Treating PTSD and TBI…Ethically

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This is the first in a series of posts on the ethical issues associated with treating post-traumatic stress disorder and traumatic brain injury.

These are the two so-called “signature wounds” of our post 9/11 wars. Unlike physical trauma, they can take years to surface. They’re also not as easy to diagnose as typical war wounds. Treating them is going to become a bigger challenge as the wars wind down and the 2.5 million young men and women who served in them come home.

By ethical issues, I mean areas where there are no clear right and wrong answers. There are often competing priorities, depending on whose viewpoint you look through.

By definition, military medical personnel serve two—or more—masters:

— There is the care of the service member.

— There are the needs of the military.

— There are the needs of the United States, including national security, the Congress and the taxpayer.

And physicians have the Hippocratic oath.

Medical ethics normally focus on four principles: autonomy, justice, beneficence and non-maleficence.

In simple terms, they mean: the right of the individual to make his or her own decisions; equal resources for all; do good for your patient; and do no harm. These same principles should be applied to military medical ethics.

Tomes have been devoted to discussion these principles, and it is perhaps dangerous to try develop a reasoned discussion in a post, or a series of posts. But although military physicians discuss these topics constantly, there is less discussion in the public space.

There are at least four ethical areas I would like to ponder:

— Whether to maintain someone in the battlefield or return them home.

— Whether to retain a service member on duty in the military, vs. recommending a medical board (medical discharge).

— Confidentiality, and/or what command needs to know.

— Disability and compensation issues, if diagnosed with PTSD.

These are all highly-charged issues. But I think they need an open, national discussion. I hope to do that here, in the next few posts.


The military's first and foremost mission and priority lies with protecting it's citizensfrom foreign threat. In order to do so, it requires a force both physically and mentally ready to endure the hardships of war. It is not a welfare program. Caring for those with PTSD is often resource intensive As a military health care provider of 13 years, 4 of which spent in combat zones, I can tell you that soldier's diagnosed with PTSD can be heavily burdensome to commanders trying to perform their primary mission of going to war. These troops typically have frequent medical appointments, often have disciplinary issues, both of which detract from the primary mission, decrease cohesiveness amongst their peers as they are not able to contribute to the mission due to inability to deploy, and frequent appointments, and require the attention of the chain of command which ultimately leads to less focus on unit readiness and training. Those diagnosed are absolutely entitled to care, but once a diagnosis is made, that care should not occur while on active duty as caring for these troops often contributes to decreased force readiness

One thing I would like to see discussed more is why we arent doing more to prevent those at greatest risk of suffering PTSD from entering the military. PTSD is not an ailment that affects people randomly, nor is it associated with what kind of horrors people are exposed to. The risk factors are well known and well studied, and the vast majority of those diagnosed with PTSD have pre-existing personality disorders, anxiety/depressive disorders, maladaptive coping skills and frequently were raised in a less-than-ideal home environment with abusive parents, parents with mental health disorders/drug/alcohol abuse or themselves have a prior history of criminal activity or drug abuse. THe military still cannot access medical records of recruits and they rely solely on self-reporting of prior illnesses for entrance physicals. Why we cannot access medical records and screen for those at greatest risk of PTSD upon entrance into the military is unfathomable, especially when recruiters frequently tell troops to not disclose prior medical/mental health problems during their entrance physicals. Screen those at greatest risk and prevent them from being exposed to the horrors of war. Military forces will have healthier/more resilient troops, will have greater time and more troops to accomplish the mission, and taxpayers less disability to have to cover.


...and inevitably there will be those that argue the early separation would be akin to "abandoning" those diagnosed. But one could easily argue that be separating them and allowing care through the VA, without being encumbered by mission tasks/training/deployment is actually doing the patient more good then keeping them in an organization for which they are unable to perform their duties, forcing others to pick up their slack and forcing taxpayers to fund their salary which is no longer being earned. Perhaps the most interesting data related to disability is the fact most veterans getting PTSD treatment from the VA report worsening symptoms until they are designated 100 percent disabled — at which point their use of VA mental health services drops by 82 percent. We have a system that encourages and incentivizes disabilty rather than encouraging overcoming disability


@jdizzle Not only that but the VA is a monster bureaucracy that does not serve GI's the way it should. As a mental health provider I have seen the VA mental health system at some of its worse moments. Having treated vets for 30 years I can say that even the small VA clinics can be full of petty "you-can't-fire-me" despots that run fiefdoms to suit their own desires. With all this need one would think that the VA & Military would streamline the process of getting GI's to mental health providers. But instead I see empty clinics, third party insurance delays, private practices with low census, skilled clinicians sitting idle and GI's and their families in serous trouble. Let's find out what works, model the VA clinics that are effective, audit the ones that are failing and pull in everybody that works with this population and let's get some real therapy done! The need and opportunity is here and now. The president and Congress must act to save lives and families NOW!  Our GI's certainly deserve it!


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