the physician partici-

pants. The host nation governments were also critical of

the benefit of early MEDRETEs [35]. The Ministry of

Health in Honduras, as well as the Honduran College of

Medicine, questioned the utility of the MEDRETEs [35].

Even Army South Command or SOUTHCOM recog-

nized the shortcomings of the MEDRETE program. In a

SOUTHCOM memorandum they stated,

We have done a good job winning the minds and

heart of our hemisphere neighbors using these train-

ing vehicles. However, despite these efforts we are

not able to demonstrate that we have actually done

anything to improve the health of those we have

treated in the past. The mere provision of a few

medicines on a periodic basis can generate a great

number of patients seen during a particular visit, but

says nothing about the impact of our effort on the

health of the population [35].

The medical practitioners provide the care then re-

peat these same critiques. The majority of participants

interviewed expressed beliefs that the medical impact of

MEDRETEs was minimal [29,32,36]. One participant

thought that medically the MEDRETE was, “a disservice

to the local population” [29]. This same participant was

in Honduras from 1999-2000 and explained that prevail-

ing physician sentiment was, “MEDRETEs would be a

disservice to the local population and there was a lot of

truth to that” [29]. Another participant referred to ME-

DRETEs as “band-aid medicine” [32]. The concept of

“band-aid” medicine refers to the idea that little is done

for the patients beyond putting on band aids and doling

out multi-vitamins. For these reasons one physician de-

scribed MEDRETEs as having, “no impact at all on a

medical basis” [36].

3.3. Positive Provider Experiences

However, not all shared these critiques. Many providers

felt that the medical care that was provided was of bene-

fit to the MEDRETE patients. These perceived benefits

on the part of the participants mark a drastic departure

S. M. Eagan Chamberlin / J. Biomedical Science and Engineering 6 (2013) 8-18 13

from the Vietnam MEDCAP. Clearly, the MEDRETE is

not a “mirror-image” of the Vietnam-style MEDCAP.

One author stated, “The hospital, and the MEDRETES,

may not have contributed to the long-term development

of a health service, but it made a long-term difference to

the patients” [28]. Another military physician who had

the opportunity to participate in both a MEDCAP and a

MEDRETE explained that the medical value of the latter

was far superior to the former [37]. This opinion was

reiterated in the literature as many were beginning to

realize that the traditional MEDCAP could be counter-

productive and fail in its goal of creating confidence in

the local host nation government due to lack of coordina-

tion and subpar medical care [38].

There were specific medical procedures and aspects of

medical care that physicians recognized as useful in the

MEDRETE setting. Internal medicine physicians were

quick to note their limitations in this context. As one par-

ticipant noted, “internal medicine is the management of

chronic disease, there is not much internal medicine can

do in a one day clinic at a MEDRETE” [39]. However,

internists did discover the value of draining and injecting

arthritic joints [36,39]. Surgeons were found to be ex-

tremely valuable for cleft lip and palate repairs, amputa-

tions, and draining abscesses [36]. Pediatricians felt great

satisfaction and saw huge impact with deworming cam-

paigns, and dentists had a significant impact on oral

health by way of tooth extraction [36,49]. Optometrists

have also had considerable success distributing perscrip-

tion glasses. Although medicine was limited in the field,

physicians were able to find avenues by which to make a

therapeutic difference. Many MEDRETE participants

found their experience rewarding, remembering these

benefits and the appreciation of the patients [29,32,36,

39].

4. A CALL REFORM

Although there were many benefits to the MEDRETE

and some participants had positive experiences, others

still called for increased reform of civilian medical assis-

tance programs. Physician participants and commenta-

tors were beginning to call for programs that, unlike the

traditional MEDCAP, prioritized medical goals and sus-

tained long-term benefits [38]. Other commentators

called for more drastic reform of medical civilian assis-

tance. Regina Gaillard is critical of the historical link

between civic action and counterinsurgency, as well as

low intensity conflict [40]. She argues that the linkage of

a strategic and humanitarian mission has tainted the ide-

alist qualities of the concept causing these programs to

be counterproductive in achieving the US military’s

goals.

Gaillard argues that a reorientation effort should at-

tempt to delink civic action programs and humanitarian

and civic assistance activities from counterinsurgency

and low intensity conflict (LIC) [40]. Gaillard was es-

sentially calling for a prioritization of medical goals over

military goals. Contemporary programs show that Gail-

lard’s desired delinking of civic action and counterinsur-

gency of LIC has not been accomplished. Physician ex-

perience tells that MEDCAPs in Afghanistan and Iraq are

aligned with the PSYOPs goals of counterinsurgency and

LIC [41]. Cramblet has similar critiques and calls for a

necessary distinction between war and low-intensity co n-

flict. Programs developed during times of conflict, such

as MEDCAPs, cannot simply be transplanted into peace-

time or low-intensity conflict operations [42]. Cramblet

also highlights noteworthy aspects of a successful ME-

DRETE such as sustainability, which includes the suc-

cessful hand off of programs to locals and simplicity

necessary for program continuation in developing na-

tions [43].

5. MILITARY DOCTRINE

A significant issue for the MEDRETE program, which

had also plagued the MEDCAP missions that preceded

them, was a lack of military doctrine that specifically

instructed participants in how to act in these environ-

ments. This lack of military doctrine was recognized by

many commentators [11,44]. As Gonzalez wrote, “At

present and in the past, even though medicine has been

extensively used, there has never been a doctrine for its

proper utilization in Latin America” [45]. The lack of

doctrine on the topic is problematic because of the foun-

dational role that it plays within the military institution.

Military doctrine is essential in shaping the behaviour of

soldiers and dictating their proper conduct. Thus, a lack

of doctrine leaves participants in these programs without

guidance.

These types of missions are au thorized under Title 10,

US Code. Section 401. Programs established under this

statute are intended as opportunities for training. A sec-

ondary goal is non-threatening engagement with a for-

eign nation. It is crucial to note that humanitarian goals

are not mentioned. Medical care is not the purpose of

these programs; the main purpose is training, while

medical care is specifically ancillary. In a way this serves

to distinguish medical civilian assistance programs from

other military, as well as non-military humanitarian pro-

grams. Funding has continued for these programs that are

specifically earmarked for military training, rather than

humanitarian assistance, stabilization, or foreign devel-

opment. The clear emphasis placed on training can be

understood a number of ways. Firstly, it can be under-

stood as protecting the program and rationalizing it

within the military budget, allowing physicians to pro-

vide at least some care to patients in need. In fact, many

physicians believe in the care that MEDRETEs provide,

S. M. Eagan Chamberlin / J. Biomedical Science and Engineering 6 (2013) 8-18

and find it rewarding as both a training and humanitarian

mission. Another way to understand the prioritization of

training is that the military is being honest about its in-

tentions. As opposed to the Vietnam-era MEDCAPs,

which sometimes in- volved dishonesty and deception,

this program presents itself as a training operation with

ancillary benefit to host-n ation patients.

FM 27-5 addressed public health, sanitation and pre-

ventive medicine initiatives but did not address direct

patient contact programs such as MEDCAPs or ME-

DRETEs [46]. FM100-20-, “Military Operations in Low

Intensity Conflict”, provides vague and uninstructive

information regarding these missions, with no mention of

the medical mission. At this time, LIC was a catchall

term with little distinct doctrine [47]. Joint Publication

3-07.6, “Doctrine for Military Operations Other Than

War” (MOOTW), provides additional guidance, stating

that the first priority of military medicine is to US troop s.

However, “when planning for MOOTW, the potential to

treat HN [host nation] population of allied military per-

sonnel must be considered” [48]. Authorized care to for-

eign civilians should be within resource limitations and

should urge continued coordination between the medical

and intelligence elements [48]. In fact, this publication

recognizes medical operations in MOOTW as a “valu-

able intelligence source” [48]. Joint Publication 4-02,

Doctrine for Health Service Support in Joint Operations,

reiterates that no operation should supplant or compete

with the existing local medical infrastructure [49]. This

piece of doctrine recognizes the necessity of not creating

redundant healthcare systems that simply duplicate local

services. History has shown that competing or duplicat-

ing local services undermine the local economy, create

hostile relations with the local medical community and

thus they can be a disservice to the healthcare of the local

community and the mission.

Taken toge ther these do ctrines provid e little in the way

of helpful guidance for military physicians participating

in these missions, however, the doctrine does clearly

establish these missions as being of strategic intent:

aimed at training and engagement. In this way, the doc-

trine clearly established a political mission for these hu-

manitarian programs. Thus, the doctrine is straightfor-

ward in its use of medicine as a “non-lethal weapon” or

tool, employed toward military ends. However, beyond

the basic programmatic intent and goals of medical ci-

vilian assistance, this doctrine provides little guidance

for soldiers engaged in this work.

Medical Rules of Engagement—“Life Limb or

Eyesight”

Aside from military directives and instructions, there are

other rules that could inform, and thus help to shape, the

conduct of officers while on medical civilian assistance

missions. Many of the participants who shared oral his-

tories identified the medical rules of engagement as the

way by which they often balance their twin roles as a

physician and a soldier [30,50,51]. These rules of en-

gagement represent another form of military doctrine that

provides guidance and informs the actions as well as the

medical and strategic decision-making of the military

physician.

Medical Rules of Engagement (MROE) are used to

outline the current military restrictions on whom physi-

cians can and cannot treat, for strategic reasons [52]. The

name draws an analogy with the military “Rules of En-

gagement” (ROE) that determine the limita tions and dic-

tate the appropriate situations when a so ldier can respond

with his or her weapon. The restrictions are dictated by

command for strategic and political purposes. Similarly,

medical rules of engagement are meant to determine

when and how medical personnel can respond with their

medical skills and technology. For instance, while the

Geneva conventions require the treatment of enemy

combatant personnel, foreign civilian populations are not

always treated within the combat zone due to scarcity of

resources or security concerns. That being said, injuries

concerning “life, limb or eyesight” are understood to be a

deciding and over-riding factor [50 ]. If a patient presents

with an injury that threatens their life, limb or vision,

physicians are allowed to treat them, regardless of other

factors. Unfortunately, although physicians use MROE

as their litmus test for providing civilian care, “life, limb

or eyesight” does not make treatment mandatory or ex-

pected. Tensions are still reported between physicians

and commanding officers over whether or not to treat

injured and diseased civilians presenting during times of

hostilities and scare resources [50].

Medical rules of engagement provide another example,

and more substantive eviden ce, to the life of the military

physician as simultaneously existing in two professional

roles: the soldier-with rules of engagement and the doc-

tor-with patient obligations. The balance necessary for

this kind of medical assistance mission is exemplified in

the concept of “integration” drawn from doctrine and put

forth by LtCOL Peter Cramblet in his US Army War Col-

lege paper entitled, “US Medical Imperatives for Low

Intensity Conflict”. Drawing on experiences in Honduras,

LtCOL Cramblet holds that

Medical commanders must understand the first

principal of war, objective, and integrate their ef-

forts with other elements of national power to en-

sure accomplishment… well meaning commanders

with sometimes bored, medical staff assume im-

plied medical missions which do not always suppor t

LIC objectives [53] .

Cramblet highlights that the balance expected of mili-

S. M. Eagan Chamberlin / J. Biomedical Science and Engineering 6 (2013) 8-18 15

tary physicians is understood by the military to prioritize

the mission. Institutional messages are mixed when they

are treated like physicians, asked to practice medicine

and yet expected to fulfill obligations to their role as a

soldier. They are expected to do more than just doctor,

and this balance can be delicate to maintain. However,

the blame should not fall solely on the shoulders of the

physician. Cramblet blamed a lack of clear mission

statements in LIC environments. The themes of ambigu-

ous mission statements, lack of doctrine and unclear di-

rectives are prevalent throughout the history of these

programs.

Beyond the lack of doctrine, participants in these pro-

grams also receive little or no training prior to their in-

volvement. A recent study showed that a quarter of the

polled participants received no training for their humani-

tarian assistance missions [54]. Of those that received

training, it was primarily on the job and in th e field train-

ing. There was no formal, pre-deployment training [54].

This lack of training was found to have a negative impact

on the effectiveness of the mission [54]. It also may ex-

plain why physicians are unaware of the strategic goals

of these missions, expecting them to be solely humani-

tarian missions without strategic intent.

In looking at primary source materials, the goals may

seem apparent. However, many oral histories confirm

that those involved in these programs were not always

aware of the strategic aim of these programs. The am-

biguous nature of the programmatic goals, and their lack

of dissemination made it difficult for physicians to un-

derstand and achieve success. While command sought

strategic achievement, physicians aimed for medical and

humanitarian triumph. The two goals had different and

sometimes conflicting methods and end-points [55]. Ac-

cording to Robert Wilen sky, the MEDCAP program was

based upon both the “altruistic inclinations of their par-

ticipants and the political aims of the US government”

[56]. The distinction between the aims and inclinations

of those people with “boots on the ground” and those de-

veloping the policy resulted in unmet expectations, con-

fusion over roles and responsibilities, successes, end-

points and inappropriate policy implementation. This

uncertainty and confusion only caused more frustration

for the military medical professional.

The strategic intent of the doctrine that dictates these

programs is unden iable. That being said the particip ants’

motivations for involvement were often remarkably dif-

ferent. Anecdotal evidence, oral histories and a recent

study by the Center for Disaster and Humanitarian As-

sistance Medicine CDHAM have shown that physicians

are motivated by altruism and actively seek out these

programs. The study included all branches, active duty

and reserves from various duty positions. It showed that

nearly half of the physicians surveyed indicated that hu-

manitarian missions were a factor in their decision to join

the military [57]. These numbers allow us to understand

the values of the physicians participating in medical ci-

vilian assistance missions, and und erstand how physician

participants may differ from the command in reference to

the goals of the program. These missions appeal to a

humanitarian urge rather than a strategic one. Although

many military physicians may also agree with larger

military goals, this study highlights the crucial role that

humanitarian and altruistic values play in shaping the

identity and cho ices of the military physician. Reg ardless

of their views on strategic goals, military physicians

place a high value on the possibility of participating in

humanitarian missions as part of their military duties.

“Many applicants to the USUHS... expressed positive

feelings about the potential to go overseas… humanitar-

ian missions are one of the key factors that led them to

apply to USUHS and to prefer a career as a military phy-

sician [58].” Their identity as military physicians is

thusly shaped by this beneficent drive, to provide medi-

cal care in a capacity they thought civilian life could not

offer. The significance for the Army is also apparent.

These programs are a key contributing factor to physi-

cian career planning. These missions also play a vital

role in retention and recruitment. The same CDHAM

study showed that 60% of respondents reported that hu-

manitarian assistance missions were influential in their

decision to stay in the military [58]. Due to the impor-

tance of these programs to military providers, their ex-

perience within these missions deserves closer attention.

The significance of humanitarian missions in physician

decision-making provides insight into the morally com-

plicated space of the historical medical civilian assis-

tance model. Medical civilian assistance programs have

historically been a well-intentioned, misdirected and

frustrating experience for physicians. While they ex-

pected a humanitarian operation of beneficent medical

care, they were faced with the reality of a military ope ra-

tion with secondary medical goals.

Physician-soldiers are not exempt from the horror and

realities of war. While MEDCAPs and MEDRETEs do

not involve the trauma of IEDs and mass casualties, one

must not discount the psychological impact of providing

care in dangerous places, and the disappointment, frus-

tration and impotence felt providing care felt to be in-

adequate. Within the setting of the MEDCAP or ME-

DRETE, a physician is the agent of a program with goals

that represent his twin-roles. Physicians of contemporary

western medicine are used to the comforts of the hospital.

They are accustomed to diagnostic tests, support staff,

specialist consults, patient follow-up and well-stocked

pharmacies. These missions challenge physicians. They

are forced to see patients with chronic diseases that

would be curable, or at least manageable, stateside but

S. M. Eagan Chamberlin / J. Biomedical Science and Engineering 6 (2013) 8-18

for which a MEDCAP or MEDRETE can do nothing.

Instead, providers are confronted with the realities of

these missions.

Although such activities collect large numbers of

villagers, the procedure appears to confirm the

peasant’s belief in magic merely with the statement

that Western magic is more powerful than local

magic. Such a procedure may win an election, but

in the long run it is truly dangerous and represents

an inexcusable prostitution of medical facilities

[59].

The feeling of provider impotence frustrates them as

they dispense multi-vitamins, aspirin, ibuprofen or a few

days’ course of antibio tics. This frustration is palpable in

the way providers joke with each other to alleviate the

tension; as one participant shared, his team would often

say “All we have done here today is maybe given a cou-

ple of people ulcers from taking too much ibuprofen”

[41]. This type of frustration has led other participants to

see this work to be, “of limited value medically, it is an

outstanding tool for propaganda” [60]. CPT John Irving

described one Medical Civic Action Program as a “mili-

tary maneuver”, rather than a humanitarian mission [60].

The moral complexity does not appear to lie with the use

of medicine as a strategic tool. Rather, what lies at the

heart of provider complaints is the prioritization of strat-

egy above all else. This reality becomes apparent in the

fact that when medical goals are emphasized, and medi-

cal good is achieved, physicians find these experiences

rewarding and positive. However, when these military

physicians are morally ch allenged by an order to provide

medical care that they believe to be inadequate and they

often feel conflicted. This problem is one of dual loyalty.

6. ACKNOWLEDGEMENTS

I would like to thank my academic mentors who have guided my re-

search and writing on this project: Dr. Jason Glenn, Dr. Howard Brody,

Laura Hermer, Dr. John Fraser and Dr. Sanders Marble. Their guidance

made this work come to fruition. The Institute for the Medical Humani-

ties and the Graduate School for Biomedical Sciences at the University

of Texas Medical Branch also provided academic and research support

throughout this proj ec t.

I also wish to extend my special gratitude to the physician-soldiers

who shared their personal stories with me. These oral histories enriched

my study of military medicine and provided valuable insight into a

uniquely complicated profession. Lastly I would like to acknowledge

the never-ending support of my family and my husband, who motivate

me in all I do.

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