In this Issue

21st century Special Operations Force medicine meets Iraqi culture

The author describes an ethical dilemma he experienced while deployed in Iraq and the associated cultural competencies, moral obligations and medical responsibility inherent in the Hippocratic Oath.

By Maj. Larry Wyatt

Medical professionals' obligation to uphold the Hippocratic Oath can intersect with local social taboos, often resulting in ethical conflicts. Comprehending foreign customs and culture can be difficult, can be excruciatingly complex, and is further strained in a combat environment. As a Special Forces (SF) Physician Assistant (PA), I have stood at these moral crossroads when cultural restrictions prevented me from touching an exsanguinating patient. This situation both mystified and infuriated me and raised ethical considerations that have confused me for years. Soldiers have engrained experiences from combat; many are tragic, and some are more positive.

An experience of mine describes this clash of 21st century medicine with Iraqi culture, and is one of my most confusing clinical experiences. Although bleeding and in shock, an Iraqi woman would not allow two of my SF medic (18 Delta [18D]) colleagues or me to touch her in order to render postnatal medical care. She had been bleeding for approximately 6-8 hours. The ethical dilemma and circumstances surrounding the medical situation caused me to repeatedly reevaluate and reassess my moral stance, cultural differences, ethical ramifications, and medical decisions. Therefore, I see it as necessary to describe this encompassing ethical dilemma and the associated cultural competencies, moral obligations, and medical responsibility inherent in the Hippocratic Oath. Additionally, I describe the internal conflicts we experienced as a band of Iraqi village women — presumably defending their culture — refused our efforts to render aid.

In the winter of 2008, during a mission in the Hamrin Mountains, SF soldiers captured several targets for questioning. Tensions are typically high when conducting such operations, as security is always balanced with the desire to minimize negative local perception of our actions. During this operation, our Sergeant Major yelled "Doc, a woman is having a baby in one of those huts!" We recognized the opportunity to render assistance. Upon arrival at the small mud hut home, I found two of my 18D colleagues distraught: They were caught in an ethical and emotional conundrum in which they were unable to make a positive impact on the clinical outcome of a postnatal Iraqi woman.

This woman had had been bleeding continuously since giving birth 6-8 hours prior. She had not been able to feed her obviously hungry and crying baby since delivery. The other village women, to include the presumed matriarch, would not allow us to help her. The interpreter told us that if the women allowed us to place our hands on her to control bleeding, upon his release from questioning, her husband would kill her. The cultural taboo against another man touching someone else's wife was strong enough to prevent us delivering care, even at expense to her life.

At its core, this Western, Hippocratic ideal of "first, do no harm" morphed into "do nothing and the patient dies." Through our interpreter, we were able to convince the matriarch that intravenous infusion would be of great benefit if she would allow us to help stop the bleeding first. Two 18D colleagues and I pooled our resources of Kerlix bandages together and told the interpreter to explain to the matriarch what had to be done. Soon after that conversation, we were forced out of the hut so the women could stop the bleeding.

Upon reentering the hut, we noted that approximately half of the Kerlix bandages had been used to clean the already pooled blood off the floor, and we could only hope that the other half had been used for what they were originally intended. The 18Ds established intravenous access, and they infused two bags of fluid that had an immediate impact on her blood pressure and overall clinical status. Throughout the entire process, the temperament of the village women was very unsettling. We left instructions with the matriarch and the rest of the Kerlix bandages. The patient's blood pressure was stable and much better than when we initially arrived. She was sitting up and conversing with the matriarch and the other village women when we left. We had also found out that this was her fourth child.

As a Special Operations Forces (SOF) clinician and soldier, I still think about that woman. I wonder whether she and her infant survived the immediate postnatal and postpartum period. More pressing is wondering if her husband exercised his cultural "right" to punish her, and if we did the right thing. Ethical decisions versus customs and cultures of another country are how I delineate the decisions made that day. Although certainly debatable, in ethically justifying our actions in my own mind, I thought of "consequentialism in which rightness is based on the consequences of an act rather than the act itself" ("Consequentialism," n.d.). Our intentions were of the highest order, to save her life.

In reflection on our Hippocratic and moral obligations, I wonder if our restraint to not render aid where we knew it was warranted was ethically appropriate. Most SOF clinical providers, especially 18Ds, have experienced morally ambiguous and traumatic situations when treating combat casualties. During my experience as a SOF PA, I have placed emergency airways; have treated numerous burns, shrapnel and traumatic brain injuries; have sewn hundreds of sutures; and have treated high-velocity missile injuries during many tours in Iraq. However, those traumatic situations were the direct result from war, not a noncombatant postnatal woman bleeding out on the floor of her mud home in the mountains of Iraq, who refused treatment from fear that her husband would kill her (because of their culture). The Hippocratic Oath states, "I will remember that I remain a member of society with special obligations to all my fellow human beings, those of sound mind and body as well as the infirm" ("Hippocratic Oath," n.d.). I took this Oath 15 years ago when I became an 18D and again as a SOF PA. The meaning continuously resonates within me and made me take a hard look at the decision I made that day in attempting to help another human being.

Part of me wanted to push past the matriarch and the other Iraqi women to get to my patient and help her, regardless of what the second and third order effects would be. However, the patient also refused care as the interpreter tried to convince her that we were there to help her. "Most especially must I tread with care in matters of life and death. If it is given to me to save a life, all thanks. But it may also be within my power to take a life; this awesome responsibility must be faced with great humbleness and awareness of my own frailty" ("Hippocratic Oath," n.d.). Helping too much could have cost the woman her life at the hands of her own husband. Not helping at all could have cost the woman her life by exsanguination. Did we do enough?

The disturbed feeling of helplessness and internal conflict in treating the bleeding Iraqi woman was reduced as my attention became focused on the newborn baby. For reasons unknown to us, the matriarch would not allow 18Ds or me to see the newborn baby. My concern was when the baby would be fed, especially if the mother did not survive. Through the interpreter, I explained to the matriarch that if we could get the bleeding mother to breastfeed, this could stimulate uterine contractions and thereby decrease or possibly stop the bleeding. I kept trying to make an accurate assessment of the amount of blood loss in the blankets and on the floor from the bleeding woman, but the matriarch was adamant about keeping my men and me at bay.

The mother refused to breastfeed her newborn baby. This was a new problem to address. The quickest resolution to the problem that was easily attainable was the old world "wet nurse" concept. Through the interpreter, I asked the matriarch if there was a new mother in the village. She understood the idea and sent for her immediately. The young new mother arrived and agreed to feed the newborn baby. The internal conflict and feeling of helplessness was somewhat subdued by knowing that my 18D colleagues and I had made some impact on the immediate needs of the newborn baby. Our perseverance paid off and allowed for this simple but viable option. Although their customs initially rendered our medical training useless, our critical and creative thinking and diplomacy allowed some level of care delivery.

As a result of 11 years of continuous war, military medicine has experienced incredible technological advancements in trauma management. The constant influx of new products and advanced training has dramatically improved patient survivability from point of injury to a higher echelon of medical care. However, some challenges cannot be addressed through technology or medical training alone. Sometimes, even cultural awareness and a broad spectrum of interpersonal skills are not enough. SF soldiers are our nation's military ambassadors. We are linguistically and culturally diverse in our specific areas of operation, and we have many skills sets, five primary functions and multiple other special duties. We take pride in our cultural sensitivity and ability to work by, with, and through foreign customs, but we still face great challenges regarding gender-specific cultural restrictions.

In conclusion, retrospectively, after analyzing this scenario multiple times and conducting my own internal after action review, the only idea that continuously presents itself as a viable option is that having a female provider/medic available could have negated all of this. The difficulty is foreseeing this type of problem occurring. A female medic assigned to a company-sized SOF mission in an Arab nation could be a great benefit, not only in helping American Forces win the hearts and minds but, even more importantly, in helping save a human life.

My own professional medical judgment to render aid to another human being was brought into question in this situation. Our medical judgment had to take the customs and culture of a tribal village in the Hamrin Mountains of Iraq into consideration or take the risk that our actions would result in the murder of a mother, further damaging any future relationship. The SF community has to take customs and culture into consideration, and it is not our position to question them. As military ambassadors, the SF community must work creatively within the limitations set forth by the culture in which we are immersed. Our limitations were apparent within the cultural differences that day: between what we expect to be the norms of our society and what the matriarch and Iraqi village women knew to be their own ways.

References

Consequentialism. (n.d.). In Wikipedia. Retrieved July 22, 2012, from http://en.wikipedia.org/w/index.php?title=Consequentialism&oldid=498759076

Hippocratic Oath. (n.d.). In Wikipedia. Retrieved July 22, 2012, from http://en.wikipedia.org/w/index.php?title=Hippocratic_Oath&oldid=503405141

About the Author

Maj. Larry Wyatt is a Special Operations Forces Physician Assistant with 10 years of experience. Prior to Command and General Staff College he served as the 5th Group Dive Medical Officer and is an Aeronautical Physician Assistant. He has a bachelor's degree in health science and a master's degree in physician assistant studies. Maj. Wyatt has more than four years of combat deployments into Iraq and multiple deployments throughout Central and South America as a prior Special Forces Medic (18D).

Mourning the loss and memory of our fallen brothers in arms, I am not holding my daughter "Jade" up; she is holding me up!

Acknowledgment

Eric Morrison, PhD, Director, National Center for Research and Practice in Military and Veteran Psychology, The Chicago School of Professional Psychology, was the editor of this article.