Med students don’t study war, ethics

A new survey of U.S. medical students shows they receive little training about what they should or should not do in wartime, despite ethical questions over physician involvement in prisoner interrogation and a legal framework making a “doctor draft” possible.

The study shows that 94 percent of medical students who took an online survey said they received less than an hour of instruction on military medical ethics. Further, respondents’ knowledge of the Geneva Conventions was shaky. Almost two-thirds didn’t know that the conventions apply even in the absence of a formal declaration of war. About a third didn’t know that doctors are supposed to treat the sickest patients first, regardless of nationality. A third were not aware that doctors are never supposed to threaten or demean prisoners, or deprive them of food or water. And a third couldn’t identify a situation where they are ethically required to disobey a direct order from a superior.

J. Wesley Boyd, a clinical instructor of psychiatry at Harvard Medical School and psychiatrist for the Harvard-affiliated Cambridge Health Alliance, said the responses show that the lessons of the U.S. abuse of Abu Ghraib prisoners are not being learned. With the possibility of a “doctor draft,” he said, it is critical that future physicians who may find themselves in a war zone understand their duties and obligations.

“For those physicians who are going to end up in the military, they certainly need to know this stuff, to be educated about these matters before they enter the military because I don’t think we can trust the military to do due diligence in teaching physicians about these things,” Boyd said. “But even for those doctors who never enter the military, I feel like they should be educated in these matters because they need to lead the calls to treat prisoners humanely. Physicians speaking out about torture and abuse is as fundamentally basic and necessary as it is to treat high blood pressure or bring down a high blood sugar in someone who is diabetic.”

Boyd was the lead author of the study, which appeared in the International Journal of Health Statistics. It was conducted with colleagues from Cambridge Hospital and the Cambridge Health Alliance, including David Bor, the Charles S. Davidson Associate Professor of Medicine and head of Cambridge Hospital’s Department of Medicine, associate professors of medicine David Himmelstein and Steffie Woolhandler, assistant professors of medicine Karen Lasser and Danny McCormick, and instructor in medicine Sarah Cutrona.

The survey grew out of a conversation several years ago at a Cambridge Health Alliance research group meeting, Boyd said. Participants were discussing why more physicians didn’t speak out about the war, and someone commented that for doctors, like most of the American public, the war is far away, and, unless they have family and friends in the military, it doesn’t affect their daily lives.

Woolhandler pointed out that a structure is in place to draft doctors if needed under the Health Care Personnel Delivery System. Many of those in the room were unaware of the system, Boyd said, and so they set out to find out more, eventually leading to the survey.

The survey was posted online with e-mail invitations sent to 5,000 medical students at eight U.S. schools. About 35 percent, or 1,756 students, took the survey, and judging from their responses, only 3.5 percent were aware of the existence of the Health Care Personnel Delivery System.

The Bush administration has said it will not use the system, Boyd said, but as long as it is on the books, its use remains a possibility, particularly given that the military has not been making its doctor-recruiting targets.

“All physicians ought to know these things, given the possibility they might be drafted,” Boyd said.

When asked what he’d advise today’s medical students, Boyd said it would be to educate themselves about what their duties and obligations are as a doctor.

“Just remember your job as a physician — your duty — is to attend to health. Nothing else should get in the way of that. If it is getting in the way, then speak out or refuse,” Boyd said.