Cynthia M.A. Geppert, MD

Like me, some of you may have been following the agonizing news about the unprecedented brushfires in Australia that have devastated human, animal, and vegetative life in that country so culturally akin to our own.¹ For many people who believe the overwhelming majority of scientific reports on climate change, these apocalyptic fires are an empirical demonstration of the truth of the dire prophecies for the future of our planet. Scientists have demonstrated that although climate change may not have caused the worst fires in Australia’s history, they may have contributed to the conditions that enabled them to spread so far and wide and reach such a destructive intensity.²The heartbreaking pictures of singed koalas and displaced people and the helpless feeling that all I can do from here is donate money set me to thinking about the relationship between the military, health, and climate change, which is the subject of this column.

As I write this in mid-January of a new decade and glance at the weather headlines, I read about an earthquake in Puerto Rico and tornadoes in the southern US. This makes it quite plausible that our comfortable lifestyle and technological civilization could in the coming decades go the way of the dinosaurs, also victims of climate change.

Initially, my first thought about this relationship is a negative one—images of scorched earth policies that stretch back to ancient wars jump to mind. Reflection and research on the topic though suggest that the relationship may be more complicated and conflicted. Alas, I can only touch on a few of the themes in this brief format.

It may not be as obvious that climate change also threatens the military, which is the guardian of that civilization. In 2018, for example, Hurricane Michael caused nearly $5 billion in damages to Tyndall Air Force Base in Florida.³ A year later, the US Department of Defense (DoD) released a report on the effects of climate change as mandated by Congress.⁴ Even though some congressional critics expressed concern about the report’s lack of depth and detail,⁵ the report asserted that, “The effects of a changing climate are a national security issue with potential impacts to Department of Defense (DoD or the Department) missions, operational plans, and installations.”⁴

The US Department of Veterans Affairs (VA) is not immune either. Natural disasters have already disrupted the delivery of health care at its many aging facilities. Climate change was called the “engine”⁶ driving Hurricane Maria, which in 2017 slammed into Puerto Rico, including its VA medical center, and resulted in shortages of supplies, staff, and basic utilities.⁷ The facility and the island are still trying to rebuild. In response to weather-exposed vulnerability in VA infrastructure, Senator and presidential candidate Elizabeth Warren (D-MA) and Senator Brian Schatz (D-HI), the ranking member of the Subcommittee on Military Construction, sent a letter to VA leadership arguing that “Strengthening VA’s resilience to climate change is consistent with the agency’s mission to deliver timely, high-quality care and benefits to America’s veterans.”⁸

It has been reported that the current administration has countered initiatives to prepare for the challenges of providing health care to service members and veterans in a climate changed world.⁹ Sadly, but predictably, in the politicized federal health care arena, the safety of our service members and, in turn, the domestic and national security and peace that depend on them are caught in the partisan debate over global warming, though it is not likely Congress or federal agency leaders will abandon planning to safeguard service members who will see duty and combat in a radically altered ecology and veterans and who will need to have VA continue to be the reliable safety net despite an increasingly erratic environment.¹⁰

Climate change is a divisive political issue; there is a proud tradition of conservatism and self-reliance in military members, active duty and veteran alike. That was why I was surprised and impressed when I saw the results of a recent survey on climate change. In January 2019, 293 active-duty service members and veterans were surveyed.

Participants were selected to reflect the ethnic makeup, educational level, and political allegiance of the military population, which enhanced the validity of the findings.¹¹Participants were asked to indicate whether they believed that the earth was warming secondary to human or natural processes; not growing warmer at all; or whether they were unsure. Similar to the general population, 46% agreed that climate change is anthropogenic.¹¹ More than three-fourths believed it was likely climate change would adversely affect the places they worked, like military installations; 61% thought it likely that global warming could lead to armed conflict over resources. Seven in 10 respondents believed that climate is changing vs 46% who did not. Of respondents who believe climate change is real, 87% see it as a threat to military bases compared with 60% who do not accept the science that the earth is warming.¹¹

This survey, though, is only a small study, and the military and VA are big tents under which a wide range of political persuasions and diverse beliefs co-exist. There are many readers of Federal Practitioner who will no doubt reject nearly every word I have written, in what I know is a controversial column. But it matters that the military and veteran constituency are thinking and speaking about the issue of climate change.¹¹ Why? The answer takes us back to the disaster in Australia. When the fires and the devastation they wrought escalated beyond the powers of the civil authorities to handle, it was the military whose technical skill, coordinated readiness, and personal courage and dedication that was called on to rescue thousands of civilians from the inferno.¹² So it will be in our country and around the world when disasters—manmade, natural, or both—threaten to engulf life in all its wondrous variety. Those who battle extreme weather will have unique health needs, and their valiant sacrifices deserve to have health care systems ready and able to treat them.

Like me, some of you may have been following the agonizing news about the unprecedented brushfires in Australia that have devastated human, animal, and vegetative life in that country so culturally akin to our own.¹ For many people who believe the overwhelming majority of scientific reports on climate change, these apocalyptic fires are an empirical demonstration of the truth of the dire prophecies for the future of our planet. Scientists have demonstrated that although climate change may not have caused the worst fires in Australia’s history, they may have contributed to the conditions that enabled them to spread so far and wide and reach such a destructive intensity.²The heartbreaking pictures of singed koalas and displaced people and the helpless feeling that all I can do from here is donate money set me to thinking about the relationship between the military, health, and climate change, which is the subject of this column.

As I write this in mid-January of a new decade and glance at the weather headlines, I read about an earthquake in Puerto Rico and tornadoes in the southern US. This makes it quite plausible that our comfortable lifestyle and technological civilization could in the coming decades go the way of the dinosaurs, also victims of climate change.

Initially, my first thought about this relationship is a negative one—images of scorched earth policies that stretch back to ancient wars jump to mind. Reflection and research on the topic though suggest that the relationship may be more complicated and conflicted. Alas, I can only touch on a few of the themes in this brief format.

It may not be as obvious that climate change also threatens the military, which is the guardian of that civilization. In 2018, for example, Hurricane Michael caused nearly $5 billion in damages to Tyndall Air Force Base in Florida.³ A year later, the US Department of Defense (DoD) released a report on the effects of climate change as mandated by Congress.⁴ Even though some congressional critics expressed concern about the report’s lack of depth and detail,⁵ the report asserted that, “The effects of a changing climate are a national security issue with potential impacts to Department of Defense (DoD or the Department) missions, operational plans, and installations.”⁴

The US Department of Veterans Affairs (VA) is not immune either. Natural disasters have already disrupted the delivery of health care at its many aging facilities. Climate change was called the “engine”⁶ driving Hurricane Maria, which in 2017 slammed into Puerto Rico, including its VA medical center, and resulted in shortages of supplies, staff, and basic utilities.⁷ The facility and the island are still trying to rebuild. In response to weather-exposed vulnerability in VA infrastructure, Senator and presidential candidate Elizabeth Warren (D-MA) and Senator Brian Schatz (D-HI), the ranking member of the Subcommittee on Military Construction, sent a letter to VA leadership arguing that “Strengthening VA’s resilience to climate change is consistent with the agency’s mission to deliver timely, high-quality care and benefits to America’s veterans.”⁸

It has been reported that the current administration has countered initiatives to prepare for the challenges of providing health care to service members and veterans in a climate changed world.⁹ Sadly, but predictably, in the politicized federal health care arena, the safety of our service members and, in turn, the domestic and national security and peace that depend on them are caught in the partisan debate over global warming, though it is not likely Congress or federal agency leaders will abandon planning to safeguard service members who will see duty and combat in a radically altered ecology and veterans and who will need to have VA continue to be the reliable safety net despite an increasingly erratic environment.¹⁰

Climate change is a divisive political issue; there is a proud tradition of conservatism and self-reliance in military members, active duty and veteran alike. That was why I was surprised and impressed when I saw the results of a recent survey on climate change. In January 2019, 293 active-duty service members and veterans were surveyed.

Participants were selected to reflect the ethnic makeup, educational level, and political allegiance of the military population, which enhanced the validity of the findings.¹¹Participants were asked to indicate whether they believed that the earth was warming secondary to human or natural processes; not growing warmer at all; or whether they were unsure. Similar to the general population, 46% agreed that climate change is anthropogenic.¹¹ More than three-fourths believed it was likely climate change would adversely affect the places they worked, like military installations; 61% thought it likely that global warming could lead to armed conflict over resources. Seven in 10 respondents believed that climate is changing vs 46% who did not. Of respondents who believe climate change is real, 87% see it as a threat to military bases compared with 60% who do not accept the science that the earth is warming.¹¹

This survey, though, is only a small study, and the military and VA are big tents under which a wide range of political persuasions and diverse beliefs co-exist. There are many readers of Federal Practitioner who will no doubt reject nearly every word I have written, in what I know is a controversial column. But it matters that the military and veteran constituency are thinking and speaking about the issue of climate change.¹¹ Why? The answer takes us back to the disaster in Australia. When the fires and the devastation they wrought escalated beyond the powers of the civil authorities to handle, it was the military whose technical skill, coordinated readiness, and personal courage and dedication that was called on to rescue thousands of civilians from the inferno.¹² So it will be in our country and around the world when disasters—manmade, natural, or both—threaten to engulf life in all its wondrous variety. Those who battle extreme weather will have unique health needs, and their valiant sacrifices deserve to have health care systems ready and able to treat them.

Like me, some of you may have been following the agonizing news about the unprecedented brushfires in Australia that have devastated human, animal, and vegetative life in that country so culturally akin to our own.¹ For many people who believe the overwhelming majority of scientific reports on climate change, these apocalyptic fires are an empirical demonstration of the truth of the dire prophecies for the future of our planet. Scientists have demonstrated that although climate change may not have caused the worst fires in Australia’s history, they may have contributed to the conditions that enabled them to spread so far and wide and reach such a destructive intensity.²The heartbreaking pictures of singed koalas and displaced people and the helpless feeling that all I can do from here is donate money set me to thinking about the relationship between the military, health, and climate change, which is the subject of this column.

As I write this in mid-January of a new decade and glance at the weather headlines, I read about an earthquake in Puerto Rico and tornadoes in the southern US. This makes it quite plausible that our comfortable lifestyle and technological civilization could in the coming decades go the way of the dinosaurs, also victims of climate change.

Initially, my first thought about this relationship is a negative one—images of scorched earth policies that stretch back to ancient wars jump to mind. Reflection and research on the topic though suggest that the relationship may be more complicated and conflicted. Alas, I can only touch on a few of the themes in this brief format.

It may not be as obvious that climate change also threatens the military, which is the guardian of that civilization. In 2018, for example, Hurricane Michael caused nearly $5 billion in damages to Tyndall Air Force Base in Florida.³ A year later, the US Department of Defense (DoD) released a report on the effects of climate change as mandated by Congress.⁴ Even though some congressional critics expressed concern about the report’s lack of depth and detail,⁵ the report asserted that, “The effects of a changing climate are a national security issue with potential impacts to Department of Defense (DoD or the Department) missions, operational plans, and installations.”⁴

The US Department of Veterans Affairs (VA) is not immune either. Natural disasters have already disrupted the delivery of health care at its many aging facilities. Climate change was called the “engine”⁶ driving Hurricane Maria, which in 2017 slammed into Puerto Rico, including its VA medical center, and resulted in shortages of supplies, staff, and basic utilities.⁷ The facility and the island are still trying to rebuild. In response to weather-exposed vulnerability in VA infrastructure, Senator and presidential candidate Elizabeth Warren (D-MA) and Senator Brian Schatz (D-HI), the ranking member of the Subcommittee on Military Construction, sent a letter to VA leadership arguing that “Strengthening VA’s resilience to climate change is consistent with the agency’s mission to deliver timely, high-quality care and benefits to America’s veterans.”⁸

It has been reported that the current administration has countered initiatives to prepare for the challenges of providing health care to service members and veterans in a climate changed world.⁹ Sadly, but predictably, in the politicized federal health care arena, the safety of our service members and, in turn, the domestic and national security and peace that depend on them are caught in the partisan debate over global warming, though it is not likely Congress or federal agency leaders will abandon planning to safeguard service members who will see duty and combat in a radically altered ecology and veterans and who will need to have VA continue to be the reliable safety net despite an increasingly erratic environment.¹⁰

Climate change is a divisive political issue; there is a proud tradition of conservatism and self-reliance in military members, active duty and veteran alike. That was why I was surprised and impressed when I saw the results of a recent survey on climate change. In January 2019, 293 active-duty service members and veterans were surveyed.

Participants were selected to reflect the ethnic makeup, educational level, and political allegiance of the military population, which enhanced the validity of the findings.¹¹Participants were asked to indicate whether they believed that the earth was warming secondary to human or natural processes; not growing warmer at all; or whether they were unsure. Similar to the general population, 46% agreed that climate change is anthropogenic.¹¹ More than three-fourths believed it was likely climate change would adversely affect the places they worked, like military installations; 61% thought it likely that global warming could lead to armed conflict over resources. Seven in 10 respondents believed that climate is changing vs 46% who did not. Of respondents who believe climate change is real, 87% see it as a threat to military bases compared with 60% who do not accept the science that the earth is warming.¹¹

This survey, though, is only a small study, and the military and VA are big tents under which a wide range of political persuasions and diverse beliefs co-exist. There are many readers of Federal Practitioner who will no doubt reject nearly every word I have written, in what I know is a controversial column. But it matters that the military and veteran constituency are thinking and speaking about the issue of climate change.¹¹ Why? The answer takes us back to the disaster in Australia. When the fires and the devastation they wrought escalated beyond the powers of the civil authorities to handle, it was the military whose technical skill, coordinated readiness, and personal courage and dedication that was called on to rescue thousands of civilians from the inferno.¹² So it will be in our country and around the world when disasters—manmade, natural, or both—threaten to engulf life in all its wondrous variety. Those who battle extreme weather will have unique health needs, and their valiant sacrifices deserve to have health care systems ready and able to treat them.

Readers may recall that at the end of each calendar as opposed to fiscal year—I know it is hard to believe time exists outside the Federal system—Federal Practitioner publishes my ethics-focused version of the familiar year-end roundup. This year I am reversing the typical order of most annual rankings by putting the worst first for 2 morally salient reasons.

The first is that, sadly, it is almost always easier to identify multiple incidents that compete ignominiously for the “worst” of federal health care. Even more disappointing, it is comparatively difficult to find stories for the “best” that are of the same scale and scope as the bad news. This is not to say that every day there are not individual narratives of courage and compassion reported in US Department of Defense, US Public Health Service, and US Department of Veterans Affairs (VA), and hundreds more unsung heroes.

The second reason is that as human beings our psychology is such that we gravitate toward the worst things more powerfully and persistently than we do the best. This is in part why it is more difficult to find uplifting stories and why the demoralizing ones affect us so strongly. In an exhaustive review of the subject, psychologists Roy Baumeister and colleagues conclude that,

When equal measures of good and bad are present, however, the psychological effects of bad ones outweigh those of the good ones. This may in fact be a general principle or law of psychological phenomena, possibly reflecting the innate predispositions of the psyche or at least reflecting the almost inevitable adaptation of each individual to the exigencies of daily life.²

I am thus saving the best for last in the hope that it will be more memorable and impactful than the worst.

Unique to this year’s look-back, both the negative and the positive accounts come from the domain of end-of-life care. And unlike prior reviews where the lack of administrative vigilance and professional competence affected hundreds of patients, families, and staff, each of this year’s incidents involve a single patient.

An incident that occurred in September 2019 at a VA Community Living Center (CLC) in Georgia stood out in infamy apart from all others. It was the report of a veteran in a VA nursing home who had been bitten more than 100 times by ants crawling all over his room. He died shortly afterward. In a scene out of a horror movie tapping into the most primeval human fears, his daughter Laquana Ross described her father, a Vietnam Air Force veteran with cancer, to media and VA officials in graphic terms. “I understand mistakes happen,” she said. “I’ve had ants. But he was bit by ants two days in a row. They feasted on him.”³

In this new era of holding its senior executive service accountable, the outraged chair of the Senate Veterans Affairs Committee demanded that heads roll, and the VA acted rapidly to comply.⁴ The VA Central Office placed the network director on administrative leave, reassigned the chief medical officer, and initiated quality and safety reviews as well as an administrative investigative board to scrutinize how the parent Atlanta VA medical center managed the situation. In total, 9 officials connected to the incident were placed on leave. The VA apologized, with VA Secretary Robert Wilke zeroing in on the core values involved in the tragedy, “This is about basic humanity and dignity,” he said. “I don’t care what steps were taken to address the issues. We did not treat a vet with the dignity that he and his family deserved.”⁵ Yet it was the veteran’s daughter, with unbelievable charity, who asked the most crucial question that must be answered within the framework of a just culture if similar tragedies are not to occur in the future, “I know the staff, without a shadow of doubt, respected my dad and even loved him,” Ross said. “But what’s their ability to assess situations and fix things?”³

To begin to give Ms. Ross the answer she deserves, we must understand that the antithesis of love is not hate but indifference; of compassion, it is not cruelty but coldness. A true just culture reserves individual blame for those who have ill-will and adopts a systems perspective of organizational improvement toward most other types of errors.⁶ This means that the deplorable conditions in the CLC cannot be charged to the failure of a single staff member to fulfil their obligations but to collective collapse at many levels of the organization. Just culture is ethically laudable and far superior to the history in federal service of capricious punishment or institutional apathy that far too often were the default reactions to media exposures or congressional ire. Justice, though necessary, is not sufficient to achieve virtue. Those who work in health care also must be inspired to offer mercy, kindness, and compassion, especially in our most sacred privilege to provide care of the dying.

The best of 2019 illustrates this distinction movingly. This account also involves a Vietnam veteran, this time a Marine also dying of cancer, which happened just about a month after the earlier report. To be transparent it occurred at my home VA medical center in New Mexico. I was peripherally involved in the case as a consultant but had no role in the wondrous things that transpired. The last wish of a patient dying in the hospice unit on campus was to see his beloved dog who had been taken to the local city animal shelter when he was hospitalized because he had no friends or family to look after the companion animal. A social worker on the palliative care team called the animal shelter and explained the patient did not have much time left but wanted to see his dog before he died. Working together with support from facility leadership, shelter workers brought the dog to visit with the patient for an entire day while hospice staff cried with joy and sadness.⁷

As the epigraph for this editorial from Dame Cicely Saunders, the founder of the modern hospice movement, says, the difference between unspeakable pain and meaningful suffering can be measured in the depth of compassion caregivers show to the dying. It is this quality of mercy that in one case condemns, and in the other praises, us all as health care and administrative professionals in the service of our country. Baumeister and colleagues suggest that the human tendency to magnify the bad and minimize the good in everyday myopia may in a wider vision actually be a reason for hope:

It may be that humans and animals show heightened awareness of and responded more quickly to negative information because it signals a need for change. Hence, the adaptiveness of self-regulation partly lies in the organism’s ability to detect when response modifications are necessary and when they are unnecessary. Moreover, the lessons learned from bad events should ideally be retained permanently so that the same dangers or costs are not encountered repeatedly. Meanwhile, good events (such as those that provide a feeling of satisfaction and contentment) should ideally wear off so that the organism is motivated to continue searching for more and better outcomes.²

Let us all take this lesson into our work in 2020 so that when it comes time to write this column next year in the chilling cold of late autumn there will be more stories of light than darkness from which to choose.

Readers may recall that at the end of each calendar as opposed to fiscal year—I know it is hard to believe time exists outside the Federal system—Federal Practitioner publishes my ethics-focused version of the familiar year-end roundup. This year I am reversing the typical order of most annual rankings by putting the worst first for 2 morally salient reasons.

The first is that, sadly, it is almost always easier to identify multiple incidents that compete ignominiously for the “worst” of federal health care. Even more disappointing, it is comparatively difficult to find stories for the “best” that are of the same scale and scope as the bad news. This is not to say that every day there are not individual narratives of courage and compassion reported in US Department of Defense, US Public Health Service, and US Department of Veterans Affairs (VA), and hundreds more unsung heroes.

The second reason is that as human beings our psychology is such that we gravitate toward the worst things more powerfully and persistently than we do the best. This is in part why it is more difficult to find uplifting stories and why the demoralizing ones affect us so strongly. In an exhaustive review of the subject, psychologists Roy Baumeister and colleagues conclude that,

When equal measures of good and bad are present, however, the psychological effects of bad ones outweigh those of the good ones. This may in fact be a general principle or law of psychological phenomena, possibly reflecting the innate predispositions of the psyche or at least reflecting the almost inevitable adaptation of each individual to the exigencies of daily life.²

I am thus saving the best for last in the hope that it will be more memorable and impactful than the worst.

Unique to this year’s look-back, both the negative and the positive accounts come from the domain of end-of-life care. And unlike prior reviews where the lack of administrative vigilance and professional competence affected hundreds of patients, families, and staff, each of this year’s incidents involve a single patient.

An incident that occurred in September 2019 at a VA Community Living Center (CLC) in Georgia stood out in infamy apart from all others. It was the report of a veteran in a VA nursing home who had been bitten more than 100 times by ants crawling all over his room. He died shortly afterward. In a scene out of a horror movie tapping into the most primeval human fears, his daughter Laquana Ross described her father, a Vietnam Air Force veteran with cancer, to media and VA officials in graphic terms. “I understand mistakes happen,” she said. “I’ve had ants. But he was bit by ants two days in a row. They feasted on him.”³

In this new era of holding its senior executive service accountable, the outraged chair of the Senate Veterans Affairs Committee demanded that heads roll, and the VA acted rapidly to comply.⁴ The VA Central Office placed the network director on administrative leave, reassigned the chief medical officer, and initiated quality and safety reviews as well as an administrative investigative board to scrutinize how the parent Atlanta VA medical center managed the situation. In total, 9 officials connected to the incident were placed on leave. The VA apologized, with VA Secretary Robert Wilke zeroing in on the core values involved in the tragedy, “This is about basic humanity and dignity,” he said. “I don’t care what steps were taken to address the issues. We did not treat a vet with the dignity that he and his family deserved.”⁵ Yet it was the veteran’s daughter, with unbelievable charity, who asked the most crucial question that must be answered within the framework of a just culture if similar tragedies are not to occur in the future, “I know the staff, without a shadow of doubt, respected my dad and even loved him,” Ross said. “But what’s their ability to assess situations and fix things?”³

To begin to give Ms. Ross the answer she deserves, we must understand that the antithesis of love is not hate but indifference; of compassion, it is not cruelty but coldness. A true just culture reserves individual blame for those who have ill-will and adopts a systems perspective of organizational improvement toward most other types of errors.⁶ This means that the deplorable conditions in the CLC cannot be charged to the failure of a single staff member to fulfil their obligations but to collective collapse at many levels of the organization. Just culture is ethically laudable and far superior to the history in federal service of capricious punishment or institutional apathy that far too often were the default reactions to media exposures or congressional ire. Justice, though necessary, is not sufficient to achieve virtue. Those who work in health care also must be inspired to offer mercy, kindness, and compassion, especially in our most sacred privilege to provide care of the dying.

The best of 2019 illustrates this distinction movingly. This account also involves a Vietnam veteran, this time a Marine also dying of cancer, which happened just about a month after the earlier report. To be transparent it occurred at my home VA medical center in New Mexico. I was peripherally involved in the case as a consultant but had no role in the wondrous things that transpired. The last wish of a patient dying in the hospice unit on campus was to see his beloved dog who had been taken to the local city animal shelter when he was hospitalized because he had no friends or family to look after the companion animal. A social worker on the palliative care team called the animal shelter and explained the patient did not have much time left but wanted to see his dog before he died. Working together with support from facility leadership, shelter workers brought the dog to visit with the patient for an entire day while hospice staff cried with joy and sadness.⁷

As the epigraph for this editorial from Dame Cicely Saunders, the founder of the modern hospice movement, says, the difference between unspeakable pain and meaningful suffering can be measured in the depth of compassion caregivers show to the dying. It is this quality of mercy that in one case condemns, and in the other praises, us all as health care and administrative professionals in the service of our country. Baumeister and colleagues suggest that the human tendency to magnify the bad and minimize the good in everyday myopia may in a wider vision actually be a reason for hope:

It may be that humans and animals show heightened awareness of and responded more quickly to negative information because it signals a need for change. Hence, the adaptiveness of self-regulation partly lies in the organism’s ability to detect when response modifications are necessary and when they are unnecessary. Moreover, the lessons learned from bad events should ideally be retained permanently so that the same dangers or costs are not encountered repeatedly. Meanwhile, good events (such as those that provide a feeling of satisfaction and contentment) should ideally wear off so that the organism is motivated to continue searching for more and better outcomes.²

Let us all take this lesson into our work in 2020 so that when it comes time to write this column next year in the chilling cold of late autumn there will be more stories of light than darkness from which to choose.

Readers may recall that at the end of each calendar as opposed to fiscal year—I know it is hard to believe time exists outside the Federal system—Federal Practitioner publishes my ethics-focused version of the familiar year-end roundup. This year I am reversing the typical order of most annual rankings by putting the worst first for 2 morally salient reasons.

The first is that, sadly, it is almost always easier to identify multiple incidents that compete ignominiously for the “worst” of federal health care. Even more disappointing, it is comparatively difficult to find stories for the “best” that are of the same scale and scope as the bad news. This is not to say that every day there are not individual narratives of courage and compassion reported in US Department of Defense, US Public Health Service, and US Department of Veterans Affairs (VA), and hundreds more unsung heroes.

The second reason is that as human beings our psychology is such that we gravitate toward the worst things more powerfully and persistently than we do the best. This is in part why it is more difficult to find uplifting stories and why the demoralizing ones affect us so strongly. In an exhaustive review of the subject, psychologists Roy Baumeister and colleagues conclude that,

When equal measures of good and bad are present, however, the psychological effects of bad ones outweigh those of the good ones. This may in fact be a general principle or law of psychological phenomena, possibly reflecting the innate predispositions of the psyche or at least reflecting the almost inevitable adaptation of each individual to the exigencies of daily life.²

I am thus saving the best for last in the hope that it will be more memorable and impactful than the worst.

Unique to this year’s look-back, both the negative and the positive accounts come from the domain of end-of-life care. And unlike prior reviews where the lack of administrative vigilance and professional competence affected hundreds of patients, families, and staff, each of this year’s incidents involve a single patient.

An incident that occurred in September 2019 at a VA Community Living Center (CLC) in Georgia stood out in infamy apart from all others. It was the report of a veteran in a VA nursing home who had been bitten more than 100 times by ants crawling all over his room. He died shortly afterward. In a scene out of a horror movie tapping into the most primeval human fears, his daughter Laquana Ross described her father, a Vietnam Air Force veteran with cancer, to media and VA officials in graphic terms. “I understand mistakes happen,” she said. “I’ve had ants. But he was bit by ants two days in a row. They feasted on him.”³

In this new era of holding its senior executive service accountable, the outraged chair of the Senate Veterans Affairs Committee demanded that heads roll, and the VA acted rapidly to comply.⁴ The VA Central Office placed the network director on administrative leave, reassigned the chief medical officer, and initiated quality and safety reviews as well as an administrative investigative board to scrutinize how the parent Atlanta VA medical center managed the situation. In total, 9 officials connected to the incident were placed on leave. The VA apologized, with VA Secretary Robert Wilke zeroing in on the core values involved in the tragedy, “This is about basic humanity and dignity,” he said. “I don’t care what steps were taken to address the issues. We did not treat a vet with the dignity that he and his family deserved.”⁵ Yet it was the veteran’s daughter, with unbelievable charity, who asked the most crucial question that must be answered within the framework of a just culture if similar tragedies are not to occur in the future, “I know the staff, without a shadow of doubt, respected my dad and even loved him,” Ross said. “But what’s their ability to assess situations and fix things?”³

To begin to give Ms. Ross the answer she deserves, we must understand that the antithesis of love is not hate but indifference; of compassion, it is not cruelty but coldness. A true just culture reserves individual blame for those who have ill-will and adopts a systems perspective of organizational improvement toward most other types of errors.⁶ This means that the deplorable conditions in the CLC cannot be charged to the failure of a single staff member to fulfil their obligations but to collective collapse at many levels of the organization. Just culture is ethically laudable and far superior to the history in federal service of capricious punishment or institutional apathy that far too often were the default reactions to media exposures or congressional ire. Justice, though necessary, is not sufficient to achieve virtue. Those who work in health care also must be inspired to offer mercy, kindness, and compassion, especially in our most sacred privilege to provide care of the dying.

The best of 2019 illustrates this distinction movingly. This account also involves a Vietnam veteran, this time a Marine also dying of cancer, which happened just about a month after the earlier report. To be transparent it occurred at my home VA medical center in New Mexico. I was peripherally involved in the case as a consultant but had no role in the wondrous things that transpired. The last wish of a patient dying in the hospice unit on campus was to see his beloved dog who had been taken to the local city animal shelter when he was hospitalized because he had no friends or family to look after the companion animal. A social worker on the palliative care team called the animal shelter and explained the patient did not have much time left but wanted to see his dog before he died. Working together with support from facility leadership, shelter workers brought the dog to visit with the patient for an entire day while hospice staff cried with joy and sadness.⁷

As the epigraph for this editorial from Dame Cicely Saunders, the founder of the modern hospice movement, says, the difference between unspeakable pain and meaningful suffering can be measured in the depth of compassion caregivers show to the dying. It is this quality of mercy that in one case condemns, and in the other praises, us all as health care and administrative professionals in the service of our country. Baumeister and colleagues suggest that the human tendency to magnify the bad and minimize the good in everyday myopia may in a wider vision actually be a reason for hope:

It may be that humans and animals show heightened awareness of and responded more quickly to negative information because it signals a need for change. Hence, the adaptiveness of self-regulation partly lies in the organism’s ability to detect when response modifications are necessary and when they are unnecessary. Moreover, the lessons learned from bad events should ideally be retained permanently so that the same dangers or costs are not encountered repeatedly. Meanwhile, good events (such as those that provide a feeling of satisfaction and contentment) should ideally wear off so that the organism is motivated to continue searching for more and better outcomes.²

Let us all take this lesson into our work in 2020 so that when it comes time to write this column next year in the chilling cold of late autumn there will be more stories of light than darkness from which to choose.

On the 11th day of the 11th month, we celebrate Veterans Day (no apostrophe because it is not a day that veterans possess or that belongs to any individual veteran).^2,3 Interestingly, the US Department of Defense (DoD) and the US Department of Veterans Affairs (VA) have web pages correcting any confusion about the meaning of Memorial Day and Veterans Day so that the public understands the unique purpose of each holiday. Memorial Day commemorates all those who lost their lives in the line of duty to the nation, whereas Veterans Day commemorates all those who have honorably served their country as service members. While Memorial Day is a solemn occasion of remembering and respect for those who have died, Veterans Day is an event of gratitude and appreciation focused on veterans still living. The dual mission of the 2 holidays is to remind the public of the debt of remembrance and reverence we owe all veterans both those who have gone before us and those who remain with us.

Memory is what most intrinsically unites the 2 commemorations. In fact, in Great Britain, Canada, and Australia, November 11 is called Remembrance Day.² Yet memory is a double-edged sword that can be raised in tribute to service members or can deeply lacerate them. Many of the wounds that cause the most prolonged and deepest suffering are not physical—they are mental. Disturbances of memory are among the criteria for posttraumatic stress disorder (PTSD). Under its section on intrusive cluster, the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) lists “recurrent, involuntary, and intrusive distressing memories of the traumatic event(s).” The avoidance cluster underscores how the afflicted mind tries to escape itself: “Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).”⁴

PTSD was first recognized as a psychiatric diagnosis in DSM-III in 1980, and since then VA and DoD have devoted enormous resources to developing effective treatments for the disorder, most notably evidence-based psychotherapies. Sadly ironic, the only psychiatric disorder whose etiology is understood has proved to be the most difficult to treat much less cure. As with most serious mental illnesses, some cases become chronic and refractory to the best of care. These tormented individuals live as if in a twilight zone between the past and the present.

Memory and war have a long history in literature, poetry, and history. Haunting memories of PTSD are found in the ancient epics of Homer. On the long treacherous journey home from sacking Troy, Odysseus and his army arrive in the land of the Lotus-eaters, where native sweet fruit induces a state of timeless forgetfulness in which torment and tragedy dissolve along with motivation and meaning.⁵ Jonathan Shay, VA psychiatrist and pioneer of the Homer-PTSD connection, suggested the analogy between the land of the Lotus-eaters and addiction: Each is a self-medication of the psychic aftermath of war.⁶

But what if those devastating memories could be selectively erased or even better blocked before they were formed? Although this solution may seem like science fiction, research into these possibilities is in reality science fact. Over the past decades, the DoD and the VA have sought such a neuroscience jewel in the lotus. Studies in rodents and humans have looked at the ability of a number of medications, most recently β blockers, such as propranolol, to interfere with the consolidation of emotionally traumatic memories (memory erasure) and disrupting their retention once consolidated (memory extinction).⁷ While researchers cannot yet completely wipe out a selected memory, like in the movie Star Trek, it has been shown that medications at least in study settings do reduce fear and can attenuate the development of PTSD when combined with psychotherapy. Neuroscientists call these more realistic alterations of recall memory dampening. Though these medications are not ready for regular clinical application, the unprecedented pace of neuroscience makes it nearly inevitable that in the not so distant future some significant blunting of traumatic memory will be possible.

Once science answers in the affirmative the question, “Is this intervention something we could conceivably do?” The next question belongs to ethics, “Is this intervention something we should do even if we can?” As early as 2001, the President’s Council on Bioethics answered the latter with “probably not.”

Use of memory-blunters at the time of traumatic events could interfere with the normal psychic work and adaptive value of emotionally charged memory....Thus, by blunting the emotional impact of events, beta-blockers or their successors would concomitantly weaken our recollection of the traumatic events we have just experienced. Yet often it is important in the after of such events that at least someone remember them clearly. For legal reasons, to say nothing of deeper social and personal ones, the wisdom of routinely interfering with the memories of traumatic survivors and witnesses is highly questionable.⁸

Many neuroscientists and neuroethicists objected to the perspective of the Bioethics Council as being too puritanical and its position overly pessimistic:

Whereas memory dampening has its drawbacks, such may be the price we pay in order to heal immense suffering. In some contexts, there may be steps that ought to be taken to preserve valuable factual or emotional information contained in memory, even when we must delay or otherwise impose limits on access to memory dampening. None of these concerns, however, even if they find empirical support, are strong enough to justify brushed restrictions on memory dampening.⁹

The proponents of the 2 views propose and oppose the contrarian position on issues both philosophical and practical, such as the function of traumatic experience in personal growth; how the preservation of memory is related to the integrity of the person and authenticity of the life lived; how blunting of memories of especially combat trauma may normalize our reactions to suffering and evil; and most important for this Veterans Day essay, whether remembering is an ethical duty and if so whose is it to discharge, the individual, his family, community, or country.

More pragmatic, there would be a need to refine our understanding of the risk factors for chronic and disabling PTSD; to determine when in the course of the trauma experience to pharmacologically interfere with memory and to what degree and scope; how to protect the autonomy of the service member to consent or to refuse the procedure within the recognized confines of military ethics; and most important for this essay, how to prevent governments, corporations, or any other entity from exploiting neurobiologic discoveries for power or profit.

Elie Wiesel is an important modern prophet of the critical role of memory in the survival of civilization. His prophecy is rooted in the incomprehensible anguish and horror he personally and communally witnessed in the Holocaust. He suggests in this editorial’s epigraph that there are deep and profound issues to be pondered about memory and its inextricable link to suffering. Meditations offer thoughts, not answers, and I encourage readers to spend a few minutes considering the solemn ones presented here this Veterans Day.

On the 11th day of the 11th month, we celebrate Veterans Day (no apostrophe because it is not a day that veterans possess or that belongs to any individual veteran).^2,3 Interestingly, the US Department of Defense (DoD) and the US Department of Veterans Affairs (VA) have web pages correcting any confusion about the meaning of Memorial Day and Veterans Day so that the public understands the unique purpose of each holiday. Memorial Day commemorates all those who lost their lives in the line of duty to the nation, whereas Veterans Day commemorates all those who have honorably served their country as service members. While Memorial Day is a solemn occasion of remembering and respect for those who have died, Veterans Day is an event of gratitude and appreciation focused on veterans still living. The dual mission of the 2 holidays is to remind the public of the debt of remembrance and reverence we owe all veterans both those who have gone before us and those who remain with us.

Memory is what most intrinsically unites the 2 commemorations. In fact, in Great Britain, Canada, and Australia, November 11 is called Remembrance Day.² Yet memory is a double-edged sword that can be raised in tribute to service members or can deeply lacerate them. Many of the wounds that cause the most prolonged and deepest suffering are not physical—they are mental. Disturbances of memory are among the criteria for posttraumatic stress disorder (PTSD). Under its section on intrusive cluster, the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) lists “recurrent, involuntary, and intrusive distressing memories of the traumatic event(s).” The avoidance cluster underscores how the afflicted mind tries to escape itself: “Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).”⁴

PTSD was first recognized as a psychiatric diagnosis in DSM-III in 1980, and since then VA and DoD have devoted enormous resources to developing effective treatments for the disorder, most notably evidence-based psychotherapies. Sadly ironic, the only psychiatric disorder whose etiology is understood has proved to be the most difficult to treat much less cure. As with most serious mental illnesses, some cases become chronic and refractory to the best of care. These tormented individuals live as if in a twilight zone between the past and the present.

Memory and war have a long history in literature, poetry, and history. Haunting memories of PTSD are found in the ancient epics of Homer. On the long treacherous journey home from sacking Troy, Odysseus and his army arrive in the land of the Lotus-eaters, where native sweet fruit induces a state of timeless forgetfulness in which torment and tragedy dissolve along with motivation and meaning.⁵ Jonathan Shay, VA psychiatrist and pioneer of the Homer-PTSD connection, suggested the analogy between the land of the Lotus-eaters and addiction: Each is a self-medication of the psychic aftermath of war.⁶

But what if those devastating memories could be selectively erased or even better blocked before they were formed? Although this solution may seem like science fiction, research into these possibilities is in reality science fact. Over the past decades, the DoD and the VA have sought such a neuroscience jewel in the lotus. Studies in rodents and humans have looked at the ability of a number of medications, most recently β blockers, such as propranolol, to interfere with the consolidation of emotionally traumatic memories (memory erasure) and disrupting their retention once consolidated (memory extinction).⁷ While researchers cannot yet completely wipe out a selected memory, like in the movie Star Trek, it has been shown that medications at least in study settings do reduce fear and can attenuate the development of PTSD when combined with psychotherapy. Neuroscientists call these more realistic alterations of recall memory dampening. Though these medications are not ready for regular clinical application, the unprecedented pace of neuroscience makes it nearly inevitable that in the not so distant future some significant blunting of traumatic memory will be possible.

Once science answers in the affirmative the question, “Is this intervention something we could conceivably do?” The next question belongs to ethics, “Is this intervention something we should do even if we can?” As early as 2001, the President’s Council on Bioethics answered the latter with “probably not.”

Use of memory-blunters at the time of traumatic events could interfere with the normal psychic work and adaptive value of emotionally charged memory....Thus, by blunting the emotional impact of events, beta-blockers or their successors would concomitantly weaken our recollection of the traumatic events we have just experienced. Yet often it is important in the after of such events that at least someone remember them clearly. For legal reasons, to say nothing of deeper social and personal ones, the wisdom of routinely interfering with the memories of traumatic survivors and witnesses is highly questionable.⁸

Many neuroscientists and neuroethicists objected to the perspective of the Bioethics Council as being too puritanical and its position overly pessimistic:

Whereas memory dampening has its drawbacks, such may be the price we pay in order to heal immense suffering. In some contexts, there may be steps that ought to be taken to preserve valuable factual or emotional information contained in memory, even when we must delay or otherwise impose limits on access to memory dampening. None of these concerns, however, even if they find empirical support, are strong enough to justify brushed restrictions on memory dampening.⁹

The proponents of the 2 views propose and oppose the contrarian position on issues both philosophical and practical, such as the function of traumatic experience in personal growth; how the preservation of memory is related to the integrity of the person and authenticity of the life lived; how blunting of memories of especially combat trauma may normalize our reactions to suffering and evil; and most important for this Veterans Day essay, whether remembering is an ethical duty and if so whose is it to discharge, the individual, his family, community, or country.

More pragmatic, there would be a need to refine our understanding of the risk factors for chronic and disabling PTSD; to determine when in the course of the trauma experience to pharmacologically interfere with memory and to what degree and scope; how to protect the autonomy of the service member to consent or to refuse the procedure within the recognized confines of military ethics; and most important for this essay, how to prevent governments, corporations, or any other entity from exploiting neurobiologic discoveries for power or profit.

Elie Wiesel is an important modern prophet of the critical role of memory in the survival of civilization. His prophecy is rooted in the incomprehensible anguish and horror he personally and communally witnessed in the Holocaust. He suggests in this editorial’s epigraph that there are deep and profound issues to be pondered about memory and its inextricable link to suffering. Meditations offer thoughts, not answers, and I encourage readers to spend a few minutes considering the solemn ones presented here this Veterans Day.

On the 11th day of the 11th month, we celebrate Veterans Day (no apostrophe because it is not a day that veterans possess or that belongs to any individual veteran).^2,3 Interestingly, the US Department of Defense (DoD) and the US Department of Veterans Affairs (VA) have web pages correcting any confusion about the meaning of Memorial Day and Veterans Day so that the public understands the unique purpose of each holiday. Memorial Day commemorates all those who lost their lives in the line of duty to the nation, whereas Veterans Day commemorates all those who have honorably served their country as service members. While Memorial Day is a solemn occasion of remembering and respect for those who have died, Veterans Day is an event of gratitude and appreciation focused on veterans still living. The dual mission of the 2 holidays is to remind the public of the debt of remembrance and reverence we owe all veterans both those who have gone before us and those who remain with us.

Memory is what most intrinsically unites the 2 commemorations. In fact, in Great Britain, Canada, and Australia, November 11 is called Remembrance Day.² Yet memory is a double-edged sword that can be raised in tribute to service members or can deeply lacerate them. Many of the wounds that cause the most prolonged and deepest suffering are not physical—they are mental. Disturbances of memory are among the criteria for posttraumatic stress disorder (PTSD). Under its section on intrusive cluster, the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) lists “recurrent, involuntary, and intrusive distressing memories of the traumatic event(s).” The avoidance cluster underscores how the afflicted mind tries to escape itself: “Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).”⁴

PTSD was first recognized as a psychiatric diagnosis in DSM-III in 1980, and since then VA and DoD have devoted enormous resources to developing effective treatments for the disorder, most notably evidence-based psychotherapies. Sadly ironic, the only psychiatric disorder whose etiology is understood has proved to be the most difficult to treat much less cure. As with most serious mental illnesses, some cases become chronic and refractory to the best of care. These tormented individuals live as if in a twilight zone between the past and the present.

Memory and war have a long history in literature, poetry, and history. Haunting memories of PTSD are found in the ancient epics of Homer. On the long treacherous journey home from sacking Troy, Odysseus and his army arrive in the land of the Lotus-eaters, where native sweet fruit induces a state of timeless forgetfulness in which torment and tragedy dissolve along with motivation and meaning.⁵ Jonathan Shay, VA psychiatrist and pioneer of the Homer-PTSD connection, suggested the analogy between the land of the Lotus-eaters and addiction: Each is a self-medication of the psychic aftermath of war.⁶

But what if those devastating memories could be selectively erased or even better blocked before they were formed? Although this solution may seem like science fiction, research into these possibilities is in reality science fact. Over the past decades, the DoD and the VA have sought such a neuroscience jewel in the lotus. Studies in rodents and humans have looked at the ability of a number of medications, most recently β blockers, such as propranolol, to interfere with the consolidation of emotionally traumatic memories (memory erasure) and disrupting their retention once consolidated (memory extinction).⁷ While researchers cannot yet completely wipe out a selected memory, like in the movie Star Trek, it has been shown that medications at least in study settings do reduce fear and can attenuate the development of PTSD when combined with psychotherapy. Neuroscientists call these more realistic alterations of recall memory dampening. Though these medications are not ready for regular clinical application, the unprecedented pace of neuroscience makes it nearly inevitable that in the not so distant future some significant blunting of traumatic memory will be possible.

Once science answers in the affirmative the question, “Is this intervention something we could conceivably do?” The next question belongs to ethics, “Is this intervention something we should do even if we can?” As early as 2001, the President’s Council on Bioethics answered the latter with “probably not.”

Use of memory-blunters at the time of traumatic events could interfere with the normal psychic work and adaptive value of emotionally charged memory....Thus, by blunting the emotional impact of events, beta-blockers or their successors would concomitantly weaken our recollection of the traumatic events we have just experienced. Yet often it is important in the after of such events that at least someone remember them clearly. For legal reasons, to say nothing of deeper social and personal ones, the wisdom of routinely interfering with the memories of traumatic survivors and witnesses is highly questionable.⁸

Many neuroscientists and neuroethicists objected to the perspective of the Bioethics Council as being too puritanical and its position overly pessimistic:

Whereas memory dampening has its drawbacks, such may be the price we pay in order to heal immense suffering. In some contexts, there may be steps that ought to be taken to preserve valuable factual or emotional information contained in memory, even when we must delay or otherwise impose limits on access to memory dampening. None of these concerns, however, even if they find empirical support, are strong enough to justify brushed restrictions on memory dampening.⁹

The proponents of the 2 views propose and oppose the contrarian position on issues both philosophical and practical, such as the function of traumatic experience in personal growth; how the preservation of memory is related to the integrity of the person and authenticity of the life lived; how blunting of memories of especially combat trauma may normalize our reactions to suffering and evil; and most important for this Veterans Day essay, whether remembering is an ethical duty and if so whose is it to discharge, the individual, his family, community, or country.

More pragmatic, there would be a need to refine our understanding of the risk factors for chronic and disabling PTSD; to determine when in the course of the trauma experience to pharmacologically interfere with memory and to what degree and scope; how to protect the autonomy of the service member to consent or to refuse the procedure within the recognized confines of military ethics; and most important for this essay, how to prevent governments, corporations, or any other entity from exploiting neurobiologic discoveries for power or profit.

Elie Wiesel is an important modern prophet of the critical role of memory in the survival of civilization. His prophecy is rooted in the incomprehensible anguish and horror he personally and communally witnessed in the Holocaust. He suggests in this editorial’s epigraph that there are deep and profound issues to be pondered about memory and its inextricable link to suffering. Meditations offer thoughts, not answers, and I encourage readers to spend a few minutes considering the solemn ones presented here this Veterans Day.

"Extreme remedies are very appropriate for extreme diseases"
- Hippocrates Aphorisms

On March 5, 2019, the US Food and Drug Administration (FDA) approved a nasal spray formulation of the drug ketamine, an old anesthetic that has been put to a new use over the past 10 years as therapy for treatment-resistant severe depression. Ketamine, known on the street as Special K, has long been known to cause dissociation, hallucinations, and other hallucinogenic effects. In many randomized controlled trials, subanesthetic doses administered intravenously have demonstrated rapid and often dramatic relief of depressive symptoms.

Neuroscientists have heralded ketamine as the paradigm of the glutamatergic modifying drug class, which represents the first real breakthrough in the pharmaceutical treatment of depression in decades.¹ There have been 2 major pharmacologic limitations attached to this promising new treatment: the IV form of the drug and the short duration of its antidepressant effect. Pharmaceutical companies and neuroscientists predictably have been engaging in a fast and furious race to successfully overcome these obstacles, hoping to win fame and fortune and bring hope and help to the millions of patients who have failed to fully respond to or been unable to tolerate existing therapies for mood disorders.²

When the FDA approved Spravato (esketamine), a nasal administration of ketamine, many people hoped that researchers had succeeded in overcoming these barriers. The risks of serious adverse events (AEs) as well as the potential for abuse and diversion led the FDA to limit prescriptions under a Risk Evaluation and Mitigation Strategy (REMS).³ Patients self-administer the nasal spray but only in a certified medical facility under the observation of a health care practitioner. Patients also must agree to remain on site for 2 hours after administration of the drug to ensure their safety. The FDA recommends the drug be given twice a week for 4 weeks along with a conventional monoamine-acting antidepressant.When the US Department of Veterans Affairs (VA) cleared the way for use of esketamine, less than 2 weeks after the FDA approval, it also launched a series of controversies over how to use the drug in its massive health care system, which is the subject of this editorial. On March 19, 2019, the VA announced that VA practitioners would be able to prescribe the nasal spray for patients who were determined to have treatment-resistant depression but only after appropriate clinical assessment and in accordance with their patients’ preferences.

A number of controversies have emerged surrounding the VA adoption of esketamine, including its cost/benefit/risk ratio and who should be able to access the medication. Each of these issues has onion layers of political, regulatory, and ethical concerns that can only be superficially noted here and warrant fuller unpeeling. In June The New York Times featured a story alleging that in response to the tragic tide of ever-increasing veteran suicides, the VA sanctioned esketamine prescribing despite its cost and the serious questions experts raised about the data the FDA cited to establish its safety and efficacy. Although the cost to the VA of Spravato is unclear, it is much higher than generic IV ketamine.⁴

The access controversy is almost the ethical inverse of the first. In June 2019, a Veterans Health Administration advisory panel voted against allowing general use of esketamine, limiting it to individual cases of patients who are preapproved and have failed 2 antidepressant trials. Esketamine will not be on the VA formulary for widespread use. Congressional and public advocacy groups have noted that the formulary decision came in the wake of ongoing attention to the role of the pharmaceutical industry in the VA’s rapid adoption of the drug.^5,6 For the thousands of veterans for whom the data show conventional antidepressants even in combination with other psychotropic medications and evidence-based psychotherapies resulted in AEs or only partial remission of depression symptoms, the VA’s restriction will likely seem unfair and even uncaring.⁷

As a practicing VA psychiatrist, I know firsthand how desperately we need new, more effective, and better-tolerated treatments for severe unipolar and bipolar depression. Although I have not prescribed ketamine or esketamine, several of my most respected colleagues do. I have seen patients with chronic, severe, depression respond and even recover in ways that seem just a little short of miraculous when compared with other therapies. Yet as a longtime student of the history of psychiatry, I have also seen that often the treatments that initially seem so auspicious, in time, turn out to have a dark side. Families, communities, the country, VA, and the US Department of Defense and its practitioners in and out of mental health cannot in any moral universe abide by the fact that 20 plus men and women who served take their lives every day.⁸

As the epigraph to this column notes, we must often try radical therapies for grave cases in drastic crises. Yet we must also in making serious public health decisions fraught with unseen consequences take all due and considered diligence that we do not violate the even more fundamental dictum of the Hippocratic School, “at least do not harm.” That means trying to balance safety and availability while VA conducts its own research in a precarious way that leaves almost no stakeholder completely happy.

"Extreme remedies are very appropriate for extreme diseases"
- Hippocrates Aphorisms

On March 5, 2019, the US Food and Drug Administration (FDA) approved a nasal spray formulation of the drug ketamine, an old anesthetic that has been put to a new use over the past 10 years as therapy for treatment-resistant severe depression. Ketamine, known on the street as Special K, has long been known to cause dissociation, hallucinations, and other hallucinogenic effects. In many randomized controlled trials, subanesthetic doses administered intravenously have demonstrated rapid and often dramatic relief of depressive symptoms.

Neuroscientists have heralded ketamine as the paradigm of the glutamatergic modifying drug class, which represents the first real breakthrough in the pharmaceutical treatment of depression in decades.¹ There have been 2 major pharmacologic limitations attached to this promising new treatment: the IV form of the drug and the short duration of its antidepressant effect. Pharmaceutical companies and neuroscientists predictably have been engaging in a fast and furious race to successfully overcome these obstacles, hoping to win fame and fortune and bring hope and help to the millions of patients who have failed to fully respond to or been unable to tolerate existing therapies for mood disorders.²

When the FDA approved Spravato (esketamine), a nasal administration of ketamine, many people hoped that researchers had succeeded in overcoming these barriers. The risks of serious adverse events (AEs) as well as the potential for abuse and diversion led the FDA to limit prescriptions under a Risk Evaluation and Mitigation Strategy (REMS).³ Patients self-administer the nasal spray but only in a certified medical facility under the observation of a health care practitioner. Patients also must agree to remain on site for 2 hours after administration of the drug to ensure their safety. The FDA recommends the drug be given twice a week for 4 weeks along with a conventional monoamine-acting antidepressant.When the US Department of Veterans Affairs (VA) cleared the way for use of esketamine, less than 2 weeks after the FDA approval, it also launched a series of controversies over how to use the drug in its massive health care system, which is the subject of this editorial. On March 19, 2019, the VA announced that VA practitioners would be able to prescribe the nasal spray for patients who were determined to have treatment-resistant depression but only after appropriate clinical assessment and in accordance with their patients’ preferences.

A number of controversies have emerged surrounding the VA adoption of esketamine, including its cost/benefit/risk ratio and who should be able to access the medication. Each of these issues has onion layers of political, regulatory, and ethical concerns that can only be superficially noted here and warrant fuller unpeeling. In June The New York Times featured a story alleging that in response to the tragic tide of ever-increasing veteran suicides, the VA sanctioned esketamine prescribing despite its cost and the serious questions experts raised about the data the FDA cited to establish its safety and efficacy. Although the cost to the VA of Spravato is unclear, it is much higher than generic IV ketamine.⁴

The access controversy is almost the ethical inverse of the first. In June 2019, a Veterans Health Administration advisory panel voted against allowing general use of esketamine, limiting it to individual cases of patients who are preapproved and have failed 2 antidepressant trials. Esketamine will not be on the VA formulary for widespread use. Congressional and public advocacy groups have noted that the formulary decision came in the wake of ongoing attention to the role of the pharmaceutical industry in the VA’s rapid adoption of the drug.^5,6 For the thousands of veterans for whom the data show conventional antidepressants even in combination with other psychotropic medications and evidence-based psychotherapies resulted in AEs or only partial remission of depression symptoms, the VA’s restriction will likely seem unfair and even uncaring.⁷

As a practicing VA psychiatrist, I know firsthand how desperately we need new, more effective, and better-tolerated treatments for severe unipolar and bipolar depression. Although I have not prescribed ketamine or esketamine, several of my most respected colleagues do. I have seen patients with chronic, severe, depression respond and even recover in ways that seem just a little short of miraculous when compared with other therapies. Yet as a longtime student of the history of psychiatry, I have also seen that often the treatments that initially seem so auspicious, in time, turn out to have a dark side. Families, communities, the country, VA, and the US Department of Defense and its practitioners in and out of mental health cannot in any moral universe abide by the fact that 20 plus men and women who served take their lives every day.⁸

As the epigraph to this column notes, we must often try radical therapies for grave cases in drastic crises. Yet we must also in making serious public health decisions fraught with unseen consequences take all due and considered diligence that we do not violate the even more fundamental dictum of the Hippocratic School, “at least do not harm.” That means trying to balance safety and availability while VA conducts its own research in a precarious way that leaves almost no stakeholder completely happy.

"Extreme remedies are very appropriate for extreme diseases"
- Hippocrates Aphorisms

On March 5, 2019, the US Food and Drug Administration (FDA) approved a nasal spray formulation of the drug ketamine, an old anesthetic that has been put to a new use over the past 10 years as therapy for treatment-resistant severe depression. Ketamine, known on the street as Special K, has long been known to cause dissociation, hallucinations, and other hallucinogenic effects. In many randomized controlled trials, subanesthetic doses administered intravenously have demonstrated rapid and often dramatic relief of depressive symptoms.

Neuroscientists have heralded ketamine as the paradigm of the glutamatergic modifying drug class, which represents the first real breakthrough in the pharmaceutical treatment of depression in decades.¹ There have been 2 major pharmacologic limitations attached to this promising new treatment: the IV form of the drug and the short duration of its antidepressant effect. Pharmaceutical companies and neuroscientists predictably have been engaging in a fast and furious race to successfully overcome these obstacles, hoping to win fame and fortune and bring hope and help to the millions of patients who have failed to fully respond to or been unable to tolerate existing therapies for mood disorders.²

When the FDA approved Spravato (esketamine), a nasal administration of ketamine, many people hoped that researchers had succeeded in overcoming these barriers. The risks of serious adverse events (AEs) as well as the potential for abuse and diversion led the FDA to limit prescriptions under a Risk Evaluation and Mitigation Strategy (REMS).³ Patients self-administer the nasal spray but only in a certified medical facility under the observation of a health care practitioner. Patients also must agree to remain on site for 2 hours after administration of the drug to ensure their safety. The FDA recommends the drug be given twice a week for 4 weeks along with a conventional monoamine-acting antidepressant.When the US Department of Veterans Affairs (VA) cleared the way for use of esketamine, less than 2 weeks after the FDA approval, it also launched a series of controversies over how to use the drug in its massive health care system, which is the subject of this editorial. On March 19, 2019, the VA announced that VA practitioners would be able to prescribe the nasal spray for patients who were determined to have treatment-resistant depression but only after appropriate clinical assessment and in accordance with their patients’ preferences.

A number of controversies have emerged surrounding the VA adoption of esketamine, including its cost/benefit/risk ratio and who should be able to access the medication. Each of these issues has onion layers of political, regulatory, and ethical concerns that can only be superficially noted here and warrant fuller unpeeling. In June The New York Times featured a story alleging that in response to the tragic tide of ever-increasing veteran suicides, the VA sanctioned esketamine prescribing despite its cost and the serious questions experts raised about the data the FDA cited to establish its safety and efficacy. Although the cost to the VA of Spravato is unclear, it is much higher than generic IV ketamine.⁴

The access controversy is almost the ethical inverse of the first. In June 2019, a Veterans Health Administration advisory panel voted against allowing general use of esketamine, limiting it to individual cases of patients who are preapproved and have failed 2 antidepressant trials. Esketamine will not be on the VA formulary for widespread use. Congressional and public advocacy groups have noted that the formulary decision came in the wake of ongoing attention to the role of the pharmaceutical industry in the VA’s rapid adoption of the drug.^5,6 For the thousands of veterans for whom the data show conventional antidepressants even in combination with other psychotropic medications and evidence-based psychotherapies resulted in AEs or only partial remission of depression symptoms, the VA’s restriction will likely seem unfair and even uncaring.⁷

As a practicing VA psychiatrist, I know firsthand how desperately we need new, more effective, and better-tolerated treatments for severe unipolar and bipolar depression. Although I have not prescribed ketamine or esketamine, several of my most respected colleagues do. I have seen patients with chronic, severe, depression respond and even recover in ways that seem just a little short of miraculous when compared with other therapies. Yet as a longtime student of the history of psychiatry, I have also seen that often the treatments that initially seem so auspicious, in time, turn out to have a dark side. Families, communities, the country, VA, and the US Department of Defense and its practitioners in and out of mental health cannot in any moral universe abide by the fact that 20 plus men and women who served take their lives every day.⁸

As the epigraph to this column notes, we must often try radical therapies for grave cases in drastic crises. Yet we must also in making serious public health decisions fraught with unseen consequences take all due and considered diligence that we do not violate the even more fundamental dictum of the Hippocratic School, “at least do not harm.” That means trying to balance safety and availability while VA conducts its own research in a precarious way that leaves almost no stakeholder completely happy.

Whoever seeks to set one religion against another seeks to destroy all religion.¹
President Franklin D. Roosevelt

Recently, a US Department of Veterans Affairs (VA) colleague knowing of my background in religious studies asked me what I thought of the recent change in VA religious policy. VA Secretary Robert Wilke had announced on July 3 that VA was revising its policies on religious symbols at all VA facilities and religious and pastoral care in the Veterans Health Administration, respectively.^2,3 A news release from the VA Office of Public and Intergovernmental Affairs designated the changes as an “overhaul.”⁴

The revisions in these VA directives are designed to address confusion and inconsistency regarding displays of religious matters, not just between different VA medical centers (VAMCs) but even within a single facility. From my decades as a federal practitioner and ethicist, I can attest to the confusion. I have heard or read from staff and leaders of VAMCs everything from “VA prohibits all religious symbols so take that Christmas tree down” to “it is fine to host holiday parties complete with decorations.” There certainly was a need for clarity, transparency, and fairness in VA policy regarding religious and spiritual symbolism. This editorial will discuss how, why, and whether the policy accomplishes this organizational ethics purpose.

The new policies have 3 aims: (1) to permit VA facilities to publicly display religious content in appropriate circumstances; (2) to allow patients and their guests to request and receive religious literature, sacred texts, and spiritual symbols during visits to VA chapels or episodes of treatment; and (3) to permit VA facilities to receive and dispense donations of religious literature, cards, and symbols to VA patrons under appropriate circumstances or when they ask for them.

Secretary Wilke announced the aim of the revised directives: “These important changes will bring simplicity and clarity to our policies governing religious and spiritual symbols, helping ensure we are consistently complying with the First Amendment to the US Constitution at thousands of facilities across the department.”⁴ As with most US Department of Defense (DoD) and VA decisions about potentially controversial issues, this one has a backstory involving 2 high-profile court cases that provide a deeper understanding of the subtext of the policy change.

In February 2019, the US Supreme Court heard oral arguments for The American Legion v American Humanist Association, the most recent of a long line of important cases about the First Amendment and its freedom of religion guarantee.⁵ This case involved veterans—although not the VA or DoD—and is of prima facie interest for those invested or interested in the VA’s position on religion. A 40-foot cross had stood in a veteran memorial park in Bladensburg, Maryland, for decades. In the 1960s the park became the property of the Maryland National Capital Park and Planning Commission (MNCPPC), which assumed the responsibility for upkeep for the cross at considerable expense. The American Humanist Association, an organization advocating for church-state separation, sued the MNCPPC on the grounds it violated the establishment clause of the First Amendment by promoting Christianity as a federally supported religion.

The US District Court found in favor of MNCPPC, but an appeals court reversed that decision. The American Legion, a major force in VA politics, joined MNCPPC to appeal the case to the Supreme Court. The Court issued a 7 to 2 decision, which ruled that the cross did not violate the establishment clause. Even though the cross began as religious symbol, with the passage of time the High Court opined that the cross had become a historic memorial honoring those who fought in the First World War, which rose above its purely Christian meaning.⁵

The American Legion website explicitly credited their success before the Supreme Court as the impetus for VA policy changes.⁶ Hence, from the perspective of VA leadership, this wider latitude for religious expression, which the revised policy now allows, renderings VA practice consonant with the authoritative interpreters of constitutional law—the highest court in the land.

Of course, on a question that has been so divisive for the nation since its founding, there are many who protest this extension of religious liberty in the federal health care system. Veterans stand tall on both sides of this divide. In May 2019 a US Air Force veteran filed a federal lawsuit against the Manchester VAMC director asking the court to remove a Christian Bible from a public display.⁷ With echoes of the Maryland cross case, the Bible in question was owned by a World War II prisoner of war (POW) and sat on a missing man remembrance table for all POWs in the lobby of the facility. Following complaints, the Bible was initially removed but was then returned after complaints over the removal.

Air Force Times compared the resulting melee to actual combat!⁷ As with the first case, such legal battles are ripe territory for advocacy and lobbying organizations of all political stripes to weigh in while promoting their own ideologic agendas. The Military Religious Freedom Foundation assumed the mantle on behalf of the Air Force veteran in the Manchester suit. The news media reported that the plaintiff in the case identified himself as a committed Christian. According to the news reports, what worried this veteran was the same thing that troubled President Roosevelt in 1940: By featuring the Christian Bible, the VA excluded other faith groups.¹ Other veterans and some veteran religious organizations objected just as strenuously to its removal, likely done to reduce potential for violence. Veterans opposing the inclusion of the Bible in the display also grounded their arguments in the First Amendment clause that prohibits the federal government from establishing or favoring any religion.⁸

Presumptively, displays of such religious symbols may well be supported in VA policy as a protected expression of religion, which Secretary Wilke stated was the other primary aim of the revisions. “We want to make sure that all of our veterans and their families feel welcome at VA, no matter their religious beliefs. Protecting religious liberty is a key part of how we accomplish that goal.”⁴

In the middle of this sensitive controversy are the many veterans and their families that third parties—for profit, for politics, for publicity—have far too often manipulated for their own purposes. If you want to get an idea of the scope of these diverse stakeholders, just peruse the amicus briefs submitted to the Supreme Court on both sides of the issues in The American Legion v American Humanist Association.⁸

VA data show that veterans while being more religious than the general public are religiously diverse: 2015 data on the religion of veterans in every state listed 13 different faith communities.⁹ My response to the colleague who asked me about my opinion of the VA policies changes was based on the background narrative recounted here. My rsponse, in light of Roosevelt’s concern and this snippet of a much larger swath of legal machinations, is the change in the VA policy is reasonable as long as it “has room for the expression of those whose trust is in God, in country, in neither, and in both.” We know from research that religion is a strength and a support to many veterans and that spirituality as an aspect of psychological therapies and pastoral counseling has shown healing power for the wounds of war.¹⁰ Yet we also know that religiously based hatred and discrimination are among the most divisive and destructive forces that threaten our democracy. Let’s all hope—and those who pray do so—that these policy changes deter the latter and promote the former.

Whoever seeks to set one religion against another seeks to destroy all religion.¹
President Franklin D. Roosevelt

Recently, a US Department of Veterans Affairs (VA) colleague knowing of my background in religious studies asked me what I thought of the recent change in VA religious policy. VA Secretary Robert Wilke had announced on July 3 that VA was revising its policies on religious symbols at all VA facilities and religious and pastoral care in the Veterans Health Administration, respectively.^2,3 A news release from the VA Office of Public and Intergovernmental Affairs designated the changes as an “overhaul.”⁴

The revisions in these VA directives are designed to address confusion and inconsistency regarding displays of religious matters, not just between different VA medical centers (VAMCs) but even within a single facility. From my decades as a federal practitioner and ethicist, I can attest to the confusion. I have heard or read from staff and leaders of VAMCs everything from “VA prohibits all religious symbols so take that Christmas tree down” to “it is fine to host holiday parties complete with decorations.” There certainly was a need for clarity, transparency, and fairness in VA policy regarding religious and spiritual symbolism. This editorial will discuss how, why, and whether the policy accomplishes this organizational ethics purpose.

The new policies have 3 aims: (1) to permit VA facilities to publicly display religious content in appropriate circumstances; (2) to allow patients and their guests to request and receive religious literature, sacred texts, and spiritual symbols during visits to VA chapels or episodes of treatment; and (3) to permit VA facilities to receive and dispense donations of religious literature, cards, and symbols to VA patrons under appropriate circumstances or when they ask for them.

Secretary Wilke announced the aim of the revised directives: “These important changes will bring simplicity and clarity to our policies governing religious and spiritual symbols, helping ensure we are consistently complying with the First Amendment to the US Constitution at thousands of facilities across the department.”⁴ As with most US Department of Defense (DoD) and VA decisions about potentially controversial issues, this one has a backstory involving 2 high-profile court cases that provide a deeper understanding of the subtext of the policy change.

In February 2019, the US Supreme Court heard oral arguments for The American Legion v American Humanist Association, the most recent of a long line of important cases about the First Amendment and its freedom of religion guarantee.⁵ This case involved veterans—although not the VA or DoD—and is of prima facie interest for those invested or interested in the VA’s position on religion. A 40-foot cross had stood in a veteran memorial park in Bladensburg, Maryland, for decades. In the 1960s the park became the property of the Maryland National Capital Park and Planning Commission (MNCPPC), which assumed the responsibility for upkeep for the cross at considerable expense. The American Humanist Association, an organization advocating for church-state separation, sued the MNCPPC on the grounds it violated the establishment clause of the First Amendment by promoting Christianity as a federally supported religion.

The US District Court found in favor of MNCPPC, but an appeals court reversed that decision. The American Legion, a major force in VA politics, joined MNCPPC to appeal the case to the Supreme Court. The Court issued a 7 to 2 decision, which ruled that the cross did not violate the establishment clause. Even though the cross began as religious symbol, with the passage of time the High Court opined that the cross had become a historic memorial honoring those who fought in the First World War, which rose above its purely Christian meaning.⁵

The American Legion website explicitly credited their success before the Supreme Court as the impetus for VA policy changes.⁶ Hence, from the perspective of VA leadership, this wider latitude for religious expression, which the revised policy now allows, renderings VA practice consonant with the authoritative interpreters of constitutional law—the highest court in the land.

Of course, on a question that has been so divisive for the nation since its founding, there are many who protest this extension of religious liberty in the federal health care system. Veterans stand tall on both sides of this divide. In May 2019 a US Air Force veteran filed a federal lawsuit against the Manchester VAMC director asking the court to remove a Christian Bible from a public display.⁷ With echoes of the Maryland cross case, the Bible in question was owned by a World War II prisoner of war (POW) and sat on a missing man remembrance table for all POWs in the lobby of the facility. Following complaints, the Bible was initially removed but was then returned after complaints over the removal.

Air Force Times compared the resulting melee to actual combat!⁷ As with the first case, such legal battles are ripe territory for advocacy and lobbying organizations of all political stripes to weigh in while promoting their own ideologic agendas. The Military Religious Freedom Foundation assumed the mantle on behalf of the Air Force veteran in the Manchester suit. The news media reported that the plaintiff in the case identified himself as a committed Christian. According to the news reports, what worried this veteran was the same thing that troubled President Roosevelt in 1940: By featuring the Christian Bible, the VA excluded other faith groups.¹ Other veterans and some veteran religious organizations objected just as strenuously to its removal, likely done to reduce potential for violence. Veterans opposing the inclusion of the Bible in the display also grounded their arguments in the First Amendment clause that prohibits the federal government from establishing or favoring any religion.⁸

Presumptively, displays of such religious symbols may well be supported in VA policy as a protected expression of religion, which Secretary Wilke stated was the other primary aim of the revisions. “We want to make sure that all of our veterans and their families feel welcome at VA, no matter their religious beliefs. Protecting religious liberty is a key part of how we accomplish that goal.”⁴

In the middle of this sensitive controversy are the many veterans and their families that third parties—for profit, for politics, for publicity—have far too often manipulated for their own purposes. If you want to get an idea of the scope of these diverse stakeholders, just peruse the amicus briefs submitted to the Supreme Court on both sides of the issues in The American Legion v American Humanist Association.⁸

VA data show that veterans while being more religious than the general public are religiously diverse: 2015 data on the religion of veterans in every state listed 13 different faith communities.⁹ My response to the colleague who asked me about my opinion of the VA policies changes was based on the background narrative recounted here. My rsponse, in light of Roosevelt’s concern and this snippet of a much larger swath of legal machinations, is the change in the VA policy is reasonable as long as it “has room for the expression of those whose trust is in God, in country, in neither, and in both.” We know from research that religion is a strength and a support to many veterans and that spirituality as an aspect of psychological therapies and pastoral counseling has shown healing power for the wounds of war.¹⁰ Yet we also know that religiously based hatred and discrimination are among the most divisive and destructive forces that threaten our democracy. Let’s all hope—and those who pray do so—that these policy changes deter the latter and promote the former.

Whoever seeks to set one religion against another seeks to destroy all religion.¹
President Franklin D. Roosevelt

Recently, a US Department of Veterans Affairs (VA) colleague knowing of my background in religious studies asked me what I thought of the recent change in VA religious policy. VA Secretary Robert Wilke had announced on July 3 that VA was revising its policies on religious symbols at all VA facilities and religious and pastoral care in the Veterans Health Administration, respectively.^2,3 A news release from the VA Office of Public and Intergovernmental Affairs designated the changes as an “overhaul.”⁴

The revisions in these VA directives are designed to address confusion and inconsistency regarding displays of religious matters, not just between different VA medical centers (VAMCs) but even within a single facility. From my decades as a federal practitioner and ethicist, I can attest to the confusion. I have heard or read from staff and leaders of VAMCs everything from “VA prohibits all religious symbols so take that Christmas tree down” to “it is fine to host holiday parties complete with decorations.” There certainly was a need for clarity, transparency, and fairness in VA policy regarding religious and spiritual symbolism. This editorial will discuss how, why, and whether the policy accomplishes this organizational ethics purpose.

The new policies have 3 aims: (1) to permit VA facilities to publicly display religious content in appropriate circumstances; (2) to allow patients and their guests to request and receive religious literature, sacred texts, and spiritual symbols during visits to VA chapels or episodes of treatment; and (3) to permit VA facilities to receive and dispense donations of religious literature, cards, and symbols to VA patrons under appropriate circumstances or when they ask for them.

Secretary Wilke announced the aim of the revised directives: “These important changes will bring simplicity and clarity to our policies governing religious and spiritual symbols, helping ensure we are consistently complying with the First Amendment to the US Constitution at thousands of facilities across the department.”⁴ As with most US Department of Defense (DoD) and VA decisions about potentially controversial issues, this one has a backstory involving 2 high-profile court cases that provide a deeper understanding of the subtext of the policy change.

In February 2019, the US Supreme Court heard oral arguments for The American Legion v American Humanist Association, the most recent of a long line of important cases about the First Amendment and its freedom of religion guarantee.⁵ This case involved veterans—although not the VA or DoD—and is of prima facie interest for those invested or interested in the VA’s position on religion. A 40-foot cross had stood in a veteran memorial park in Bladensburg, Maryland, for decades. In the 1960s the park became the property of the Maryland National Capital Park and Planning Commission (MNCPPC), which assumed the responsibility for upkeep for the cross at considerable expense. The American Humanist Association, an organization advocating for church-state separation, sued the MNCPPC on the grounds it violated the establishment clause of the First Amendment by promoting Christianity as a federally supported religion.

The US District Court found in favor of MNCPPC, but an appeals court reversed that decision. The American Legion, a major force in VA politics, joined MNCPPC to appeal the case to the Supreme Court. The Court issued a 7 to 2 decision, which ruled that the cross did not violate the establishment clause. Even though the cross began as religious symbol, with the passage of time the High Court opined that the cross had become a historic memorial honoring those who fought in the First World War, which rose above its purely Christian meaning.⁵

The American Legion website explicitly credited their success before the Supreme Court as the impetus for VA policy changes.⁶ Hence, from the perspective of VA leadership, this wider latitude for religious expression, which the revised policy now allows, renderings VA practice consonant with the authoritative interpreters of constitutional law—the highest court in the land.

Of course, on a question that has been so divisive for the nation since its founding, there are many who protest this extension of religious liberty in the federal health care system. Veterans stand tall on both sides of this divide. In May 2019 a US Air Force veteran filed a federal lawsuit against the Manchester VAMC director asking the court to remove a Christian Bible from a public display.⁷ With echoes of the Maryland cross case, the Bible in question was owned by a World War II prisoner of war (POW) and sat on a missing man remembrance table for all POWs in the lobby of the facility. Following complaints, the Bible was initially removed but was then returned after complaints over the removal.

Air Force Times compared the resulting melee to actual combat!⁷ As with the first case, such legal battles are ripe territory for advocacy and lobbying organizations of all political stripes to weigh in while promoting their own ideologic agendas. The Military Religious Freedom Foundation assumed the mantle on behalf of the Air Force veteran in the Manchester suit. The news media reported that the plaintiff in the case identified himself as a committed Christian. According to the news reports, what worried this veteran was the same thing that troubled President Roosevelt in 1940: By featuring the Christian Bible, the VA excluded other faith groups.¹ Other veterans and some veteran religious organizations objected just as strenuously to its removal, likely done to reduce potential for violence. Veterans opposing the inclusion of the Bible in the display also grounded their arguments in the First Amendment clause that prohibits the federal government from establishing or favoring any religion.⁸

Presumptively, displays of such religious symbols may well be supported in VA policy as a protected expression of religion, which Secretary Wilke stated was the other primary aim of the revisions. “We want to make sure that all of our veterans and their families feel welcome at VA, no matter their religious beliefs. Protecting religious liberty is a key part of how we accomplish that goal.”⁴

In the middle of this sensitive controversy are the many veterans and their families that third parties—for profit, for politics, for publicity—have far too often manipulated for their own purposes. If you want to get an idea of the scope of these diverse stakeholders, just peruse the amicus briefs submitted to the Supreme Court on both sides of the issues in The American Legion v American Humanist Association.⁸

VA data show that veterans while being more religious than the general public are religiously diverse: 2015 data on the religion of veterans in every state listed 13 different faith communities.⁹ My response to the colleague who asked me about my opinion of the VA policies changes was based on the background narrative recounted here. My rsponse, in light of Roosevelt’s concern and this snippet of a much larger swath of legal machinations, is the change in the VA policy is reasonable as long as it “has room for the expression of those whose trust is in God, in country, in neither, and in both.” We know from research that religion is a strength and a support to many veterans and that spirituality as an aspect of psychological therapies and pastoral counseling has shown healing power for the wounds of war.¹⁰ Yet we also know that religiously based hatred and discrimination are among the most divisive and destructive forces that threaten our democracy. Let’s all hope—and those who pray do so—that these policy changes deter the latter and promote the former.

The disputes about those who decline to vaccinate their children for communicable infectious diseases, especially measles, have been in the headlines of late. Those refusals are often done in the name of “medical freedom.”¹ Yet this is a much older debate for the military. It seems fitting in this month in which we celebrate the 243rd anniversary of the Declaration of Independence to reflect on the earliest history of the interaction between vaccinations and war in the US and what it tells us about the fight for religious and political freedom and individual liberty.

Go back in time with me to 1776, long before the Fourth of July was a day for barbecues and fireworks. We are in Boston, Philadelphia, and other important cities in colonial America. This time, concern was not about measles but the even more dreaded smallpox. In the first years of the Revolutionary War, General George Washington took command of a newly formed and named Continental Army. A catastrophic 90% of casualties in the Continental Army were from infectious diseases, with the lion’s share of these from smallpox, which at that time had a mortality rate of about 30%.^2,3

Early efforts to introduce inoculation into the colonies had failed for many of the same reasons parents across the US today refuse immunization: fear and anxiety. When the renowned New England Puritan minister and scientist Cotton Mather attempted in 1721 to introduce variolation, his house was firebombed and his fellow clergy and physicians alleged that his efforts at inoculation were challenging God’s will to send a plague.³ Variolation was the now antiquated and then laborious process in which a previously unexposed individual was inoculated with material from the vesicle of someone infected with the disease.^4,5 Variolation was practiced in parts of Africa and Asia and among wealthy Europeans but remained controversial in many colonies where few Americans had been exposed to smallpox or could afford the procedure.³

It is important to note that the use of variolation was practiced before Edward Jenner famously demonstrated that cowpox vaccine could provide immunity to smallpox in 1798. The majority of those inoculated would develop a mild case of smallpox that required a 5-week period of illness and recovery that provided lifelong immunity. However, during those 5 weeks, they remained a vector of disease for the uninoculated. Southern and New England colonies passed laws that prohibited variolation. Those anti-inoculation attitudes were the basis for the order given to the surgeons general of the Continental Army in 1776 that all inoculations of the troops were forbidden, despite the fact that perhaps only 25% of soldiers possessed any natural immunity.^2,3

There was yet another reason that many colonial Americans opposed government-sponsored preventative care, and it was the same reason that they were fighting a war of independence: distrust and resentment of authority. The modern antivaccine movement voices similar fears and suspicions regarding public health campaigns and especially legislative efforts to mandate vaccinations or remove extant exemptions.

In 1775 in Boston, a smallpox outbreak occurred at the same time the Americans laid siege to the British troops occupying the city. Greater natural immunity to the scourge of smallpox either through exposure or variolation provided the British with a stronger defense than the mere city fortifications. There are even some suspicions that the British used the virus as a proto-biologic weapon.

General Washington had initially been against inoculation until he realized that without it the British might win the war. This possibility presented him with a momentous decision: inoculate despite widespread anxiety that variolation would spread the disease or risk the virus ravaging the fighting force. Perhaps the most compelling reason to variolate was that new recruits refused to sign up, fearing not that they would die in battle but of smallpox. In 1777, Washington mandated variolation of the nonimmune troops and new recruits, making it the first large-scale military preventative care measure in history.

Recapitulating an ethical dilemma that still rages in the military nearly 3 centuries later, for British soldiers, inoculation was voluntary not compulsory as for the Americans. There was so much opposition to Washington’s order that communications with surgeons were secret, and commanding officers had to oversee the inoculations.^2,3

Washington’s policy not only contributed mightily to the American victory in the war, but also set the precedent for compulsory vaccination in the US military for the next 3 centuries. Currently, regulations require that service members be vaccinated for multiple infectious diseases. Of interest, this mandatory vaccination program has led to no reported cases of measles among military families to date, in part because of federal regulations requiring families of those service members to be vaccinated.⁶

Ironically, once General Washington made the decision for mass inoculation, he encountered little actual resistance among the troops. However, throughout military history some service members have objected to compulsory vaccination on medical, religious, and personal grounds. In United States v Chadwell, a military court ruled against 2 Marine Corps members who refused vaccination for smallpox, typhoid, paratyphoid, and influenza, citing religious grounds. The court opined that the military orders that ensure the health and safety of the armed forces and thereby that of the public override personal religious beliefs.⁷

The paradox of liberty—the liberty first won in the Revolutionary War—is that in a pluralistic representative democracy like ours to secure the freedom for all, some, such as the military, must relinquish the very choice to refuse. Their sacrifices grant liberty to others. On June 6, we commemorated the seventy-fifth anniversary of D-Day, remembering how great the cost of that eternal vigilance, which the patriot Thomas Paine said was the price of liberty. On Memorial Day, we remember all those men and women who died in the service of their country. And while they gave up the most precious gift, we must never forget that every person in uniform also surrenders many other significant personal freedoms so that their fellow civilians may exercise them.

The question General Washington faced is one that public health authorities and our legislators again confront. When should the freedom to refuse, which was won with the blood of many valiant heroes and has been defended since 1776, be curtailed for the greater good? We are the one nation in history that has made the defense of self-determination its highest value and in so doing, its greatest challenge.

The disputes about those who decline to vaccinate their children for communicable infectious diseases, especially measles, have been in the headlines of late. Those refusals are often done in the name of “medical freedom.”¹ Yet this is a much older debate for the military. It seems fitting in this month in which we celebrate the 243rd anniversary of the Declaration of Independence to reflect on the earliest history of the interaction between vaccinations and war in the US and what it tells us about the fight for religious and political freedom and individual liberty.

Go back in time with me to 1776, long before the Fourth of July was a day for barbecues and fireworks. We are in Boston, Philadelphia, and other important cities in colonial America. This time, concern was not about measles but the even more dreaded smallpox. In the first years of the Revolutionary War, General George Washington took command of a newly formed and named Continental Army. A catastrophic 90% of casualties in the Continental Army were from infectious diseases, with the lion’s share of these from smallpox, which at that time had a mortality rate of about 30%.^2,3

Early efforts to introduce inoculation into the colonies had failed for many of the same reasons parents across the US today refuse immunization: fear and anxiety. When the renowned New England Puritan minister and scientist Cotton Mather attempted in 1721 to introduce variolation, his house was firebombed and his fellow clergy and physicians alleged that his efforts at inoculation were challenging God’s will to send a plague.³ Variolation was the now antiquated and then laborious process in which a previously unexposed individual was inoculated with material from the vesicle of someone infected with the disease.^4,5 Variolation was practiced in parts of Africa and Asia and among wealthy Europeans but remained controversial in many colonies where few Americans had been exposed to smallpox or could afford the procedure.³

It is important to note that the use of variolation was practiced before Edward Jenner famously demonstrated that cowpox vaccine could provide immunity to smallpox in 1798. The majority of those inoculated would develop a mild case of smallpox that required a 5-week period of illness and recovery that provided lifelong immunity. However, during those 5 weeks, they remained a vector of disease for the uninoculated. Southern and New England colonies passed laws that prohibited variolation. Those anti-inoculation attitudes were the basis for the order given to the surgeons general of the Continental Army in 1776 that all inoculations of the troops were forbidden, despite the fact that perhaps only 25% of soldiers possessed any natural immunity.^2,3

There was yet another reason that many colonial Americans opposed government-sponsored preventative care, and it was the same reason that they were fighting a war of independence: distrust and resentment of authority. The modern antivaccine movement voices similar fears and suspicions regarding public health campaigns and especially legislative efforts to mandate vaccinations or remove extant exemptions.

In 1775 in Boston, a smallpox outbreak occurred at the same time the Americans laid siege to the British troops occupying the city. Greater natural immunity to the scourge of smallpox either through exposure or variolation provided the British with a stronger defense than the mere city fortifications. There are even some suspicions that the British used the virus as a proto-biologic weapon.

General Washington had initially been against inoculation until he realized that without it the British might win the war. This possibility presented him with a momentous decision: inoculate despite widespread anxiety that variolation would spread the disease or risk the virus ravaging the fighting force. Perhaps the most compelling reason to variolate was that new recruits refused to sign up, fearing not that they would die in battle but of smallpox. In 1777, Washington mandated variolation of the nonimmune troops and new recruits, making it the first large-scale military preventative care measure in history.

Recapitulating an ethical dilemma that still rages in the military nearly 3 centuries later, for British soldiers, inoculation was voluntary not compulsory as for the Americans. There was so much opposition to Washington’s order that communications with surgeons were secret, and commanding officers had to oversee the inoculations.^2,3

Washington’s policy not only contributed mightily to the American victory in the war, but also set the precedent for compulsory vaccination in the US military for the next 3 centuries. Currently, regulations require that service members be vaccinated for multiple infectious diseases. Of interest, this mandatory vaccination program has led to no reported cases of measles among military families to date, in part because of federal regulations requiring families of those service members to be vaccinated.⁶

Ironically, once General Washington made the decision for mass inoculation, he encountered little actual resistance among the troops. However, throughout military history some service members have objected to compulsory vaccination on medical, religious, and personal grounds. In United States v Chadwell, a military court ruled against 2 Marine Corps members who refused vaccination for smallpox, typhoid, paratyphoid, and influenza, citing religious grounds. The court opined that the military orders that ensure the health and safety of the armed forces and thereby that of the public override personal religious beliefs.⁷

The paradox of liberty—the liberty first won in the Revolutionary War—is that in a pluralistic representative democracy like ours to secure the freedom for all, some, such as the military, must relinquish the very choice to refuse. Their sacrifices grant liberty to others. On June 6, we commemorated the seventy-fifth anniversary of D-Day, remembering how great the cost of that eternal vigilance, which the patriot Thomas Paine said was the price of liberty. On Memorial Day, we remember all those men and women who died in the service of their country. And while they gave up the most precious gift, we must never forget that every person in uniform also surrenders many other significant personal freedoms so that their fellow civilians may exercise them.

The question General Washington faced is one that public health authorities and our legislators again confront. When should the freedom to refuse, which was won with the blood of many valiant heroes and has been defended since 1776, be curtailed for the greater good? We are the one nation in history that has made the defense of self-determination its highest value and in so doing, its greatest challenge.

The disputes about those who decline to vaccinate their children for communicable infectious diseases, especially measles, have been in the headlines of late. Those refusals are often done in the name of “medical freedom.”¹ Yet this is a much older debate for the military. It seems fitting in this month in which we celebrate the 243rd anniversary of the Declaration of Independence to reflect on the earliest history of the interaction between vaccinations and war in the US and what it tells us about the fight for religious and political freedom and individual liberty.

Go back in time with me to 1776, long before the Fourth of July was a day for barbecues and fireworks. We are in Boston, Philadelphia, and other important cities in colonial America. This time, concern was not about measles but the even more dreaded smallpox. In the first years of the Revolutionary War, General George Washington took command of a newly formed and named Continental Army. A catastrophic 90% of casualties in the Continental Army were from infectious diseases, with the lion’s share of these from smallpox, which at that time had a mortality rate of about 30%.^2,3

Early efforts to introduce inoculation into the colonies had failed for many of the same reasons parents across the US today refuse immunization: fear and anxiety. When the renowned New England Puritan minister and scientist Cotton Mather attempted in 1721 to introduce variolation, his house was firebombed and his fellow clergy and physicians alleged that his efforts at inoculation were challenging God’s will to send a plague.³ Variolation was the now antiquated and then laborious process in which a previously unexposed individual was inoculated with material from the vesicle of someone infected with the disease.^4,5 Variolation was practiced in parts of Africa and Asia and among wealthy Europeans but remained controversial in many colonies where few Americans had been exposed to smallpox or could afford the procedure.³

It is important to note that the use of variolation was practiced before Edward Jenner famously demonstrated that cowpox vaccine could provide immunity to smallpox in 1798. The majority of those inoculated would develop a mild case of smallpox that required a 5-week period of illness and recovery that provided lifelong immunity. However, during those 5 weeks, they remained a vector of disease for the uninoculated. Southern and New England colonies passed laws that prohibited variolation. Those anti-inoculation attitudes were the basis for the order given to the surgeons general of the Continental Army in 1776 that all inoculations of the troops were forbidden, despite the fact that perhaps only 25% of soldiers possessed any natural immunity.^2,3

There was yet another reason that many colonial Americans opposed government-sponsored preventative care, and it was the same reason that they were fighting a war of independence: distrust and resentment of authority. The modern antivaccine movement voices similar fears and suspicions regarding public health campaigns and especially legislative efforts to mandate vaccinations or remove extant exemptions.

In 1775 in Boston, a smallpox outbreak occurred at the same time the Americans laid siege to the British troops occupying the city. Greater natural immunity to the scourge of smallpox either through exposure or variolation provided the British with a stronger defense than the mere city fortifications. There are even some suspicions that the British used the virus as a proto-biologic weapon.

General Washington had initially been against inoculation until he realized that without it the British might win the war. This possibility presented him with a momentous decision: inoculate despite widespread anxiety that variolation would spread the disease or risk the virus ravaging the fighting force. Perhaps the most compelling reason to variolate was that new recruits refused to sign up, fearing not that they would die in battle but of smallpox. In 1777, Washington mandated variolation of the nonimmune troops and new recruits, making it the first large-scale military preventative care measure in history.

Recapitulating an ethical dilemma that still rages in the military nearly 3 centuries later, for British soldiers, inoculation was voluntary not compulsory as for the Americans. There was so much opposition to Washington’s order that communications with surgeons were secret, and commanding officers had to oversee the inoculations.^2,3

Washington’s policy not only contributed mightily to the American victory in the war, but also set the precedent for compulsory vaccination in the US military for the next 3 centuries. Currently, regulations require that service members be vaccinated for multiple infectious diseases. Of interest, this mandatory vaccination program has led to no reported cases of measles among military families to date, in part because of federal regulations requiring families of those service members to be vaccinated.⁶

Ironically, once General Washington made the decision for mass inoculation, he encountered little actual resistance among the troops. However, throughout military history some service members have objected to compulsory vaccination on medical, religious, and personal grounds. In United States v Chadwell, a military court ruled against 2 Marine Corps members who refused vaccination for smallpox, typhoid, paratyphoid, and influenza, citing religious grounds. The court opined that the military orders that ensure the health and safety of the armed forces and thereby that of the public override personal religious beliefs.⁷

The paradox of liberty—the liberty first won in the Revolutionary War—is that in a pluralistic representative democracy like ours to secure the freedom for all, some, such as the military, must relinquish the very choice to refuse. Their sacrifices grant liberty to others. On June 6, we commemorated the seventy-fifth anniversary of D-Day, remembering how great the cost of that eternal vigilance, which the patriot Thomas Paine said was the price of liberty. On Memorial Day, we remember all those men and women who died in the service of their country. And while they gave up the most precious gift, we must never forget that every person in uniform also surrenders many other significant personal freedoms so that their fellow civilians may exercise them.

The question General Washington faced is one that public health authorities and our legislators again confront. When should the freedom to refuse, which was won with the blood of many valiant heroes and has been defended since 1776, be curtailed for the greater good? We are the one nation in history that has made the defense of self-determination its highest value and in so doing, its greatest challenge.

The title of this essay is more often posed as “Is War Good for Medicine?”² The career VA physician in me, and the daughter and granddaughter of combat veterans, finds this question historically accurate, but ethically problematic. So I have rewritten the question to one that enables us to examine the historic relationship of medical advances and war from a more ethically justifiable posture. I am by no means ascribing to authors of other publications with this title anything but the highest motives of education and edification.

Yet the more I read and thought about the question(s), I realized that the moral assumptions underlying and supporting each concept are significantly different. What led me to that realization was a story my father told me when I was young which in my youthful ignorance I either dismissed or ignored. I now see that the narrative captured a profound truth about how war is not good especially for those who must wage it, but good may come from it for those who now live in peace.

My father was one of the founders of military pediatrics. Surprisingly, pediatricians were valuable members of the military medical forces because of their knowledge of infectious diseases.³ My father had gone in to the then new specialty of pediatrics because in the 1930s, infectious diseases were the primary cause of death in children. Before antibiotics, children would often die of common infections. Service as a combat medical officer in World War II stationed in the European Theater, my father had experience with and access to penicillin. After returning from the war to work in an Army hospital, he and his staff went into the acute pediatric ward and gave the drug to several very sick children, many of whom were likely to die. The next morning on rounds, they noted that many of the children were feeling much better, some even bouncing on their beds.

Perhaps either his telling or my remembering of these events is partly apocryphal, but the reality is that those lethal microbes had no idea what had hit them. Before human physicians overused the new drugs and nature struck back with antibiotic resistance, penicillin seemed miraculous.

Most likely, in 1945 those children would never have been prescribed penicillin, much less survived, if not for the unprecedented and war-driven consortium of industry and government that mass-produced penicillin to treat the troops with infections. Without a doubt then, from the sacrifice and devastation of World War II came the benefits and boons of the antibiotic era—one of the greatest discoveries in medical science.⁴

Penicillin is but one of legions of scientific discoveries that emerged during wartime. Many of these dramatic improvements, especially those in surgical techniques and emergency medicine, quickly entered the civilian sector. The French surgeon Amboise Paré, for example, revived an old Roman Army practice of using ligatures or tourniquets to stop excessive blood loss, now a staple of emergency responders in disasters. The ambulance services that transported wounded troops to the hospital began on the battlefields of the Civil War.⁵

These impressive contributions are the direct result of military medicine intended to preserve fighting strength. There are also indirect, although just as revolutionary, efforts of DoD and VA scientists and health care professionals to minimize disability and prevent progression especially of service-connected injuries and illnesses. Among the most groundbreaking is the VA’s 3D-printed artificial lung. I have to admit at first I thought that it was futuristic, but quickly I learned that it was a realistic possibility for the coming decades.⁶ VA researchers hope the lung will offer a treatment option for patients with chronic obstructive pulmonary disease (COPD), a lung condition more prevalent in veterans than in the civilian population.⁷ One contributing factor to the increased risk of COPD among former military is the higher rate of smoking among both active duty and veterans than that in the civilian population.⁸ And the last chain in the link of causation is that smoking is more common in those service members who have posttraumatic stress disorder.⁹

However, there also is a very dark side to the link between wartime research and medicine—most infamously the Nazi hypothermia experiments conducted at concentration camps. The proposed publication aroused a decades long ethical controversy regarding whether the data should be published, much less used, in research and practice even if it could save the lives of present or future warriors. In 1990, Marcia Angel, MD, then editor-in-chief of the prestigious New England Journal of Medicine, published the information with an accompanying ethical justification. “Finally, refusal to publish the unethical work serves notice to society at large that even scientists do not consider science the primary measure of a civilization. Knowledge, although important, may be less important to a decent society than the way it is obtained.”¹⁰ Ethicist Stephen Post writing on behalf of Holocaust victims strenuously disagreed with the decision to publish the research, “Because the Nazi experiments on human beings were so appallingly unethical, it follows, prima facie, that the use of the records is unethical.”¹¹

This debate is key to the distinction between the 2 questions posed at the beginning of this column. Few who have been on a battlefield or who have cared for those who were can suggest or defend that wars should be fought as a catalyst for scientific research or an impetus to medical advancement. Such an instrumentalist view justifies the end of healing with the means of death, which is an intrinsic contradiction that would eventually corrode the integrity of the medical and scientific professions. Conversely, the second question challenges all of us in federal practice to assume a mantle of obligation to take the interventions that enabled combat medicine to save soldiers and apply them to improve the health and save the lives of veterans and civilians alike. It summons scientists laboring in the hundreds of DoD and VA laboratories to use the unparalleled funding and infrastructure of the institutions to develop promising therapeutics to treat the psychological toll and physical cost of war. And finally it charges the citizens whose family and friends have and will serve in uniform to enlist in a political process that enables military medicine and science to achieve the greatest good-health in peace.

The title of this essay is more often posed as “Is War Good for Medicine?”² The career VA physician in me, and the daughter and granddaughter of combat veterans, finds this question historically accurate, but ethically problematic. So I have rewritten the question to one that enables us to examine the historic relationship of medical advances and war from a more ethically justifiable posture. I am by no means ascribing to authors of other publications with this title anything but the highest motives of education and edification.

Yet the more I read and thought about the question(s), I realized that the moral assumptions underlying and supporting each concept are significantly different. What led me to that realization was a story my father told me when I was young which in my youthful ignorance I either dismissed or ignored. I now see that the narrative captured a profound truth about how war is not good especially for those who must wage it, but good may come from it for those who now live in peace.

My father was one of the founders of military pediatrics. Surprisingly, pediatricians were valuable members of the military medical forces because of their knowledge of infectious diseases.³ My father had gone in to the then new specialty of pediatrics because in the 1930s, infectious diseases were the primary cause of death in children. Before antibiotics, children would often die of common infections. Service as a combat medical officer in World War II stationed in the European Theater, my father had experience with and access to penicillin. After returning from the war to work in an Army hospital, he and his staff went into the acute pediatric ward and gave the drug to several very sick children, many of whom were likely to die. The next morning on rounds, they noted that many of the children were feeling much better, some even bouncing on their beds.

Perhaps either his telling or my remembering of these events is partly apocryphal, but the reality is that those lethal microbes had no idea what had hit them. Before human physicians overused the new drugs and nature struck back with antibiotic resistance, penicillin seemed miraculous.

Most likely, in 1945 those children would never have been prescribed penicillin, much less survived, if not for the unprecedented and war-driven consortium of industry and government that mass-produced penicillin to treat the troops with infections. Without a doubt then, from the sacrifice and devastation of World War II came the benefits and boons of the antibiotic era—one of the greatest discoveries in medical science.⁴

Penicillin is but one of legions of scientific discoveries that emerged during wartime. Many of these dramatic improvements, especially those in surgical techniques and emergency medicine, quickly entered the civilian sector. The French surgeon Amboise Paré, for example, revived an old Roman Army practice of using ligatures or tourniquets to stop excessive blood loss, now a staple of emergency responders in disasters. The ambulance services that transported wounded troops to the hospital began on the battlefields of the Civil War.⁵

These impressive contributions are the direct result of military medicine intended to preserve fighting strength. There are also indirect, although just as revolutionary, efforts of DoD and VA scientists and health care professionals to minimize disability and prevent progression especially of service-connected injuries and illnesses. Among the most groundbreaking is the VA’s 3D-printed artificial lung. I have to admit at first I thought that it was futuristic, but quickly I learned that it was a realistic possibility for the coming decades.⁶ VA researchers hope the lung will offer a treatment option for patients with chronic obstructive pulmonary disease (COPD), a lung condition more prevalent in veterans than in the civilian population.⁷ One contributing factor to the increased risk of COPD among former military is the higher rate of smoking among both active duty and veterans than that in the civilian population.⁸ And the last chain in the link of causation is that smoking is more common in those service members who have posttraumatic stress disorder.⁹

However, there also is a very dark side to the link between wartime research and medicine—most infamously the Nazi hypothermia experiments conducted at concentration camps. The proposed publication aroused a decades long ethical controversy regarding whether the data should be published, much less used, in research and practice even if it could save the lives of present or future warriors. In 1990, Marcia Angel, MD, then editor-in-chief of the prestigious New England Journal of Medicine, published the information with an accompanying ethical justification. “Finally, refusal to publish the unethical work serves notice to society at large that even scientists do not consider science the primary measure of a civilization. Knowledge, although important, may be less important to a decent society than the way it is obtained.”¹⁰ Ethicist Stephen Post writing on behalf of Holocaust victims strenuously disagreed with the decision to publish the research, “Because the Nazi experiments on human beings were so appallingly unethical, it follows, prima facie, that the use of the records is unethical.”¹¹

This debate is key to the distinction between the 2 questions posed at the beginning of this column. Few who have been on a battlefield or who have cared for those who were can suggest or defend that wars should be fought as a catalyst for scientific research or an impetus to medical advancement. Such an instrumentalist view justifies the end of healing with the means of death, which is an intrinsic contradiction that would eventually corrode the integrity of the medical and scientific professions. Conversely, the second question challenges all of us in federal practice to assume a mantle of obligation to take the interventions that enabled combat medicine to save soldiers and apply them to improve the health and save the lives of veterans and civilians alike. It summons scientists laboring in the hundreds of DoD and VA laboratories to use the unparalleled funding and infrastructure of the institutions to develop promising therapeutics to treat the psychological toll and physical cost of war. And finally it charges the citizens whose family and friends have and will serve in uniform to enlist in a political process that enables military medicine and science to achieve the greatest good-health in peace.

The title of this essay is more often posed as “Is War Good for Medicine?”² The career VA physician in me, and the daughter and granddaughter of combat veterans, finds this question historically accurate, but ethically problematic. So I have rewritten the question to one that enables us to examine the historic relationship of medical advances and war from a more ethically justifiable posture. I am by no means ascribing to authors of other publications with this title anything but the highest motives of education and edification.

Yet the more I read and thought about the question(s), I realized that the moral assumptions underlying and supporting each concept are significantly different. What led me to that realization was a story my father told me when I was young which in my youthful ignorance I either dismissed or ignored. I now see that the narrative captured a profound truth about how war is not good especially for those who must wage it, but good may come from it for those who now live in peace.

My father was one of the founders of military pediatrics. Surprisingly, pediatricians were valuable members of the military medical forces because of their knowledge of infectious diseases.³ My father had gone in to the then new specialty of pediatrics because in the 1930s, infectious diseases were the primary cause of death in children. Before antibiotics, children would often die of common infections. Service as a combat medical officer in World War II stationed in the European Theater, my father had experience with and access to penicillin. After returning from the war to work in an Army hospital, he and his staff went into the acute pediatric ward and gave the drug to several very sick children, many of whom were likely to die. The next morning on rounds, they noted that many of the children were feeling much better, some even bouncing on their beds.

Perhaps either his telling or my remembering of these events is partly apocryphal, but the reality is that those lethal microbes had no idea what had hit them. Before human physicians overused the new drugs and nature struck back with antibiotic resistance, penicillin seemed miraculous.

Most likely, in 1945 those children would never have been prescribed penicillin, much less survived, if not for the unprecedented and war-driven consortium of industry and government that mass-produced penicillin to treat the troops with infections. Without a doubt then, from the sacrifice and devastation of World War II came the benefits and boons of the antibiotic era—one of the greatest discoveries in medical science.⁴

Penicillin is but one of legions of scientific discoveries that emerged during wartime. Many of these dramatic improvements, especially those in surgical techniques and emergency medicine, quickly entered the civilian sector. The French surgeon Amboise Paré, for example, revived an old Roman Army practice of using ligatures or tourniquets to stop excessive blood loss, now a staple of emergency responders in disasters. The ambulance services that transported wounded troops to the hospital began on the battlefields of the Civil War.⁵

These impressive contributions are the direct result of military medicine intended to preserve fighting strength. There are also indirect, although just as revolutionary, efforts of DoD and VA scientists and health care professionals to minimize disability and prevent progression especially of service-connected injuries and illnesses. Among the most groundbreaking is the VA’s 3D-printed artificial lung. I have to admit at first I thought that it was futuristic, but quickly I learned that it was a realistic possibility for the coming decades.⁶ VA researchers hope the lung will offer a treatment option for patients with chronic obstructive pulmonary disease (COPD), a lung condition more prevalent in veterans than in the civilian population.⁷ One contributing factor to the increased risk of COPD among former military is the higher rate of smoking among both active duty and veterans than that in the civilian population.⁸ And the last chain in the link of causation is that smoking is more common in those service members who have posttraumatic stress disorder.⁹

However, there also is a very dark side to the link between wartime research and medicine—most infamously the Nazi hypothermia experiments conducted at concentration camps. The proposed publication aroused a decades long ethical controversy regarding whether the data should be published, much less used, in research and practice even if it could save the lives of present or future warriors. In 1990, Marcia Angel, MD, then editor-in-chief of the prestigious New England Journal of Medicine, published the information with an accompanying ethical justification. “Finally, refusal to publish the unethical work serves notice to society at large that even scientists do not consider science the primary measure of a civilization. Knowledge, although important, may be less important to a decent society than the way it is obtained.”¹⁰ Ethicist Stephen Post writing on behalf of Holocaust victims strenuously disagreed with the decision to publish the research, “Because the Nazi experiments on human beings were so appallingly unethical, it follows, prima facie, that the use of the records is unethical.”¹¹

This debate is key to the distinction between the 2 questions posed at the beginning of this column. Few who have been on a battlefield or who have cared for those who were can suggest or defend that wars should be fought as a catalyst for scientific research or an impetus to medical advancement. Such an instrumentalist view justifies the end of healing with the means of death, which is an intrinsic contradiction that would eventually corrode the integrity of the medical and scientific professions. Conversely, the second question challenges all of us in federal practice to assume a mantle of obligation to take the interventions that enabled combat medicine to save soldiers and apply them to improve the health and save the lives of veterans and civilians alike. It summons scientists laboring in the hundreds of DoD and VA laboratories to use the unparalleled funding and infrastructure of the institutions to develop promising therapeutics to treat the psychological toll and physical cost of war. And finally it charges the citizens whose family and friends have and will serve in uniform to enlist in a political process that enables military medicine and science to achieve the greatest good-health in peace.

National K9 Veterans Day celebrates the loyalty, bravery, and sacrifice of canine warriors. On March 13, 1942, canines officially became members of the Armed Services, with the Army’s founding of its New War Dog Program, more popularly known as the K9 Corps. The dogs underwent basic training and then entered more specialized preparation just as human soldiers did.² There had been unofficial dogs of war who served courageously and selflessly in almost all of our armed conflicts.³ Indeed, the title of this column is taken from a wonderful article of the same name narrating the heroism of dogs in the 2 world wars.⁴

The dedication of canines to those who serve is not confined to combat or even active duty. Thousands of military and veteran men and women have benefited immensely from their relationship with service and emotional support dogs.

Before I continue, let me state 2 important limitations of this column. First, I am a dog person. Of course, veterans have formed healing and caring relationships with many types of companions. Equine therapy is increasingly recognized as a powerful means of helping veterans reduce distress and find purpose.⁵ Nevertheless, for this column, I will focus exclusively on dogs. Second, there are many worthy organizations, projects, and programs that pair veterans with therapeutic dogs inside and outside the VA. I am in no way an expert and will invariably neglect many of these positive initiatives in this brief review.

The long, proud history of canines in the military and the many moving stories of men and women in and out of uniform for whom dogs have been life changing, if not life-saving, have created 2 ethical dilemmas for the VA that I examine here. Both dilemmas pivot on the terms of official recognition of service dogs, the benefits, and who can qualify for them in the VA.

Under VA regulation and VHA policy, a service companion only can be a dog that is individually trained to do work or perform tasks to assist a person with a disability; dogs whose sole function is to provide emotional support, well-being, comfort, or companionship are not considered service pets.⁶

A valid question to ask is why couldn’t the most vulnerable of these veterans, for instance those with severe mental health conditions, have service dogs that could accompany them into at least most areas of the medical center? Part of the reason is cost: Some training organizations estimate it may cost as much as $27,000 to train service dogs.⁸ Though there are many wonderful volunteer and not-for-profit organizations that train mostly shelter dogs and their veteran handlers—a double rescue—the lengthy process and expense means that many veterans wait years for a companion.

Congressional representatives, ethicists, veterans advocates, and canine therapy groups claim that this was unjust discrimination against those suffering with the equally, if not more disabling, mental health conditions.⁹ For many years, the VA has done a very good deed: For those who qualify for a service dog, VA pays for veterinary care and the equipment to handle the dog, but not boarding, grooming, food, and other miscellaneous expenses.¹⁰ But until 2016, those veterans approved for service dogs in the main had sensory or physical disabilities.

A partial breakthrough emerged when the Center for Compassionate Care Innovation launched the Mental Health Mobility Service Dogs Program that expanded veterinary health benefits to veterans with a “substantial mobility limitation.” For example, veterans whose hypervigilance and hyperarousal are so severe that they cannot attend medical appointments.¹¹

VA experts argue that at this time there is insufficient evidence to fund service dogs as even adjunctive PTSD therapy for the hundreds of veterans who might potentially qualify. It becomes an ethical question of prudent stewardship of public funds and trust. There is certainly plenty of compelling anecdotal testimony that companion canines are a high-benefit, relatively low-risk form of complementary and integrated therapy for the spectrum of trauma disorders that afflict many of the men and women who served in our conflicts. Demonstrating those positive effects scientifically may be more difficult than it seems, although early evidence is promising, and the VA is intensively researching the question.¹² For some veterans and their legislators, the VA has not gone far enough, fast enough in mainstreaming therapy dogs, they are calling for VA to expand veterans’ benefits to include mental health service dogs and to define what benefits would be covered.

National K9 Veterans Day is an important step toward giving dogs of war the homage they have earned, as are increasing efforts to ensure care for military canines throughout their life cycle. But as the seventeenth century poet John Milton wrote when he reflected on his own worth despite his blindness, “Those also serve who only stand and wait.”¹³ The institutions charged to care for those the battle has most burdened are still trying to discover how to properly and proportionately revere that kind of furry valor.

National K9 Veterans Day celebrates the loyalty, bravery, and sacrifice of canine warriors. On March 13, 1942, canines officially became members of the Armed Services, with the Army’s founding of its New War Dog Program, more popularly known as the K9 Corps. The dogs underwent basic training and then entered more specialized preparation just as human soldiers did.² There had been unofficial dogs of war who served courageously and selflessly in almost all of our armed conflicts.³ Indeed, the title of this column is taken from a wonderful article of the same name narrating the heroism of dogs in the 2 world wars.⁴

The dedication of canines to those who serve is not confined to combat or even active duty. Thousands of military and veteran men and women have benefited immensely from their relationship with service and emotional support dogs.

Before I continue, let me state 2 important limitations of this column. First, I am a dog person. Of course, veterans have formed healing and caring relationships with many types of companions. Equine therapy is increasingly recognized as a powerful means of helping veterans reduce distress and find purpose.⁵ Nevertheless, for this column, I will focus exclusively on dogs. Second, there are many worthy organizations, projects, and programs that pair veterans with therapeutic dogs inside and outside the VA. I am in no way an expert and will invariably neglect many of these positive initiatives in this brief review.

The long, proud history of canines in the military and the many moving stories of men and women in and out of uniform for whom dogs have been life changing, if not life-saving, have created 2 ethical dilemmas for the VA that I examine here. Both dilemmas pivot on the terms of official recognition of service dogs, the benefits, and who can qualify for them in the VA.

Under VA regulation and VHA policy, a service companion only can be a dog that is individually trained to do work or perform tasks to assist a person with a disability; dogs whose sole function is to provide emotional support, well-being, comfort, or companionship are not considered service pets.⁶

A valid question to ask is why couldn’t the most vulnerable of these veterans, for instance those with severe mental health conditions, have service dogs that could accompany them into at least most areas of the medical center? Part of the reason is cost: Some training organizations estimate it may cost as much as $27,000 to train service dogs.⁸ Though there are many wonderful volunteer and not-for-profit organizations that train mostly shelter dogs and their veteran handlers—a double rescue—the lengthy process and expense means that many veterans wait years for a companion.

Congressional representatives, ethicists, veterans advocates, and canine therapy groups claim that this was unjust discrimination against those suffering with the equally, if not more disabling, mental health conditions.⁹ For many years, the VA has done a very good deed: For those who qualify for a service dog, VA pays for veterinary care and the equipment to handle the dog, but not boarding, grooming, food, and other miscellaneous expenses.¹⁰ But until 2016, those veterans approved for service dogs in the main had sensory or physical disabilities.

A partial breakthrough emerged when the Center for Compassionate Care Innovation launched the Mental Health Mobility Service Dogs Program that expanded veterinary health benefits to veterans with a “substantial mobility limitation.” For example, veterans whose hypervigilance and hyperarousal are so severe that they cannot attend medical appointments.¹¹

VA experts argue that at this time there is insufficient evidence to fund service dogs as even adjunctive PTSD therapy for the hundreds of veterans who might potentially qualify. It becomes an ethical question of prudent stewardship of public funds and trust. There is certainly plenty of compelling anecdotal testimony that companion canines are a high-benefit, relatively low-risk form of complementary and integrated therapy for the spectrum of trauma disorders that afflict many of the men and women who served in our conflicts. Demonstrating those positive effects scientifically may be more difficult than it seems, although early evidence is promising, and the VA is intensively researching the question.¹² For some veterans and their legislators, the VA has not gone far enough, fast enough in mainstreaming therapy dogs, they are calling for VA to expand veterans’ benefits to include mental health service dogs and to define what benefits would be covered.

National K9 Veterans Day is an important step toward giving dogs of war the homage they have earned, as are increasing efforts to ensure care for military canines throughout their life cycle. But as the seventeenth century poet John Milton wrote when he reflected on his own worth despite his blindness, “Those also serve who only stand and wait.”¹³ The institutions charged to care for those the battle has most burdened are still trying to discover how to properly and proportionately revere that kind of furry valor.

National K9 Veterans Day celebrates the loyalty, bravery, and sacrifice of canine warriors. On March 13, 1942, canines officially became members of the Armed Services, with the Army’s founding of its New War Dog Program, more popularly known as the K9 Corps. The dogs underwent basic training and then entered more specialized preparation just as human soldiers did.² There had been unofficial dogs of war who served courageously and selflessly in almost all of our armed conflicts.³ Indeed, the title of this column is taken from a wonderful article of the same name narrating the heroism of dogs in the 2 world wars.⁴

The dedication of canines to those who serve is not confined to combat or even active duty. Thousands of military and veteran men and women have benefited immensely from their relationship with service and emotional support dogs.

Before I continue, let me state 2 important limitations of this column. First, I am a dog person. Of course, veterans have formed healing and caring relationships with many types of companions. Equine therapy is increasingly recognized as a powerful means of helping veterans reduce distress and find purpose.⁵ Nevertheless, for this column, I will focus exclusively on dogs. Second, there are many worthy organizations, projects, and programs that pair veterans with therapeutic dogs inside and outside the VA. I am in no way an expert and will invariably neglect many of these positive initiatives in this brief review.

The long, proud history of canines in the military and the many moving stories of men and women in and out of uniform for whom dogs have been life changing, if not life-saving, have created 2 ethical dilemmas for the VA that I examine here. Both dilemmas pivot on the terms of official recognition of service dogs, the benefits, and who can qualify for them in the VA.

Under VA regulation and VHA policy, a service companion only can be a dog that is individually trained to do work or perform tasks to assist a person with a disability; dogs whose sole function is to provide emotional support, well-being, comfort, or companionship are not considered service pets.⁶

A valid question to ask is why couldn’t the most vulnerable of these veterans, for instance those with severe mental health conditions, have service dogs that could accompany them into at least most areas of the medical center? Part of the reason is cost: Some training organizations estimate it may cost as much as $27,000 to train service dogs.⁸ Though there are many wonderful volunteer and not-for-profit organizations that train mostly shelter dogs and their veteran handlers—a double rescue—the lengthy process and expense means that many veterans wait years for a companion.

Congressional representatives, ethicists, veterans advocates, and canine therapy groups claim that this was unjust discrimination against those suffering with the equally, if not more disabling, mental health conditions.⁹ For many years, the VA has done a very good deed: For those who qualify for a service dog, VA pays for veterinary care and the equipment to handle the dog, but not boarding, grooming, food, and other miscellaneous expenses.¹⁰ But until 2016, those veterans approved for service dogs in the main had sensory or physical disabilities.

A partial breakthrough emerged when the Center for Compassionate Care Innovation launched the Mental Health Mobility Service Dogs Program that expanded veterinary health benefits to veterans with a “substantial mobility limitation.” For example, veterans whose hypervigilance and hyperarousal are so severe that they cannot attend medical appointments.¹¹

VA experts argue that at this time there is insufficient evidence to fund service dogs as even adjunctive PTSD therapy for the hundreds of veterans who might potentially qualify. It becomes an ethical question of prudent stewardship of public funds and trust. There is certainly plenty of compelling anecdotal testimony that companion canines are a high-benefit, relatively low-risk form of complementary and integrated therapy for the spectrum of trauma disorders that afflict many of the men and women who served in our conflicts. Demonstrating those positive effects scientifically may be more difficult than it seems, although early evidence is promising, and the VA is intensively researching the question.¹² For some veterans and their legislators, the VA has not gone far enough, fast enough in mainstreaming therapy dogs, they are calling for VA to expand veterans’ benefits to include mental health service dogs and to define what benefits would be covered.

National K9 Veterans Day is an important step toward giving dogs of war the homage they have earned, as are increasing efforts to ensure care for military canines throughout their life cycle. But as the seventeenth century poet John Milton wrote when he reflected on his own worth despite his blindness, “Those also serve who only stand and wait.”¹³ The institutions charged to care for those the battle has most burdened are still trying to discover how to properly and proportionately revere that kind of furry valor.

I am a doctor, not an engineer.Dr. McCoy, Star Trek “Mirror, Mirror” episode

Last year in my annual wrap-up, I wrote back-to-back editorials (December 2017 and January 2018) on the worst and best of 2017 from a federal health care perspective, emphasizing ethics or the lack thereof. I featured the altruism of federal health care providers (HCPs) responding to natural disasters and the terrible outcome of seemingly banal moral lapses.

This year the best and worst are one and the same, and I am not sure how it could be otherwise: the Department of Veterans Affairs (VA) and Department of Defense (DoD) electronic health record (EHR) contract with Cerner (North Kansas City, MO). Former VA Secretary David Shulkin, MD, announced the deal in 2017 shortly before his departure, and it was signed under then Acting VA Secretary Robert Wilkie in May of 2018.¹ But the reason the Cerner contract is the most impactful and momentous ethical event of the year is perhaps not what readers expect. Search engines will efficiently unearth plentiful drama with ethical import about the contract. There were conspiracy charges that the shadow regime improperly engineered the selection.² The usual Congressional hearings on the VA leadership mismanagement of the EHR culminated in Sen Jon Tester’s (D-MO) martial declaration in a letter to the newly sworn-in VA Chief Information Officer James Paul Gfrerer that “EHR modernization cannot fail.”³

While all this is obviously important, it is not why the annual awards for ethical and unethical behaviors are bestowed on what is essentially an information technology acquisition. The Cerner contract is chosen because of its enormous potential to change the human practice of health care for good or ill; hence, the dual nomination. This column is not about Cerner qua Cerner but about how the EHR has transformed—or deformed—the humanistic aspects of medical practice.

I am old enough to remember the original transition from paper charts to VistA EHR. As an intern with illegible handwriting, I can remember breathing a sigh of relief when the blue screen appeared for the first time. The commands were cumbersome and the code laborious, but it was a technologic marvel to see the clean, organized progress notes and be able to print your medication list or discharge summary. However, it also was the first stuttering waves of a tsunami that would alter medical practice forever. The human cost of the revolution could be seen almost immediately as older clinicians or those who could not type struggled to complete work that with paper and pen would have been easily accomplished.

For many years there was a steady stream of updates to VistA, including the Computerized Patient Record System (CPRS). For a relatively long time in technology terms, VistA and CPRS were the envy of the medical world, which rushed to catch up. Gradually though, VA fell behind; the wizard IT guys could not patch and fix new versions fast enough, and eventually, like all things created, VistA and CPRS became obsolete.⁴ Attitudes toward this microcosm of the modernization of an aging organization were intense and diverse. Some of us held onto CPRS as though it was a transitional object that we had personalized and became attached to with all its quirks and problems. Others could not wait to get rid of it, believing anything new and streamlined had to be better.

Yet the opposite also is true. EHRs have been, and could be again, incredible time-savers, enabling HCPs to deliver more evidence-based, patient-centered care in a more accurate, integrated, timely, and comprehensive manner. For example, Cerner finally could discover the Holy Grail of VA-DoD interoperability and even—dare we dream—integrate with the community. Yet as science fiction aficionados know, the machine designed to free humankind of drudgery may also end up controlling us.

The other commonplace year-end practice is for ersatz prophets to predict the future. I have no idea whether the Cerner EHR will be good or bad for VA and DoD. According to the insightful critic of medical culture, Atul Gawande, MD, who has examined the practitioner-computer interface, what we must guard against is that it does not replace the practitioner-patient relationship.⁵ The most common complaint I hear from patients in VA mental health care is: “They never listen to me, they just sit there typing.” Similarly, clinicians complain: “I spend all my time looking at a screen not at a patient.” As an ethicist, I cannot tell you how many times the blight of copy and paste has thwarted or damaged a patient’s care. And the direct correlation between medical computing and burnout has been well documented as all health care systems struggle with a doctor shortage particularly in primary care—arguably where computer fatigue hits hardest.⁶

What will decide whether EHR modernization will be a positive or negative development for VA and DoD patients? And is there anything we as federal HCPs can do to tip the scales in favor of the what is best for patients and clinicians? The most encouraging step has already been taken: VA and Cerner have set up EHR Councils composed of 60% practicing VA HCPs to provide the clinical perspective and 40% from VA Central Office to encourage synchronization of the top-down and bottom-up processes.⁷

Many experts have pointed out the inherent tension between how computers and human beings work, which I will simplify as the battle between the 3 S’s and the 3 F’s.⁵ The optimal operation of EHRs requires systems, structure, stability; to function successfully human beings need flexibility, freedom, and fragmentation. VistA had more than 100 versions according to a report from the Federal News Network (FNN), which is a striking example of the challenge EHR modernization faces in bridging the 2 orientations. As former VA Chief Information Officer Roger Baker told FNN, replacing this approach of EHR tinkering with a locked-down commercial system will require “a culture change that is orders of magnitude bigger than expected.”⁸

Think of the 2 domains as a Venn diagram. Where the circles overlap is all the things we and patients want and need in health care: empathic listening, strong enduring relationships, accurate diagnosis, accessibility, personalized treatment, continuity of care, mutual respect, patient safety, room to exercise professional judgment, and the data needed to promote shared decision making. Our contribution and duty are to make that inner circle where we all dwell together as wide and full as possible and the overlap between the 2 outer circles as seamless as human imperfection and artificial intelligence permit.

The Gawande article is titled “Why Doctors Hate Their Computers.” Of course, his piece shows that we also love them. None of the proposed liberations from our EHR domination—be they medical scribes or dictation programs—has solved the problem, probably because they are all technologic and just move the slavery downstream. We have come too far, and medicine is too complex, to go back to the age of paper. If we can no longer do the good work of healing and caring without computers, then we have to learn to live with them as our allies not our enemies. After all, even Dr. McCoy had a tricorder.

I am a doctor, not an engineer.Dr. McCoy, Star Trek “Mirror, Mirror” episode

Last year in my annual wrap-up, I wrote back-to-back editorials (December 2017 and January 2018) on the worst and best of 2017 from a federal health care perspective, emphasizing ethics or the lack thereof. I featured the altruism of federal health care providers (HCPs) responding to natural disasters and the terrible outcome of seemingly banal moral lapses.

This year the best and worst are one and the same, and I am not sure how it could be otherwise: the Department of Veterans Affairs (VA) and Department of Defense (DoD) electronic health record (EHR) contract with Cerner (North Kansas City, MO). Former VA Secretary David Shulkin, MD, announced the deal in 2017 shortly before his departure, and it was signed under then Acting VA Secretary Robert Wilkie in May of 2018.¹ But the reason the Cerner contract is the most impactful and momentous ethical event of the year is perhaps not what readers expect. Search engines will efficiently unearth plentiful drama with ethical import about the contract. There were conspiracy charges that the shadow regime improperly engineered the selection.² The usual Congressional hearings on the VA leadership mismanagement of the EHR culminated in Sen Jon Tester’s (D-MO) martial declaration in a letter to the newly sworn-in VA Chief Information Officer James Paul Gfrerer that “EHR modernization cannot fail.”³

While all this is obviously important, it is not why the annual awards for ethical and unethical behaviors are bestowed on what is essentially an information technology acquisition. The Cerner contract is chosen because of its enormous potential to change the human practice of health care for good or ill; hence, the dual nomination. This column is not about Cerner qua Cerner but about how the EHR has transformed—or deformed—the humanistic aspects of medical practice.

I am old enough to remember the original transition from paper charts to VistA EHR. As an intern with illegible handwriting, I can remember breathing a sigh of relief when the blue screen appeared for the first time. The commands were cumbersome and the code laborious, but it was a technologic marvel to see the clean, organized progress notes and be able to print your medication list or discharge summary. However, it also was the first stuttering waves of a tsunami that would alter medical practice forever. The human cost of the revolution could be seen almost immediately as older clinicians or those who could not type struggled to complete work that with paper and pen would have been easily accomplished.

For many years there was a steady stream of updates to VistA, including the Computerized Patient Record System (CPRS). For a relatively long time in technology terms, VistA and CPRS were the envy of the medical world, which rushed to catch up. Gradually though, VA fell behind; the wizard IT guys could not patch and fix new versions fast enough, and eventually, like all things created, VistA and CPRS became obsolete.⁴ Attitudes toward this microcosm of the modernization of an aging organization were intense and diverse. Some of us held onto CPRS as though it was a transitional object that we had personalized and became attached to with all its quirks and problems. Others could not wait to get rid of it, believing anything new and streamlined had to be better.

Yet the opposite also is true. EHRs have been, and could be again, incredible time-savers, enabling HCPs to deliver more evidence-based, patient-centered care in a more accurate, integrated, timely, and comprehensive manner. For example, Cerner finally could discover the Holy Grail of VA-DoD interoperability and even—dare we dream—integrate with the community. Yet as science fiction aficionados know, the machine designed to free humankind of drudgery may also end up controlling us.

The other commonplace year-end practice is for ersatz prophets to predict the future. I have no idea whether the Cerner EHR will be good or bad for VA and DoD. According to the insightful critic of medical culture, Atul Gawande, MD, who has examined the practitioner-computer interface, what we must guard against is that it does not replace the practitioner-patient relationship.⁵ The most common complaint I hear from patients in VA mental health care is: “They never listen to me, they just sit there typing.” Similarly, clinicians complain: “I spend all my time looking at a screen not at a patient.” As an ethicist, I cannot tell you how many times the blight of copy and paste has thwarted or damaged a patient’s care. And the direct correlation between medical computing and burnout has been well documented as all health care systems struggle with a doctor shortage particularly in primary care—arguably where computer fatigue hits hardest.⁶

What will decide whether EHR modernization will be a positive or negative development for VA and DoD patients? And is there anything we as federal HCPs can do to tip the scales in favor of the what is best for patients and clinicians? The most encouraging step has already been taken: VA and Cerner have set up EHR Councils composed of 60% practicing VA HCPs to provide the clinical perspective and 40% from VA Central Office to encourage synchronization of the top-down and bottom-up processes.⁷

Many experts have pointed out the inherent tension between how computers and human beings work, which I will simplify as the battle between the 3 S’s and the 3 F’s.⁵ The optimal operation of EHRs requires systems, structure, stability; to function successfully human beings need flexibility, freedom, and fragmentation. VistA had more than 100 versions according to a report from the Federal News Network (FNN), which is a striking example of the challenge EHR modernization faces in bridging the 2 orientations. As former VA Chief Information Officer Roger Baker told FNN, replacing this approach of EHR tinkering with a locked-down commercial system will require “a culture change that is orders of magnitude bigger than expected.”⁸

Think of the 2 domains as a Venn diagram. Where the circles overlap is all the things we and patients want and need in health care: empathic listening, strong enduring relationships, accurate diagnosis, accessibility, personalized treatment, continuity of care, mutual respect, patient safety, room to exercise professional judgment, and the data needed to promote shared decision making. Our contribution and duty are to make that inner circle where we all dwell together as wide and full as possible and the overlap between the 2 outer circles as seamless as human imperfection and artificial intelligence permit.

The Gawande article is titled “Why Doctors Hate Their Computers.” Of course, his piece shows that we also love them. None of the proposed liberations from our EHR domination—be they medical scribes or dictation programs—has solved the problem, probably because they are all technologic and just move the slavery downstream. We have come too far, and medicine is too complex, to go back to the age of paper. If we can no longer do the good work of healing and caring without computers, then we have to learn to live with them as our allies not our enemies. After all, even Dr. McCoy had a tricorder.

I am a doctor, not an engineer.Dr. McCoy, Star Trek “Mirror, Mirror” episode

Last year in my annual wrap-up, I wrote back-to-back editorials (December 2017 and January 2018) on the worst and best of 2017 from a federal health care perspective, emphasizing ethics or the lack thereof. I featured the altruism of federal health care providers (HCPs) responding to natural disasters and the terrible outcome of seemingly banal moral lapses.

This year the best and worst are one and the same, and I am not sure how it could be otherwise: the Department of Veterans Affairs (VA) and Department of Defense (DoD) electronic health record (EHR) contract with Cerner (North Kansas City, MO). Former VA Secretary David Shulkin, MD, announced the deal in 2017 shortly before his departure, and it was signed under then Acting VA Secretary Robert Wilkie in May of 2018.¹ But the reason the Cerner contract is the most impactful and momentous ethical event of the year is perhaps not what readers expect. Search engines will efficiently unearth plentiful drama with ethical import about the contract. There were conspiracy charges that the shadow regime improperly engineered the selection.² The usual Congressional hearings on the VA leadership mismanagement of the EHR culminated in Sen Jon Tester’s (D-MO) martial declaration in a letter to the newly sworn-in VA Chief Information Officer James Paul Gfrerer that “EHR modernization cannot fail.”³

While all this is obviously important, it is not why the annual awards for ethical and unethical behaviors are bestowed on what is essentially an information technology acquisition. The Cerner contract is chosen because of its enormous potential to change the human practice of health care for good or ill; hence, the dual nomination. This column is not about Cerner qua Cerner but about how the EHR has transformed—or deformed—the humanistic aspects of medical practice.

I am old enough to remember the original transition from paper charts to VistA EHR. As an intern with illegible handwriting, I can remember breathing a sigh of relief when the blue screen appeared for the first time. The commands were cumbersome and the code laborious, but it was a technologic marvel to see the clean, organized progress notes and be able to print your medication list or discharge summary. However, it also was the first stuttering waves of a tsunami that would alter medical practice forever. The human cost of the revolution could be seen almost immediately as older clinicians or those who could not type struggled to complete work that with paper and pen would have been easily accomplished.

For many years there was a steady stream of updates to VistA, including the Computerized Patient Record System (CPRS). For a relatively long time in technology terms, VistA and CPRS were the envy of the medical world, which rushed to catch up. Gradually though, VA fell behind; the wizard IT guys could not patch and fix new versions fast enough, and eventually, like all things created, VistA and CPRS became obsolete.⁴ Attitudes toward this microcosm of the modernization of an aging organization were intense and diverse. Some of us held onto CPRS as though it was a transitional object that we had personalized and became attached to with all its quirks and problems. Others could not wait to get rid of it, believing anything new and streamlined had to be better.

Yet the opposite also is true. EHRs have been, and could be again, incredible time-savers, enabling HCPs to deliver more evidence-based, patient-centered care in a more accurate, integrated, timely, and comprehensive manner. For example, Cerner finally could discover the Holy Grail of VA-DoD interoperability and even—dare we dream—integrate with the community. Yet as science fiction aficionados know, the machine designed to free humankind of drudgery may also end up controlling us.

The other commonplace year-end practice is for ersatz prophets to predict the future. I have no idea whether the Cerner EHR will be good or bad for VA and DoD. According to the insightful critic of medical culture, Atul Gawande, MD, who has examined the practitioner-computer interface, what we must guard against is that it does not replace the practitioner-patient relationship.⁵ The most common complaint I hear from patients in VA mental health care is: “They never listen to me, they just sit there typing.” Similarly, clinicians complain: “I spend all my time looking at a screen not at a patient.” As an ethicist, I cannot tell you how many times the blight of copy and paste has thwarted or damaged a patient’s care. And the direct correlation between medical computing and burnout has been well documented as all health care systems struggle with a doctor shortage particularly in primary care—arguably where computer fatigue hits hardest.⁶

What will decide whether EHR modernization will be a positive or negative development for VA and DoD patients? And is there anything we as federal HCPs can do to tip the scales in favor of the what is best for patients and clinicians? The most encouraging step has already been taken: VA and Cerner have set up EHR Councils composed of 60% practicing VA HCPs to provide the clinical perspective and 40% from VA Central Office to encourage synchronization of the top-down and bottom-up processes.⁷

Many experts have pointed out the inherent tension between how computers and human beings work, which I will simplify as the battle between the 3 S’s and the 3 F’s.⁵ The optimal operation of EHRs requires systems, structure, stability; to function successfully human beings need flexibility, freedom, and fragmentation. VistA had more than 100 versions according to a report from the Federal News Network (FNN), which is a striking example of the challenge EHR modernization faces in bridging the 2 orientations. As former VA Chief Information Officer Roger Baker told FNN, replacing this approach of EHR tinkering with a locked-down commercial system will require “a culture change that is orders of magnitude bigger than expected.”⁸

Think of the 2 domains as a Venn diagram. Where the circles overlap is all the things we and patients want and need in health care: empathic listening, strong enduring relationships, accurate diagnosis, accessibility, personalized treatment, continuity of care, mutual respect, patient safety, room to exercise professional judgment, and the data needed to promote shared decision making. Our contribution and duty are to make that inner circle where we all dwell together as wide and full as possible and the overlap between the 2 outer circles as seamless as human imperfection and artificial intelligence permit.

The Gawande article is titled “Why Doctors Hate Their Computers.” Of course, his piece shows that we also love them. None of the proposed liberations from our EHR domination—be they medical scribes or dictation programs—has solved the problem, probably because they are all technologic and just move the slavery downstream. We have come too far, and medicine is too complex, to go back to the age of paper. If we can no longer do the good work of healing and caring without computers, then we have to learn to live with them as our allies not our enemies. After all, even Dr. McCoy had a tricorder.

It is that time of year when federal compliance officers, clinical ethicists, and staff counsels are flooded with queries about the legal and ethical acceptability of gifts. And no wonder, all the winter holidays often involve giving gifts. The simple and spontaneous acts of giving and receiving gifts become more complicated and deliberative in the federal health care system. Both legal rules and ethical values bear upon who can offer and accept what gift to whom upon what occasion and in what amount. The “Standards of Ethical Conduct for Employees of the Executive Branch” devotes 2 entire subparts to the subject of gifts.¹ We will examine a small section of the document that can become a big issue for federal practitioners during that holiday—gifts from patients.

First, veterans (patients) are “prohibited sources” in section 5 CFR §2635.203 (d).¹ And since VA employees are subject to restrictions on accepting gifts from sources outside the government, unless an exception applies, federal employees may not accept a gift because of their official position (eg, Federal Practitioner, editor-in-chief) or a gift from a patient (prohibited source; [5 CFR §2635.201]).

It might seem like this is going to be a very short column this month, as gifts from patients are forbidden. Yet, a Christmas card or homemade fudge isn’t really a gift, is it?
5 CFR §2635.203 (b) defines what is and is not a gift: For example, minor items of food or items like a thank-you card are specifically excluded in section (b) 1-10.

Is Christmas an exception or are just types of gifts excluded?
There are exceptions to the general regulation about accepting gifts from prohibited sources. Many staff will recall hearing about the “$20 rule,” which is actually the “$20-50” rule stating that a federal employee may accept a gift from a patient (prohibited source) if the value of said gift is under $20 and the employee does not accept more than $50 from any single source in a calendar year. §2635.204 lists the exceptions. However, starting in 2017, the regulations changed to require that federal employees also consider not just whether they could accept a gift but—ethically—they should take the gift even if it was permitted under the law. The Office of Government Ethics made this change because it wanted to emphasize the importance of considering not just how things are but how things appear to be. The regulations contain detailed descriptions of what employees should think about and stipulates that the decisions will not be further scrutinized (5 CFR §2635.201[b]).¹

Based on this new emphasis on appearances, ethically, no doctor or nurse should accept the keys to a new BMW from a patient who owns a luxury car dealership. But what about more prosaic and probable presents: the holiday cookies a single father made with his children for the nurse practitioner who has been his primary care practitioner for years; the birdhouse a Vietnam veteran made in her crafts class for the surgeon who removed her gallbladder; or even the store-bought but no less heartfelt tin of popcorn from an elderly veteran for the hospitalist who saw him through a rough bought of pneumonia?

Related: Happy Federal New Year

The rules about practitioners accepting patient gifts are rational and unambiguous: It is the values conflict surrounding patient gifts that is often emotion driven and muddled; it may be easier and safer to adopt the “just say no” policy. And yet, while this might seem the most unassailable position to avoid a conflict of interest, could this possibly be a more practitioner- than patient-centered standard? Authoritative sources in the ethics literature are equally divided and ambivalent on the question.^2,3 The American College of Physicians Ethics Manual states: “In deciding whether to accept a gift from a patient, the physician should consider the nature of the gift and its value to the patient, the potential implications for the patient-physician relationship of accepting or refusing it, and the patient’s probable intention and expectations.”⁴ A small gift as a token of appreciation is not ethically problematic. Favored treatment as a result of acceptance of any gift is problematic, undermines professionalism, and may interfere with objectivity in the care of the patient.⁴

Related: Am I My Brother’s/Sister’s Keeper?

Many an ethics commentator have cautioned, “beware of patients bearing gifts.”⁵ In making an ethical assessment of whether or not to accept the gift, a key question a practitioner needs to ask him or herself is about the patient’s motive. Even the patient may be unaware of the reasons behind their giving, and the wise practitioner will take a mindful moment to think about the context and timing of the gift and the nature of his or her relationship to the patient. Sadly, many of our patients are lonely especially at this family time of year and on some level may hope the gift will help slide the professional relationship toward a more personal one. Some patients may think a gift might earn them preferential treatment. Finally, a few patients may have a romantic or sexual attraction toward a clinician.

Often in the latter 2 cases, a pattern will develop that discloses the patient’s true intent. Very expensive gifts, monetary gifts, excessively personal gifts, or frequent gifts should alert the practitioner that more may be going on. A kind reminder to the patient that providing good care is the only reward needed may be sufficient. For practitioners whose ethical code does not permit them to accept gifts, then a genuine thank you and an explanation of the rules and/or values behind the refusal may be necessary. There are other times when the practitioner or a supervisor/advisor may need to reset the boundaries or even to transfer the patient to another practitioner. The norms in mental health care and psychotherapy are more stringent because of the intimacy of the relationship and the potential vulnerability of patients.⁶

For gifts that seem genuine and generous or cost a trivial amount, then there is an ethical argument to be made for accepting them with gratitude. In many cultures, hospitality is a tradition, and expressing appreciation a virtue, so when a practitioner refuses to graciously take a small gift, they risk offending the patient. Rejection of a gift can be seen as disrespectful and could cause a rupture in an otherwise sound practitioner-patient relationship. Other patients experience strong feelings of gratitude and admiration for their practitioners, stronger than most of us recognize. The ability for a patient to give their practitioner a holiday gift, particularly one they invested time and energy in creating or choosing, can enhance their sense of self-worth and individual agency. These gifts are not so much an attempt to diminish the professional power differential but to close the gap between 2 human beings in an unequal relationship that is yet one of shared decision making. All practitioners should be aware of the often underappreciated social power of a gift to influence decisions.

Related: Caring Under a Microscope

At the same time, clinicians can strive to be sensitively attuned to the reality that, sometimes the cookie is just a cookie so eat and enjoy, just remember to share with your group. External judgments are often cited as practical rules of thumb for determining the ethical acceptability of a gift: Would you want your mother, newspaper, or colleague to know you took the present? I prefer an internal moral compass that steers always to the true north of is accepting this gift really in the patient’s best interest?

It is that time of year when federal compliance officers, clinical ethicists, and staff counsels are flooded with queries about the legal and ethical acceptability of gifts. And no wonder, all the winter holidays often involve giving gifts. The simple and spontaneous acts of giving and receiving gifts become more complicated and deliberative in the federal health care system. Both legal rules and ethical values bear upon who can offer and accept what gift to whom upon what occasion and in what amount. The “Standards of Ethical Conduct for Employees of the Executive Branch” devotes 2 entire subparts to the subject of gifts.¹ We will examine a small section of the document that can become a big issue for federal practitioners during that holiday—gifts from patients.

First, veterans (patients) are “prohibited sources” in section 5 CFR §2635.203 (d).¹ And since VA employees are subject to restrictions on accepting gifts from sources outside the government, unless an exception applies, federal employees may not accept a gift because of their official position (eg, Federal Practitioner, editor-in-chief) or a gift from a patient (prohibited source; [5 CFR §2635.201]).

It might seem like this is going to be a very short column this month, as gifts from patients are forbidden. Yet, a Christmas card or homemade fudge isn’t really a gift, is it?
5 CFR §2635.203 (b) defines what is and is not a gift: For example, minor items of food or items like a thank-you card are specifically excluded in section (b) 1-10.

Is Christmas an exception or are just types of gifts excluded?
There are exceptions to the general regulation about accepting gifts from prohibited sources. Many staff will recall hearing about the “$20 rule,” which is actually the “$20-50” rule stating that a federal employee may accept a gift from a patient (prohibited source) if the value of said gift is under $20 and the employee does not accept more than $50 from any single source in a calendar year. §2635.204 lists the exceptions. However, starting in 2017, the regulations changed to require that federal employees also consider not just whether they could accept a gift but—ethically—they should take the gift even if it was permitted under the law. The Office of Government Ethics made this change because it wanted to emphasize the importance of considering not just how things are but how things appear to be. The regulations contain detailed descriptions of what employees should think about and stipulates that the decisions will not be further scrutinized (5 CFR §2635.201[b]).¹

Based on this new emphasis on appearances, ethically, no doctor or nurse should accept the keys to a new BMW from a patient who owns a luxury car dealership. But what about more prosaic and probable presents: the holiday cookies a single father made with his children for the nurse practitioner who has been his primary care practitioner for years; the birdhouse a Vietnam veteran made in her crafts class for the surgeon who removed her gallbladder; or even the store-bought but no less heartfelt tin of popcorn from an elderly veteran for the hospitalist who saw him through a rough bought of pneumonia?

Related: Happy Federal New Year

The rules about practitioners accepting patient gifts are rational and unambiguous: It is the values conflict surrounding patient gifts that is often emotion driven and muddled; it may be easier and safer to adopt the “just say no” policy. And yet, while this might seem the most unassailable position to avoid a conflict of interest, could this possibly be a more practitioner- than patient-centered standard? Authoritative sources in the ethics literature are equally divided and ambivalent on the question.^2,3 The American College of Physicians Ethics Manual states: “In deciding whether to accept a gift from a patient, the physician should consider the nature of the gift and its value to the patient, the potential implications for the patient-physician relationship of accepting or refusing it, and the patient’s probable intention and expectations.”⁴ A small gift as a token of appreciation is not ethically problematic. Favored treatment as a result of acceptance of any gift is problematic, undermines professionalism, and may interfere with objectivity in the care of the patient.⁴

Related: Am I My Brother’s/Sister’s Keeper?

Many an ethics commentator have cautioned, “beware of patients bearing gifts.”⁵ In making an ethical assessment of whether or not to accept the gift, a key question a practitioner needs to ask him or herself is about the patient’s motive. Even the patient may be unaware of the reasons behind their giving, and the wise practitioner will take a mindful moment to think about the context and timing of the gift and the nature of his or her relationship to the patient. Sadly, many of our patients are lonely especially at this family time of year and on some level may hope the gift will help slide the professional relationship toward a more personal one. Some patients may think a gift might earn them preferential treatment. Finally, a few patients may have a romantic or sexual attraction toward a clinician.

Often in the latter 2 cases, a pattern will develop that discloses the patient’s true intent. Very expensive gifts, monetary gifts, excessively personal gifts, or frequent gifts should alert the practitioner that more may be going on. A kind reminder to the patient that providing good care is the only reward needed may be sufficient. For practitioners whose ethical code does not permit them to accept gifts, then a genuine thank you and an explanation of the rules and/or values behind the refusal may be necessary. There are other times when the practitioner or a supervisor/advisor may need to reset the boundaries or even to transfer the patient to another practitioner. The norms in mental health care and psychotherapy are more stringent because of the intimacy of the relationship and the potential vulnerability of patients.⁶

For gifts that seem genuine and generous or cost a trivial amount, then there is an ethical argument to be made for accepting them with gratitude. In many cultures, hospitality is a tradition, and expressing appreciation a virtue, so when a practitioner refuses to graciously take a small gift, they risk offending the patient. Rejection of a gift can be seen as disrespectful and could cause a rupture in an otherwise sound practitioner-patient relationship. Other patients experience strong feelings of gratitude and admiration for their practitioners, stronger than most of us recognize. The ability for a patient to give their practitioner a holiday gift, particularly one they invested time and energy in creating or choosing, can enhance their sense of self-worth and individual agency. These gifts are not so much an attempt to diminish the professional power differential but to close the gap between 2 human beings in an unequal relationship that is yet one of shared decision making. All practitioners should be aware of the often underappreciated social power of a gift to influence decisions.

Related: Caring Under a Microscope

At the same time, clinicians can strive to be sensitively attuned to the reality that, sometimes the cookie is just a cookie so eat and enjoy, just remember to share with your group. External judgments are often cited as practical rules of thumb for determining the ethical acceptability of a gift: Would you want your mother, newspaper, or colleague to know you took the present? I prefer an internal moral compass that steers always to the true north of is accepting this gift really in the patient’s best interest?

It is that time of year when federal compliance officers, clinical ethicists, and staff counsels are flooded with queries about the legal and ethical acceptability of gifts. And no wonder, all the winter holidays often involve giving gifts. The simple and spontaneous acts of giving and receiving gifts become more complicated and deliberative in the federal health care system. Both legal rules and ethical values bear upon who can offer and accept what gift to whom upon what occasion and in what amount. The “Standards of Ethical Conduct for Employees of the Executive Branch” devotes 2 entire subparts to the subject of gifts.¹ We will examine a small section of the document that can become a big issue for federal practitioners during that holiday—gifts from patients.

First, veterans (patients) are “prohibited sources” in section 5 CFR §2635.203 (d).¹ And since VA employees are subject to restrictions on accepting gifts from sources outside the government, unless an exception applies, federal employees may not accept a gift because of their official position (eg, Federal Practitioner, editor-in-chief) or a gift from a patient (prohibited source; [5 CFR §2635.201]).

It might seem like this is going to be a very short column this month, as gifts from patients are forbidden. Yet, a Christmas card or homemade fudge isn’t really a gift, is it?
5 CFR §2635.203 (b) defines what is and is not a gift: For example, minor items of food or items like a thank-you card are specifically excluded in section (b) 1-10.

Is Christmas an exception or are just types of gifts excluded?
There are exceptions to the general regulation about accepting gifts from prohibited sources. Many staff will recall hearing about the “$20 rule,” which is actually the “$20-50” rule stating that a federal employee may accept a gift from a patient (prohibited source) if the value of said gift is under $20 and the employee does not accept more than $50 from any single source in a calendar year. §2635.204 lists the exceptions. However, starting in 2017, the regulations changed to require that federal employees also consider not just whether they could accept a gift but—ethically—they should take the gift even if it was permitted under the law. The Office of Government Ethics made this change because it wanted to emphasize the importance of considering not just how things are but how things appear to be. The regulations contain detailed descriptions of what employees should think about and stipulates that the decisions will not be further scrutinized (5 CFR §2635.201[b]).¹

Based on this new emphasis on appearances, ethically, no doctor or nurse should accept the keys to a new BMW from a patient who owns a luxury car dealership. But what about more prosaic and probable presents: the holiday cookies a single father made with his children for the nurse practitioner who has been his primary care practitioner for years; the birdhouse a Vietnam veteran made in her crafts class for the surgeon who removed her gallbladder; or even the store-bought but no less heartfelt tin of popcorn from an elderly veteran for the hospitalist who saw him through a rough bought of pneumonia?

Related: Happy Federal New Year

The rules about practitioners accepting patient gifts are rational and unambiguous: It is the values conflict surrounding patient gifts that is often emotion driven and muddled; it may be easier and safer to adopt the “just say no” policy. And yet, while this might seem the most unassailable position to avoid a conflict of interest, could this possibly be a more practitioner- than patient-centered standard? Authoritative sources in the ethics literature are equally divided and ambivalent on the question.^2,3 The American College of Physicians Ethics Manual states: “In deciding whether to accept a gift from a patient, the physician should consider the nature of the gift and its value to the patient, the potential implications for the patient-physician relationship of accepting or refusing it, and the patient’s probable intention and expectations.”⁴ A small gift as a token of appreciation is not ethically problematic. Favored treatment as a result of acceptance of any gift is problematic, undermines professionalism, and may interfere with objectivity in the care of the patient.⁴

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Many an ethics commentator have cautioned, “beware of patients bearing gifts.”⁵ In making an ethical assessment of whether or not to accept the gift, a key question a practitioner needs to ask him or herself is about the patient’s motive. Even the patient may be unaware of the reasons behind their giving, and the wise practitioner will take a mindful moment to think about the context and timing of the gift and the nature of his or her relationship to the patient. Sadly, many of our patients are lonely especially at this family time of year and on some level may hope the gift will help slide the professional relationship toward a more personal one. Some patients may think a gift might earn them preferential treatment. Finally, a few patients may have a romantic or sexual attraction toward a clinician.

Often in the latter 2 cases, a pattern will develop that discloses the patient’s true intent. Very expensive gifts, monetary gifts, excessively personal gifts, or frequent gifts should alert the practitioner that more may be going on. A kind reminder to the patient that providing good care is the only reward needed may be sufficient. For practitioners whose ethical code does not permit them to accept gifts, then a genuine thank you and an explanation of the rules and/or values behind the refusal may be necessary. There are other times when the practitioner or a supervisor/advisor may need to reset the boundaries or even to transfer the patient to another practitioner. The norms in mental health care and psychotherapy are more stringent because of the intimacy of the relationship and the potential vulnerability of patients.⁶

For gifts that seem genuine and generous or cost a trivial amount, then there is an ethical argument to be made for accepting them with gratitude. In many cultures, hospitality is a tradition, and expressing appreciation a virtue, so when a practitioner refuses to graciously take a small gift, they risk offending the patient. Rejection of a gift can be seen as disrespectful and could cause a rupture in an otherwise sound practitioner-patient relationship. Other patients experience strong feelings of gratitude and admiration for their practitioners, stronger than most of us recognize. The ability for a patient to give their practitioner a holiday gift, particularly one they invested time and energy in creating or choosing, can enhance their sense of self-worth and individual agency. These gifts are not so much an attempt to diminish the professional power differential but to close the gap between 2 human beings in an unequal relationship that is yet one of shared decision making. All practitioners should be aware of the often underappreciated social power of a gift to influence decisions.

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At the same time, clinicians can strive to be sensitively attuned to the reality that, sometimes the cookie is just a cookie so eat and enjoy, just remember to share with your group. External judgments are often cited as practical rules of thumb for determining the ethical acceptability of a gift: Would you want your mother, newspaper, or colleague to know you took the present? I prefer an internal moral compass that steers always to the true north of is accepting this gift really in the patient’s best interest?