The Ethics of Care Under Fire

   As youngsters growing up in a small village in the early 1970s, my friends and I looked up to our local firefighters. My home was located along a river, and the bridge next to my house was a great place from which to draft water. We grew up with the fire department in our front yard, engines roaring, streams ripping through the air like swords of righteousness.

   Firefighters faced danger, and to a little boy, these larger-than-life characters carried an infectious air of invincibility about them, stomping out flames with selfless abandon, seemingly secure with faith in their no greater love.

   As our childhood years passed, from time to time we witnessed our heroes leave off their firefighting armor and provide aid to the wounded and comfort to the ailing. Parked beside the engines was the very angel of mercy herself...the ambulance. She was small by today's standards, her profile an ordinary white van, set apart by the subtle outline of gleaming lights. Every inch of her carried blankets for the cold, splints for the broken, and all manner of comfort for the sick. Her gleaming white paint reminded me of the flowing robes of angels, and even her tires hummed liked heaven's own harps as she raced through the night, brilliant beams of red light driving back the darkness of human suffering.

   In 1985, at the age of 17 and still a junior in high school, I enlisted in the military, taking my place in a long line of brave Americans who answered the call. It was the height of the Cold War, and no one imagined we would ever be in another ground war.

   After basic training, I returned home to finish my senior year of high school. The aging rescue captain in our volunteer fire department asked if I would consider becoming an EMT. The fire department was down to only six EMTs at the time, and they were getting older. I agreed, and completed the EMT course that fall.

   Soon afterward, I picked up an old base station radio and set it up at home. The village siren activated whenever there was a fire or ambulance call, and unless we were at home, we never knew what the call was until we got to the station.

   The first time the radio went off was in the middle of the night for a barn fire in the next town. I didn't have any training in firefighting yet, but I responded anyway. I spent the whole night spraying water at the barn and had a great time. The following morning I responded to my first ambulance call--a cardiac arrest.

   I was hooked, and from then on, I was both a firefighter and EMT. I used to tell my high school classmates that helping other people in a medical emergency was incredibly rewarding, but that going in with a hose and knocking down a really hot fire was like winning the Super Bowl. Each presented its own set of challenges and rewards. Seven years later, I was incredibly blessed to land a job doing what I loved as a career firefighter/EMT-I with the Burlington, VT, Fire Department.

   Twenty years later, our nation suffered the unprecedented attacks of September 11, 2001. The active military was soon stretched thin and, in 2005, our National Guard found itself in the midst of its largest wartime deployment since World War II.

   My family and I watched as the towers fell, and we felt the pain, the loss, the tragedy. In the months afterward, I reflected deeply upon the justification for war. Clearly, our nation was attacked, but by whom? Most of us had never heard of this outlaw band of radical Muslims called al Qaeda. How would we fight this invisible enemy, nestled within the safe havens of sovereign nations who ostensibly meant us no ill will? Would this be primarily a police investigation, tracking down rogue terrorists, or something larger?

   We continued on…raising our children, fighting fires, easing human suffering. In 1999, in the midst of my career as a firefighter/EMT, I became a registered nurse. After a lifetime on the engines and ambulances, I now worked full time as an assistant fire marshal/public information officer and per-diem as an ED nurse. So began the dichotomy that would later come to define my life as a combat medic fighting alongside the infantry in Ramadi.

   In healthcare, easing human suffering in a non-judgmental way was a central part of my being. I extended compassion to the homeless, the destitute and the disease-riddled. While not always successful in this self-imposed discipline, I strove to treat all human beings with kindness. My greatest challenge at that time was learning to shift my view from one patient at a time in EMS to the larger group of people treated by far fewer providers in the hospital setting. I enjoyed working one on one with the most critical patients in the emergency department, and felt frustration when stretched too thin in other parts of the ED, unable to meet all the needs of less critical patients, constantly triaging the needs of many.

   I slowly learned to reconcile fire code enforcement and arson investigation with my long-ingrained commitment to not judge the faults of others. I initially viewed enforcement as a necessary responsibility rather than a calling unto itself. I thrived on the public education aspects of my job, and trudged reluctantly into this new mind-set in which I had to view others with suspicion.

   These early challenges helped me later define my role as a combat medic, embroiled in some of the fiercest fighting of the war in the streets of Ramadi. Not everyone was my patient. I came to adjust my view to include the larger perspective in which the entire patient population becomes one patient. The airway of one patient took priority over the sore toe of another. Lesser suffering must be ignored temporarily, while immediate threats to human life are dealt with.

   In the civilian sector, medical aid is often provided as service for a fee. In other settings, it is provided as ministry to the suffering, often without earthly compensation. The whole mission in both cases is to ease human suffering, regardless of our motivation for doing so.

   In the field of military medicine, the mission is defined on a much larger scale…to protect and defend the United States. The medical soldier recognizes his or her role in this larger mission of national defense: to preserve the fighting strength so that our larger mission may be accomplished.

   Though it might seem odd, perhaps even unethical to the civilian healthcare provider, military medicine uses a different set of priorities. In the civilian sector, our mission is somewhat narrow: preserve human life and ease human suffering. In the military, our role is to return the largest number of soldiers to the fight as quickly as possible to give our forces the strength for victory in battle. Sometimes this means applying a Band-Aid to the lesser--injured so they might defend us while we perform surgery on the more critical.

   This initial journey of ethical acceptance took place for me in the abstract…in training, long before I set foot on the battlefield. It was very beneficial, however, when I was forced to take the next leap of faith and take lives so that others might live.

   Though an extremely difficult concept for medical professionals to accept, the use of force is an unpleasant but necessary act of preventative medicine needed to save the greater patient: the population as a whole. There is only one justification for taking a life: to save the life of another. Even in this context, the taker of lives places himself in great moral peril. While we can rationalize our actions to ourselves, ultimately we will be judged by others--perhaps a jury in this world and more permanent judgment in the hereafter. Will those judges share our view of our patient as the larger whole or the individual before us?

   In the October issue, I will explore in greater depth some of the lessons we can glean from the experience of our military medics--from the practical application of a tourniquet to the ethical journeys few in the civilian world will ever face. Read more about this topic, as well as the wartime accomplishments of our National Guardsmen, in my book, Saber's Edge, a Combat Medic in Ramadi, Iraq (UPNE, July 2009) available through sabersedgebook.com and in most bookstores.

Thomas A. Middleton is the assistant fire marshal and public information officer for the Burlington (VT) Fire Department, and has been a long-time firefighter and EMT. He served as a combat medic in Iraq as part of Task Force Saber from June 2005–June 2006 and is a member of the Vermont Army National Guard.