I’ve weighed the ethical issues in post-traumatic stress disorder care in my last few posts, focusing on:
— Military medical personnel having dual agency (serving both individual Soldiers and the military at large).
— Deciding when to evacuate and/or return patients to combat.
Now I’d like to focus on a fourth, critical one: unequal access to care for service members.
The good news: with the money that Congress and others have poured into military issues, there are some really great programs for service members with PTSD and traumatic brain injury. These programs tend to serve a relatively small number of Soldiers, Marines and other service members.
The bad news: those small numbers mean access to such good care is highly unequal.
That means some troops needing care get the Cadillac of programs, and some get the stalling (broken) Chevy.
Exhibit A: the National Intrepid Center of Excellence in Bethesda, Md., has a terrific program of intensive evaluation and treatment. So do a few other installations, including the Warrior Resilience Center at Fort Bliss, Texas, and the TBI unit at Fort Campbell, Ky. They have month-long programs where Soldiers receive intensive, evidence-based treatment.
But in most places, these programs do not exist, or, even where they do, the programs are not available to most Soldiers. They may be seen within the access standards of seven days, but then are lucky to be seen once a month thereafter.
The evidence-based therapies, like prolonged-exposure and cognitive-behavioral therapy, require treatment at least once a week, and twice is better.
If a Soldier does not get better, he or she is referred for a medical board, all but inevitably resulting in a medical discharge from the Army. Is that fair, if they have not received adequate therapy?
Which brings us back to the basic principles of bioethics: autonomy, justice, beneficence, and non-maleficence, which I defined in my first post.
The problem is simple, and fundamental: it boils down – there is no other way to put this – to a lack of justice. Our Soldiers today have unequal access to care.
When you sign up for military service, you know beforehand that you’re taking a chance you might take a bullet. But our troops shouldn’t be taking a chance on getting the best medical care – mental as well as physical – once they’re wounded.
The lack of care means that some Soldiers will get better, and others will not. Those who do not get it will be—most likely–separated from the Army, and enter the VA or public mental health system.
This is not at all for the lack of trying on the part of military and civilian medical practitioners. They work incredibly hard, and are often unappreciated for their labors.
Do I have an easy answer here? Of course not. I don’t want to stop our best, state-of-the-art programs. I do want to all Soldiers to get such state-of-the-art treatment.
Unfortunately, I know that many of those who need it are not getting it.