For my Catalyst project, I chose to look into autonomy and the importance of it at risk of sacrificing mental health. Specifically, I looked into the US military and veterans: this is something applicable globally, as most countries have some form of militia. See my exploration, written in the format of a letter to the Department of Veteran Affairs, below.
To whom it may concern within the Department of Veteran Affairs,
Post traumatic stress disorder (from here on out referred to as PTSD) manifestation is an epidemic currently deeply affecting the lives of those who have served active duty in our armed forces. If they have not experienced loss themselves—an extremely rare occurrence, as this is war we speak of—they have been motivated to kill or be violent themselves, something in direct opposition with morals that many of those who have served possess.
Oftentimes, in PTSD, tempers grow shorter; in fact, domestic violence has been shown to have significant correlation to untreated cases of the disease. Additionally, paranoia and chronic stress cause insomnia in veteran populations, factors that directly affect work performance and can enact negative changes in relationships with loved ones and activities that used to be positive influences on their lives. Jitteriness and hyperarousal caused by constantly being on edge and believing oneself to be in danger also may result in irritable personalities and less cooperativeness with structured systems much like the military itself, leading to dishonorable discharge even before diagnosis.
PTSD is reported to affect anywhere around 21% (~⅕) of veteran populations. Within this statistic, we must also account for the fact that much of the data has been contributed by populations over 65, from Vietnam and World War II, from cultures that highly stigmatise such a diagnosis or reporting, and underrepresents those engaged in the “total war” of the desert, while fighting in the War on Terror. It is often comorbid with chronic illnesses such as depression, anxiety, and alcoholism. Most of these factors, one would agree, play into one’s ability to fully consent to treatment, in one direction or the other.
Currently in Virginia, the DVA does sponsor around 200 free psychiatric clinics to those who have received honorable discharge. Other positive initiatives are a rise in eHealth that further provides access in highly stigmatized communities, and coverage in the media helps psychiatrists identify symptoms in those who do seek out help. However, there are several major inhibiting factors that prohibit those suffering PTSD-related symptoms from searching for help. For one, there is only a very select few that are even eligible to receive DVA-sponsored aid. An individual must have:
- Completed active military service in the Army, Navy, Air Force, Marines, or Coast Guard (or Merchant Marines during WWII)
- Were discharged under other than dishonorable conditions
- Were National Guard members or Reservists who have completed a federal deployment to a combat zone
In other words, not all populations (especially the dishonorably discharged) can access this care, and in many cases those who have the strongest need for treatment are those who may have exhibited dishonorable behavior induced by their condition. Some individuals who have been discharged in a non-honorable fashion from service not only have the grief of seeing many they consider close be murdered, but may also have guilt over inflicting harm on others, shame from sexual assault—a horrifyingly common occurrence, especially in female demographics—and other conditions such as depression or anxiety aggravated. These are rarely addressed by the government and often prevent veterans from reaching out or seeking help, and largely contribute to the swaths of veterans now living on the streets, all too often also addicted to alcohol or incarcerated for drugs or violent transgressions. In PTSD Treatment for Veterans: What’s Working, What’s New, and What’s Next, Reisman writes the following:
“[Veterans find themselves barred from care because of] the requirement that they have either an honorable or general discharge to access Department of Veterans Affairs (VA) medical benefits, long waiting lists at VA medical centers, and the social stigma associated with mental illness within military communities.4,5 According to a study conducted by the RAND Center for Military Health Policy Research, less than half of returning veterans needing mental health services receive any treatment at all, and of those receiving treatment for PTSD and major depression, less than one-third are receiving evidence-based care.”
Veteran households also have a considerably higher incidence of homelessness than the average civilian, in part due to these personality changes and recurring flashbacks triggered by situations such as crowds, and often individually have annual income levels of less than $50,000.
One may be wondering, why spurt out facts mostly known by the Department of Veteran Affairs itself? Why press on this issue when it is often thought to be such an individual process of recovery? My argument is thus: much as in the case of those vulnerable to descend into a state of mind that prevents informed consent, we must take preventative steps by instituting systems to aid returning members of our armed forces before they ever set foot inside a training room.
Here, I will delve into the bioethical perspectives with which we must assess programs for PTSD.
PTSD affects competency.
- In a state of PTSD so severe that the individual is vulnerable to severe alcoholism or major depressive episodes, doctors would typically assess a mental state such as that listed to disqualify a veteran in this state of mental unhealthiness to opt out of such a treatment.
- There is the ability to comprehend what psychologists or therapists are asking of patients to cooperate. Especially if policies are instituted in which military personnel consent to treatment before stepping foot on training grounds (see conclusion section), it can be insinuated that these individuals have passed mental health bars that would declare them competent to consent to treatment before-the-fact and to be expected to uphold that contract even after entering the battlefield and encountering PTSD and traumatic situations.
Bioethical principles in question
- What is the right of the individual to refuse care?
- When does the situation become dire enough that intervention is necessary?
- How does the treatment of PTSD positively impact all participating parties?
- Balancing the stakeholders’ needs
- Does CBD actually diminish symptoms of PTSD?
- What is the margin of beneficence in relation to government and nonprofit money that can be invested into other health-related ventures such as oncology?
- Should whatever policies be standardized or applied on an individual basis?
Principles of justice in question
- A veteran at the point of alcoholism, liver disease, lung disease (from smoking), and deep suicidality is arguably in a state of more need of USDVA-ordered CBD and medication than a fresh recruit who only experienced scouting missions and never reached the front lines. That said, this is not a matter that is standardized in every way.
- Similarly to the above, how should therapy resources be allocated?
- Should this be calculated through time spent on the front line?
- Priority to those who spent longer periods of time on active duty?
- Research into different wars and outposts and looking at statistics for which demographics/posted troops exhibit most trauma as a whole
- Equal access to all individuals who come out of service?
- How should we draw what the minimum and maximum treatments should be?
- Should there be imposed limits on how much the government invests in each individual? What should that limit be?
- How should the US government indicate their responsibility in the matter?
- Is there a responsibility of therapists and mental health practitioners to offer more privacy, privately subsidized and reduced prices for treatments (if not free), and greater allocations of time and resources to veterans?
- What are support systems that “success story” veterans can set up to help each other in community?
- Similarly to equity, should there be greater allocation to those who have dedicated time as a general and have fought for 10 years than those who reached cadet at West Point and were deployed for 6 months in less active zones?
Who are the stakeholders in this conversation?
- Veterans themselves: every citizen has the right to a happy, fulfilled life; we must also consider how one’s reputation will be impacted in such a stigmatized situation if this was to be a “voluntary” treatment service. There’s a certain balance that must be struck between seeking help and maintaining reputation within communities.
- Doctors: patients who can lead more sustainable lives means fewer individuals on the streets and thus (often) fewer health problems, less alcoholism, etc.
- USDVA: the reputation of the US Department of Veteran Affairs—along with the military in general—both rely on good relations with the families of the individuals who have served for their country and a healthy population of incoming recruits ascribing to its creed. Many serve in good faith because they believe in the message and philosophy of protection and service to their country. Bad relations and the government not, in turn, serving the members of aforementioned country as they experience traumatic side effects puts the USDVA in a very bad light to many military families and prospective members of the Armed Forces.
This all leads me to the final component of my letter. I have attached a proposal, just a general guideline, by which we can work on instituting change. Most of this takes a rather long-term perspective on how best to solve these issues: after all, it would be rather immediate in terms of improving the lives of veterans and their families to simply dump a portion of the Defense Fund into their bank accounts as compensation. Instead, I implore the reader of this letter to look out for long-term solutions to this immediate issue, in which we are able to implement the proper scaffolding to ensure a secure system of financial and mental healthcare security for generations of veterans to come.
Proposal for Integrated Post Traumatic Stress Disorder Screening Program Within the United States Armed Forces
- We must mandate free screenings of PTSD to each and every individual who experienced active duty.
- This should be supplemented with 3- and 6-month check-ins, with screenings for depression and anxiety at these points in time. If the screenings come back with positives in any of the categories, treatment will become mandatory for longer periods of time (see sections II and IV).
- Overall, this would help with the following principles of justice:
- RESPONSIBILITY: putting our brave soldiers in traumatic circumstances indebts us to their service, the protection of our country, and the sacrifices they make in their mental health on behalf of the civilians benefitting from their protection. We are responsible to continue to care for them in sensitive times, and the least we should do is to screen for debilitating mental illnesses that progressively negatively impact those suffering from it.
- EQUITY: additionally, allocating resources/pushing those with greater trauma to take further steps allows us to grant those who have invested greater amounts of their mental health to the horrors of war and PTSD/major depression to receive treatment in ways that are destigmatized (under the philosophy of “necessary in the training to fight for our country”, it is difficult to disagree with this.
- The military should run a similar program to banks, in which $3,000 is invested in the mental wellbeing of each man, woman, or person who has committed to service; if not all that money is used, then it goes back into the pool and can be drawn upon for emergency circumstances.
- If patients were ranked with levels of PTSD (Level 1, 2, 3, and 4 perhaps, with 1 being mild trauma and 4 being severe PTSD and impacted life) then demonstrating each level would grant more allocated money.
- This would address the following principles of justice:
- EQUALITY: a standard allotment of $3,000 to use as one needs is about as equal as can be.
- NEED: further allotting the pool of unused money to treat veterans with greater severity further divvies up the cost efficiently and will reach further in long-term treatment effectiveness.
- Higher-level patients should also receive government funding to financially support themselves when in flux between active service and finding a job.
- This should be paired with the written mandate that individuals using these grants attend twice-weekly government-subsidized therapy services in the meantime and swear sobriety.
- This would effectively target the following bioethical principles:
- JUSTICE: it is only just to have a set of standard conditions that must be met to continue financial aid. Within justice, this also targets need and the responsibility of those in better positions to support veterans in dire mental health and attempt to prevent the slide in the first place.
- NONMALEFICENCE: mandating these practices not only insists that these victims of trauma maintain healthy habits, but also can greatly decrease the stigma of attending clinics in the first place.
- Additionally, it would cut down on violent outbursts from the untreated cases, as treatment and screening would be mandated until stable jobs can be found; having a steady income also would decrease stressors around money that might otherwise aggravate mental conditions.
- AUTONOMY: individuals can choose whether or not to opt into this programming IF their mental state reflects a certain level of health; additionally, after securing a job they can choose to detach from such government subsidization.
- There should be a series of government-subsidized treatment centers, with 2 or more per county (directly correlationally to population of active or discharged military personnel), where psychologists, therapists, and students can work together to not only further research PTSD, but also treat patients. This should either be done with absolute confidentiality or have measures instituted to ensure that there will be no impact on future employment opportunities for those who are mandated to participate in such programming.
- This initiative not only would help our economy by providing more jobs, but would also help us to fill gaps within said jobs by helping students in sciences of the mind to find residency, gain job experience, and have an opportunity to further .
- This would address the following bioethical principles:
- BENEFICENCE: branching out from just discharged (honorably or otherwise), reserve, and active-duty military personnel, this would also help our economy and job market in a variety of ways. Additionally, exposure to psychology, psychiatry, and therapy fields may give veterans more perspective on potential jobs. Clinics may even be able to staff military personnel currently in limbo while searching for jobs.
- NONMALEFICENCE: there
- It should be noted that a fair amount of autonomy would have to be sacrificed for this to be instituted. In circumstances where up to ⅕ of close to 2 million individuals are affected by moderate to severe (and oftentimes debilitating) PTSD, however, initial obligatory treatment will foster better habits and help our veterans to lead more fulfilling and autonomous lives after going through the treatment plans.
- The principle of justice surrounding power also is not taken much into account with these initiatives, in that all levels of military personnel are affected by the horrors of war and there should not be a difference in treatment except for in reference to equity and how much trauma each individual has endured (a combination of equity and need).
- Ensuring informed consent:
- There would be full disclosure of all potential treatments (PTSD CBD, antidepressants if required, etc.) as individuals enlist in the armed forces.
- Screenings for competency to operate a weapon or enlist in the first place require a certain level of adequate understanding, ensuring that future screen-ees are able to comprehend future steps taken to ensure their mental clarity and minimize the impacts of traumatic circumstances they are nearly guaranteed to encounter.
- By signing contracts in a completely voluntary setting (enlisting is not the same as drafting, and currently we do not have a draft running), future vets are consenting to treatment in the future on a completely voluntary basis. From the standpoint of veterans who did not see this before, there should be a widely released statement requiring all veterans to comply to a preliminary screening; from thereon out, they may choose to enroll in the programming and receive government aid or not to. However, past Level 2 (as seen in clause II) there is a requirement to fulfill treatment until psychologist-declared fitness to leave treatment is given. This does impact consent, but contracts with the military and veteran benefits currently are also subject to change; though it’s bad, in other words, it is ultimately helpful in regaining a healthy state of mind for many veterans and can help to give back autonomy to individuals that had mental acuity stolen from them by the debilitating side effects of PTSD and comorbid mental illness.
- Lastly, the consent acquired from the above decisions is made permanent in signing the contract to enter the armed forces. Thus, all steps to ensure informed consent have been completed as part of standard protocol for the US Army.
California, United States