Medical ethics are not a particularly important subject for most people. Most people aren’t nurses or doctors or paramedics, and they certainly are not military medics. Military medics straddle the gray area between soldier and medic because some carry weapons (despite popular belief) and most operate outside the “normal scope” of medicine. By this I mean most are constrained by rules when working in the U.S., yet are given a pretty broad scope of practice once they get to a combat zone.
I was trained as a civilian paramedic and know that paramedics are hog-tied to the rules regarding what he/she can do. Specifically, paramedics are bound to a doctor’s license, and (almost always) have to ask permission before administering any type of medical care that is difficult or risky. Without getting too specific, and without spelling out all the rules for all 50 states, it is safe to say that most paramedics operate only with a doctor’s permission. This makes ethical decisions simpler, because as a civilian nurse or paramedic there is a lot of oversight, there are hard-set procedures within a hospital, and there are a lot of cameras.
Medical ethics are less obvious in combat.
On my fourth tour to Afghanistan, I was intrigued by the side effects of a certain class of pharmaceuticals called Benzodiazepines. This class of drugs contains the popular drug Valium, which as we all know makes people feel groovy and lethargic and good for nothing except binge-watching season one of “True Detective.” This class of drugs also contains Midazolam, which we carried and used regularly for traumatic injuries. We would usually combine Midazolam with an opiate like morphine (which everyone and their mother constantly bug us about since it is the drug of choice in every military movie ever made). Morphine works by making people not care about their pain; Midazolam makes them stop convulsing and become a little sleepy. In regular-people words, that’s about all they do. When used together, they work really well to control pain, relax patients, and get them to the hospital.
Midazolam also has the side effect of causing amnesia, specifically what is known as retrograde amnesia, meaning even after you take it, you might lose memories of the time before you ingested the drug, while you were injured, and even hours afterward. Some studies say it does, others say it doesn’t. There is an entire subsection of the medical industry called the pharmaceutical industry, and that industry lobbies hard to make sure their specific drugs aren’t associated with any unwanted side effects. (DISCLAIMER: Perhaps I am wrong about this exact drug, but even if I am, the argument remains pertinent because there are drugs that produce amnesia. Basically, I’m saying that even if I’m an idiot, this is still a topic worth discussing.)
Amnesia and PTSD have a funny relationship. According to two studies listed here[1][2], there is possibly a link between the development of PTSD and a patient’s ability to remember the traumatic event that caused their injury. This theory has been argued among doctors and scientists who are much smarter than I am, and any interference on my part would only matter if the scientific community wanted a neanderthal’s opinion. Nonetheless, it became a hotly debated topic around the QRF (quick reaction force) tent, and we asked ourselves the same few questions:
- “Would I, as a medic, consider administering a very specific cocktail of drugs in an attempt to erase the traumatic memory (getting shot, blown up, or being caught in a shitty ambush) a soldier had just experienced?”
- “In so doing, could I erase the memories that develop PTSD, and as a result stop the bulk of the PTSD from forming?”
- “Am I charged with such a duty? Or is this morally reprehensible?”
Anyone who has deployed knows that a war zone, the popular centerpiece of brutal state-on-state barbarism, is actually quite boring. Civilians I know ask if it is “crazy” or “just like in the movies,” and my only consistent description has been that is it hot, and that it is also an endlessly calm and dusty workplace punctuated by screaming bouts of terror and confusion. This eternal landscape of bitch-sessions and guard shifts is the perfect melting pot in which to have heated debates about the merits of “playing god” with regards to memories, PTSD, and medical ethics.
In 2010, I rescued a guy who had been shot in the head and fell down a mountain in the process. I’ll leave the specifics vague for everyone’s sake, but suffice to say the bullet grazed his scalp as it rattled through his helmet, shearing off the skin on his head and essentially “scalping” him. When I got to him, I could see his skull. He won a free, all-you-can-take craniectomy (where they cut a square in your skull so that your brain can swell, and then recede back into your head without causing any lasting damage.) He lived, had a full recovery, and is now back to being a bad-ass again. He has no memory of the event, or of events during the week of the event, and I think I know why. First of all, he took a bullet to the face and fell 200 feet down a mountain. That type of concussion could have bruised his brain enough to prevent any memories from forming at all. Second, when he was in the helicopter, we gave him some drugs that should have wiped his memory: Midalozam and morphine. I’m sure the aid station gave him some more, but I can’t be sure.
When the time came to make the decision, I didn’t even hesitate. I considered the options for pharmaceuticals and the recent literature that we had studied regarding amnesia and the usage of Midazolam and morphine. I thought about his company, caught in a firefight below us, and how this day may stand out like a punctuation mark among all the days he spent in this country. I made all these considerations in a fraction of a second, because I was a medic, I was on autopilot, and because those two drugs were the two best we had at the time. So I pushed a Hunter-S.-Thompson-level of meds into this guy and got him to the surgical table.
Years later, he still does not remember the event or the week beforehand. He is a graduate student and well-adjusted. He and I email regularly and are friends, although we have never actually met face-to-face since the incident. Since he has no memories of the incident, he and I (by all accounts) have never met.
When I gave him those drugs, I knew perfectly well that I was making a decision for him that might not be undone. Some people would call that being a bad medic, or taking too much responsibility as a medic. Even some of those more poetic and backward few would call that “playing God.” I call that being a good steward of my battle buddy. If I am ever in the same situation, please do the same for me. I don’t need to be a tormented, all-knowing war hero with a heart of gold who spends his sleepless nights swimming in his own sweat. I’d rather be a happy cow-like buddha enjoying his steak from well inside The Matrix. I don’t need to remember every aspect of when my Stryker hit an IED; I would prefer to be able to sleep at night. Night terrors cause some veterans to commit suicide, and veterans are a demographic that has recently been drawing attention for their rising suicide rates. I am no fool, and I think that anyone can look at the data and conclude to some extent that PTSD, horrific nightmares, and vivid flashbacks are potential outcomes of combat. The only link I would need you to concede is that these results can lead to suicide. Perhaps after some reflection you will begin to agree that the absence of these issues can lead to better outcomes.
I am no longer a medic. I don’t have the passion for it, and after eight years of practice I know that I did my best, but that I had better leave the profession of medicine to those who, when they close their eyes, can see themselves only as a medic. I think medicine is a rare type of calling, one that consumes the individual and can cause a dualistic (or even nihilistic) outlook on life. Using all the blood in the emergency room to save a gang-banger involved in a shoot-out in a residential neighborhood only to have a 10-year-old innocent bystander die a few hours later because of that decision puts a lot of pressure on someone to figure out what they think about medical ethics. It’s a lot of responsibility. And they don’t mention this kind of stuff in anatomy class.
Sources:
[1] Sbordone RJ, Distinguishing traumatic amnesia in closed head injury
[2] Warden DL, Labbate LA, Salazar AM, et al: Post-traumatic stress disorder in patients with traumatic brain injury and amnesia for the event?)
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