LTC Aron-Gheoghe ARON (MD) (ROU)

The goal of this article is to analyze two medical situations from the Romanian mission in Afghanistan, situations with significant relevance in the right of soldiers to choose their doctor versus the importance of mission accomplishment. This has historically been a significant dilemma for all military leaders. For Romania, as it continues to develop a modern and effective military medical system, this continues to be an issue which must be addressed.

      1.C.D., 26, male, 2012, Kandahar, Afghanistan

A 26 year old male soldier, with altered mental status, pallor, cold sweating and fine tremors, presents to the doctor, two weeks into his deployment. His glycemic level on presentation was 1200 mg/100. After administration of insulin, his blood sugar returned to normal. The remainder of his evaluation confirmed the diagnosis of diabetes mellitus. On further questioning, the patient admitted that he was a known insulin dependent diabetic. He managed to hide this because he was concerned about the effect of his condition on his military career. Back home, he had a civilian family medicine doctor, and he was taken care by a civilian diabetologist. Of course, during the annual military medical check, he had a normal blood glucose level. Since his blood glucose was normal no other blood tests, such as an Hgb A1C, was performed. He was declared healthy and he was cleared for deployment. During the mission he lost his insulin and his previously stable health status began to decompensate.


As a gunner in his platoon, this soldier’s decompensated medical condition during a combat mission not only jeopardized his life, but also those his colleagues. The mission was also compromised since a medical evacuation is usually criteria for an “abort mission”.

      2. M.R. , 30, male, 2013, Zabul, Afghanistan

This patient came to see the doctor after two months of deployment, describing a dry cough for about 10 days, episodic fever, fatigability, irritability, and profuse sweating. On examination he was found to have warm and wet skin, tachycardia (HR-120-140 bpm), blood pressure of 150/90 mmHg, normal respiratory examination, no lymphadenopathy, and no other significant findings. After this initial assessment, hyperthyroidism syndrome was suspected, and the patient was evacuated at ROLE 3 MTF in KAF for further investigation. After further testing, hyperthyroidism was excluded, but a suspicious finding was noted on his chest x-ray. Subsequent chest MRI showed bilateral apical formations as well as mediastinal lymphadenopathy. Tuberculosis could not be excluded, so this patient became a significant epidemiological threat. The patient was immediately isolated and aggressive anti TB triple therapy was strongly recommended. If his therapy was initiated without a positive confirmation of TB infection, any chance for a correct and complete diagnostic work up would become impossible. The patient would be considered infected, under treatment, and forced by the law to complete the entire anti TB treatment regimen back in Romania. Considering the length of therapy with aggressive antibiotics, the patient would be exposed to significant side effects, without having a clear confirmation of   the infection. Furthermore, a TB patent is socially stigmatized, with significant impact on his personal life, on his family and on his career.

Given the fact that there were strong clinical arguments against infection, for example normal X-ray before deployment, vaccination, tuberculin reaction negative, no bacteria in sputa, the battalion doctor deferred treatment in consideration of another more likely pathologic process like sarcoidosis. The patient was evacuated in Romania, where the TB infection was excluded and the final diagnostic was sarcoidosis. Being a self-limited disease, the patient was cured, and able to continue his career, and his social and family life.


Suspicion of highly contagious diseases in a high risk population, is a major threat for public health. Decisive measures should be applied rapidly and effectively. On the other hand, these measures should be balanced with a complete assessment, considering the patient interest, as well.


Analyzing that two medical cases in an operational environment, two apparently opposite ethical meanings can be observed:

  1. Hiding a disease can jeopardize the life and health of soldiers during missions, and also can impact the mission accomplishment.
  2. During missions, the individual’s best interest can be affected by collective force health protection, especially if there is limited access to a second opinion.

The soldier’s best interest, their right to benefit from the best medical care and the best medical decisions can be affected by one of the main functions of the medical system during the missions: force health protection.

So, here is the ethical dilemma: Is the limitation of the right to choose their doctor in the best interest of the soldier? Are the rights of the military community more important than the rights of the individual soldier? Is the military medical system able to provide the best medical care for all soldiers in all circumstances?


Institutional and individual interests should be not divergent. On the contrary, they should be in a synergistic and complementary position.

An effective medical system should be able to provide both, the best medical care for all soldiers and the best medical protection for the troops.

A permanent and accurate system for monitoring individual health status should be a goal to achieve.

Medical decisions should serve the best interest of all the patients and force health protection measures should be well grounded with solid objectives arguments.


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Well written and very interesting article that I think the NATO medical community will also find interesting.  My comment is related to the question of a soldier being able to choose his/her doctor.  In these 2 case examples, that did not seem to be one of the issues since one soldier was hiding a diagnosis and the other was a “new” FHP issue.  Otherwise, thank you for sharing!

CAPT (N) Kimberly A. Ferland (USA)


Your questions are really burning and thought-provoking. I would look these problems from another aspect at. It is clear that Military Medicine needs the clear picture of medical status of all soldiers.  But to deprive someone’s personal rights –is avoidable in the military too, it is sensitive issue, especially as you write – the military is not always able to provide (although this is the goal) the same level of medical care as the civilian one.  In my reading the solution would be the establishment of a single healthcare data storage system to which the military doctors have access to their patients/soldiers health data and vice-versa. (e.g. Leishmanial symptoms often occurs 6-12 months later after the exposure; or PTSD). Another issue would be conscious thinking of the soldiers, this is the foundation of Force Health Protection. If a soldier thinks himself invulnerable (I’m better than the others, they are losers! or To take medicines is weakness) makes the military unit vulnerable and threatens not only the operational effectiveness but soldiers lives. So all soldiers have to develop conscious thinking during their military training from the very beginning.

LTC Dr. Tamás BOGNÁR (HUN ) 



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