Few medical students received adequate training in military medical ethics, many were ignorant of a physician's responsibilities under the Geneva Conventions, and the majority don't realize civilian physicians are subject to being drafted, according to a survey.
Dr. J. Wesley Boyd and colleagues at Harvard Medical School, Boston, and the Cambridge (Mass.) Health Alliance, contacted 5,000 medical students at eight U.S. medical schools by e-mail. Overall, 1,756 (35%) completed the survey. Of those, a little more than 5% served in the military or have an obligation to serve in the future (Int. J. Health Services 2007;37:643-50).
Of the total, 94% received less than 1 hour of instruction during medical school about the ethical obligations of physicians in the military, 4.3% had 1-5 hours of instruction, and 1.5% had more than 5 hours.
About 6% reported being "very familiar" with the Geneva Conventions, and 66% reported being "somewhat familiar." Nevertheless, only 37% correctly answered that the conventions apply regardless of whether one's country has declared war.
About two-thirds of the students correctly stated that wounded individuals should be treated in the order of severity regardless of their nationality, but 27% incorrectly stated they should treat their own soldiers according to the level of severity and only then tend to the wounded enemy.
Thirty-seven percent of the students did not know that the Geneva Conventions state that it's never acceptable to deprive prisoners of war of food or water, expose them to physical stresses such as heat, cold, and uncomfortable positions, or threaten them with physical violence even if those threats are not carried out.
The investigators asked the students under what circumstances an officer is ethically required to disobey a direct order from a superior. The options were, "when ordered to threaten a prisoner with injection of a psychoactive drug that will not actually be administered," "when ordered to inject a harmless bolus of saline into a prisoner who fears he is receiving a lethal injection," "when ordered to inject a lethal drug into a prisoner," "all of the above," or "none of the above." Though 66% correctly answered "all of the above," 27% thought they must only disobey when actually injecting a lethal drug; 6% thought none of the above was the right answer.
"The abuses at Abu Ghraib [in Iraq] and Guantanamo [Bay, in Cuba] have galvanized much of the world against the U.S.," Dr. Boyd wrote. "Those abuses, in part abetted by physicians, will likely go down as one of our century's most egregious ethical lapses. The dearth of teaching about these issues in medical schools is a travesty, and medical schools need to begin teaching military medical ethics to ensure all physicians have a solid understanding of their ethical obligations in times of war."
Congress approved the Health Care Personnel Delivery System in 1987, establishing a process for drafting physicians. Only 3.5% of the students knew this, and only 23.8% thought a medical draft was more likely than a general draft. Less than 50% would willingly serve in such a draft, with 34% saying they would use all legal means to avoid service, about 7% saying they would consider emigration, and just under 14% saying they would refuse military induction as an act of civil disobedience.
"I believe that there should be a mandatory ethics course in every medical school program, and that should include an examination," Dr. Abraham L. Halpern said in an interview. Dr. Halpern, who was not involved in the survey, is professor emeritus of psychiatry at New York Medical College, Valhalla. He said that on occasions when he has instructed medical students in ethics, he has noticed that many of the seats in the lecture hall were empty.
"The fact is that most physicianslet alone medical studentsare not familiar with the code of medical ethics," he said. "Any course in medical ethics should absolutely include the worldwide acceptance of the Geneva Conventions."
'There should be a mandatory ethics course in every medical school program, and that should include an examination.' DR. HALPERN