Published by: Eli Kanon
Reviewers: Amelie Benedikt, Robert Fischer, Dean Geuras, Vincent Luizzi, Paul Wilson
“The Moral Landscape of Military Medicie: Describing the Problem of Dual Loyalty” by Sheena M. Eagan Chamberlin
“To Love and Be Loved: The Philosopher’s Epistemological Relationship with the City” by Angela Mistaleski
Sheena M. Eagan Chamberlin, MPH
Institute For the Medical Human”ties
University of Texas Medical Branch
The Moral Landscape of Military Medicine:
Describing the Problem of Dual Loyalty
Military physicians hold two professional identities as members of both the medical profession and the profession of arms. Self-identifying as both a medical doctor and Army soldier introduces the problem of dual loyalties by establishing obligations to two distinct professional moralities. The military and its operations have become an increasingly important issue in recent years, while recent and enduring conflicts have thrust the problem of dual loyalties into the spotlight, prompting much scholarship. This paper will explore and analyze the unique moral landscape of military medicine by focusing on this foundational issue: the problem of dual-loyalty.
Perhaps the most popular example of this recent attention is that given to those physicians involved in the development and implementation of “harsh” interrogation techniques used against prisoners of war, and the alleged abuses that occurred in the course of their implementation. In the well-known book entitled, Oath Betrayed: Torture, Medical Complicity, and the War on Terror, Steven H. Miles explores the problem of medical complicity and involvement in torture and interrogation. The author focuses on three case studies: Afghanistan, Iraq (Abu Ghraib) and Guantanamo Bay, Cuba. While only mentioning the term “dual loyalty” a few times, Miles provides an excellent example of when the twin role of the physician-soldier can lead to ethical conflict.
Miles’ book, based on tens of thousands of pages of government documents obtained by the American Civil Liberties Union (ACLU) through a Freedom of Information Act lawsuit, examines how physicians came to be involved in practices that he constructs as contrary to medical morality. According to the author, “health professionals are accountable for the health of their patients, regardless of the fact of imprisonment.” Miles grounds this accountability, these medical obligations, within the codes of conduct published and supported by international professional medical associations such as the World Medical Association’s Declaration of Tokyo, which states, “the doctor’s fundamental role is to alleviate the distress of his or her fellow men, and no motive whether personal, collective or political shall prevail against this higher purpose.”
Despite this declaration and the general understanding of physicians’ morality as involving obligation to care for individual patients, physicians were intimately linked to the “harsh interrogation” techniques in use in Prisoner of War (POW) camps throughout the Global War on Terror. In fact, medicine was built into the torture system by way of institutional policy. According to Miles, “In 2002, Defense Department attorney Diane Beaver crafted Guantanamo’s request for harsh interrogation, arguing that such techniques were legally permissible ‘with appropriate medical monitoring.’” Thus, non-clinicians saw the use of medicine as being a more humane approach to the issue of harsh interrogation. Similarly, Secretary of Defense Donald Rumsfeld included physicians in his harsh interrogation plans for Abu Ghraib and Afghanistan.
Physicians played 3 significant roles in the system of harsh interrogation, which included, the vetting patients to ensure that they could withstand torture, monitoring of patients during interrogations, and personalizing torture plans according to medical indicators. The third and final role was performed by a group of psychologists and psychiatrists known as Behavioral Science Consultation Teams (BSCTs). These teams were responsible for creating harsh interrogation plans that exploited medical weakness and were informed by psychological knowledge and theory.
The problem of dual loyalty was addressed at an institutional level by positioning the military as the physician’s client, rather than the individual patient. According to Defense Department Deputy Assistant Secretary for Health, Dr. David Tomberg, there was “no doctor-patient relationships for interrogatees.” Thus, the physician is institutionally freed from their medical obligation to the health and welfare of individual patients, by rhetorically redefining the doctor-patient relationship. This line of thought was reinforced by specific policy. “Under Guantanamo’s 2002 policy, medical personnel were obliged to give nonmedical personnel, including members of the BSCT, medical information relative to the ‘national security mission’ upon request.”
Interestingly, these policies do little to resolve the problem of dual loyalties in practice because those in power directly contradicted them. While rejecting the allegations that physicians were involved in these harsh interrogation programs, Assistant Secretary of Defense for Health, Dr. William Winkenwerder Jr., stated, “…we always expected a physician to behave ethically in any circumstance.” This highlights the military’s institutional failure to fully address the problem of dual loyalty, while simultaneously compounding the problem with mixed institutional messages.
These institutional issues surrounding the dual-loyalty problem are what need to be addressed. Scholarly work should push beyond physician complicity with torture and interrogation specifically, to provide a philosophical grounding for the debate surrounding dual loyalties (such as this), and appeal to historical illustrations where military and medical goals conflict. While much has been written on the topic of dual loyalties, little has been done to explore the problem at an institutional level. Much focus has been placed on the individual medical professional, ignoring the larger institutional issues that play an important part in complicating the moral agency of the physician-soldier (or soldier- physician).
The literature is replete with examples of the problem of dual loyalties at the level of the individual military physician, spanning from issues involving patient confidentiality to the rationing of medical care. In order to establish a background understanding of this issue, these examples of the dual-loyalty problem will be briefly explored. Authors discussing dual loyalties within the military often describe the same or similar individual-level examples of ethical conflict involving doctor-patient confidentiality, treatment aimed at returning the soldier to duty and issues involving triage.
The dual-loyalty problem, sometimes called “mixed-agency,” refers to dilemmas that challenge military physicians to prioritize the obligations of one of their professions over the other. These physicians find themselves confronted with situations where military protocol, orders or strategy requires them to behave in a way that is contrary to norms of civilian medical ethics. The military is an ancient profession, with a rich history and long understood social duty. Since the founding of the Army Medical Department in the United States in 1775, military medicine has differed greatly from civilian medicine. Generally these differences were manifested in scale and scope: military physicians, unlike their civilian counterparts, were responsible for the health of large numbers of men, in crowded environments such as camps and transports. By contrast, private practice physicians were largely unfamiliar with the unique medical issues of large populations in crowded environments. However, scope and scale are not the only differences between these two groups of medical doctors. Beginning during the First World War, just after the bacteriological revolution, military physicians and outside critics alike began to discuss what they saw as an ethical dilemma inherent in physician participation in the military and war. Namely, while private physicians were obligated to serve the individual patient, having sworn the Hippocratic Oath and made a public promise, military physicians had also sworn an oath- making the public promise to serve their country and Constitution. During times of war, this meant preparing men to be deployed into war zones that could result in mass death. Military physicians were also subject to military hierarchy, where they were often outranked by men with no medical training and had to adopt an almost utilitarian framework in order to “maintain the fighting force.” Using medical expertise and knowledge to ensure the strength and health of the military as a whole, rather than that of the individual patient, was officially recognized as the mission of military medicine during times of conflict. These conflicting obligations, caused by the twin role of physician-soldier, serve as an excellent example of the problem of dual loyalties.
Treating to Return to Duty
According to military ethicist, lawyer and psychiatrist Edmund Howe, “mixed agency” is and has been among the most significant issues in military medical ethics. One of the most common examples of the problem of dual loyalty is that of “Treating to return to Duty.” At a general level, this refers to the act of returning an injured soldier to battle when he would normally (i.e. in civilian, peace time medical practice) continue to receive treatment. This issue is particularly significant during times of intense combat when soldiers begin to suffer from combat fatigue and post traumatic stress disorder. Combat fatigue is regarded as a psychiatric issue and treated by military physicians, with food and shelter, often referred to as “three hots [hot meals] and a cot [for sleeping]” in military jargon. The ethical question arises in the fact that this treatment is not standard of care for psychiatric stress such as this and places the physician squarely within a situation characteristic of the problem of dual loyalty. Treating and returning to duty goes hand in hand with another well-known and often cited example of the problem of dual loyalties, namely treating to conserve the fighting force. According to Howe, “Military physicians’ obligation to treat soldiers with the goal of conserving the fighting strength is most clearly seen in three arenas: (1) treating soldiers to return to duty; (2) setting treatment priorities in triage situations; and (3) removing unstable soldiers from combat.” Maintaining an adequate fighting force is an instrumental and undeniable component of military strategy especially in wars of attrition. Conserving the fighting force in this way is a main part of the mission of military medicine.
Another significant issue related to the problem of dual loyalty is the violation of patient confidentiality under military order or in support of the military mission. Generally, these cases exist along a continuum and ethicists such as Howe believe that physicians should violate patients’ confidentiality only in some occasions, where the demands of military necessity are stronger. A commonly invoked example involved the “don’t ask, don’t tell” policy that was recently abolished by President Barack Obama. This policy had banned openly gay citizens from active military duty, and would occasionally place psychiatrists in positions that exemplified the problem of dual loyalty. If a patient were to open up to them about their homosexuality, military psychiatrists had an obligation to report them to their commanding officer, as their sexuality violated regulation. This regulatory obligation was problematic to psychiatrists because they felt that medical ethics called for doctor-patient confidentiality, which was breached by this policy. However, in light of recent policy change this example is no longer relevant. That being said, there may be other occasions in which physicians may be compelled to breach confidentiality—such as reporting diseases and illnesses that affect mission readiness or a soldier’s ability to fulfill his or her obligations or duties on the job.
The Case of CPT Howard Levy
There is also a body of case studies representative of the problem of dual loyalty. Robert Veatch contributes one such study, entitled “Soldier, Physician and Moral Man,” from the larger work Case Studies in Medical Ethics. This piece discusses the real-life case of U.S. Army Captain (CPT) Howard Levy, a military physician who felt torn between his twin obligations as a soldier and a physician. CPT Levy’s case centers around his refusal to train Green Beret medics with dermatological skills in Vietnam, skills that would be used for strategic goals including the campaign to win the “hearts and minds” of the civilian Vietnamese population. The use of medicine as a strategic tool represents an example of the dual-loyalty problem at an institutional level.
Veatch’s case study is useful in helping us to understand the moral reasoning of individual practitioners placed in these dual loyalty situations. CPT Levy based his refusal of orders on two specific arguments, one of which focused on his obligations as a medical professional.
1) The order to train the Special Forces was illegal because to do so would require him to participate in the war crimes of the Special Forces in Vietnam.
2) It forced him, as a physician, to violate medical ethics (supported by the Hippocratic Oath)
Levy understood the work of these programs as “prostituting medicine for political and military purposes.” Thus, Levy understood the act of training medics to provide medicine as a strategic tool as in conflict with his professional medical morality. Although he does not use the term “dual loyalty” or “professional medical morality,” his sense of violating medical ethics, as justified by the Hippocratic Oath calls to a sense of professional morality, shared by all physicians and grounded in the act of swearing said oath or publicly joining the profession.
CPT Levy’s position finds issue with the larger non-medical motivation of the refused work. As a member of the Army Judge Advocate General stated, “We sought to use medicine as a means of approaching the enemy and imposing our will on his.” Within the Guerrilla warfare of Vietnam, medicine was seen a necessary and vital component of the military’s strategic mission. “The one great ‘in’ that you have is this medic because people are short on doctors and trained medical personnel in there; that the thing to do is sort of push a medical up there in front and let him get the confidence of these people by treating them…”
This case study is useful in highlighting the perspective and moral reasoning of physicians, which appears to be grounded in a sense of professional medical morality. Similarly, this case emphasizes the differing perspectives present within the institution of the military. Specifically highlighting the differing opinions towards the appropriate use of medicine between non-medical institution-level policy makers and those individual physicians who are supposed to operationalize their policies.
Other Problems of Dual loyalty
Analogies are often drawn between those examples just discussed and the conflicting loyalties that occur in the civilian sector. The editors of the Institute of Medicine’s published workshop summary entitled Military Medical Ethics: Issues Regarding Dual Loyalties acknowledge that this type of dual loyalties problem exists outside of the military sphere, having many civilian analogies:
In occupational medicine, particularly in small corporations, where the physician or nurse reports directly to corporate executives, an injured employee’s desire to return to work in order to obtain full benefits may conflict with corporate productivity goals. In sports medicine, a triad of decision makers—physician, coach, and athlete—typically make a joint decision, based on a full assessment of risks and benefits offered by the physician.
That being said, although this issue is significant for many fields, this paper specifically and exclusively focuses on the relationship between the military and medicine, as it represents a uniquely complicated example of dual loyalties. The military physician differs from the above-mentioned professionals in terms of moral obligations and professional status. Howe points out that “the conflicting obligations military physicians face generally are greater in both magnitude and frequency than those faced by their civilian counterparts.” According to this argument, the main difference is the fact that the stakes in the military are substantially higher. Military physicians practice medicine in the context of war: a context seen as unparalleled in civilian medicine. Due to this fact it is possible that medical decisions could lead to the loss of the war, potentially resulting in many millions of deaths and great harm. Occasions such as that may be rare but are nonetheless real. The context of war coupled with the high stakes accompanying such an endeavor differentiates military problems of dual loyalty from those of the civilian sphere. This difference highlights the ethical dilemmas unique to military physicians.
Beyond that, while practitioners of sport and occupational medicine may be placed in situations that challenge their obligation to care for an individual patient, their other allegiances are not to professions in the same sense as medicine and the military. These physicians have not made a public promise as a member of two distinct professions, entering into specific relationships with inherent moral obligations in the same way as a military physician. As one military physician said, “I took a lot of oaths in a single day… one for the military- to uphold the Constitution, and another for medicine-the Hippocratic oath.” The act of profession, of publicly promising to become a member of a specific profession, with everything that entails, is a foundational component of professional morality. Practitioners of sports medicine, or occupational medicine have only joined the profession of medicine; they have not taken an oath to the non-medical institution they serve. This oath confers both a moral and a legal obligation to follow orders that support the military mission. Beyond that, their second, non-medical roles generally lack the established professional morality of medicine, making medical obligations easier to prioritize over other, non-medical goals. Although other concerns may enter into their decision-making, including job security and pleasing their employer and patient, the second role of an occupational or sports medicine physician does not carry the same moral and legal obligations as those in the military.
The Problem of Dual loyalty & the Military
In order to gain a more complete understanding of the dual-loyalty debate it is important to move beyond the descriptive accounts. Although these descriptions provide useful insight regarding the realities of military medicine, they do not address the underlying assumptions of the dual loyalty problem. Analytical work that moves beyond descriptions of military-medico practices that challenge physicians provides a richer understanding of the dual-loyalties debate by attempting to understand the conflicting loyalties themselves, rather than the activities or manifestations of this dual-loyalties problem.
Philosopher John Moskop has offered a brief examination of the moral status of military medicine in his 1998 article, “A Moral Analysis of Military Medicine,” which sheds light on the morally complicated intersection at which the soldier-physician stands. Here he explains that military physicians assume a set of obligations as physicians (which he characterizes as a fiduciary relationship grounded in the four principles of Beauchamp and Childress) and another as soldiers (as framed by the institution of the military itself). Moskop acknowledges that these obligations may come into conflict and seeks to highlight the important moral decision a physician faces when joining the military. Standing in contrast to other authors who posit the supremacy of one of the physician-soldiers’ twin roles, Moskop recognizes both as having prima facie legitimacy. While acknowledging the moral difficulties of the physician-soldier, Moskop leaves it to the individual to decide his or her own ethical and professional path. According to Moskop, “a physician’s decision to enter military service is thus a morally weighty one that bears reflection on the practices of the military service to which one is pledging obedience.”
The edited work, Military Medical Ethics: Issues Regarding Dual Loyalties–Workshop Summary, published by the Institute of Medicine (IOM) provides substantial analysis of the dual-loyalties issue. The published workshop summary focuses on two case studies, (1) issues related to treating to return to duty, and (2) the treatment of detainees “in ethically charged circumstances, such as a hunger strike.” Aside from the descriptive value of this work, its analysis of the dual-loyalties problem is significant because it turns its focus to the military institution. The IOM workshop, “proceeded from the premise that such conflicts are best brought to light and discussed by military and civilian leaders rather than relegated to individuals to cope with them alone in situations of stress.” This premise is substantial because it highlights the institutional component of this issue. As previously mentioned, the institutional dynamic is often overlooked by the literature. The editors emphasize the importance of ethics training outside the classroom “in a real-world situation, such as aboard a naval hospital ship on a humanitarian mission, offers teachable moments for addressing ethical dilemmas.” This training is important to IOM because it recognizes organizational or institutional values and behaviors as exerting great influence over the actions and decision making of the moral agents working within it. According to the IOM editors, “In the military, the commander sets the tone, as does his or her counterpart in civilian senior management. A just organization exhibits ethical awareness, judgment, and motivation and implements ethical standards.” The IOM emphasizes the idea of a just culture or organization that can be used to instill specific ethical values to those moral agents involved. The workshop summary gives plaudits to the military, which has increased its guidance on medical ethics in the last decade to include an extensive “body of literature, policy and standard operating procedures at the operational level.”
The introduction of the public health ethics model contributes a new dimension to the dual-loyalty debate by grounding it in a philosophical model very different from that of traditional patient-centered bioethics. The analogy between the military and public health was prompted by perceived similarities between military and civilian dual-loyalty issues. “If valid analogies can be drawn between dual loyalty in the military context and in civilian life, then it should be possible to develop a conceptually clear and consistent approach to the problem of dual loyalty.” The contextual analogy here draws comparison between war and a crisis of public health (such as an epidemic or pandemic). This analogy is useful because both involve a similar paradigm shift in ethical thinking and reasoning. The stakes can be high in both contexts, where the survival of millions may literally hang in the balance and require a shift in mind-set from strong individualism toward communitarianism and utilitarianism. After all, public health ethics have long recognized the fact that during serious threats to public health, individual choices may be subordinated to the greater good.
However, despite these contextual similarities this model fails to analyze a significant difference between public health practitioner and those medical professionals who have joined the military. Namely, while doctors may be confronted with similar situations in a public health emergency, such as a pandemic, they have not joined a public health profession beyond medicine with its own inherent obligations (with the exception of the Public Health Service- a uniformed service). Conversely, military physicians have joined two distinct professions. Thus, though contextually similar, this analogy fails upon closer inspection. Of course, this discussion is not meant to dismiss the professional ethics of public health. Public health can be understood as a type of medicine that differs from clinical medicine, which is grounded in obligations to the individual patient. Rather, physicians practicing public health are often understood to abide by a different professional medical morality that while still grounded in ideas of beneficence, looks to population-level, or aggregate concerns. This shift from individual to aggregate is the “paradigm shift in ethical thinking and reasoning” mentioned earlier. Thus, the physician practitioner of public health differs from the practitioner of military medicine. The military remains a unique example of the problem of dual loyalty in which a physician has joined yet another profession, that of arms. The physician-soldier is placed in a uniquely difficult position where the setting is not the only complicating factor in moral decisions. Rather, the main hurdle to moral decision-making is an allegiance to two professional moralities.
Victor Sidel and Barry Levy take an extreme position, namely that there is an ethical conflict that renders the use of physicians by the military objectionable on the grounds of medical morality. These authors believe that it is “morally unacceptable for a physician to serve as both a physician and a soldier in the United States military forces, and probably in other military forces as well.” The authors ground their position in the belief that the “overriding ethical principles” of each of these professions are incompatible with the other. Sidel and Levy define the overriding ethical principles of medical practice as “concern for the welfare of the patient” and “primarily do no harm.” The authors understand these principles to be rooted in the ethical codes of professional organization and further codified in the Geneva conventions and similar international documents. On the other hand, the overriding principles of military service are defined as “concern for the effective function of the fighting force” and “obedience to the command structure.” These are seen as incompatible because a medical morality is understood as necessitating prioritization of the patient above military concerns. Due to this incompatibility, Sidel and Levy believe that the role of the physician-soldier is an “inherent moral impossibility.” They elaborate on their position by way of description of specific ethical dilemmas rather than further analysis of the “overriding principles” they introduced. In this way, their work straddles the line of description and analysis in a familiar way, which fails to address the underlying basis for these medical and military obligations.
As a response to the arguments of Sidel and Levy, other thinkers have gone so far as to posit that there is in fact no problem of dual loyalties for the physician soldier. William Madden and Brian S. Carter have argued that the values are not that different when one explores the essence or ethos of the profession’s moral world. According to Madden and Carter, the ethos of each profession is characterized by the values that define the profession and the professionals, establishing their collective rights and responsibilities. According to these authors, both professions seek protection of the vulnerable, rendering the dual loyalties inherently compatible.
Madden and Carter ground the ethos of medicine in the professional oaths of medicine (such as the Hippocratic Oath and AMA code of ethics), which have historically existed to prevent medical professionals from becoming “agents of death.” Their understanding of professional medical morality is further grounded in social and political policy, which have used “professional, civil, and criminal sanctions to prevent members of the medical profession from becoming involved in activities that led to the deaths of members of their society.” This professional medical morality is discussed in conversation with the morality of the profession of arms, which Madden and Carter see as, “tasked with defending members of that society by becoming directly involved in activities that lead to the wounding or death of others.”
These authors refute the arguments of Levy and Sidel by appealing to medical necessity and a long history of physician’s involvement in war. Physicians have “gone to war” throughout history. Their involvement is necessary because of the very nature and context of war. The unsanitary and overcrowded conditions of war lead to rampant illness and infectious disease, which warrants medical attention. Beyond these conditions, the ability to maintain or conserve the fighting force is paramount to military success, necessitating the skills of a medical doctor.
Importantly, Madden and Carter recognize the physician’s role in the military system in a way other authors fail to. Madden and Carter acknowledge that physicians have become part of the formal military system, joining in the act of profession by swearing the same oath as non-medical officers and wearing the same uniform. These physicians are not just individuals doctoring in the context of war, they are doctoring within the military profession and that institution. Drawing on the work of Samuel Huntington, which will be discussed in detail in chapter three, Madden and Carter enrich the understanding of the profession of arms as one of the historically recognized professions: namely, divinity, law, medicine, and the military.
Madden and Carter define the goals of medicine as “prevention whenever possible; curative treatment when prevention fails; and healing, the relief of pain and suffering, when specific treatment will not benefit the patient.” The goals of the military professional are defined as security. Madden and Carter argue that men and women are “drawn to the profession of arms both by their desire to serve society and by the inherent attraction of the ultimate means of the profession—war.” The authors then trace the professional similarities between medicine and the military. They argue that medicine aims at aiding individuals in maintaining and restoring health or working to ease the patient’s suffering if a cure is not possible. This goal serves society because society benefits from having healthy citizens. The goals of the military also seek to benefit society by protecting it and dissuading others from attacking it. Madden and Carter offer the argument that societies need both of these professions, as they both serve it in preserving its future.
By appealing to the ethos of these professions Madden and Carter appeal to a normative conception of professional morality. In shaping the conception of military morality in this way and understanding the profession of as beneficently protecting society, Madden and Carter are able to frame military morality in a more positive way as compared to Sidel and Levy. This distinction highlights the importance of remembering to maintain both normative theories and descriptive realities in any dialogue of professional morality. The morality of the military profession depends on the morality of the military mission and how that mission is carried out. While some military missions, programs and operations do aim to protect society and uphold constitutional values, there have been historical examples of missions with colonial and imperialistic goals. There are also contemporary cases of military missions charged with protecting corporate interests or on a broader scale protecting markets for the capitalist system. Since the military institution is built on the foundational values of obedience and loyalty, soldiers are trained to uphold the mission and follow orders regardless of whether they agree with the mission. Similarly, the morality of the medical profession depends on morality of the medical mission. There are many physicians whose goals are to care for and cure their patients. Others act in a way that is contrary to normally understood medical morality, instead motivated by profit (only delivering care to well insured patients) or to mismanage patients for personal gain. Although this paper does not attempt to resolve whether each profession’s purported morality is actually moral, the disjuncture between normative conceptions of professional morality and descriptive reality warrants mention.
Regardless of descriptive realities, the truth is that the prescriptive or normative conceptions of these professional moralities may also conflict. The internal morality of medicine demands patient-centered consequentialism, driven by beneficence and non-maleficence. Physicians are supposed to act as advocates for their vulnerable patient, to cure when possible and to care always. The internal morality of the military demands the protection of the nation, service to your fellow soldier, and an obligation to a mission first mentality. Yet, the military physician is not taught how to balance on this precarious ledge. The goals of the mission expect them to prioritize their roles as soldiers, while practicing medicine—a morally problematic predicament and a unique feature of the moral landscape of military medicine.
When physicians were clearly non-combatants in a civilian culture, tending to the sick and wounded of belligerent, armed combatants, regardless of country of origin, protecting and preserving the integrity of the healing arts was less complicated. Today physicians wear the uniforms of their countries, travel imbedded with the fighting forces to intervene and to provide care and treatment to the sick or wounded soldier as quickly as possible with the best expectation of survival.
 Steven H Miles, Oath Betrayed: Torture, Medical Complicity, and the War on Terror (New York, NY: Random House, 2009); Jed Adam and Michael L. Gross Gross, “Caring for and About Enemy Injured [Comment] ” American Journal of Bioethics 8, no. 2 (2008); Mark A Levine, “Role of Physicians in Wartime Interrogations,” American Medical Association Journal of Ethics 9, no. 10 (2007); Robert J Lifton, ” Doctors and Torture,” New England Journal of Medicine 351, no. 5 (2004); SH Miles, “Abu Ghraib: Its Legacy for Military Medicine,” Lancet 364, no. 9435 (2004); Wendy Orr, “Physician’s Duties in Treating Wartime Detainees,” American Medical Association Journal of Ethics 9, no. 10 (2007); M Conant PR Lee, AR Jonsen and S Heilig “Participation in Torture and Interrogation: An Inexcusable Breach of Medical Ethics,” Cambridge Quarterly Healthcare Ethics 15, no. 2 (2006); P.R. Lee, M. Conant, A.R. Jonsen and S. Heilig “Participation in Torture and Interrogation: An Inexcusable Breach of Medical Ethics,” Cambridge Quarterly Healthcare Ethics 15, no. 2 (2006).
 Miles, Oath Betrayed: Torture, Medical Complicity, and the War on Terror.
 Ibid, 65.
 Ibid, 34.
 Ibid, xiii.
 Ibid, 50-51.
 “Torture” is the term used by the author, however there is much debate surrounding whether or not the “enhanced interrogation” technique employed by the U.S. military constitutes torture.
 Miles, Oath Betrayed: Torture, Medical Complicity, and the War on Terror, xiv.
 Ibid, xiv.
 Ibid, 54.
 Ibid, 63.
 Mary C. Gillett,. The Army Medical Department, 1775-1818, (Washington, DC: Center for Military History, 1981), 3.
 Ibid, 1-18.
 Carol R Byerly, Fever of War: The Influenza Epidemic in the U.S. Army During World War I (New York, NY: New York University Press, 2005).
 The official mission of the Army Medical Department (AMEDD).
 Byerly, Fever of War: The Influenza Epidemic in the U.S. Army During World War I.
 Edmund Howe, “Mixed Agency in Military Medicine: Ethical Roles in Conflict,” in Military Medical Ethics, ed. Thomas E. Beam, Linette R. Sparacino, Edmund D. Pellegrino, Anthony E. Hartle and Edmund G. Howe (Washington, DC: TMM Publications, Borden Institute, Walter Reed Army Medical Center, 2003), 333.
 Ibid, 336-337.
 Ibid, 339.
 The official mission of the Army Medical Department (AMEDD).
 Howe, “Mixed Agency in Military Medicine: Ethical Roles in Conflict,” 345.
 Robert Veatch, ” Soldier, Physician and Moral Man,” in Case Studies in Medical Ethics (Cambridge, MA: Harvard University Press, 1977).
 Ibid, 63.
 Ibid, 63.
 Neil E. Weisfeld, Victoria D. Weisfeld and Catharyn T. Liverman, ed. Military Medical Ethics: Issues Regarding Dual Loyalties–Workshop Summary, edited by Institute of Medicine, (Washington, DC: National Academies Press, 2009), 2.
 Howe, “Mixed Agency in Military Medicine: Ethical Roles in Conflict,” 334.
 Participant 8, interview by Sheena M. Eagan Chamberlin, January 31, 2013, transcript.
 Edmund D. and David C. Thomasma Pellegrino, A Philosophical Basis of Medical Practice: Toward a Philosophy and Ethic of the Healing Professions (New York, NY: Oxford University Press, 1981, 81.
 John C. Moskop, “A Moral Analysis of Military Medicine” Military Medicine 163, no. 2 (1998), 76-79.
 The four principles originally put forth by Beauchamp and Childress are autonomy, beneficence, non-maleficence and justice. Tom L. Beauchamp and James F. Childress, Principles of Biomedical Ethics, (New York, NY: Oxford University Press, 2009).
 John C Moskop, “A Moral Analysis of Military Medicine ” Military Medicine 163, no. 2 (1998).
 Neil E. Weisfeld, Victoria D. Weisfeld and Catharyn T. Liverman, ed. Military Medical Ethics: Issues Regarding Dual Loyalties–Workshop Summary (Washington, DC: National Academies Press, 2009), 2.
 Ibid, 9.
 Ibid, 3.
 Ibid, 3.
 Ibid, 29.
 Ibid, 35.
 Solomon R. and Ross EG Upshur Benatar, “Dual Loyalties of Physicians in the Military and in Civilian Life,” Public Health and the Military 98, no. 12 (2008).
 Ibid, 2163.
 Ibid, 2164.
 Victor W. and Barry S. Levy Sidel, “Physician-Soldier: A Moral Dilemma?,” in Military Medical Ethics, ed. Thomas E. Beam, Linette R. Sparacino, Edmund D. Pellegrino, Anthony E. Hartle, and, and Edmund G. Howe : TMM Publications, Borden Institute, Walter Reed Army Medical Center, 2003. (Washington, DC: TMM Publications, Borden Institute, Walter Reed Army Medical Center, 2003).
 William Madden and Brian S. Carter, “Physician-soldier: a moral profession,” in Military Medical Ethics, Thomas E. Beam, Linette R. Sparacino, Edmund D. Pellegrino, Anthony E. Hartle, Edmund G. Howe, eds. (Washington, DC: TMM Publications, Borden Institute, Walter Reed Army Medical Center: 2003), 269-291.
 Ibid, 269-291.
 Ibid, 272.
 Willian and Brian S. Carter Madden, “Physician-Soldier: A Moral Profession,” in Military Medical Ethics, ed. Thomas E.; Sparacino Beam, Linette R., Pellegrino, Edmund D.; Hartle, Anthony E.; Howe, Edmund G. (Washington, D.C.: TMM Publication, Borden Institute, Walter Reed Army Medical Center, 2003).
 Ibid. It is worth noting that the professional status of law, divinity and medicine has been well developed and explored- but little attention has been paid to the professional status of the military.
 There are venues for soldiers to appeal or refuse orders and missions that are illegal and immoral—this will be discussed in chapter three. That being said, many feel as though this does not represent a realistic option and could negatively affect their military career.
 Fritz Allhoff, Physicians at War: The Dual-Loyalties Challenge (New York, NY: Springer, 2008). 39
Benatar, Solomon R. and Ross EG Upshur. “Dual Loyalties of Physicians in the Military and in Civilian Life.” Public Health and the Military 98, no. 12 (2008): 2161-66.
Byerly, Carol R. Fever of War: The Influenza Epidemic in the U.S. Army During World War I. New York, NY: New York University Press, 2005.
Gross, Jed Adam and Michael L. Gross. “Caring for and About Enemy Injured [Comment] ” American Journal of Bioethics 8, no. 2 (2008): 3-12.
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University of Dallas
To Love and Be Loved: The Philosopher’s Epistemological Relationship with the City
Michael Polanyi, a Hungarian chemist and philosopher, was shaped by the influence the Union of Soviet Socialist Republics (USSR) had on his life and community. Much like Plato, whose philosophy came to focus on the trial and death of his teacher, Socrates, Polanyi illustrates the necessary connection the philosopher, the scientist, or intellectual elite has with his or her city. Eros, or the love of wisdom, drives the most passionate of intellectuals into the city, far from reclusiveness. Polanyi describes the philosophical quest for “the true sense of objectivity” as a love that requires both passion and devotion to eternal truth. First, I will explain how the love of wisdom equips the philosopher with seemingly self-sufficient resources and yet, also leaves the philosopher in incredible poverty. Then I will address how this dual character of eros, poverty and resource, is reconciled in the city. The love of wisdom leaves a philosopher in incredible need of the city and at the same time a great benefactor.
The resourceful side of the eros-driven quest for objectivity at first appears to alienate the philosopher from the city. Skill or talent creates an impression of independence. Socrates says through the voice of Diotima, “On his Father’s side, [Love] is… resourceful in his pursuit of intelligence, a lover of wisdom through all his life, a genius with enchantments, potions, and clever pleadings.” Polanyi also describes an independent resourcefulness: “To select good questions for investigation is the mark of scientific talent.” A lover of knowledge is equipped with a knack for philosophical pursuits in a way that suggests self-sufficiency. One’s skill and clever proceedings are one’s own.
Further, as a “schemer after the beautiful and the good,” the very object of a philosopher’s knowledge suggests a separation from the city and its concern for everyday life. As Polanyi describes, objectivity “claims to establish contact with reality beyond the clues on which it relies.” Much like Plato’s forms, objectivity is universal and eternal. The notion that “truth lies in the achievement of a contact with reality” implies that life happening around us, “the clues,” is not the immediate reality the philosopher or scientist seeks.
To better understand how the search for objectivity may separate a philosopher from the city, one may turn to the resulting criticisms of such philosophical endeavors. In his Genealogy of Morals, Nietzsche problematizes the character of objectivity, or absolute truth: “The truthful man… thereby affirms another world than that of life, nature, and history; and insofar as he affirms this ‘other world,’ does this not mean that he has to deny its antithesis, this world, our world?” By proclaiming a scientific theory or a moral good as objective and therefore universal, one simultaneously denies that the matter could be left to an individual, to either alter or abolish. The truth of the proclamation stands by itself, regardless of life’s particulars, and so it appears impersonal, or “life-denying.” There is a hint that Plato himself recognized static lifelessness as a problem with his own theory of the forms, or “that which wholly is,” in the Sophist. The Visitor asks:
“But for heaven’s sake, are we going to be convinced that it’s true that change, life, soul, intelligence are not present in that which wholly is, and that it neither lives nor thinks, but stays changeless, solemn, and holy, without any understanding?”
To which Theaetetus responds, “If we did, sir, we’d be admitting something frightening.” Life does not appear to the people of the city in broad strokes of absolute truths. The city is preoccupied with the particulars of war, commerce, and law. The philosopher longs to crawl outside of the cave, but the statesman’s jurisdiction remains within the shadows.
Frightening to the city indeed, it would appear as though Plato’s conception of true knowledge is static and wholly above the world of experience. Aristophanes crudely criticizes Socrates and his followers for being ignorant of and hazardous to the city in the Clouds. Socrates is shown as a buffoon, his head too high in the clouds to know the simplest of common knowledge, which is crucial to the city: he is unable to locate Sparta on a map; he sleeps in flea-ridden beds; and he undermines familial relations, the gods, and attachments to the city, which people love most as being a part of this world—in other words, what is one’s own. As the political philosopher Leo Strauss suggests, Aristophanes’ charge is that philosophy, unlike poetry, is “unerotic and a-music… Philosophy is blind to the human things as experienced in life, in the acts of living.” Philosophy appears to be incompatible with the city because it is not concerned with the lives of the people over which the city governs.
However, this portrayal of the philosopher is only one-sided. Any few pages of Plato’s dialogues reveal that he is a dynamic and earthy philosopher—one who is not so lofty as to forget the hangovers from the night before or to not be interrupted by hiccups. Allan Bloom, inspired by Plato’s Symposium says, “Socrates is the most erotic of the philosophers.” The dialogue captures intellectual beauty, never drifting far from the sensuous experience of love.
To view the philosopher as self-sufficient and above the city is to forget the impoverished side of the eros-driven quest for wisdom. Love is not simply born of poros, resource, but also of penia, poverty. A fundamental poverty first moves the philosopher to inquire. In other words, one searches for an answer because one does not have it. The lover of wisdom is then not wholly self-sufficient. Necessity underlies Aristophanes’ account of love in the Symposium. He explains the myth that at the beginning of time every human being was united as one with another, until human pride made Zeus angry. Zeus punished the human beings by having each one sliced in half, “the way people cut sorbapples before they dry them,” so that every half is as we are now, left searching and yearning for the other half. Similar to Plato’s theory of recollection, which suggests that knowledge of the forms comes from knowledge one already has from one’s immortal past, one has a longing for something missing that one once had. “When the person meets the half that is his very own… the two are struck from their senses by love, by a sense of belonging to one another.” Just as one recognizes a lover, one is able to recall the form of “Equality itself” after being reminded by seeing two sticks similar in length. The discovery of truth is like the first embrace between two lovers.
Curiously, when a philosopher finds an answer, he or she still continues to search for more. A lover of wisdom is always lacking. Aristophanes makes it a point to mention that not only are two lovers struck with the sense that they belong together, but that they also desire each other. The two lovers continue to desire one another, even after they have each other. A lover is not simply fulfilled by finding the beloved; He or she wants to be with the beloved forever. A lover cannot have enough of the beloved. This idea is continued through Socrates’ account of love. Diotima describes love as “always poor… tough and shriveled, shoeless and homeless, always lying at people’s doorsteps and in roadsides under the sky.” Like a homeless wanderer, the philosopher never reaches the completion of his or her pursuit. Intellectual satisfaction must come from elsewhere. As Polanyi says, “So that [the scientist’s] triumph lies precisely in his foreknowledge of a host of yet hidden implications which his discovery will reveal in later days to other eyes.” The heuristic passion for discovery finds fulfillment in the possibility for new knowledge, even knowledge that one’s self may never find, not in the sense that one’s knowledge is complete. There is always more to learn. The love of wisdom, by its very nature, is lacking.
This duality of the eros-driven quest for truth, resource and poverty, is reconciled in the city. Poverty requires the city, while resource necessarily overflows to support the city’s societal structures. Intellectual discovery presupposes the foundations of the community, tacit components of culture, such as modes of communication and a general ability to trust others, which the laws of a city seek to uphold. Polanyi believes in the “interpersonal coincidence of tacit judgments,” which makes language possible, and the “mute interaction of powerful emotions,” which become the backbone of the ability to submit to authority for the cultivation of knowledge from one generation to the next. Knowledge is passed on through imitation, which relies on basic structures of trust formed by the emotional bonds between parent and child. More complex intellectual knowledge is transmitted, “when one person places an exceptional degree of confidence in another.” Scientific discoveries require that the “affiliation begins with the fact that a child submits to education within a community, and it is confirmed throughout life to the extent to which the adult continues to place exceptional confidence in the intellectual leaders of the same community.” Such an act of submission, as a granting of personal allegiance, depends on heuristic passion; it is the “passionate pouring of oneself” into the pursuit of intellectual discovery.
The city is also necessary for the longevity and progress of philosophical knowledge. Socrates’ speech in the Symposium declares that love longs to be immortal. It is pregnant, in both body and mind. Through reproduction, love “always leaves behind a new young one in place of the old.” Love is not kept to one’s self. It describes a relationship, and thus it requires an “other.” Socrates critiques Agathon’s speech by asking, “Is love the love of nothing or of something?” Socrates illustrates the question by pointing out examples of love in familial relations, especially between parent and child. This illustrates not only the need of the intellectual to “give birth” to one’s ideas so that they may become immortal, but also one’s dependence on future generations for one’s idea to live on and one’s debt to generations past for the knowledge one first had to have inherited.
Philosophical progress requires generational bonds more specifically through the roles of master and pupil. The philosopher does not set out to discover on one’s own. Even Epicurus, who unlike Plato, secludes himself away from the city, sees an inherent importance in the bonds of friendship to the intellectual pursuits. Plato may search for the separate unchanging reality of the forms, but he always begins his inquiries with the opinions of those around him. His philosophy, rather than being straightforward treatises or introspective works, depends on dialogue with others. He explains in Letter VII, “For this knowledge is not something that can be put into words like other sciences; but after long-continued intercourse between teacher and pupil, in joint pursuit of the subject, suddenly, like light flashing forth when a fire is kindled, it is born in the soul and straighway nourishes itself.” The relationship between a student and a teacher keeps alive the fiery passion for the pursuit of knowledge. Even when the lure of a theory like relativity has gotten old, Polanyi suggests that its teaching continues to incite a passion in new learners who rediscover its beauty. Polanyi especially outlines the importance of a community of teachers and learners in his discussion of tradition. While some knowledge can be taught through explicit statements, nothing can replace the tacit learning involved in a student learning by example of his or her teacher. He cites as examples craftsmanship, which survives only in small local areas, and the notion that scientific communities in Europe where the scientific method was first formulated are still more advanced today than other areas with more money. Personal contact between lovers of the same knowledge is necessary both in order to preserve old discoveries and also to better facilitate new ones.
The crucial role of the community in providing for tacit knowledge, and the longevity and progress of ideas would not be possible without the city. The city provides the atmosphere of trust and communications through both its foreign defense and domestic policies. It provides security to invest in future generations. Without the city providing defense and standards of commerce, the leisure time required for study would not exist in the first place. Rather than spend time in the thinkery, the philosopher would have to spend time growing food or warding off enemies. Laws and court systems are further required to secure avenues of philosophical discussion against injustices, which may cause suppression of thought or general mistrust.
In other words, the philosopher needs a city that allows him or her to share with the community. The love for knowledge includes the passion to share that knowledge in order to strengthen it against encroaching doubts. At the heart of great philosophical debates or great professors is the fulfillment of this need through writing and teaching. Polanyi explains that the heuristic passion, which first prompted the discovery of a certain piece of knowledge necessarily overflows into a persuasive passion. This is inherent in the very character of discovering hidden reality. A piece of objective truth “raises a claim and makes a tremendous demand.” The claim, as universal and eternal, requires that other men also submit to it. The claim loses its strength as an inherent quality that all rational men should assent to if other men refuse to assent to it. When others remain opposed or indifferent to the topic, what ensues is what Polanyi describes as a sort of suffering: “For a general unbelief imperils our own convictions by evoking an echo in us.” Consequently, “Our vision must conquer or die.” Socrates is the icon of a philosopher who suffered the consequences of sharing a philosophy at odds with the city. The gadfly is not content keeping his knowledge, or at least the knowledge that he knows he does not know, to himself. He sits outside in the Agora all day questioning the actions and beliefs of all the Athenian leaders as well, but he does not conquer the city. He is brought to drink the hemlock.
The philosopher’s love of truth promotes a way of life that demands a responsibility to the city, making it a beneficiary of the resourceful side of philosophical love. An eros-driven pursuit of knowledge does not equate to a sort of intellectual isolation or selfishness. It becomes a way of life directed at moral virtue. Polanyi observes a “dual satisfaction” for contemplation as well as the practice of one’s science. He makes this point in order to stress the need for the capacity to contemplate, but the dual character suggests that emphasis could be asserted in reverse. One cannot have a proper capacity for contemplation without the experience of application. It is perhaps for this reason that Diotima says to the young Socrates, “But by far the greatest and most beautiful part of wisdom deals with the proper ordering of cities and households, and that is called moderation and justice.” Supporting the life of the city is the application of The Good, The True, and The Beautiful at its highest level. One does not wish to simply assert that such things exist, or cultivate them in isolation only for one’s own soul, one also desires to live among them, “to go about seeking the beauty in which to beget.” To live among them requires effort on the part of those who aspire to know them to create a city in which the philosophical soul may be capable of living a virtuous life. Similarily Polanyi says, “Love of truth and of intellectual values in general will now reappear as the love of the kind of society which fosters these values.” Perhaps it was this realization that led Socrates out to the Agora each day.
The polis can be viewed as the recipient of Plato’s philosophical eros through the lens of Socrates’ death. Jan Patočka, a Czech philosopher and, like Polanyi, an adversary of the intellectual conditions he was forced to live under in the USSR, argues that Socrates left Plato a philosophical program to redeem his city—to make it the sort of place where “Socrates and those like him will not need to die.” The real tragedy in Socrates’ death, explains Patočka, was for the community: “for it showed its blindness, its incapacity to see both its own duty and what the community could be in general and what it ought to be.” A passionate concern for the city around him must have prompted Plato to create some of his most enduring works, such as the Apology, the Phaedo, and the Republic. Socrates may have had to drink the hemlock, but his voice lived on through Plato’s writings and continues to better political institutions through their academics today.
Polanyi also exhibits a responsibility to his community that is integral to his intellectual passion. His passionate passages and tangents on Marxism, as well as almost an entire chapter (“Conviviality”) motivated by the subject, reveal a deep-seated concern for the intellectual conditions propagated by the political atmosphere of his time. Richard Allen explains Polanyi’s thought: “All continuing pursuits and practices, such as the arts and sciences, not only require trust and shared interests among their participants but also from society at large.” Even in the midst of heavy intellectual debate, a responsible and honest quest for the truth requires basic convictions and common ground to appeal to in order to maintain a civil atmosphere based on trust. Polanyi appeals to the guidance of “intellectual leaders” and emphasizes the importance of such leaders in maintaining institutions that foster such environments. Without the responsibility of such intellectual leaders to their societal institutions the ability to pursue and trust in objectivity would be severely undermined.
The philosophical love of wisdom brings one to an active life in support of the intellectual atmosphere of one’s community. The objectivity—the hidden reality—that one seeks is far from detaching one from our world. On the contrary, the philosopher’s knowledge and natural resources, which acquaint one with higher principles, allow one to better recognize them in the people and things in our world. While the city may rely on the philosopher to perpetuate an atmosphere of intellectual progress, the philosopher continues to rely on the city. Consequently, the love of wisdom, characterized by resource and necessity, can be seen as culminating in the city. Love is two-sided. The philosopher loves by his or her resource and is loved in turn by necessity.
 Michael Polanyi, Personal Knowledge: Towards a Post-Critical Philosophy, (Chicago: University of Chicago Press, 1962), at 64.
 Plato, Symposium, in Plato: Complete Works, Ed. John M. Cooper, Trans. Glenn R. Morrow, (Indianapolis: Hackett, 1997): 457–505, at 203.
 Polanyi, Personal Knowledge, 30.
 Polanyi, Personal Knowledge, 64.
 Friedrich Nietzsche, On the Genealogy of Morals, Trans. Walter Kaufmann, (New York: Random House, 1967), at 152.
 Plato, Sophist, in Plato: Complete Works, Ed. John M. Cooper, Trans. Glenn R. Morrow, (Indianapolis: Hackett, 1997), at 249a.
 Leo Strauss, On Plato’s Symposium, (Chicago: University of Chicago Press, 2001), at 6.
 Allan Bloom, “The Ladder of Love,” in Plato’s Symposium, (Chicago: University of Chicago Press, 2001): 55–179, at 55.
 Plato, Symposium, 189e–192b.
 Ibid., 192c.
 Plato, Phaedo, in Plato: Complete Works, Ed. John M. Cooper, Trans. Glenn R. Morrow, (Indianapolis: Hackett, 1997):, at 74a–d.
 Plato, Symposium, 192c.
 Ibid., 203d.
 Polanyi, Personal Knowledge 64.
 Polanyi, 205, 207.
 Ibid., 207.
 Ibid., 207.
 Plato, Symposium, 207d.
 Ibid., 199d.
 Plato, “Letter VII,” Plato: Complete Works, Ed. John M. Cooper, Trans. Glenn R. Morrow, (Indianapolis: Hackett, 1997): 1646–1667, at 341c.
 Polanyi, Personal Knowledge, 172.
 Polanyi, 53.
 Ibid., 150.
 Ibid., 150.
 Ibid., 53–54.
 Socrates, Symposium, 209b.
 Ibid., 209b.
 Polanyi, Personal Knowledge, 203.
 Jan Patočka, Plato and Europe, (Stanford, CA: Stanford University Press, 2002), at 110.
 See for example, during a discussion on scientific value: “Marxism, equipped with only the flimsiest scientific characteristics.” Polanyi, Personal Knowledge, 139.