Conflicting values - everyday ethical and leadership challenges related to care in combat zones within a military organization

Introduction: Licensed medical personnel (henceforth LMP) experience ethical problems related to undertaking care duties in combat zones. When employed in the Armed Forces they are always under the command of tactical officers (henceforth TOs). Aim: The overall aim was to explore everyday ethical problems experienced by military medical personnel, focusing on licensed medical personnel in combat zones from a descriptive and normative perspective. A further aim was to explore leadership challenges in leading licensed medical personnel. Methods: For the research descriptive, explorative (inductive and abductive) and normative designs were used. Data collection was undertaken by using different methods. Altogether 12 physicians, 15 registered nurses, seven combat lifesavers and 15 tactical officers were individually interviewed. The participants were selected by strategic (I), purposive (II) and theoretical sampling (III). The interviews were analyzed by using qualitative content analysis. Study III used classic grounded theory and study IV was a normative analysis of an ethical problem based on the idea of a wide reflective equilibrium. Results: We found that LMP experience ethical problems related to dual loyalty when serving in combat zones. They give reasons for undertaking, or not, military duties that can be seen as combat duties. Sometimes they have restricted reasons for undertaking these military duties. Furthermore, LMP are under the command of TOs who found it challenging when leading LMP, since TOs have to unify LMP in the unit. The unifying makes it difficult since LMP experience dual loyalty. Conclusions: LMP experience dual loyalty in combat zones. The reason maybe that humanitarian law and the medical ethical codes are not clear-cut or explicit about how to be interpreted around these everyday ethical problems in internal military operations. In order to fit in todays context humanitarian law needs to be revised. Furthermore, LMP need further training in parallel with reflections on ethical problems in order to adapt to the combat zones of today