The Military Surgeon or Medic

An appropriate introduction to the topic is consideration of the military surgeon. In many ways, such an individual parallels the TPS. The military surgeon serves as both a physician and potentially as a defensive combatant. Military surgeons or medics are expected to act in self-defense as well as in defense of the patients for whom they provide care, including opposing force injured combatants or detainees.Reference Donovan and Mellen⁸ These imperatives are driven by both the 1949 Geneva Conventions⁹ as well as the military Force Protection Program.¹⁰ Careful note is made to identify that the military physician is not expected to be a primary combatant. Of course, such realities are principally operative in forward and far-forward operational theaters rather than in what are effectively tertiary centers of care. Nonetheless, there are ample data that opposing forces fail to uniformly follow the Geneva Conventions’ principles when medically treating non-combatant physicians.Reference Harrison and Fleming¹¹

How Do Medical Ethics Interface With Military Responsibilities?

The overlap of medical ethics and military responsibilities primarily relates to medical and medical support personnel, but commanders need to be cognizant of these ethics as well. In particular, detainee or injured opposing force combatant care is a major area of ethical responsibility for medical and non-medical commanders in theater and has been amply explored during the Global War on Terror.^12, Reference Sessums, Colleen, O'Malley, Jackson and Roy¹³ The front-line medical provider may be a General Medical Officer, a physician with little post-graduate training, who is relatively isolated at a forward or far-forward care station. As such, this individual is vulnerable to the exigencies and stresses of care for combat wounded as well as concerned with self-preservation. Further complicating this highly stressful situation is the relative lack of direct contact with senior and experienced supervisory medical personnel, as those individuals are generally placed to the rear. The Geneva Conventions and the US Army Field Manual specify physicians as non-combatants, but note that they may act in a combatant capacity in self-defense and in the defense of patients for whom they are providing care.^{9, 14} However, there is a history of physicians and other medical personnel acting in a primary combatant capacity.

The clearest example of the juxtaposition of medical and combatant roles is that of the Knights Hospitaller of St. John of Jerusalem, who were known as “warring physicians” and embraced both roles in equal measure.Reference Vastyan¹⁵ Prior to 1915, three US physicians were awarded the Medal of Honor for their combatant roles, not their physician roles.¹⁶ Importantly, these examples raise the question of whether one can “stop” being a physician. More recently in Vietnam, one notes the “weaponization” of medicine. During that time, Special Forces Aidmen could choose to apply or withhold medical support from opposing force injured combatants or injured non-combatants. This practice came to a head in US v Levy (1967).Reference Langer¹⁷ This case arose from the refusal of a physician to teach dermatology to Special Forces Aidmen, as he was convinced that they would unethically apply or withhold what he would be teaching them. His concerns regarding how others would act on the basis of the roles he would enable them to assume is known as secondary ethical responsibility. Ultimately, the physician was both dishonorably discharged and imprisoned.

Weaponization of medicine can take many other forms. These include care without consent, refusal to provide care, triage inequity, and the use of detainees, captured combatants, or captured non-combatants for medical research. The uneven provision of opioid analgesia to provide comfort as well as to hasten death from a non-survivable injury is another example. Lastly, providing field medical care as a means of supporting concealment and enabling Force Protection is another form of the “weaponization” of medicine. Therefore, interpretation of the ethical correctness of medical care may depend on the situation in which the care is provided as well as the intent that underpins that care.

The Civilian Tactical Police Surgeon

The civilian TPS is not tasked as a combatant, and has a carefully prescribed role within the SWAT team. The role may be crafted as an agreement among a police department, hospital, medical school, and an individual; it also may exist entirely outside of a hospital or medical school, depending on the individual and the responsible police department. The agreement, commonly known as a memorandum of understanding (MOU), defines the boundaries of participation in a TPS role, as well as the expectations of each party that is signatory to the MOU. A primary combatant role is generally prohibited within the MOU as a result of liability and regulatory concerns, risk of personal injury, lack of appropriate training (i.e., not trained as a police officer), and the physician ethic to “do no harm.” A physician discharging a firearm that results in a suspect injury would be well-explored in the media. Therefore, physicians who are not also police officers are generally not equipped with firearms, neither personal nor police department-issued. In the US, physicians in the TPS role generally function as if in the prehospital environment. Clearly, this role is different from that of the military physician who may be positioned far-forward in the military theater and attached to an active combat unit.

TEMS as a Bridge Between Military and Civilian Worlds

A TPS role may provide a bridge between the civilian and military surgeon's domains, and may be supported by prior police or military experience. However, there are multiple issues raised by embedding a surgeon in a tactical team. These issues include but are not limited to: salary support; time commitment; call or clinical activity coverage; liability insurance; disability coverage; training (team participation as well as safety); fiduciary responsibility; and the surgeon's role in determining officer suitability to participate in the tactical team based on health and fitness, as well as post-activity debriefing. Clearly there are multiple opportunities for partnering between the medical and police communities, but such collaboration requires interest and recognition of the benefits that may accrue to both parties, and a balanced appraisal of the potential risks. Risk assessment for this role is hampered by a lack of guiding principles addressing physician behavior and responsibility in the context of a TPS role. In contrast, there is a well-defined set of responsibilities for a non-tactical police surgeon who may not be trained as a surgeon and whose primary responsibility is health and wellness screening, as well as serving on a police commission's disability board. In the UK, police surgeons also embrace a forensic analysis role at the scene—a responsibility assumed by forensic technicians and forensic pathologists in the US.Reference Moon, Kelly, Savage and Bradshaw¹⁸

Important for TPS “acceptable behavior” is the impact of the assumption of risk (personal and professional). Risk assessment must address the mitigation of on-scene risk for the TPS. Generally, one to two SWAT officers are tasked with ensuring TPS safety, but this strategy reduces available manpower for threat management. This is especially a problem during active shooting scenarios with an injured officer where the “best medicine” may be threat suppression or elimination.Reference Vayer and Schwartz³ Moreover, one or both of the SWAT officers protecting the TPS may be called to address another active threat, leaving the TPS to manage an injured individual without protection. It is apparent that risk, safety, and acceptable behavior interact with a host of issues.

Ethical Principles and Specific Scenarios

Although multiple professional medical societies (including the American College of Surgeons, the American Medical Association, the American College of Emergency Physicians, the Society of Academic Emergency Medicine, the American Society of Anesthesiology, the World Health Organization, and the World Medical Association) have articulated codes of ethical conduct, none currently specifically address the embedded TPS. Therefore, one might turn to a local ethics committee for guidance, but it is similarly unlikely to have a readily available set of answers to inform the clinician, hospital, medical school, or police department. Instead, it is useful to explore the following scenarios and the issues that they raise.

Where Is The Border Between Physician And Combatant?

In the setting of firearm (lethal and less-than-lethal) use, one may ask where the border lies between physician and non-physician. It is clear that physician behavior may vary, but a behavioral change does not equate to changing one's identity to that of a non-physician. In many ways, a physician's professional identification is also his or her core personal identifier. It is important to explore whether a physician embracing a combatant role necessarily relinquishes his or her obligation to function as a physician from the perspective of professional obligation.

Tactically deployed physicians are garbed and outfitted with body armor and communication devices identically to all other tactical team members so as to not call undue attention to themselves as potential targets. Two elements do readily distinguish civilian tactical team physicians: the lack of weaponry and the presence of a gear bag. Therefore, a shifting role does not require a shift in external identifying badging or other identifiers such as the familiar Red Cross on military medic helmets in World War II. Along these lines, if a physician did discharge a firearm (lethal or less-lethal) in self-defense or in defense of an active patient, it would have to be done as part of a sound tactical medical plan. According to the Tactical Combat Casualty Care doctrine, often the best medical care is firepower superiority to end the threat and then allow unimpeded appropriate medical care. If the physician must participate in self or active patient defense, then doing so embraces rather than negates this professional obligation. Nonetheless, it must be explicit that under no circumstances is a physician to use his or her medical skillset to inflict harm, nor to aid tactical officers in gaining strategic advantage (i.e., offering medical care as a ruse to enable tactical team entry). Such actions would be categorically viewed as inappropriate.

It is unclear whether there is likely to be any professional impact (deleterious or otherwise) for a TPS who acts in a defensive fashion that results in suspect injury. This would hinge on whether the actions were clearly defensive as opposed to whether the actions were not clear or not immediately clear to an external observer. Professional impact may include but is not limited to loss of employment, suspension or revocation of medical licensure, and degradation of professional reputation. The effect on the TPS's surgery practice may be significant, as that TPS's activity would undoubtedly be examined in detail in the lay press and this may sway potential or current patients away from that physician's practice. It is not anticipated that lay press exposure would augment an individual's practice. Similarly, the legal inquiry for a volunteer TPS who is not employed by the police department is likely to be both lengthy and complex, and require substantial amounts of time away from clinical care and academic activity. To date, no such events have occurred.

One method of potentially mitigating such events is to have the physician act as a combatant only under the explicit direction of a tactical team officer. Civilians are generally expected to follow clear directives put forth by police officers, and the TPS would be no exception. Another mechanism is to have a motion-activated helmet camera that records what the TPS sees, ambient sounds (including verbal commands), and the TPS's response to a given situation. Newer tactical helmets have side rail mounting systems that readily support such technology. Since most communication system exchanges between tactical team members as well as the team and the command post are recorded, the TPS's need to act in self-defense or defense of a patient may be supported in this way as well. Lastly, each team should have a specified protocol and action plan for the circumstances that support the TPS engaging in a defensive combatant role and the mechanisms to allow that engagement.

How Does Military Unit or SWAT Team Responsibility Impact Triage Decisions?

Since the TPS is in general not a police department employee, team integration is essential. Such integration is enabled by regular training as a unit, and requires adjusting SWAT training to incorporate the TPS into team movement, rescue scenarios, and police officer training in basic first aid and emergency medical care principles and procedures. In this way, the police officer SWAT members learn how to help themselves, one another, and the TPS in the event of team member, suspect, or bystander injury. As a result of the negotiations required to generate and complete the MOU, regular (at least monthly) team training, and team activation and deployment, durable and meaningful interpersonal bonds develop. Moreover, there is an expected behavior set that accompanies integrating into a team. Deviation from the “normative” set of behaviors within a team dynamic, especially in a high-stress and potentially lethal environment, may incur censure in a variety of forms.Reference Bourne^22, Reference Gratton and Erickson²³ In a hostile environment, where one's life may rest in another's hands, departure from the expected team dynamic may be disruptive, dangerous, and divisive. Such team training sessions offer a superb opportunity to maximize the TPS's likelihood of maintaining team cohesion while respecting professional ethical standards. Such sessions allow the team to practice multiple permutations of the scenarios outlined above, explore triage and treatment decisions, and discuss team member observations (successes, failures, and misgivings) during the debriefing that occurs immediately after each sequence is completed. Such sessions enable triage decisions that the TPS renders when a SWAT member and anyone else is concomitantly injured.

Given the above, one might wonder whether treating a suspect who is more grievously injured that an injured officer would critically damage the TPS's role, position, and viability within the tactical team. The parallel within the military scenario is quite apt with injured same-force and opposing-force combatants presenting simultaneously to an aid station or definitive care facility.Reference Tuck²⁴ This scenario occurs quite commonly, and is resolved, in general, using standard triage decision-making; nonetheless, conflict does occur. However, the military physician is generally not embedded within a tactical team and does not risk disrupting that specific team dynamic. This seemingly obvious but critically important difference cannot be overstated. Recognition of this difference again raises the question of whether the TPS may or should ethically treat an injured SWAT member before all others.

One approach to answering this question would determine and rank the strength of the duties with which the TPS is faced. There are duties to one's self, one's family, one's team, one's employer and society that are readily identifiable and binding in different ways. These duties are accompanied by duties based upon the unique skillsets derived from a profession and the discharge of those duties to individuals in need. Since the SWAT members act on society's behalf, and in so doing, derive benefit from (emergency inner perimeter care) and provide benefit to (protection while providing care) the TPS, it may be that there is a more binding duty between each of the TPS and the SWAT members than there is between the TPS and any other on-scene individuals regardless of injury. This argument should not be interpreted to mean that the TPS would treat an injured team member with a clearly minor injury (e.g., a sprain) before treating an injured suspect or bystander with a truly life-threatening injury. Instead, the articulated principle may inform a TPS in the circumstance when there is concomitant injury and equal access.

Should A TPS Be A Sworn Police Officer?

It is readily apparent that having the TPS be a salaried employee of the police department would establish a fiduciary responsibility to the department and its members. If the TPS also satisfied the requirements to be a police officer, then concerns with regard to training, firearms, salary, injury compensation, and professional responsibilities would be substantially minimized, and in some circumstances, eliminated. However, there is no substantial precedent upon which one may rely, nor is there generally sufficient available time to appropriately train a physician in a way that would satisfy state regulatory agency requirements. One solution is the establishment of a new police officer designation, a Medical Police Officer. Such an individual would be a practicing physician who would undergo an abbreviated training program in law enforcement with the training focused on tactical teamwork, applicable laws and regulations, and firearm use, as well as an expanded curriculum addressing forensic medicine. This individual could be employed by the police department, and have all of the authorities and responsibilities of a police officer, confined to those required to support tactical team activities. This individual would not participate in routine patrol activities, but would be required to maintain skills and knowledge bases appropriate to the discharge of tactical team duties. No such program currently exists, but creation of such a program could readily be explored as one means to enhance safety, training, and efficacy of the TPS role.