All right , welcome back everyone for our second session titled Military Medical Ethics in the New era of symmetrical conflict presented by Doctor Megan Applewhite . Doctor James Giordano . Mr Joshua Girton , retired army Colonel Frederick Lowe and Mr Joseph , a procaccini junior . Doctor Megan Applewhite is an Associate professor of Surgery and associate director of the mclean Center for Clinical Medical Ethics at the University of Chicago in Chicago , Illinois . She is also a consultant bioethicist for the Department of Defense Med Medical Ethics Center . Doctor James Giordano is a Pellegrino Center professor of Neurology and biochemistry chief of the neuroethics studies program , Chair of the subprogram in Military Medical Ethics and co-director of the program in brain science and global law and policy at Georgetown University Medical Center in Washington DC . He also serves as a senior bioethicist for the Department of Defense Medical Ethics Center and Adjunct Professor of Psychiatry at the Uniformed Services University of Health Sciences . Mr Joshua Girton is the Deputy Director of the Department of Defense Medical Ethics Center and an Assistant professor at Uniformed Services University of the Health Sciences . Mr Girton also serves as an adjunct professor of law at the US Naval Academy , retired army Colonel Frederick C Lowe is the Director of the Department of Defense Medical Ethics Center at Uniformed Services University of the Health Sciences . Mr Joseph A procaccini junior is the legal advisor of the Department of Defense Medical Ethics Center and an adjunct assistant professor for the Department of Preventive Medicine and Biostatistics at the Uniformed Services . University of the Health Sciences . Please welcome our second session presenters . Welcome everyone . My name is Doctor James Giordano . I am Rino Center professor in the Department of Neurology and Biochemistry at Georgetown University and also serve as one of the senior bioethicists at the Defense Medical Ethics Center of the Uniformed Services , University of Health Sciences in Bethesda Maryland . The presentation here today will be conducted by Doctor Al White . Doctor Lau and uh Mr Ucci . All of our speakers have no relevant financial or non-financial relationships to the close as relate to the content of the activity . The views that are expressed in this presentation are those of the presenters and do not necessarily reflect the official policy positions or perspectives of the Department of Defense Uniformed Services , University of Health Sciences nor the United States government . This continuing education activity is managed and accredited by the Defense Health Agency J seven Continuing Education program . That's ce po DH AJ seven , ce po and all accrediting organizations do not support or endorse any product or service mentioned in this presentation or activity as well . The activity planners and reviews have no relevant financial or non-financial interest disc closed and commercial support was not received or solicited for this presentation . The activities in next slide , please , you know , we'll be talking about a couple of key questions . I think they are not necessarily viable as polling questions per se but more as thought stimulating questions . As we go through our presenters lectures today , consider each and all of these not only singularly but in total , in some . How do they relate , how do the issues that we are posing to you pose viable issues for your reflection , your engagement and your action . Next slide , please . For example , if the Geneva Conventions are only being followed by select groups , should there be some measure of recourse for the organizations who then violate them ? Overwhelmingly ? Your responses are yes . And although that's easy to say and certainly easy to type three simple letters , the question then becomes , what are the mechanisms for such recourse ? And if such recourse involves some type of retributive justice , what does that obtain entail ? And how do we go about doing that on the ever changing global stage ? Next slide please . That being the case , I think one of the precipitating factors that relates to Geneva conventions and the conduct of not only the battle scape itself but military medicine is how the scope and conduct of current and future conflicts has changed . And so we can pose this as a yes or no question the obvious , of course , being answered , how has the scope changed ? Has it changed ? And do you believe that the scope and conduct of current and future conflict will not only affect the battle scape , but will also affect the focus scope and terror of military medicine and the ethics that undergird it a question mark to a question . Let me see if I can clarify the question . In other words , if what we're looking at is the new dimensions of the 21st century , both battlefield and the horizon of probability , possibility and potentiality of what can occur on the battle scape of the near future . Do you believe that this will in fact change the scope and conduct of military medicine and its ethics perhaps too broad a question . But clearly , I think a broad question to consider and to engage given the multi dimensionality of the various developments that are occurring in science , technology , sociology , politics and the relatively delicate balances of power , capability and leverage that are occurring cont temporarily , yes . And this would be specific to military contexts . Let's go to the next question , please . Excellent . Given the fact that there are extent and reign principles , guidelines and signatory treaties , the question then becomes really , do you think that and or why should opposing forces continue to follow these ethical and legal guidelines if they actually serve to give the unethical enemy something of a tactical advantage to be sure many of the answers . Talk about leading from the front , fighting for right and freedom . Yet keeping our honor , clean ethics , morals laws . And if we consider ethics to be a systematic approach to the development and articulation of what individuals and groups consider to be morality , what they view as good , bad , right or wrong , acceptable , unacceptable . And the legal system then provides if you will a structure for some form of retribution within the scope of conduct of consensus . Well , then an important consideration here would be to paraphrase the philosophical musings of Alistair mcintyre at the University of Notre Dame . What good ? Whose morals ? What set of ethics ? What laws when ? In fact , much of the current legal landscape inclusive of that of the rules of engagement , laws on conflict and the international stage are being directly affected by our international peer competitors , whom potential adversaries , the questions certainly give rise to thought and as you can see from your answers , give rise to something of both consensus and dissensus and the answers and perspectives that they yield and that they stimulate . Next slide please . Next slide please . That said the learning objectives for this presentation are threefold throughout and at the conclusion of the activity , we hope that you'll be able to describe the Geneva Convention in Law of War and standards during conflict . Certainly that falls into the pros of our class speaker , Mr Proo , explain how laws and rules have been and are advocated for self serving and practicing predatory purposes where ends may justify the means a utilitarian ethic . If you will not only on the battlefield , but perhaps also as it relates to the scope and conduct of military medicine . And what is the unique role and mission of the defense , medical ethics Center and medical ethics in general . And how may it influence standardized or standard ethical practices , both the United States and its international allies and perhaps more broadly as regards to the overall conduct of the battles in the 21st century . Next slide please , if we consider the tactics that have been used in recent years by terrorists and even nation states that violate these quote standards of war . Once again , why should any opposing force follow these to be able to orient what we're talking about those sort of larger contexts , both approximately and more distantly . What we'll be talking about . First is the broadening scope of clinical medical ethics in the civilian setting . To be sure many of the issues that arise within medical context in the civilian world are also directly applicable to military context . But in some cases , there are aspects of uniquity where things that occur within the military are indeed unique to the military and vice versa . Yet still that level of intersection and particularly in an open society such as we have in the United States and among our democratic allies as such that the military serves the polis and therefore some level of transparency to the conduct of not only combat and battle but also of military medicine is axiomatic to that obligatory responsibility . But as we enter this new symmetrical battle space , it may very well be that changing context of not only military activity , but military medical ethics are such that those ethics need to be adapted to the new battles shape as science and technology advance . Perhaps there are capabilities even in those capabilities that involve the absence of human engagement in the direct interface of battle , the use of drones and a variety of other unmanned systems . Inclusive of those who use machine learning and A I may change that scope and tenor but may also lead to different forms of injury that certainly prompt changes in the conduct of military medicine and perhaps the ethics that need to go along with it to guide and to govern and in governing . We then engage military medical ethics within this era of symmetrical conflict with regard to ethical and legal perspectives . Next slide , please . So indeed , what we'll talk about then is this broadening scope of clinical medical ethics in both the civilian setting and its applicability to military medical ethics in a world of ever more sophisticated and capable science and technology . The scope tenor and actual conduct of warfare is poised to increasingly become symmetrical , scientifically symmetrical , technologically symmetrical and yet what we realize is with that symmetry of scientific and capability and technological capability may also come exercise of our peer competitors and adversaries cultural distinctions which may obtain and entail ethical distinctions as well inclusive of the way these cultures who we now meet on the new battles scale , whether that be actual or virtual , engage the conduct of medicine and medical personnel . Indeed , key factors of scientific and technological capability that affect the battlefield also influence the effectiveness , efficiency and ethics of military medicine on this evolving current and future battles shape across horizons of the near term future . What is very probable , the intermediate term future , what becomes possible ? And as we look beyond the 15 to 30 year point to that , which is potential to reiterate many of those issues spawned by science and technology or constituent to civilian medical practice , its ethics and its interface with military context to address that interface specifically and to situate it within the broader conduct of military medicine in this new symmetrical battle scape is our first speaker , Professor Megan Applewhite , senior ethics consultant of DEC and Associate professor of Surgery and Associate Director of the mclean Center of Clinical Ethics at the University of Chicago . Doctor Applewhite over you . Thank you , Doctor Giordano . Uh It's a pleasure to talk to you all this morning . I'm just gonna sort of set up the , the game for the rest of my group here . Um And we're gonna talk about um sort of where do we focus our attention in the world of clinical ethics . Um We have uh traditionally sort of had a very conservative view of what medical ethics is and what kind of the very particular relationships are between the patient and the physician and the other caretakers . Um But I guess you'll see as we go through these next few slides , um kind of an expanding way , we have increasing responsibilities , not only to our patients but to the communities around them . Um There are animated bullets here , so if you could just go through them , sort of as I speak . Thanks so much . Um So this is slide 16 here . Um So as our scope defines what we see as our ethical responsibilities , uh we have to sort of figure out what is our scope . So as we shift our point of view , our ethical responsibilities similarly shift and brought in . Um and in the civilian setting , they've sort of shifted from the bedside of the patient to the bedside of an entire community . Our responsibilities shift from an individual person to the entire community that surrounds that person . Next slide , please . So the traditional view of clinical ethics is , is much like this painting , right ? We we see this um doctor and patient in a very intimate relationship . In so far as um they share decision making between the two of them . They're largely isolated from the outside world . We are focused on the relationship that exists between the two of them , the disease state of the patient and the doctor who is taking care of him or her and how they can um best intervene to help that singular individual person . Exactly . So you can see the scope broadening a little bit when you consider the bigger picture of the patient and doctor within say a family context . So here in the painting , you see a doctor taking care of a sick child , you see the upset parents in the background . And we realized pretty closely that this is not specifically the patient and doctor Dia that that we traditionally view as clinical ethics , autonomy , beneficence , not doing um ill by the patient , no maleficent . And really the one on one relationship expands , our scope expands to include the patient and their family or those close to them . Next slide please . And then you think that um health care involves many other caregivers as well . So not only are there more players in the game on the patient side , but there are more players in the game on the provider side , you know , we , we need support , we need one another . We all serve really important roles on the teams that take good care of patients . We need nurses , advanced practice providers , therapists , social workers , technicians , and medical assistants . So you see the scope of what our obligation is in clinical medical ethics , broadening and broadening . Next slide , please . So here we are on slide number 20 . Um and this has really become much more obvious in the in the past few years . That health care occurs within a health system , within a society , right ? And so we think about , um you know , individual hospitals previously or people being able to hang shingles and just having independent practices and this is becoming less and less common . We function um at a very high level now with many um uh sort of systematic constraints , um if you could forward , please . Yep , our clinical interactions can't be isolated from the broader system in which they occur . And we're realizing this more and more daily that we cannot assume a narrow view of clinical ethics that ignores the broad appreciation of public health and how it impacts individual patients no longer . Is it just the very patient that's sitting in front of us that we have an obligation to ? And this includes scarce resource allocation as the civilian population really witnessed to an extreme during the COVID pandemic , military medical docs have to deal with scarce resource allocation all the time . And so thinking on the bigger level of um uh who we actually are obligated to care for . And it's not just the person in front of us . It's not just that very , very narrow view , the traditional view of clinical ethics with the doctor and the patient . In fact , it's the , it's within a society , it's within a community next side , please . So this , this comes to the increase in complexity um that we'll talk about for the remainder of the talk in military medical ethics . So even in civilian medical care , there's a very broad scope of ethical responsibilities that providers have to navigate daily disparities in access and health care outcomes are evident . They are proven and they do need to be mitigated and introducing challenges encountered in combat heads . Further layers of responsibility and truly , as we state in the first slide broadens the scope of who our ethical responsibility is toward and it becomes very complicated . So we have to think about resource allocation . We have to think of weighing the needs of the mission with the needs of the patient . And this isn't always clear , it can get very tangled . So we'll talk about the Geneva Conventions for the establishment of international legal standards for humanitarian treatment and war . The attempt to protect those caring for the wounded . Next slide , please . So , uh yep , you can go ahead and forward through . So this was most commonly known to have been created in uh 1949 1949 in the aftermath of World war two . But it was actually adopted in its initial form in 18 64 . It was created to provide specific rules to safeguard combatants or members of the armed forces who are wounded , sick or shipwrecked prisoners of war , civilians , as well as medical personnel , chaplains and civilian support workers of the military . It is in fact the foundation of modern international humanitarian law and now listed below we'll go through . Um And you can just forward through . So all four of the conventions are filled in , that would be great . Um So we'll focus here for the rest of our talk on convention four . which as you see , the evolution over time has , um , the conventions have broadened to include more and more safeguard , um , combatants and um , members of the armed forces as well as those civilians which are addressed in convention four . the civilians are afforded the same protection from inhumane treatment and attack afforded to sick and wounded soldiers . This also prohibits attack on civilian hospitals and medical transports . And it discusses how occupiers are to treat an occupied populace . Next slide , please . So I mean , you can forward through the bullets on this one too . I appreciate it . Um So here we are on slide 23 . Um just looking at the emblems under International Humanitarian Law and my , my partners are gonna discuss these in a little bit more detail following , but just to introduce something that I'm sure you're all familiar with . And that is the symbol of a red cross on a white background , red crescent and red crystal . And these serve to identify and protect medical relief workers , military and civilian medical facilities , mobile units and hospital ships during armed conflict . So the idea that you would have an emblem placed on the side of a vehicle on the side of a facility or on someone's um uh on their protective medical gear the , the idea that having this , this , this symbol that would effectively protect them from harm is aspirational . It's an ideal . And what we'll talk about is that there are tactical realities um that they're different , they're different circumstances that do not always align with the aspirational . And this presents a significant challenge when groups may not respect the agreed upon rules of conduct . So that's what we'll talk about today . Um Next slide , please . I thank you for your time . Thank you , Doctor Dr made some interesting points about the constructs of military medicine and the construct of civilian medicine , which then raises an age old question one that was first posed by the Roman philosopher K in the first century BCE . You see in Pali and in below , which translates roughly to as it is in civilian peace . Is it such also in war to directly address the questions of what this new symmetrical battle space may yield and how that may affect the changing context of both military activities and and in its ethics . Our next speaker is Colonel Fred Lau . Doctor Lau is the director of the Griffith Institute and the Director of the Department of Medical Ethics at , at the Uniformed Services of Health Sciences . I hand the discussion over to Doctor Lau , sir , to you , Doctor Arnold . Thank you very much and welcome to the group this morning . Thank you for joining us for this important discussion . Um As Jim mentioned , I'm the director of the Department of Defense Medical Ethics Center at the Uniformed Services University . And to begin , I will uh give a description of exactly what our , what we call the D MC is . Its origin begins with the early phases of the war in Iraq and Afghanistan . And the issues dealing with detainees at Guantanamo . There were issues at that time that um were recognized as problematic , yet there was no entity within the Department of Defense to assist and deal with individuals , health care professionals , et cetera who were having and facing challenges . So in 2017 , the Department of Defense issued an instruction that the pre uniformed services University would create an entity which would focus on medical ethics within the health care force for the Department of Defense . So the Department of Defense Medical Ethics Center at E I was created , it's a Department of Defense Center which reports to the president to the Assistant Secretary of Defense for Health Affairs . Its mission has three components . First , it is to collate and collect appropriate medical , ethical material and ideas for the military health care force . Second , it is to teach these uh elements to the health care force and to the wider military . And finally , it was tasked to develop a portal whereby health care professionals , physicians , military and civilian nurses , military and civilian medics , all those involved in health care in the Department of Defense , which is a force of approximately 100,000 people who face medical ethical challenges could reach an entity which would provide some assistance to date . We've handled over 100 and 20 cases from the Department of Defense Health Care Force and have worked closely with our health care partners to reach um uh equitable solutions . We do not send directives or tell individuals what they should or should not do . We are not authorized nor do we have prescriptive authority . What we typically send back once we acquire information from the field are questions that will allow the individuals at the site to deal with the issues . We have a staff of two surgeons , two attorneys who have military experience , a senior nurse with extensive military experience , an experienced administrative officer and a scientist , ethics ethicist at Georgetown . So with that working group , we have successfully dealt with challenges to include dealing and writing the bioethics guide for the Department of Defense , uh dealing with COVID . We have a lecture series of available on our website in the field of medical ethics . And in the last year , we developed an app for phone use , um which is 80% not internet dependent . So it can be taken to remote remote locations and provides some ethical background and support for individuals . We also came about because I think the Department of Defense Health Care Force recognizes the rapidly changing medical environment . Um In my experience , years ago , medical ethics was relatively stable because medicine didn't change as rapidly yet in the last 2 to 3 years , we have seen extensive changes uh both in civilian sector and in the military sector which affects uh the military , ethical con environment for the military health care professionals . Two that can , that uh came up in the last year , one had to do with the avail availability or non availability of abortion assistance uh to our military health care providers depending upon where they're stationed . Additionally , we have artificial intelligence and now chat GP T which is entering the ethical arena and will have an enormous influence on uh things as we go forward . Next slide , please . So as our previous speakers had talked about , there are questions that involve ethics when we involve symmetrical conf conflict . Um The wars in Iraq and Afghanistan were uh very , very different as far as what is anticipated for the future and the influence will be primarily based on logistics . If one imagines an environment in which one has all the resources one needs , then their ethical challenges are diminished . There is adequate blood , adequate physicians , adequate space , adequate transportation , the battlefields of the future will have severe logistical constraints in the form of personnel , time , availability of blood . So the military and the medical ethic , military health care professionals need to be aware of these constraints and be ready for change . Next slide please , as mentioned , triage for care will be limited and a key element uh will be treatment of local nationals and enemy combatants in a resource constrained environment . This is where medical ethics in the civilian life differs from medical ethics in the military and that the military uh physicians deal with the mission requirements . It may be uh important for the mission to move the health care facilities away from where they're needed . And the physicians and health care professionals in the dod will have to abandon local nationals who may need their hair , their care in order to support the military needs . Next line , please . Next one , please . Um Finally , we can , I would conclude with remarks about our international partners . The discussion to date has been um involved um with strictly US forces . However , the Geneva Convention is was signed by many nations and in the NATO environment . Uh we work with our NATO partners who interestingly have different views on some of these topics about uh whether me medical professionals should wear or not wear insignia and from a practical matter on the battlefield in Ukraine , military medical personnel are being targeted by the enemy force . So it is to their disadvantage , to wear protective um rather identifying items . But the Geneva Conventions for protection of the health care professional requires that individuals identify themselves broadly as health care professionals and are limited in their participation in offensive operations . They're also limited as far as what weapons they can carry . And this um is an issue which is currently under discussion between the United States and our NATO partners developing a new um medical ethics guideline for the battlefield for our military professionals . I'll conclude my remarks , remarks at this time in order to save time , I'm available for questions . Thank you very much for your attention back to you . Doctor Giordano . Thanks very much , Doctor LA as doctor illustrated , clearly the changes that are occurring globally in science and technology and in the sociology of intercultural and international relations As such that this may prompt for distinctions on the conduct of the battlefield . And as such may affect the conduct of military medicine and the ethics that guide government support it . Well , the adage is that good ethics may make for good laws . But the truth of the issue is that ethics provides systems of moral judgment and action within the scope and tenor of whatever the laws may be . And the entire edifice of contemporary clinical ethics and research , bioethics is built upon judgments at Nuremberg during the doctor's trials of 1946 and 1947 . The working argument in the defense was that the actions conducted in military medicine under the Hitler regime were in fact in accordance with the scope of the law . So as we approach this new battle scape , the question is where do ethics and laws align tacitly ? This raises questions of if and to what extent ethics and laws are aligned or dissonant on this battle scape such things as the law on conflict and rules of engagement , whether or not these comport or contrast with the ethics of military engagement and the ethics of military medicine to address these questions in their provocative and often contentious directions and trajectories . This is our final speaker , Professor Joseph Proo . Professor Proo . Over to you , sir . Thanks , Professor Giordano . Uh Hello , everybody . Uh I am the dreaded lawyer on this team . Uh You've already heard from my colleagues speaking very eloquently about the theories of ethics and you might expect the , the lawyer of course to , to obfuscate , to confuse , to befuddle . Uh after such an eloquent group of presentations , uh I can assure you this morning that you are correct . Uh I , I will attempt to do so . Uh I want to start of course , by thanking the DH AJ seven staff for their incredible support with this . Uh Although I must say those of you that watched the earlier presentation on uh dentistry . Uh I could swear that four of those challenging photos of people with bad teeth were my own photos . But that's for another day . Uh Let me go to the next slide . If I can please . You've heard Doctor Apple , I talk about some of the principles of medical ethics , some that are very , very near and dear to most of the providers , at least on this uh in the audience here . You have autonomy , of course , which is right of self and this is usually found in the form of informed consent in our medical facilities . And of course , even in the a or uh sometimes in competition with this , I'd suggest to you is the concept of beneficence from the Latin bene fare to make or to do well . And I say this is in conflict quite often because what you as a provider may believe is in the best interest of the patient may not necessarily be what the patient believes is in the best interests of the patient . You know , positive you will uh a patient that comes in with blood gushing out of their stomach and they'll be dead in two minutes without a transfusion . But they look up at you and they say that they're Jehovah's witness and to get a transfusion is anathema to their faith and they'll be denied life everlasting . And if they're a competent adult , you may have to stand and watch them die because of their autonomous right to do so . Even though your beneficence would say I need to save this person , hold that in the back of your module because we may see this come back in a few minutes , non maleficence . It talks about kind of the negative opposite which is doing no harm premium , no n right ? And , and here again , providers find dilemmas here because quite often in not wanting to do harm . You wonder sometimes particularly say with research in order to try to find a good end . Uh How do you find that without experimenting and in the course of experimentation may perhaps cause some harm . Is that harm enough for you to say , I don't want to participate justice , not the legal definition , but the ethical definition of treating people equally . This becomes a tremendous dilemma , particularly in a combat environment , particularly when you're being asked to care for enemy uh soldiers uh or even civilian population that may be resistant to the kind of change that or the care that you have . But the one that probably is the most unique and confusing here , which is unique really to military medicine . Is this other ball in the juggling act ? And that is the military mission because the mission as you wearing uniforms know supersedes here . And sometimes if that mission accomplishment conflicts with the other four elements of ethics , where does that leave you from your medical or health care training as to doing the right thing ? And that really does become the awkwardness of this discussion positive you will . Doctor Applewhite mentioned briefly the dilemmas with COVID . I'd suggest that this was probably the first time in recent history where the civilian population realized that there was something more than simply caring for a patient because they had to face reverse triaging here . Something the military is used to in a combat environment where suddenly as opposed to treating the sickest person in the emergency room . Now , now because of allocation of scarce resources , they had to do essentially a survival of the fittest type of mentality , where do the ventilators work best , who can survive the best ? And this is something that is new to most of the civilian population . Next slide , if we could please . So , Doctor Applewhite very , very eloquently gave a good summary of the law of armed conflict . And again , based on the 1945 Geneva convention and approved agenda . And of course , it talks about the idea of military necessity to fight . And again , it talks about discrimination and distinction that you want to protect innocent civilians . But again , the the devil's advocate lawyer is going to say , look at the world situation where we see combat going on right now . How do we even know who is innocent and who is not innocent , particularly in environments where there are terrorist activities going on humanity and unnecessary suffering . The whole idea that here you want to have troops that are trusted . But again , we hear reports in some of the battles around the world where the civilian population is terrified about troops coming in because of what they may do to the civilian population . And then the issue of proportionality use a decisive force and you notice collateral loss of life and damage should not be excessive in relation to the military advantage gained . But what does that mean ? How many civilian lives are you allowed to take in order to accomplish a military mission ? This is very awkward . Decisive force is not indiscriminate force and again , overkill may become an awkward issue . Here . Next slide , if we could . So if we talk about lawful targets , obviously , combatant personnel are gonna be lawful to targets because they're the ones that are involved in the fighting . Also military objectives , objects that contribute to the enemy's war , fighting , sustaining effort and whose destruction would constitute a definite military advantage . But who defines that ? So our electrical outlet systems or , or , or the the water supplies , if they help to accomplish a mission objective of thwarting the opposite side from being able to sustain itself . Is that a reasonable military objective when you're actually starving the civilian population or freezing them ? At the same time , how do you do this when it includes both military and economic targets ? This becomes more muddled these days . Unfortunately , next slide as far as unlawful targets , the non combatants and here , as I noted earlier , it's sometimes hard to distinguish particularly in environments where people aren't wearing uniforms . We're used to that kind of World War Two movie situation where every boy , everybody wore a distinct uniform and it was easy to know who was the enemy , who was an ally . And that's not so clear anymore . Civilian facilities not used for the war effort should be unlawful targets . But again , how do we know this ? What happens if people of , of enemy uh troops escape into a church or synagogue or mosque and use that to be able to hide themselves and even fire from there . Does that suddenly change the whole situation here ? And again , you see , on the bottom bullet over there , what if occupied and used by combatants ? I wouldn't even throw out the possibility of you're driving an ambulance and you should be protected under those circumstances because you clearly have medical marking on the side of the ambulance . And as you're driving along , you happen to see one of your soldiers who got uh waylaid from uh his or her unit and they're very tired and they're trying to get back to the headquarters and you pull over and say , hey , can I give you a lift ? And when they get inside the ambulance , they're a combatant . Does that change the status of your ambulance ? Because you're now supporting a combatant as opposed to specifically working with people that are injured ? These are the awkward questions here that could change the whole scope of who is susceptible to targeting . Next slide if we could . So as far as the non combatant is concerned , they're supposed to be a protective status . They cannot be the primary object of attack . But again , as I noted with that ambulance example , they may lose their status if they contribute to the war effort or engage in hostilities . Next slide . Now , Doctor Giordano used some eloquent Latin and because of uh being a classics major myself , I think if you leave this session knowing nothing more than having learned Latin you've done an awful lot for yourselves . But Cicero , the same author that Doctor Giordano referenced also said Inter Inter Arm an which is during war , the laws are silent and this is the sad reality because even though we set up all sorts of rules and regulations about how we're supposed to govern ourselves , ethically , Allah the Geneva Convention , then you'll notice that during war time , the mission , the ultimate end , the utilitarian end that Doctor Giordano referenced seems to supersede all of these things . I would even suggest to you another Latin writer , Avid who comes out and says Exitus OTA Probo , which says the end justifies the means , one of the initial slides that were in this presentation today and this becomes the sad sometimes reality that if the means of getting there really cause harm , should we not be doing it ? Should we be acting as we'll see ? Deontological or should we be worrying only about the ultimate end no matter how , what it takes to get there ? I'd also reference an Italian writer . Most of you are familiar with the name Machiavelli . And in his book in chapter 15 , he actually notes a man who wishes to live up to his professions of virtue in every circumstance soon meets his destruction among so many who are evil . And he goes on to say that it is necessary for a prince wishing to maintain his position , to know how to do wrong and to make use of it or not make use of it according to necessity . So again , think about some of the world leaders through history or even today that may be violating what we believe are appropriate ethical principles of good in order to achieve their end , even if it does take blowing up a nuclear power plant , contaminating water supply , sending chemical or biological weapons into an environment in their eyes or even shooting at medical providers , If they believe that that sends a message that it decreases the morale of the other side because they don't have enough folks to offer medical care . That app actually helps them from a mission standpoint . They're all looking at it from a very utilitarian standpoint . Now , Doctor Giordani used the term good . But again , as he also said , who defines good ? It's interesting . The Oxford language dictionary has two definitions . One which is the one that we in the medical world in a normal situation would think of that , which is morally right , righteousness is what it says . But the second definition says a benefit or advantage to someone or something . So again , who defines what that advantage or benefit is ? Now , if the Japanese had won the war in World War Two , do you think members of the American military or even the , the administration would have been hung because of dropping an atomic bomb on Hiroshima and Nagasaki would the British have been put in prison for bombing Dresden in World War two where tens of thousands of civilian people were killed under those circumstances . Again , it's all through whose eyes one is looking at in these situations . Next slide , if we could . So again , Doctor Applewhite noticed these noted these protective emblems here . But what value are they if they suddenly become targets and and weapons of opportunity really for the opposing side in order to decrease morale in order to wipe out those elements that are helping sustain the other side . Next slide please . And again , you know , you can see from this photo over here , this is the sad reality of what's happening . So why should we maintain , as we noted at the beginning , ethical standards . When the opposition does not , it's very , very frustrating that you try to maintain what we believe are appropriate humane ethical standards . And yet we don't get that in receipt from the other side that they will use other methods to try to overcome that and take advantage of our effort to be ethical and it creates an increased risk . Now it goes back to the point I just made are correct laws and ethical conduct then determined by the victor . In some cases , it may be . Yes . So when are orders not legitimate ? Next slide , if we could . So we go back to this term , the mission and the mission quite often conflicts with individual care decisions . We have the quandary of superseding goals . So it it conflicts with respecting patient autonomy and informed consent posit the following if you will . There's AAA soldier who unfortunately steps on an IED overseas is blown up and is rushed to a hospital tent . This poor soldier has lost both of his legs , one arm . He's now blinded in one eye and he's got a gaping hole in his stomach where blood is coming out . The surgeon looks at him and says , soldier calm down here . Hold on with me over here because the soldier incredibly is cogent and awake and he says , I , I can get you sewn up and I can stabilize you . And we're gonna get you on a helicopter and get you back to Germany and they're gonna do incredible work and you've probably seen all of this stuff that can be done now at Walter Reed , at the intrepid all of this to make things good for you . And this 21 year old soldier looks down at his body and he says to this doctor , doctor , please , uh my girlfriend just left me . My parents are elderly and we're poor . I just know that when I get home after everybody claps at the hospital when I come through on my wheelchair and I go back to the va hospital and back to my home in the middle of the country who's gonna really care for me . Look at me , please , please let me go . Now in a civilian environment , more than likely if this is a competent adult would you respect their autonomy under the circumstances . But here supposing this particular private speaks three dialects that are critical to intelligence gathering in that part of the a or , or what's the message someone may say that you're sending if you let him die to all the other soldiers about the need to protect them and to make them better . And even though it may be his desire to die , someone else in a similar situation might not . So again , does the mission , should the mission supersede again , impact on combat ? Look at the morale , the safety , the success of doing this . And again , we go back to that non maleficence , do no harm . Now , the double effect a higher good , if you're gonna be causing harm to an individual , are you doing it for something better in the process ? And this goes down to our last point here of allocation of resources and the concept of necessity . Next slide , if we could . It's interesting during World War Two , Henry Beecher uh wrote a book , researching the individual and cited an interesting case in World War Two about a shortage of penicillin in a particular area . When they arrived in North Africa . You see the beds were overflowing with wounded men . Many had been wounded in battle , many also had been wounded in Brussels , which would get the penicillin by all . It is just it should go to the heroes who had risked their lives who were still in jeopardy . And some of whom were dying , they did not receive it nor should they have . It was given to those infected in the brothels before indignation takes over . Let's examine this . First beer noticed there were desperate shortages of manpower on the front . Second , those with broken bodies and broken bones would not swiftly restore to the battle line even with penicillin . Whereas those with VD on being treated with penicillin would in a matter of days free the beds they were occupying and return to the front . And no one will catch osteomed until he's cured a reservoir infection . In terms of customary morality , a great injustice was done . But in view of the circumstances , I believe that the course chosen was the proper one . This becomes arguably the doctrine of necessity and again , somewhat unique to a military combat environment where something may again be anathema to you in a civilian environment . It may be something that you have to do to accomplish the mission that live because so we go down to these two theories of ethics and you've heard the concept utilitarianism be used . And again , again , that the end justifies the means , but we hope that the action is right . If it leads to the greatest possible good , you will climb any mountain , you will swim through any ocean . Nothing will stop you as far as trying to save your patient or make that patient better . But sometimes it's conflicted with this other concept of deontology . Where here it's a means issue . Yes , I want to get to that good end . But if getting to that good end causes some kind of moral qualm in me as good as the end is . Do I really wanna go there ? Do I wanna go ahead and bomb civilian targets in order to decrease morale in that particular environment to end the war sooner ? Or should I have some other methods I could try to use instead . What about someone who you have as a patient who is dying and is in pain ? And you'd love to give them an overdose of morphine to allow them to achieve an a a good death . But here you don't because of the law but also the means of doing that may make you a murderer . So again , you've got this conflict here . Next slide . If we could , I would also note to you that in military medicine and military health care , I suggest that you have constant conflicts between your personal ethic versus your professional ethic versus your military and organizational ethic . So posit , for example , you happen to have a neighbor that lives next door that just moved in . And when you're looking at your window , you're seeing that neighbor doing things , acting , saying things that would make you want to pick up the phone and call the police . But then you go to medical school and you get your degree and you happen to specialize in psychiatry and you hang a shingle out . And incredibly , the first patient that comes into your office is your next door neighbor who sits down and opens up to you and essentially confirms all of the suspicions you had that made you want to call the police . But can you call the police now ? Probably not why ? Because of the physician patient privilege ? But then you join the military and now the line commander comes up to you and says , I'm concerned we're about to be deployed . And in my unit , Pro Cocina has been acting a little bit odd more than normal and I'm really concerned about his fitness for duty . I want you to tell me if he's got some real problems here . Now , your professional ethic might say , I'm not telling you a thing because of the physician patient privilege . But organizationally , you tell the commander because the mission , the fitness for duty supersedes again , something not really found in the civilian community . Next slide , if we could . So the key takeaways from all of the presentations here might include the following when you'd have to make decisions either here or overseas in a combat environment . Try to be objective . Objectivity also implies consistency and fairness . Try to balance the mission needs with patient needs as much as possible . But knowing that in a military situation , in a combat situation , the mission may have to supersede but in doing so never abandon ethical principles to the point where you simply cannot , cannot as a human being accomplish something that you're being asked to do because it is so heinous communication , communication , obviously , with your colleagues , with patients , enemy patients , civilian patients , even the dreaded lawyers that are there education continue to learn on the this complex never lose your compassion for your patients . Even in a combat environment , try to maintain your humanity . But there but for the grace of God goes your spouse or your child or your brother and how would you want them to be treated ? Also act with a sense of integrity because you'll be able to sleep a heck of a lot better at night . And always remember self-care because in a combat environment , sometimes the person that's most often forgotten is the provider who really has to be watched to make sure they can maintain themselves . Next slide back to you , Doctor Giordano . Thank you , Professor Pocono in the words of the well-known orator and to keep the Latin theme consistent , the well-known orator is and the words are I , I think we know Suey Pork was better by his English name . Porky Pig again . Yes , that's all folks . So we open the floor for questions over to you . Uh Thank you so much for that fabulous presentation . I think all of us learned quite a lot and have a lot to ponder on . So for our audience , it's now time to uh post your questions in the chat box . If you have not yet submitted those . And uh for this session , obviously , we'll do our best to respond to as many questions as time permits . We actually have a bit of time to um discuss here . So I appreciate you all submitting any questions that you have . So give us a moment . Let me just scan through the chat and I would also just take a moment to invite our presenters if you are able and willing to turn on your video cameras so that we can eu as we have this Q and A portion of the presentation . Thanks so much . All right , let me just scroll through . We had quite a lot of great comments I would say . Um there is one question , uh it says , considering the practices of media entities , how are the nuances of medical ethics shared or received ? Great question . I don't know which of you may want to take a stab at that or several of you , but feel free . Let me , let me , let me give it a shot if I could because much of what we deal with , not only in de but also on the civilian side , Georgetown deals with the interface between the conduct of medicine and how medicine is . Then if you will depict it either in public media , such as news media or also in fiction . And I think that there's a reciprocal responsibility clearly , one of the things that's happening in contemporary media is that those individuals who are highly dedicated as if you will , medical writers and professionals have been diffused somewhat by a broader and more ubiquitous media community be whereby a lot of things that my virtue of shared contract and or even by individuals who are working , I I if you will freelance . And as a consequence of that , very often their integrity with regard to their , their integrity and dedication to medicine as a profession and or their , their relevant capability to work with them . This year may be somewhat compromised in other cases . It is not . However , there's also if you will , a general trend and , and our group has looked at this with regard to the interface between humanities and medicine and bioscience , a general trend towards sensationalism where aspects of certain domains of conduct or the scope and tenor of what's being done may be sensationalized because of their relative impact upon public sentiment and sensibilities . And so I think as we become more capable and as that capability also affords informational ubiquity and afford capability to be able to get , get that information out to the public , there's an increased responsibility that is reciprocal , increased responsibility to communicate accurately in those ways that are viable and valuable . In other words , those of us who are working on the inside of the biomedical community , whether it's in terms of therapeutics or the ethics to be able to communicate those in clear and viable ways that are valuable to those who read it , but also a reciprocal obligation , if not abject responsibility of the media , to be able to engage that conversation in a way that is clear , concise and truthful . And this represents one of the key ethical precepts that we like to engage with regard to biomedicine in the media , which is verticality . In other words , telling the truth and recognizing in some case that truth may be fleeting as a consequence of the tools we have to evaluate it over to my colleagues . I'm not sure I can even add to that at this point . And needless to say the media , particularly the social media uh causes a great deal of uh challenge really to medical providers and to medicine itself . Uh and particularly for those who are trying to obtain information uh that you never really know what is the correct thing that is going on right now because of , sadly , the polarization of this and it plays out domestically and can even play out overseas . And quite often as an example , uh civilian populations and much of the media doesn't have a true appreciation uh often of the mission requirement . And so if something is done that may not be considered totally appropriate , say in a hospital in Washington or New York or San Francisco , uh because it's happening in the battlefield , the argument would be that it doesn't matter , medical care is medical care is medical care . And , and that is and should be true . But we have that additional ball in the juggling act that we cannot abandon in order to accomplish our mission as war fighters , Mary , if I could just add , um Joe and Jim bring up uh excellent points about the mission . And uh and in my portion of the talk , I mentioned working with our international partners . Um in my own experience , I was in Afghanistan on a Spanish base with Italian uh commander and it became clear that each of the NATO partners viewed things very differently and that there wasn't consensus of exactly what should happen . And I was quite struck by this and we were the first military , we were the first US medical unit to be placed in a NATO hospital , which was not uh English speaking hospital , the Spanish facility . And so um Joe and Jim's points about the mission very important because in our military culture , mission is all . But in other cultures , there are different views on mission and even medicine and how physicians or health care professionals view each other , which can , which can contribute to ethical dilemmas when you bring health care professionals together from different environments to create uh try to get some consensus on what to do . So the the point is that ethics while we in America can sit and have this discussion and agree on certain principles that is not universally held by our either our NATO partners and certainly those who are not in the NATO environment . Thank you . Mhm . Mary Ann . I'm seeing a couple of chatting questions if I may really quickly here to try to maybe uh answer some of those one had to do with the uh ethical concept of practicing uh within the scope of licensure and military training . Uh And , and again , this is something that is uh a legal quandary quite often because we do train a lot of our enlisted provi providers and I call them providers uh up to do things in the civilian world that only licensed individuals would be able to do . And under the concept of federal supremacy , we do have that authority to do so . But at the same time , we do need to be cognizant of licensure requirements of others , particularly those that may be required to supervise those individuals and to make sure that their own individual licenses may not be in jeopardy . And , and this does become a challenge uh uh as far as the , the certification of people . But again , in a combat environment , inter army , you know , the laws may be silent in that regard as opposed to the necessity of licensure certification in a domestic environment . Uh There was another question about , are there available resources within the MH S to resolve problems and ethical situations if you're in a larger medical facility , hopefully you do have an ethics committee or at least ethics advisors either in house or regional . But d A one of the goals that we have a as uh uh Doctor Lau has suggested is that if you do need additional support or help , we are there to help you . We are there to help your ethics committees not to , to override or step in instead of them , but to augment that with suggestions and at least advisories , we don't make policy but we simply advise . Uh So don't , don't hesitate to contact us if local support is not there . Thanks so much Mr Pocano for those comments and to um Doctor Giordano and Doctor Lau for your prior comments . Um This is such a great uh discussion . I think that we're having and lots of good questions that those of us um you know , who maybe haven't been deployed or those of us who haven't necessarily been in some of these situations have maybe even considered some of the ethical challenges that we face quite often or that our colleagues face . Um There was a question here that I'm seeing related to um you know , this question about during COVID less focus was on seniors and elders until the alarm was sounded how many military personnel die . Um from CV , I'm assuming they're saying from COVID and maybe the difference there in the type of individual patient . Anybody have comments on that . II I do Doctor Lau , you may have better uh um information on this . I , I would only guess as , as , as uh just a , a layperson that you're not gonna see the same level of death uh in the military because you've got a healthier population generally to begin with . Uh Secondly , the availability of health care , uh it was probably more prevalent in those situations than in much of the civilian world at the time . Uh But again , you know , the idea of this , this uh survival of the fittest , particularly in the civilian environment uh took hold . And you did see as part of that people that were older people that were already infirm uh that were not getting that same initial care that younger people had to build their ability to survive , might be able to get . Some were arguing that was discriminatory , it was ageism . Uh It was a violation of the uh the Rehabilitation Act . Uh answer to that uh Joe . So the , the actual figure of military mortalities from COVID at this point is 100 and 21 with over half a million reported cases of infection . And of those half a million reported cases of infection , over 100,000 of those cases remain at least at some point prevalent for some sign or symptom of COVID that has impacted their relative job scope . So those are figures that are released at the end of March of this year , they may be somewhat higher or they may be somewhat lower based upon the subsequent adjustment , particularly to the latter figures . But in terms of death , that's less than 100 and 50 over . Thank you . Thank you so much . Yeah , very um interesting discussion . There's another question , I think kind of back to the licensure and the scope of practice related to military medics providing humanitarian missions , uh specifically like Katrina or Rita and the hurricane situations . I didn't know if you guys had more details regarding that . I , I would just say briefly and generally the same principle of federal supremacy would apply that if you're acting in the scope of federal duties , whether it's through the military through what's called the Stafford Act , which allows us to work in a domestic environment during emergencies or as part of fema , which often happens that these are federal entities and that you are allowed to practice based on what your capabilities are within the military . You'll also find that most states that are in emerging situations will allow their good Samaritan Act to take hold and provide additional support for you in the event , something like that should happen over . Thank you , Mr Pocano . There's another good question here coming in about the uh back to the consideration of families and the kind of the broader picture it asks what are some guidelines when addressing medical needs and decision making for teenage patients ? Specifically that conflict with parents desires . That's a great question , I think and certainly one that I'm um uh somewhat familiar with from a pediatric perspective . I would let my attorneys go at that one . Thank you . Yeah . I think , uh Professor Pocano will probably have , you know , sort of the legal side of this and I can sort of align my answer with a , a further question talking about how shared decision making practices have impacted the medical ethics framework . And I guess what I'll say is it sort of speaks to the broadening scope of the physician to care for their patient , which includes more than just the patient . It includes a family , it includes the system , it includes the hospital , it includes other health care workers . Um And I guess we'll say , share decision making becomes supremely important when you think that the patient might not be making a decision that you yourself would make or that you consider to be a reasonable decision . Um But if they do have capacity , if they are , you know , of age , and if they are um uh fully um aware of the risks and the benefits and the alternatives to whatever it is that they're choosing and then they recognize where their disease process falls within that , that spectrum , then then they are allowed to make that decision . And so the shared decision making component means basically listening to your patient , providing your expe expertise , but then listening when patient may give , give you their perspective that might not align . And so learning to compromise , learning to educate and learning to think bigger and broader um can , can really help to take better care of patients because what is good care if it's not the care that the patient wants , like , is that good ? Um Is that adequate ? Is that , is that right ? Um And , and maybe uh Professor Proo , you can address the the minority . Iii I think Doctor Apple White was , was hit , hit the point . Uh I I would say thinking back being a moldy oldie to my prior career as , as a legal advisor to the Air Force surgeon General for so long , I've seen a lot of cases in which they did have this ethical conflict . And I recall one where at two o'clock in the morning , uh a mom brings a 14 year old daughter into the emergency room and she's screaming . And she says to the medical staff , my daughter snuck out last night and went on a date and I think she had . I want you to examine her to see if she's still a virgin and the 14 year old start screaming and saying , don't you touch me ? Don't you touch me ? Now , the medical staff initially is saying , well , look first , she's a mature minor . Secondly , this is not a medical issue . It's a social issue between the mom and the daughter . So we really shouldn't be getting involved in this until the mom throws a curveball and says , oh , by the way , the boyfriend , I think she went on a date with is a 21 year old airman . Uh Now , is there a potential statutory rape situation here . Does that change the nature of the beast ? This is why again , it's nice to communicate with the dreaded lawyers on the base every once in a while to make sure you're acting legally . But you do have this ethical conflict that may pop up between uh the the mature minor and the parents , right ? This also comes up particularly in environments where the minor may be receiving birth control without the parents' knowledge . And the parents just react horribly if and when they do find out that's happened , saying we're the ones that are responsible here , why didn't you contact us ? Well , the law says that she or he can get this kind of information . So uh quite often the law does not play well into the attitudes of parental control . It's over . Yeah . Thank you so much for those comments . And certainly at least my recollection from um having dealt with some of those situations is uh trying to be guided by the applicable state law of where you're , wherever you're located comes into play if I'm not mistaken . Wonderful . So there's another good question that um wants to ask how the difference in power related to rank , be addressed or approached ethically in a provider , client relationship , which I think is a really wonderful question challenging . But you know , it's , it's a funny thing you mentioned that because , you know , we we talk about the concept of justice which is treating people equally and I know when I , I give lectures , I , I sometimes uh caustically will say , uh how many of you have worked in MMTFS that have executive suites . Uh and uh the , the executive wing . And uh why is it that , that we have something like that when health care is health care is health care ? Uh And uh unfortunately , there are situations where uh the grade or rank of the individual may provoke more immediate care . Now , you could make a mission justification of that , say if it's an active duty member , that's about to be deployed and because of the the responsibilities they have , they need to be seen first or whatever . Uh but you really have to balance the reasonableness of doing this and not just do it because of somebody's grade or rank . It's interesting that when the French developed triaging in the mid 18 hundreds , uh their , their theory of this was officers get treated first . Uh Fortunately that kind of went out the window , but you can see the mentality of this . Uh and it , you know , it kind of perpetuates itself sub rosa uh within the military . Yeah , if I could add the , the military health care professional is not a doctor or a nurse wearing a uniform , they have to be aware of the culture in which they work , which has some positives and at times some difficult nature which the rank situation can bring itself to the fore in many , many ways the junior doctor with a senior doctor , a senior doctor with a junior junior enlisted personnel as far as rank and also in the deployed environment . The doctor may have a view of what's going on with the casualties , et cetera and the commander or a different view . So this is where I think it's important that physicians who are in nurses and other health care professionals in the military need to be really aware of the environment in which they work so that they can work in that environment . If that makes any sense that they have to be cognizant of this rank and structure because that is not just an offsite , a non offsite thing , but rather an entity by itself . It's meant to support the mission , the rank et cetera are designed to support . Well , it comes the mission . What is the unit supposed to do ? That's what the whole thing is all about . And the senior officers are charged with doing that . I'm talking about the deployed or in a combat environment in the United States , in the executive suites , in the hospitals . That's a different environment . So it it's tremendously demanding on the health care professionals that they'd be capable of adapting to these various uh environments which they may find themselves . And really , that's why we're here . They , these environments will bring up ethical challenges as we've been talking about and we're here to assist anyone who encountered something like this over . Thank you . Thanks , Doctor Lau . Appreciate those comments as well . And I wonder if um any of those challenges uh came up in the midst of COVID , uh the COVID pandemic where , um and I don't know so much with the military , but at least maybe in civilian land where um a person's power or um rank or position may have um been uh one of the various challenges in sorting through the triage process or the treatment process for patients . I don't know if you guys have any comments on that . I I can make a comment on that , that our was contacted relatively early in um the COVID outbreak COVID had not arrived at any of the military bases but the , the hospitals and the commanders were preparing and we were queried because at one base or for uh the base commander wanted to take over the hospital and decide that he and his staff would do , the triaging would do the assignments of various people would be the ones in charge of what was actually inside the hospital and medical decision making . So they reached us to seek help and how to deal with their um unit commander , their highest unit commander at the base . What we did was create a plan of how the hospital would conduct itself and they presented that to the unit commander and the unit commander backed away , but it was a very unique uh challenge if you will and really uh crossed lines of authority into the , who was really in charge of medical care at this facility . So , it , it , I'd never heard of that before , but it uh did happen during COVID and was successfully , uh dealt with . Thank you . It , it's interesting that , uh , during that same period , we happen to see a tiny sentence in , I think it's dod I 6200 3 , which is the uh public health emergency instruction of dod , which says that military members , active duty members shall have priority of care inside mtfs . Now , that , that may seem kind of innocuous at first and seem like a no-brainer . But uh during COVID , if you as a family member needed to be seen because of COVID and waited to come into an MTF only to be told that you're lower on the priority list for the ventilator because we treat active duty . First , one ethical question that came up was , should the dependants be notified beforehand that if they do have COVID ? And with this kind of triaging in an MTF , should they consider going to a civilian facility first ? Uh And again , that's not something we ever confronted before , but it's these little nuances and that's a very good word to use here that it suddenly it takes an emergency like this to put it on , you know , square in front of the table here over . Yeah , really interesting intriguing discussion , things that , you know , we've never faced before . Um I wanted to jump back really quickly to just a couple of comments related to minors . And , uh , you know , they are speaking to the fact that there's , um , you know , obviously state differences in , um , the treatment of minors and the disclosure requirements , um , depending on what you're treating and the age of the individual in some cases . And I'm just curious if you all have any input or concept over whether there's been discussion , uh , sort of on a policy level or um uh a , a legal level over whether there may someday be more standardization across states for the treatment of that particular population . I I'll let my legal colleagues weigh on that one . See , always the lawyer gets , gets the grenades thrown at them um that it's , it's a very logical question to ask and a good question . But , but I think all of us can see with the , with the polarization among states right now , uh particularly in medical and social issues uh trying to achieve some kind of unanimity . Uh I is , is almost really a pipe dream . Uh And uh for instance , you will see that mature minor if you look at state laws . Uh And I think it was at the good mocker institute , some really good , had some really good stats on this . But uh you could be as early as 12 or 13 years of age in some states . Some states don't even put an age on it . It's up to the discretion of the provider . Uh , other states will say 16 . So it really is all over the map . And that's a very legitimate question too because if you do have a 14 year old that's been treated , say in New Jersey . And I don't know if 14 is in New Jersey right now , but , uh , say for birth control and then suddenly the family's P CS to Texas , uh , and , uh , the , the rules may be different down there . And suddenly this 14 year old is told we can't give you birth control at your age because you're not deemed a mature minor without your parents' consent . You see the , the , the conflict and dilemma that the providers are faced with in trying to overcome this difference . Uh And certainly if we had a unified standard , it , it would help . But uh we , we are constrained to follow the standards of care of the host jurisdiction . Yeah , if I might , it , it , this parallel is the end of life decisions that uh end of life decisions in all our military hospitals are dictated by the state in which that hospital happens to reside . So physicians and other health professionals who transfer need to be aware that when they're in California , there are one set of guidelines and if they go to Texas , it's another and if they go to Hawaii , it's yet another . So um uh two examples of where there are big differences across uh state laws . Yeah , great . Point there that I as a pediatrician had not necessarily considered the opposite end of the spectrum . So thanks for that . Um There is a question uh related to the process of um obtaining ethical kind of recommendations that says if a combat related medical care decision needs to be evaluated from an ethical standpoint , what is the process to engage that ? So let me jump in and take that if I could and then I'll hand it on over to Doctor Lao . The the basic ethical decision making process is either five or seven steps depending on , on your orientation to it . First , you you always every ethical decision and every ethical action must proceed from facts . So the question here is what are the facts of this case ? And clearly one of the facts may be that you can't have all the facts available to you within the exigency of time necessary to make this decision to demand a decision particularly in combat or even garrison related constructs may be such that you have to be expedient . So what facts are most humane that you have at your disposal ? And what facts are affordable to you at that period of time ? Two , based upon those facts , is there actually an ethical issue ? It's been my experience of being an ethicist for the past three decades that very often the ethical issue devolves into one of an absence of communication , either on the part of the sender or on the part of the receiver or something with regard to signals in between talking past each other or simply not talking at all . And very often that absence of communication is then foster secondary and tertiary ethical issues . They're easily resolved as a simple consequence of effective communication . And that's where the ethicist may in fact serve as , as a mediator , a moderator based upon that . If an ethical issue does exist , the question then becomes what is the moral basis of the ethical issue ? Again , ethics are systems , they toolkits and they're toolkits that allow you to engage moral decisions and actions in accordance with particular contexts that are defined by the nature of that environment . And here we have organizational context , institutional contexts and this then becomes the professional guidelines . And if you will do these , the de onto of the field , military being one of them , now , this may bring up certain issues about whether or not the duties of medicine and the duties of the military are conflicting de onto conflicting duties . And our stance has always been and persists in being that these are not conflicting at all but are rather reciprocal and complimentary . Uh clearly , the goal of medicine is to , is to heal and the goal of the military is to fight at least to fight with regard to what it is a liberal democracy to protect the polis . But in so doing the goal of the medical ethicist , the goal of the medical clinician in the military is to help mission capability by healing one patient at a time . It may very well be that , that demands certain decisions that put key individuals back into harm's way . That would be a unique situation that our civilian counterparts don't share . But based upon that second step and third step , in terms of what are the actual issues and what is the moral basis ? The next becomes what is considered to be the prudential ethical step . What can be done given all the things that go into these facts , these situations , who are the agents , who are the actors , what are their circumstances ? What could be done ? What represents viable options and then extrapolating those if you could sort of doing a little bit of war gaming . If I take this to this trajectory to this ends , what could occur , what could occur in ways that are beneficial , burdensome , riskier , potentially even harmful . And then from those capabilities and capacities of what could be done to then select what should be done here , we'll go back to a little bit of Latin because it sounds cool from the right measure of speculation comes the right measure of appropriate action . In this case , for this patient in this context and in this circumstance , within the larger framework of the military context and it contingencies and exigencies from mission capability and force effectiveness and efficiency . And then after that is done , if you decide what you should do the question then becomes , how well can you do it ? We can't always do the things we should based upon resources , et cetera . And that's where some of these dimensionality of the new symmetrical battles come very much into . So again , those steps , what are the facts ? Who are the agents and the actors ? Is there an ethical issue ? And what is that ethical issue based upon the moral issue from that ? What could be done and from what could be done , what should be done if you will the ethical resolution of what is sometimes considered equipoise . But there are two additional steps . Number one is let it play out . Sometimes we won't know how things ethically turn out until they turn out . It's a variation of what's sometimes referred to as the calling ridge dilemma . In other words , you won't know unless you go take the risk , take the step very often . We're prompted if not obligated to act . And then from that comes that seventh step , which is hot wash debrief . We can't always make the right decisions given all of the facts that may or may not be available to us . But we can certainly utilize each and every ethical experience in practice as simply that a basis for building expertise in what's called a casuistic way . Taking if you will our own professional casebook and feeding it forward so that we learn what to do next time . Should circumstances and settings be identical be dissonant or somewhere in between . Now take , take what what Professor Geoana just said and put it into a practical situation in the tent , the hospital tent in the combat zone . You have a soldier , one of ours that's been brought in profusely bleeding and needs a transfusion to survive in a bed already in that same tent as an enemy soldier who you happen to know has the blood type , which is the same as this particular soldier of ours . It's a very rare blood type . Nobody else has it nearby . Now , you ask the enemy soldier who's conscious and competent , we'd like to transfuse some of your blood and that soldier says , go to hell , I'm not giving you anything in mind . Don't you touch me ? Now , if you know you're gonna lose your soldier , do you override that refusal of consent ? Which in the civilian environment here we would not do in order to save one of our own ? So are you causing harm for a higher good ? Does the mission super seed here or are you abrogating rules of humanity here in the process ? And if you say this is ok , because the harm is minimal , then what is that threshold point ? What about a kidney transplant ? What about something that may be more potentially harmful to the other person ? But those are the dilemmas that are faced and that's why the step process that Professor Giorgio just gave is so critical here over brilliant Wow . Thank you so much for all the wonderful discussion and for this very thought provoking presentation , um I did wanna just say that we have come to the end of our time . Uh And to our audience , my hope is that we can continue to help provide some answers to the questions that you , that you've been submitting in the chat box . So I'll um help uh just relay to our presenters . Thank you if you're able to take some time to do that and then um wanted to quickly just recap that we , we had obviously great discussions today about the various challenges that we are seeing when we're faced with certain medical ethics and situations with regard to this new age of medicine and health care and military conflict . So thanks again to all of our presenters . We're now going to take a 10 minute break .