Analysis of an Ethical Conflict in Practice:
Battlefield Nursing

by
Jonathan Wells

A PAPER
Submitted to the faculty of the Excelsior College, in partial fulfillment of the requirements for the degree of Master of Science in Nursing.
ALBANY, NY
2012

Abstract
In the legal world that we live in, we are constantly at risk of facing ethical dilemmas that may arise from conflicting legal obligations. If caring is important in nursing, then nurses will have to make a concerted effort to define a specific duty of care in clinical, administrative, educational, research and military environments. In order to fully preserve tradition and concept of caring within the profession of nursing, we must make every effort to understand its ethical implications and provide the guidance needed for navigating dilemmas that regularly arise in relation to it.

Analysis of an Ethical Conflict in Practice: Battlefield Nursing
This paper will provide a brief overview of a possible ethical dilemma that may arise within the field or nursing during war time. It will then move on to explain the multiple ethical issues within the overall situation, the decision making model that the author has chosen to apply to the dilemma, and the stakeholders with their possible interest in the decision making process. With this information defined, the paper will move on to state the author’s derived solution to the situation, as well as a moral justification for the plan of action to be implemented.

Overview
The ethical dilemma I have chosen to address in this paper is that of battlefield nursing as addressed by Janet Kelly in her 2010 article. As the author so aptly states, “This article offers a critique of the concept of military nurses owing a duty of care to wounded soldiers on the battlefield (where direct contact with the enemy takes place owing to hand-to-hand fighting or where soldiers and the enemy are closely engaged in firing bullets, rockets and grenades at each other). It suggests that the battlefield environment is so unusual that the duty of care, which is normally owed by military nurses to their patients, should not apply” (p. 636). At the heart of the dilemma is the assumption that all nurses are required or duty bound to care for their patients, but in the case of the military healthcare professional, this duty can be overridden by legal responsibilities such as following orders from superiors, the obligation to the good of the fighting force superseding the good of the individual, and even the conditions that are encountered on the battlefield. While these are the basic ideas that underpin this dilemma, I believe there are yet others that should be given equal consideration such as the moral stance and beliefs of the healthcare professional. The author’s focus seems to be largely upon the legal perspective of the nurse’s duty to care versus other duties and obligations that come along with being a member of the armed forces. This is most certainly and important consideration, but definitely not the only one that resides within this dilemma. The author illustrates the dilemma wonderfully with the story of a nurse caught in the struggle between her duty to care for a soldier who has been seriously injured by a land mine, her personal safety, and her orders to avoid mine fields. Within this struggle is also the argument of whether the good of the one outweighs the good of the many. If the nurse is injured while trying to save the life of this individual soldier, it may prevent her from saving many other lives or even from keeping an entire military unit in a state of readiness to fight battles and contribute to winning the war. At the same time, the nurse must also take into account her personal beliefs and sense of morality. Overall, this makes for a very difficult situation, because the ultimate decision will largely be determined by which idea or obligation she values the most. From the perspective of the military, the nurse is duty bound to follow orders for the perceived greater good of the entire fighting force. Though she does have a legal duty to care for her patients as a nurse, the military establishment would argue that she is a soldier or military member first and a nurse second. Therefore, from this perspective she should unquestioningly follow the order to avoid mine fields and not give aid to the wounded soldier, at least until the mine field can be cleared by professionals trained to do so. From the perspective of professional nursing, one would most likely argue that the duty to care is paramount to all else and that the nurse should aid the wounded soldier even if it means putting her own life in danger. Though nurses are often advised to take care of themselves so that they can better care for their patients, this is almost always meant to be secondary to the duty to care. From a purely legal point of view, the nurse, in America, Britain, and many other countries is bound to follow all legal military orders once they have enlisted in or sworn an oath to serve as a part of an established fighting force. This would lead the nurse to avoid the mine field in order to avoid any legal repercussions. Depending on the moral values and beliefs of the nurse, however, she may find the idea of allowing a wounded person to suffer to be irreprehensible and possibly even sinful in the eyes of her religion. Therefore, it is clear to see that arriving at a solution for this dilemma is anything but clear and will likely involve a different process for every individual pondering it.

Ethical Issues The ethical issues involved in this dilemma are quite varied and far reaching in that they can and should be viewed from the level of the individual and the level of the collective whole (in this case being the military establishment and society) in order to truly understand the situation. Thusly, one should begin by considering whether the needs and rights of an individual are as important or occasionally take precedence over the needs of the larger body that the individual is a part of. While the military may take the stance that the needs of the fighting force outweigh the needs of any individual, we could argue that if a certain individual soldier is saved, even at the risk or loss of others, and that soldier goes on to become an integral leader in military or civilian life, then this life may have much greater value than was first imagined. In building upon the preceding issue, we must then move on to determine a working definition of the concept of caring. If the nurse, as a professional, owes her patients a duty of care, then what does this duty encompass? Does it mean that a nurse must do everything within her power to keep her patients healthy at all times or can the call to care be met by simply being concerned about the well-being of others? While making this determination we should not neglect to take into account the impact that a sense of morality and a belief system may have upon the concept of caring. While one nurse may adhere to a purely professional definition of care, another may feel that caring is directed by their religious affiliation and this takes precedence over all other conceptions of the term. Assuming that the duty of care is a concept which healthcare professionals are legally bound too, one needs also consider the legal system which they are a part of and why the determination has been made that not caring should have legal consequences attached for certain professionals. In relation, we should question whether following some laws takes precedence over others and why. As Kelly points out, this can set the stage for, “a dual loyalty conflict” (2010). Overall, there are actually several ethical issues or considerations within the confines of this dilemma. While they are all connected and do impact one another, at some point, anyone analyzing such a situation in order to reach a solution, must eventually assign values or weights to these issues. Without such a step, it would be virtually impossible to reach one unified conclusion, but instead the researcher would be left with multiple possible resolutions based upon the world view of the person making the final determination. This, in and of itself, presents another ethical issue in that one must compare several separate, but important issues in seeking to decide which one should take precedence over the others and even how they rank from most important to least important.

Ethical Decision Making Model The ethical decision making model I have chosen for this analysis is that suggested by Toren and Wagner in their 2010 article that addresses the subject. In this article, the authors propose following a six step process in order to properly analyze, make a decision about, and resolve a dilemma. These six steps are, “Define the ethical dilemma; Clarify the personal and professional values, ethical principles and laws involved; Identify the alternatives for action; Choose an action; Initiate discussion about unresolved issues; Generalize the solution to other similar cases” (p. 395). The reason for choosing this decision making model is because the steps are clear, concise, and easy to follow, along with being applicable to a dilemma such as the one I have chosen to address. This model encourages taking into consideration personal and professional values as well as identifying all of the ethical principles involved. In doing so, one may very well come to the realization that there are multiple courses of action to choose from and, therefore, at some point during the decision making process the analyst must make a choice as to which course they feel is the most ethical, advantageous to the majority of parties, in in line with their moral values or least harmful to the stakeholders. I also gravitated toward this model in that it leads one to consider what unresolved issues will remain once a final solution is decided upon. In the case of battlefield nursing, there will most likely be multiple unresolved issues, because there are multiple ethical issues to be addressed from the beginning of said analysis. Depending on which issue is given precedence, the other issues involved in the dilemma may, quite possibly, be left partially or totally unresolved. This may be acceptable to some degree, but should be addressed and given thought so as to prepare for questions that may arise from others involved in this situation and to better understand how the solution may or may not apply to other like cases.

Stakeholders Developing a list of stakeholders for this ethical dilemma could be nearly impossible due to the fact that this issue involves a large organization which is endorsed and subsidized by the government of a country and therefore the entire population represented by that government. Thus, the stakeholders in this situation range from society at large, the military as an organization within that society, the justice system of the society as a whole and that of the armed forces (as they are often distinct), the professional body which the nurse is a member of, the nurse herself, and the wounded soldier in the example or any other soldier that the nurse may be called upon to treat in the varying wartime situations that she may find herself in. As if this list were not exhaustive enough, we must also take into consideration any religious body that the nurse may be part of, the nurses family and friends which most likely have a degree of impact upon her values, beliefs, morality and overall thought or decision making process. The interest of society would most likely be what is best for the whole or what would keep society functioning in the best possible way and be in the interest of the majority. In this case, that would most likely be keeping the military strong, efficient, and effective at maintaining the rights and liberties that the citizens of the society currently enjoy or realistically expect to gain at some point in the future. With this said, however, we must keep in mind that the loss of certain individuals could be incredibly detrimental to an entire society, so in some instances, it may be argued that the best interest of the society is safeguarding the life of the individual, even if it results in immediate detriment to the society overall. The overarching interest of the military would generally be to maintain sufficient force to defend the boundaries of the country it serves. This is normally accomplished through manpower and the use of force multipliers such as weapon systems and other strategic advantages in battle. Therefore, it is likely that those in positions of military command would wish to keep soldier/nurse levels as high as possible and would not be willing to risk one life in order to save one more that may not be capable of fighting again in the future. The justice system of the country the nurse resides in would tell her that she, as a healthcare professional and part of a professional body, is bound to care for those considered her patients. In this case, as a military nurse, would include any soldier that she knows to be in need of care, even if in the middle of a mine field. So, the interest of the civilian justice system would be for the nurse to uphold this duty. On the other hand, though, the military justice system, which, in almost all cases, appears to hold precedence over the civilian system when related to a member of the military on duty, would say that the nurses primary duty is to follow all lawful orders handed down to her by her superiors. Thus, she is duty bound, first and foremost, to avoid the minefield instead of attempting to save the life of the wounded soldier. The interest of the military justice system is to make sure that the authority structure of the organization is upheld so that orders are carried out from top to bottom in an efficient and effective a manner as possible. Of course, the nurse is a stakeholder in this dilemma as she may face legal consequences no matter which decision she makes. Her interest may be split between her profession, her perceived calling in life, her obligation to the military, and even an overriding obligation that she may feel towards her fellow man, the god that she believes in or the traditions/values that she was raised with. In a similar way, the wounded soldier is also a stakeholder in that his life hangs in the balance and it is understandable, if not expected, that his interest would be to continue living. However, as a member of the military we must allow for the possibility that he may feel that saving his life is not worth risking the life or lives of others and possibly doing harm to the overall military structure and mission. This soldier’s beliefs and values would also come into play in determining what he sees as being in his best interest and the best interest of those he is connected too in any number of ways.

Final Ethical Position After having defined the dilemma and the possible stakeholders, based solely upon the information given in the article on battlefield nursing by Kelly (2010), the possible actions would be to either disobey military orders and attempt to save the life of the soldier in the most expeditious manner possible, call for a trained crew to come and clear the mines that may remain around the wounded soldier so that he could then be treated if still living, contact a superior officer to seek clarification of orders or a change in orders, or leave the wounded soldier in the state he was discovered in with no attempt to render aid. Since the information presented was largely from a legal perspective, the course of action I would choose based upon it would be to initially avoid the mine field area as ordered by military superiors since this would be the law that would take precedence given that the nurse is clearly on active duty and bound to the military justice system. With that said, I feel that the morally correct course of action, even when placing the preponderance of value upon the legality of the situation, would be to contact one’s superior and inform them that there is a soldier in need of care though they are in dangerous surroundings. It is quite possible that the standing order given to the nurse will remain in effect without any change, and if so, this should be obeyed under the circumstances. However, it is also possible that the nurse’s superior officer may rescind the order or, at least, make an exception to it for this single situation. In either case, the nurse, as a part of the military organization has involved her authority structure in the decision making process and opened the door for another possible solution. This course of action would likely leave the question of individual versus organization left unresolved. Though this resolution would defer to the military interest that the whole is more important that the individual, it may very well be at the sake of denying a personal belief about the subject. This action plan also does not address whether the military or civilian legal system should be preeminent. Since the military justice system exists within the framework of the civilian legal system, one would think that it should take a back seat, but tradition has been that the military justice system is used in relation to matters involving active duty military personnel, so, in this case we shall accept that non-resolution. When solely taking into account the legality of the situation there would likely be multiple unresolved moral, value, religious or belief issues along with the overall idea of what constitutes caring and a duty to care. Though it could be difficult to generalize this solution to other related situations, it is possible based upon the legal perspective taken above. If one has made a legal commitment to the government sanctioned military organization of their nationality of residence, then that person has agreed to be legally bound to the code of justice enacted by that military body when in service to it, even if that legal system may contradict the civilian legal system or any professional standards adhered to while not in uniform service. This solution does not take place much weight upon moral considerations other than attempting to seek out the best possible outcome within the legal boundaries established, but it can be applied to almost any situation where one legal/professional standard seems to contradict another or create a dual loyalty conflict. Now that I have pondered this ethical dilemma based only upon the legal information presented in the article, I would like to move on to present the course of action that I would personally take if in said situation. Having spent some time in the military, I am very aware of the legalities of being a member of the armed services and, for the most part, I support this legal and authority structure. I believe that it is necessary to carry out the overall mission at hand and would be very hesitant to ever advise someone to disregard it. However, individually I strive to maintain my allegiance to God as the most important one in my life. In most instances I feel that the Bible leads us to follow civilian laws as stated in Romans 13:1-2 where we can read, “Let everyone be subject to the governing authorities, for there is no authority except that which God has established. The authorities that exist have been established by God. Consequently, whoever rebels against the authority is rebelling against what God has instituted, and those who do so will bring judgment on themselves.” In this case, though, I feel that the above guideline is superseded by another when Jesus was asked what the two greatest commandments were and, “He answered, “‘Love the Lord your God with all your heart and with all your soul and with all your strength and with all your mind’; and, ‘Love your neighbor as yourself’” (Luke 10:27). Alone, this verse may not seem like enough to justify breaking a military or civilian law, but when combined with other wise stories from the Bible such as the good Samaritan who risked his own life to save the life of a sworn enemy in Luke 10:25-37 or the story of the shepherd who left 99 sheep to rescue the one that was lost in Luke 15, I believe that this means my duty to care for individuals around me, as a Christian and as a nurse, takes precedence over a military order such as the one presented in our dilemma. I do not believe that my religious beliefs prod me to foolishly put my life at risk without considering the cost or without determining the best course of action, but I do feel that I am called to care, even in the face of danger. If, in responding to the needs of this wounded soldier, I were able to save his life, that would be wonderful, but even if all I am able to accomplish it to let him know that someone cares about him and is trying to help as he draws his final breath, then I still feel that my efforts would be worthwhile and morally justified. Overall, I believe that the duty to care, or better yet, the privilege of caring should involve more than just providing health related treatment. It should also include presence, a genuine sense of concern, a certain amount of self-sacrifice (even if the sacrifice is just a bit of time and interest), and a willingness to take responsibility for the overall well-being of another.
Moral Action Plan The action plan that I would implement to carry out this resolution is to give my best effort to save the life of the wounded soldier, even in the face of possible legal consequences. As has already been addressed, a nurse in this situation could face legal repercussions no matter which course of action is chosen and since, morally, I would feel obligated to help a fellow human being in need, my specific plan would be to carefully, but as quickly as reasonably possible, make my way to the wounded service member while watching and probing for any remaining active land mines in my path. Though speed would be of the essence, logic concludes that if am were also seriously injured while attempting to reach the wounded soldier, I would likely be unable to save his life and may even place another person in the ethical dilemma of whether or not to try and save my life. Upon safely reaching the wounded soldier I would provide the care necessary to sustain his life or, at least, offer as much comfort as possible as his life ends. I would also take the necessary steps to call for additional assistance in regards to healthcare for the soldier and making the environment safe for extraction and for others to render aid. This would likely include calling in a medical evacuation unit such as an ambulance or helicopter and an explosives disposal team. If, for any reason, I were unable to save the life of the injured soldier, I would try my best to let him know that he is not alone, he is cared for, and any last wishes that can possibly be addressed, will be.
Conclusion
Though there would likely be as many different action plans developed from the analysis of this dilemma as there were individuals analyzing it, my religious beliefs and moral convictions would, ideally, lead me to the aforementioned course. By its very nature, an ethical dilemma is wrought with difficulty and usually leaves several unanswered or inadequately answered questions in its wake depending on the point of view of the analyst. This dilemma has proven to be such a case and in spite of being personally comfortable with the answer I have arrived at, there is little doubt in my mind that others would vehemently oppose my position and feel completely justified doing so. With this in mind I do not assume that my stance is any more valid than that of another, that my beliefs should be more highly valued than anyone else’s or that others should be expected to try and see this situation from my point of view. I propose this analysis and resolution as nothing more than my opinion in regards to this challenging situation.

References
Holy Bible: New International Version. (2011). Grand Rapids, Mich.: Zondervan.

Kelly, J. (2010). Battlefield conditions: Different environment but the same duty of care. Nursing
Ethics, 17(5), 636-645. doi:10.1177/0969733010373434

Mathes, M. (2005). Ethical decision making and nursing. Dermatology Nursing, 17, 444-
458.

Toren, O., & Wagner, N. (2010). Applying an ethical decision-making tool to a nurse management dilemma. Nursing Ethics, 17(3), 393-402. doi:
10.1177/0969733009355106