Dual loyalties: Everyday ethical problems of registered nurses and physicians in combat zones

Introduction

When registered nurses (RNs) and physicians (MD) (henceforth licensed medical personnel (LMP)) undertake healthcare in a military combat zone, they are exposed to various ethical problems, for example, having to prioritise scarce resources, being obliged to choose between caring for enemies and allies, being caught between military and medical duties and causing a conflict involving dual loyalties. ^{1 –7} In earlier research on ethical problems in military medicine, the focus has been on exploring severe types of ethical problems when healthcare personnel take part in clearly unlawful actions, for example, assisting in torture-like situations intimidating patients, or intentionally inflicting pain on a person for the purpose of obtaining information. ^{8 –11} This branch of research has mainly been focused on the role of physicians.

However, the ethical problems focused in this study are more everyday ethical problems where the guiding laws and regulations might not give clear advice or instruction as to what to do. This study also includes nurses’ perspectives. The everyday ethical problems in this study have to do with dual loyalties, that is, choosing between providing medical care and performing military actions that per se may be lawful and beneficial for the military mission. ^{1,12 –14} This problem has also been observed in other studies, but we have found further examples illustrated by the following typical situations: (a) that LMPs gathered information they claimed to be intelligence when providing care for citizens of the host nation; (b) that LMPs performed guard duties in the Tactical Operations Centre ^i,15 at the military camp and at the main gate, that is, the entrance to the camp; and (c) that LMPs also filled vacancies and became temporary healthcare personnel, that is, primarily combatants and secondarily healthcare personnel.

In these cases, LMPs might have breached the ethical rules and principles that should have guided their actions. General ethical rules and codes are, for RNs, the International Council of Nurses (ICN) Code of Ethics for Nurses ¹⁶ and, for MDs, the World Medical Association (WMA) International Codes of Medical Ethics. ¹⁷ Both professions must comply with the codified ethical rules in national healthcare legislation (in this case Sweden). ¹⁸ Besides these ethical rules, humanitarian law also applies in combat zones. ¹⁹ When LMPs are exclusively assigned to healthcare duties, they must be equipped with a Red Cross ID, issued by the International Committee of the Red Cross, and wear a Red Cross armlet according to humanitarian law. ^{20 –22} This emblem signifies being a non-combatant, that is, not taking part in hostile actions and only using weapons for self-protection and for the protection of patients. Every country’s LMPs implement healthcare, and some, like Swedish LMPs, are uniformed and armed since they are member of military units and may look like combatants. ²³ In employment by the armed forces, LMPs receive preparatory and military training before rotation to combat zones. The military preparation, a basic military training course, aims to convey practical and theoretical knowledge to increase understanding about the military organisation and to develop basic military skills. They also train combat techniques, even though they are non-combatants. Discipline, the importance of good military spirit and the ability to work in groups characterise these preparations. Also included is specific training aimed at imparting knowledge and understanding of problem-solving in combat zone contexts, that is, of how to supply the required nursing and medical skills in a specific combat zone. ²⁴

As it is documented that LMPs can side both with the medical and the military in cases of dual loyalty, it is important to know their respective reasons for doing so. Both to understand how they view their role in the military and to be able to assess to what extent the reasons provided are legitimate given ethical codes and rules that are supposed to guide their operation. Now, there is a knowledge gap on how LMPs reason when they face the types of everyday ethical situations listed above.

Aim

This study aims to describe how Swedish LMPs reason about everyday ethical problems stemming from dual loyalties when providing healthcare in combat zones.

Method

Setting

A semi-structured interview topic guide was developed ^25,26 containing four vignettes presenting situations 1–4 (see Appendix 1). The purpose with using vignettes was to encourage the participants to reflect on ethical problems by presenting them with a potential situation they might encounter. ²⁷ This guide was tested on participants belonging to a Swedish unit during a training session at the Armed Forces Centre for Defence Medicine in Gothenburg, late 2014. The participants were preparing for a peace enforcement UN operation (Chapter VII mandate) in a combat zone during 2015.

After the training session, the interview topic guide was modified based on the participants’ comments during the session. All the participants at the training session were orally invited to partake in individual interviews. Later on, the participants received an e-mail and were asked to confirm whether they would participate, and the ones who wanted to participate were interviewed.

The inclusion criteria required all participants to be LMPs and to have been stationed with the Swedish Armed Forces in a combat zone within the past 3 years.

Participants recruited for this study are presented in Table 1.

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Table 1.

Demographic table.

Participants	Sex		Age (years)				Years in profession
	Female	Male	25–35	36–45	46–55	56–65	1–10	11–20	21–30
RNs	2	5	3	2		2	2	3	2
Physicians (MDs)	2	5	2	2	1	2	2	2	3

RNs: registered nurses.

Ethical considerations

This project applied for and gained the approval of the Regional Ethics Review Board in Gothenburg (D no. 816-14; 2014-11-24) since the research involved humans and sensitive questions were asked. ^28,29 Informed consent was obtained. ²⁵ Before the interviews, LMPs were informed about the aim and methods of the study, how the principle of confidentiality was to be upheld and how the concept of confidentiality would be applied to the data in this study. The LMPs were then reassured that they had the right to withdraw from the interviews at any time without providing reasons.

Findings

Three categories and 11 subcategories emerged from the data material (see Table 2).

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Table 2.

Result table.

Categories	Subcategories
Reasons for not undertaking combat duties	Lacking military competence
	Against the ethos of the care-giving role
	Following the letter and intention of humanitarian law
	Should prioritise healthcare and not military duties
Reasons for undertaking combat duties	Humanitarian law is not relevant
	Having a military role and a military competence
	Doing one’s share
	Contribute to force protection
Restricted loyalty to military duties	Undertaking combat duties when under threat
	Undertaking combat duties if unseen
	Undertaking combat duties if not needed for healthcare duties

Reasons for not undertaking combat duties

Reasons for undertaking combat duties

Restricted loyalty to military duties

Under specific conditions described below, LMPs would perform duties that are combat duties.

Discussion

The results show that when LMPs are integrated into a military system in combat zones, two seemingly different value systems are combined, the healthcare and the military. This is shown when LMPs are reasoning around undertaking combat duties or not, if they are having the having competence or not for undertaking these duties, how they view humanitarian law, LMPs prioritising of resources and undertaking military duties when being under threat and when not being visible.

When LMPs referred to their competence, they had different perceptions of having the competence. Some of the LMPs claimed that they lacked the military competence, since they were primarily healthcare personnel and not trained in combat duties. They also claimed it was not in their role to undertake combat duties. The LMPs said that combat duties are normally undertaken by trained soldiers. For example, monitoring systems are not systems that automatically are understood by healthcare personnel, and that therefore technical skills or technical competence for these monitoring systems are often required. In this, their reasoning concerned practical skills and qualifications rather than reflecting around their ethical codes or their caring role. During preparation before rotating to a combat zone, ethics and ethical problems were discussed, but LMPs did not refer explicitly to their own ethical codes. It seems as if the practical skills involved in executing combat duties, that is, the competence per se, were of greater importance or at least more in the forefront of their thinking than ethical values and norms.

However, when claiming they had the competence in undertaking combat duties, LMPs did refer to a sense of justice, claiming that they belonged to a military unit and therefore should undertake military duties. The reasons then were that LMPs wanted to contribute through military duties, even if these duties were combat duties. Furthermore, LMPs were told during training that ‘everyone is a soldier’. Some of them may have interpreted this as allowing them to assist the soldiers with different tasks, even if that would have been combat duties. Besides, they found it hard to justify non-participation to their fellow soldiers, for example, if they refused duties such as standing guard at the entrance to the camp. But some of the LMPs are likely to be trained and have military competence and therefore competent to undertake combat duties, but may not have been aware that the duties can be combat duties and as such incompatible with the ‘healthcare’ mission (such as undertaking body search).

When LMPs are wearing the distinctive emblem, which designates they are exclusively assigned to caring duties, they should refrain from undertaking duties referred to as combat duties according to humanitarian law. ^{20 –22} However, today most armed conflicts are non-international, and a significant part of humanitarian law, that is, the Four Geneva Conventions from 1949 and the First Additional Protocol, ^30,31 applies only in international armed conflicts. When Sweden partakes with a military unit in combat zones, the Second Additional Protocol may apply, ³² including Article 3 common to all four Geneva Conventions. ³³ On the other hand, humanitarian law, which is closely related to human rights, is today included in what we refer to as customary law ¹⁹ and applies in non-international armed conflicts. In international armed conflicts, ‘combatant’ is defined as soldiers participating in the fighting squad ¹⁹ (Rule 3), and LMPs are clearly excluded from participating in such a squad. But in these non-international conflicts, in which Swedish LMPs participate, ‘combatant’ is not clearly defined. ³⁴

Therefore, when LMPs were claiming that humanitarian law did not apply, they were referring to that they partook in non-international operations, where humanitarian law is not explicit about how to define ‘combatant’. The Swedish LMPs may not even have been aware of that the duties they partook in can be combat duties and then considered to be forbidden. Being uniformed and armed, belonging to a military unit and may appear as combatants, ²³ the Swedish LMPs may even have viewed themselves as combat soldiers. Some of the armed conflicts Sweden has partaken in recently (Afghanistan and Mali) have been under a UN Chapter VII mandate, that is, peace enforcement conflicts, where the Second Additional Protocol and the common Article 3 applied. But when Sweden partook with soldiers outside the coastline of Somalia, the operation was governed by the Human Rights and Military Operation Rules (SOP) only.

However, customary law does explicitly condemn that LMPs partake in ‘hostile acts, outside their humanitarian function’. ¹⁹ An example of ‘hostile act’ may be ‘violation of neutrality’ and ‘act harmful against enemy’, ¹⁹ but customary law is not explicit if ‘hostile acts’ could be interpreted as being the duties which some LMPs take part in here. Normally, duties such as standing guard and gathering intelligence are combat duties and referred to as duties undertaken by combatant soldiers. ¹ Since customary law is not clear, or explicitly forbid LMPs undertaking the duties referred to here, and do not clearly define combatants, ³⁴ they may have reasons for diminishing the significance of humanitarian law and therefore have a pragmatic view on the law.

On these operations, there are sometimes shortages of LMPs, and even vacancies resulting in shortage of LMPs, resulting in that they have time for healthcare duties only. Even though they had time left and were not needed in healthcare all the time, some of the LMPs claimed that there were no reasons to undertake military duties, or combat duties, since it would have been a wrong priority of resources. However, in these situations, when not needed in their healthcare duties, some LMPs found it hard to motivate non-participation of military duties. They felt a pressure to undertake military duties, even if the duties were combat duties, which is seen in earlier research. ^{34 –38} But LMPs also referred to justice that it was fair to the peers if they also undertook other duties when not needed in the healthcare duties. If LMPs would not have contributed and undertaken these combat duties, the military tasks would not have been solved, LMPs reasoned. At the same time, even if it is understandable that it might be difficult to refuse doing such duties to enable their fellow soldiers to rest and recover, it might imply that the LMPs are tired and less focused when having to perform life-saving interventions. Further reasons for undertaking combat duties could be that LMPs also wanted to show that they were as much soldiers as anybody else and that they were not afraid of undertaking duties that were not caring duties. It has been voiced that LMPs can experience not being taken seriously as important parts of the unit, or at least as less important parts.

LMPs were sometimes willing to undertake combat duties if they remained unseen from external observers, such as serving in the monitoring centre. When serving there, only their own unit could observe that LMPs had a Red Cross armlet. For visitors at the military camp, LMPs would have been invisible. On the other hand, if LMPs would have been standing guard in the entrance to the military camp, it would have been visible for everyone who passed the entrance that LMPs were guarding. The rationale behind this would be that when wearing a Red Cross armlet it is obvious who they are and what function they have in the unit. ³³ From an ethical perspective, this is a problematic reasoning, since there is a risk in undermining the confidence in Swedish LMPs if it is discovered that they act as potential combatants and thereby seemingly make exceptions to humanitarian law when it suits them. Consequently, that could have been risky for the whole Swedish LMP unit and also damage the trust for the Swedish Armed Forces.

LMPs are always obliged to prioritise caring for the patients and uphold a relationship built on trust and honesty in all contexts. This is extra important in combat zones where they represent what might be seen as a hostile military force. But there are circumstances when it is possible to interpret that LMPs are entitled to violate their obligations towards their patients. When a patient poses a risk, in armed conflicts or in peacetime, LMPs may use violence, according to the ethical codes for MDs in times of war. ³⁹ In combat zones, the threats may be experienced as constant, and therefore LMPs may think they could use violence towards enemy forces or illegitimate warriors. Therefore, LMPs stated that under certain conditions, such as being under threat, they might undertake duties that were normally executed by combat soldiers, such as participating in a fighting squad.

In previous research, employment as healthcare personnel in the military is described as creating dual loyalties between healthcare duties and military requirements. ^{1,11,14,37,40} One may expect that their primary obligation should be towards their ethical codes, ^17,41 that is, to put the patient first, care for the injured and reduce suffering, while at the same time being a part of a military organisation means being expected to facilitate and support killing. ⁴² In extreme situations, healthcare personnel were ordered to participate in torture which demand dual loyalties, ^43,44 which is clearly against humanitarian law, ethical codes and human rights ⁴⁵ (Article 5). However, in the everyday ethical situations described in our studies, some LMPs willingly undertook the military duties required from them. ¹⁴ Group pressure or group identification and loyalty rather than formal requirements seem to constitute the explanation for this behavior. ⁴⁶ This is in line with some earlier research, for example, Gross ³⁶ who wrote that healthcare personnel sometimes had to put their own ethics aside and carry out combat duties. Rubenstein ⁴⁷ contested this however, claiming that humanitarian law and human rights laws and ethical codes ^{16,17,31,39,45,48} should guide healthcare personnel in all decisions. Kottow ⁷ argued somewhat sceptically that times have changed and that healthcare ethics in recent years seem to have become estranged from honouring principles like ‘do no harm’.

Reasons for dual loyalty may be that LMPs did not receive enough training and guidance to identify situations where dual loyalties violated human rights, and also where they risked setting their own ethics aside. Education in ethical codes and humanitarian law may be a powerful tool for reflection and resilience when faced with everyday ethical problems and may serve to prepare healthcare personnel and also their military chiefs and all the other soldiers in the unit. Integrating ethics and humanitarian law in training in the military context may also empower healthcare personnel to be more aware of what kinds of military duties they may and may not perform, if any. ⁴⁹

It is apparent that the existing humanitarian law and customary law as well as ethical codes do not explicitly advise health professionals how to evaluate humanitarian contra military claims, especially when it comes to more everyday ethical problems. Nor do they give explicit advice on how to determine when the protection of patients’ human rights requires health personnel to put state interests aside.

Even if humanitarian law has been revised and become more adjusted to our times when most armed conflicts are non-international, that is, customary law, ^19,34 it is perhaps once again time for a new, updated humanitarian law to be complemented with regulations concerning the kinds of everyday ethical problems we have found. ⁵⁰ If not a revision, then a suggestion may perhaps be to identify the exceptions to this law where LMPs tend to experience dual loyalties, which is seen in this study. Another suggestion may be to tighten up the ethical codes and stipulate precisely which military duties healthcare personnel may perform when employed in the military despite being exclusively assigned to healthcare.

Although healthcare personnel do not perform military duties that could be interpreted as hostile, there are reasons to be explicit about which military duties their own ethics and humanitarian law allow them to undertake. Military organisations tend to be explicit, but here it seems as if LMPs choose to undertake military duties.

One suggestion for further research is to investigate how military chiefs view their LMPs executing combat duties and how they view the ethical problems discussed here. Since LMPs have only fragmentary knowledge of humanitarian law, another area of research is to investigate how military chiefs are educated in humanitarian law and the relationship between their training and knowledge and the training and knowledge of subordinates. A third area of research is whether there are parallel situations of dual loyalties in civilian healthcare which can help shed light over dual loyalties in military healthcare and vice versa.

Conclusion

The study shows that LMPs reason differently in relation to potential dual loyalty situations. Some provide reason from abstaining doing military tasks referring to competence, role, humanitarian law and ethical codes and lack of resources. However, others provide reasons for doing military tasks with or without restrictions, referring to views on humanitarian law, competence, lack of resources or demands or aspects in the situation. To some extent, the LMPs seem to be ignorant about to what extent humanitarian law applies, but there is also lack of explicit guidance in relation to these situations and some room for interpretation in humanitarian law. Even if the duality in LMPs is understandable, it is problematic that they do interpret their obligations in the combat zone differently, and there is reason to further explore how a more consistent approach could be achieved, for examples by further training and reflection on ethical issues before rotation to combat zone.

Methodological considerations

Credibility was supported by the first and third authors being involved in the analysis process of data and using quotations from participants, and also by ensuring that the findings represent the data analysed. ⁵¹ Dependability was supported using the same topic guide and interview questions with all the participants. Confirmability was supported by all authors being involved in the process of reading the condensed codes and naming the categories. ⁵¹ Confidence in the interviewer (first author) and third author was established before the interviews, since they met the participants during the education session. The first author has served in the same context as some of the healthcare personnel, although she was stationed as a military chaplain since she is a priest in the Lutheran Church of Sweden. Due to this, it was important to emphasise to interviewees that this was an interview for a study and not a pastoral counselling, and to maintain reflexivity. The results may be transferable in other care situations where dual loyalty is experienced. ⁵² If any the participant had so wished, the interview would have been terminated without any questions being asked. This did not happen however.