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health reform • winter 2016 639
The Journal of Law, Medicine & Ethics, 44 (2016): 639-651. © 2016 The Author(s)
DOI: 10.1177/1073110516684809
Introduction
Most medical codes of ethics, based as they are in the
Hippocratic Oath, state that physicians have a pri-
mary obligation to act in and protect their patients’
best interests.1
According to this view, real or perceived pressure to
divert a physician’s duty away from his patients creates
an important ethical conflict,2 as would be the case for
military physicians, but also for physicians and other
health professionals working in occupational medi-
cine or employed to ensure the healthy functioning of
a workforce (e.g., sports teams, workers’ health insur-
ance programs). For example, how does a military
physician decide what to do when asked by a com-
manding ocer not to provide care to an enemy com-
batant? At first glance, military principles that seek to
maintain the combat readiness of soldiers and opera-
tional success, and a military culture that traditionally
relies both on professional autonomy and obedience
to orders as part of a hierarchical chain of command,
seem to conflict with medical principles that prioritize
patient well-being, non-maleficence and a rejection of
medical paternalism.3 To put it bluntly, how can the
military profession, whose mission of defending state
interests can involve the use of deadly force, be com-
patible with the medical profession whose primary
mission is to heal and save lives?
Often referred to as dual loyalty challenges or pro-
fessional role conflicts, such situations require physi-
cians to weigh their patient’s interests against other
considerations, such as governmental or institu-
tional objectives.4 In cases where these hypothetical
or actual challenges have been studied, some authors
find the problem to be that medical codes of eth-
ics are not adapted to the actual contexts of clinical
practice.5 Clinicians are sometimes asked to ascribe
to and be bound by two codes of ethics or codes of
conduct — i.e., that of the medical profession and of
their employer — which may at times conflict or even
be seen as incompatible. Should one code of ethics,
i.e., that of medicine, always have primacy over other
codes or guidelines (e.g., those of the institution)?
Codes of ethics are foundational documents that
identify the core values and rules of ethical conduct
for members of a profession, and so are intended to
be used by professionals to guide their behavior and
delineate their responsibilities.6 Yet, codes of ethics
cannot fully encompass or address all the ethical issues
likely to be faced by members of a profession, and they
have important limits in terms of scope (e.g., issues
addressed within the code), specificity (e.g., for par-
ticular specialities or types of practice) and applicabil-
ity (e.g., utility in particularly challenging contexts).
Potential for conflict exists and is probably inevitable
Are Military and Medical Ethics
Necessarily Incompatible?
A Canadian Case Study
Christiane Rochon and Bryn Williams-Jones
Christiane Rochon, M.Psych., M.B.A., Ph.D., is a Consul-
tant in Montréal, Canada. She has worked for more than 20
years as a consultant with the Canadian International Devel-
opment Agency (CIDA), primarily in the Maghreb (Algeria,
Tunisia, Morocco), West Africa (Senegal, Ivory Coast, Burkina
Faso, Benin), Central Africa (DR Congo, Rwanda and Cam-
eroon) and Haiti. Her doctoral research focused on bioeth-
ics in armed conflicts and the ethical reasoning of military
physicians. Bryn Williams-Jones, Ph.D., is a Professor and
Director of the Bioethics Program, Department of Social and
Preventive Medicine, School of Public Health at the Univer-
sité de Montréal in Montréal, Canada. An interdisciplinary
scholar trained in bioethics, Dr. Williams-Jones is interested
in the socio-ethical and policy implications of health innova-
tions in diverse contexts; current projects focus on issues in
professional ethics, public health ethics, research integrity and
ethics education. He heads the Research Ethics and Integrity
Group and is Editor-in-Chief of a bilingual (French, English)
open access bioethics journal, BioéthiqueOnline (bioethique-
online.ca).
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The Journal of Law, Medicine & Ethics, 44 (2016): 639-651. © 2016 The Author(s)
since there are dierent principles, beliefs and values
systems that are held by military physicians them-
selves, and the military institution.7 Professionals
will thus likely refer to other guiding documents (e.g.,
norms of practice, decision-making tools, institutional
codes of ethics or conduct, national or international
laws) to support their ethical judgments when their
professional codes of ethics prove insucient for the
problem at hand.
In the case of the Canadian military, for example,
physicians work in an institution — i.e., the Canadian
Armed Forces (CAF) — where most (if not all) mem-
bers are viewed as professionals bound by a social
contract (i.e., granted professional autonomy by the
state in exchange for working towards an important
social good) and having an obligation to act accord-
ing to specific values that are articulated in an institu-
tional code of ethics, the DND and CF Code of Values
and Ethics.8 The challenge for a military medical o-
cer may be presented as one of reconciling guidance
from dierent codes of ethics, i.e., that of the CAF and
the Canadian Medical Association (CMA). But if we
return to the dilemma facing the military physician
who is asked not to treat an enemy combatant, the
professional response actually is relatively straightfor-
ward since codes of medical ethics and international
humanitarian law provide that combatants be treated
according to the severity of their wounds, and that
they have a right to healthcare. The military physician,
as a health professional who is subject to national and
international codes of medical ethics, thus has strong
arguments for refusing to meet such a request from
a commanding ocer. It is therefore important to
examine more carefully the nature of the ethical guid-
ance available to military physicians to see whether,
in fact, such guidance is necessarily conflictual and
source of significant professional dilemmas.
In this paper, we examine and compare the his-
tory and content of two national professional codes of
ethics — the Defence Ethics of the Canadian Armed
Forces and the Code of Ethics of the Canadian Medi-
cal Association — in order to identify where conflicts
could potentially occur between a military physician’s
professional responsibility towards their patient, on
the one hand, and to their employer institution (the
military) and society more generally, on the other.
In contrast to the conflictual view of military medi-
cal ethics often presented in the bioethics literature,9
our analysis shows that the Canadian military and
medical codes of ethics are not fundamentally or nec-
essarily incompatible. Even though there are clearly
important dierences in both the approach adopted
(i.e., values-based vs. principle-based) and their focus
(i.e., common good vs. patient-centered) that can pose
ethical challenges for military physicians (and other
health professionals), there is still sucient overlap
between the core values, principles and objectives of
these two codes to provide a relatively coherent moral
framework for Canadian military physicians. What
remains underdeveloped in both codes, however, is
specific attention to the particular challenges and
realities of professionals — and thus an articulation of
specific duties and responsibilities — who are bound
by two distinct codes of ethics, such as the medical
profession and the military.
Being Military: Just about the Legitimate
Use of Force?
In modern Western militaries, soldiers are part-time
(reserve) or full-time employees who chose to join the
military institution, i.e., they are not conscripts, they
often have fixed contracts of service and are remuner-
ated for their work. Further, as members of the “pro-
fession of arms,” soldiers are trained to develop, share,
and perform according to specific professional moral
values. Soldiers have a mandate to protect society and
defend national values, and are one of the few groups
— along with police and security services — permit-
ted to use arms and deadly force, something that is
normally contradictory with other important demo-
cratic values (i.e., respect for individual liberty and
human dignity). As with all professionals, members
of the military are required to meet higher ethical
standards than what would be expected of the general
population (i.e., jus ad bellum, or the justifiability of
using force or engaging in war, and jus in bello, or the
proportionality of force used to meet military/politi-
cal objectives).10 The military profession is thus bound
by a social contract: in exchange for working in the
interests of the state (i.e., the common good), the pro-
fession is granted significant autonomy, for example,
in establishing eligibility and membership criteria,
evaluating and judging member qualifications, setting
ethical norms of conduct and imposing sanctions.11
Modern militaries are complex organizations,
reflecting much of the professional and cultural diver-
sity of the modern state. Members of the Canadian
Armed Forces (CAF), for example, consider them-
selves as “a distinct sub-set of the entire Canadian
fabric,”12 meaning that they must reflect and practice
the democratic values of Canadian society.13 With the
merger of Canadian Department of National Defence
(DND) and the Canadian Forces in 1972, there was
what some authors have called a “civilianization” of
the CAF — i.e., the increased presence of specialized
technicians, engineers, and managers working along-
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side combat personnel, as well as other civilian pro-
fessionals working at DND resulted in a significant
culture change.14 It has even been argued by some that
“military morale and values have been eroded by the
transference of civilian values and management tech-
niques to the Forces.”15
Military Ethos
In the manual Duty with Honour: The Profession of
Arms in Canada,16 there is a detailed description
of “what it means to be a Canadian military profes-
sional” articulated through four attributes: responsi-
bility, expertise, identity, and military ethos. Military
ethos is considered to be at the centre of the profes-
sion of arms because it “embodies the spirit that binds
the profession together. It clarifies how members
view their responsibilities, apply their expertise, and
express their unique military identity. It identifies and
explains military values and defines the subordination
of the armed forces to civilian control and the rule of
law”; thus “military ethos serves to shape and guide
conduct, especially in the face of ethical dilemmas.”
The Canadian military ethos is composed of three
components:
1. beliefs and expectation about military service
which includes accepting unlimited liability,
fighting spirit, discipline and team work;
2. Canadian values: foundational legislation
(essentially the Constitution and the Char-
ter of Rights and Freedoms), the Statement
of Defence Ethics, Canadian Security Policy
(human security, international stability and
viable international relationships), perform-
ing duty with humanity; and
3. military values: duty, integrity, loyalty and
courage.
Defence Ethics Program
In light of a changing institutional culture, and in
response to the challenges of post-cold war operations
in which the CAF were involved — notably peacekeep-
ing operations in Eastern Europe, the Middle East and
Africa — the Canadian Defence Ethics Programme
(DEP)17 was developed in 1994 and implemented in
1997,18 including the first formal code of ethics in 1997,
the Statement of Defence Ethics.19 Following the imple-
mentation in 2011 of The Values and Ethics Code20 for
all Canadian Public Sector employees (including the
DND and the CAF), in 2013 a specific DND and CF
Code of Values and Ethics21 was created
which “fully integrates and expands on
the values and expected behaviours found
in the Values and Ethics Code for the Pub-
lic Sector, as well as on the values and eth-
ics found in the Canadian Forces customs
and practices described in Duty with
Honour: the Profession of Arms in Can-
ada.”22 The DND and CF Code of Values
and Ethics is “a binding directive applica-
ble to all DND employees and is an order
for all CF members.” It is presented as a set of three
principles (Respect the dignity of all persons, Serve
Canada before self, Obey and support lawful orders)
and five specific values (Integrity, Loyalty, Courage,
Stewardship, Excellence; see Table 1) each articulated
with expected behaviors; these principles and values
are also enumerated in the Statement of Defence Eth-
ics.23 The resulting Canadian Defence Ethics is built
on the values of Canadian society (democratic values
and laws, including respect for the principles of war),
respect for international commitments such as the
Universal Declaration of Human Rights, and values
that are part of the military profession (i.e., the mili-
tary ethos).24
The goal of the DEP is to provide the necessary
tools (codes of ethics, support documents, training
programs) for members of DND and the CAF to build
their capacity for value-based ethical judgments.25
That is, the aim is “to foster the practice of ethics in the
workplace and in operations such that members of the
CF and employees of the DND will consistently per-
form their duties to the highest ethical standards.”26
As explained in an accompanying Student Manual, the
DEP is a top-down, normative values-based program
that “maintains a dynamic balance between judge-
ments based on compliance and judgements based on
ethical values.”27 The Student Manual presents a basic
decision-making model (based on Rest’s Model28)
with a four step process — perception, judgement,
intent-commit and action — and describes a number
of well-known theoretical frameworks that can help
guide ethical judgement (rule-based, consequence-
based, care-based, virtue-based, multiple-approach
based, and self-interest-based).
The goal of the DEP is to provide the
necessary tools (codes of ethics, support
documents, training programs) for members
of DND and the CAF to build their capacity
for value-based ethical judgments.
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Military and Professionalism
For our purposes, a particularly interesting aspect of
the Statement of Defence Ethics, the DND and CF Code
of Values and Ethics and the DEP more generally is
the use of the language of professionalism, as in, “The
Statement is intended for use as a normative guide to
professional conduct.”29 Nonetheless, there is some
ambiguity about this concept in the military context.
Indeed, who should be called a “professional” soldier
or member of the military seems to be problematic
and there is a tendency to view professionalism along
a continuum depending on the role/position and
length of service.30 For example, soldiers who serve for
only a few years and then return to civilian life, or are
part-time reservists, may not be considered to be mili-
tary professionals by their fulltime “career” colleagues
because the former may be viewed as lacking the skills,
discipline or ability to self-regulate that characterizes
professional activity.31 On the other hand, non-com-
batant ocers such as physicians or nurses may be
considered military professionals if they spend their
career in the armed forces; but they are also “profes-
sionals” because of their membership in formal pro-
fessional orders (medicine, nursing, etc.).
The DND readily acknowledges the limitations of
employing the paradigm of “profession” as the foun-
dation for its ethics program.32 The concept of a pro-
fessional (with associated duties and responsibilities)
must be understood in a particular context — i.e., that
of a democratic society and a military institution —
and so for the DND is insucient, in itself, to pro-
moting robust ethical reflection. For this reason, the
DEP defines and specifies principles and values (and
associated expected behaviors) that are in line with
the professional obligations of its members, instead of
focusing on providing a comprehensive list of duties
as would be common in most (health) professional
codes of ethics.
Bayles’ professional-client model can usefully
be applied to Defence, in as much as Defence
represents a professional exercise of an activity
in the public domain. Walzer is just one of many
who have written insightfully on the military
using the paradigm of a “profession”. It can assist
our understanding of what is involved in the
special ethical obligations of defence personnel
by explaining them in terms of universal and
role-related norms or in terms of general and
role-specific obligations or, again, in terms of
hierarchical and non-hierarchical obligations.
However, the professional-client model and,
more generally, the paradigm of a “profession”
is not sucient to provide a firm foundation
for a value-based approach to Defence ethics…
Reference to this broader context will inevitably
aect which ethical values should have primacy
in defence and the relative weights assigned to
these values in decision-making.33
The DEP distinguishes between values that are “uni-
versal” in the context of professions in general, such
as the health or safety of the population, and those
related to a specific role (e.g., for combatants or non-
combatants). Following Michael Walzer,34 the profes-
sional role is also subdivided into two types of respon-
sibilities, those in hierarchical relationships (e.g., duty
to follow orders and the chain of command), and those
in non-hierarchical relationships (e.g., responsibilities
towards people, especially non-combatants, who can
be aected by military action).35
Furthermore, the DEP recognizes an organiza-
tional responsibility to apply ethical principles and to
develop an ethical organizational culture within the
military institution, one that is “strongly supported
[by] the virtues of open dialogue on ethics in the
workplace and on the need for ethical risk manage-
ment.”36 The foundation of this ethics program — and
the associated codes of ethics — is thus best described
as multidimensional, because it involves obligations to
society, to the military institution and to government,
to the Canadian population and to the populations of
other countries aected by the actions of the CAF.
Even though there is significant attention to profes-
sionalism and professional ethics, the DEP is unlike
other (health) professional codes of ethics because it
is explicitly based on “the belief that the responsibility
for defence ethics is a shared responsibility between
the organization and the individual.”37 In healthcare
contexts, institutions often have an organizational
code of values or conduct but these remain relatively
general in nature. More fundamentally, most medi-
cal codes of ethics are oriented towards the individual
responsibility of professionals, whether to their indi-
vidual patients or more broadly to society, and are not
generally associated with any particular institution.
By contrast, the DEP brings together institutional
and individual responsibilities. This commitment by
the CAF to a model of shared responsibility is clearly
demonstrated in the regular tri-annual review of the
DEP, which started in 1999 and was then repeated
in 2003,38 2007,39 and 2010.40 The “Department of
National Defence Ethics Questionnaire” (DNDEQ)
aims to “assess the current ethical climate of CF/
DND and the approaches to ethical decision-making
favoured by CF/DND personnel” (Department of
National Defence, 2007). For example, the 2010 sur-
vey found that the DEP program helped improve the
Rochon and Williams-Jones
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overall ethical organizational climate and reduce the
gap between perceived organizational climate and
individuals values.41
All four Defence Ethics Surveys have been based
on the “Ethical Decision-Making Model” developed
by Kelloway et al.42 which stipulates that there are
four indicators of ethical decision-making: organi-
zational ethical climate, individual values, individual
ethical ideology, and situational moral intensity. The
surveys assess ethical decision-making based on six
philosophical approaches: rule-based, care-based,
consequence-based, virtue-based, self-interest based,
and multiple approaches. In 2003, it was found that
ocers were more likely to use rule-based approaches
while others were more likely to use consequence-
based approaches. The same was found in the 2007
survey,43 but the authors concluded that “Members/
employees largely favour mixed approaches to eth-
ics for ethical decision-making,” e.g., combining both
rule- and consequence-based approaches, along with
their own personal values.
Canadian Defence Ethics: Strengths and
Weaknesses
In summary, in Canada, the existence of a well-artic-
ulated military ethics inscribed in codes of ethics and
integrated into training is a relatively recent phenom-
enon, arguably starting in the mid-1990s with the cre-
ation of the DEP and the 1997 Statement of Defence
Ethics, but continually evolving to its current form
in the 2013 DND and CF Code of Values and Ethics.
Obviously, military ethos and the concepts of jus ad
bellum (the justifiability of using force and jus in bello
(the proportionality of force used) have long been a
part of the CAF professional culture, as were respect
for international laws governing military operations,
and so predate the DEP. The innovation of the DEP
is that through its development of a code of ethics,
and supporting documents and training programs, it
provides a thorough and well-articulated approach to
promoting ethical reflection on the part of all DND
and CAF personnel in order to establish an ethical cli-
mate across the entire organization.
The comprehensive, systematic, and integrated
approach taken by the DEP to developing profes-
sional and organizational ethics is quite remarkable,
and something rarely seen in other institutions. The
associated training program and related documents
were developed with reference to the most recent
academic research in philosophy, sociology, psychol-
ogy, and organizational studies, and were elaborated
in order to teach practical ethical decision-making
so that members of the CAF and DND do not just
rely on the code of ethics. The main limitation of the
DEP and associated code of ethics, however, is their
scope. That is, the Canadian Defence Ethics applies
to the multitude of professions found within the mili-
tary institution, including both combatants and non-
combatants. As such, while the DEP, the Statement of
Defence Ethics, and the DND and CF Code of Values
and Ethics provide important guiding principles and
a good set of tools for ethical reflection at an insti-
tutional level, they arguably do not yet provide the
detailed support necessary for a specific group with
In Canada, the existence of a well-articulated military ethics inscribed in
codes of ethics and integrated into training is a relatively recent phenomenon,
arguably starting in the mid-1990s with the creation of the DEP and the 1997
Statement of Defence Ethics, but continually evolving to its current form in
the 2013 DND and CF Code of Values and Ethics. Obviously, military ethos
and the concepts of jus ad bellum (the justifiability of using force and jus
in bello (the proportionality of force used) have long been a part of the CAF
professional culture, as were respect for international laws governing military
operations, and so predate the DEP. The innovation of the DEP is that
through its development of a code of ethics, and supporting documents and
training programs, it provides a thorough and well-articulated approach to
promoting ethical reflection on the part of all DND and CAF personnel
in order to establish an ethical climate across the entire organization.
644 journal of law, medicine & ethics
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particular and distinct needs, such as military health
professionals.
Being a Physician: To Heal and Save Lives?
To return to the question of the compatibility of the
military and medical professions, we can ask ourselves
whether it is realistic to think that physicians (and
other health professionals) have as a primary mis-
sion to save lives and work first and foremost in their
patients’ best interests. The history of medical ethics
shows that, like military ethics, what is ethical prac-
tice for a physician reflects the values and concerns
of the society in which the physician works. From
its origins as a profession with a strong paternalistic
relationship between the physician and the patient,
Western medical codes of ethics have evolved towards
a model where respect for the autonomy and rights
of patients have become core values and duties (e.g.,
articulated through informed consent and shared
decision-making).
History of the Canadian Medical Association
Code of Ethics
As with the Hippocratic Oath, Western medical ethics
today is centered around the physician-patient rela-
tionship (e.g., respect for autonomy, beneficence, do
no harm, confidentiality) and the responsibility of the
physician (behavior and duties). And while the evo-
lution of science, as well as social, political and eco-
nomic developments over the centuries, have influ-
enced the practice of medicine, the basic principles of
Hippocrates still remain at the heart of contemporary
medical ethics.44
In 1947, and in large part in reaction to the atroci-
ties conducted by physicians during the Second World
War, the World Medical Association (WMA) was cre-
ated and the Hippocratic Oath modernized, remov-
ing religious references and elaborating the Declara-
tion of Geneva in 1948 (latest revision 2006). Respect
for human dignity is present throughout the WMA
Geneva Declaration Physician Oath,45 with article 1
stipulating: “I solemnly pledge to consecrate my life
to the service of humanity” and articles 8 and 9: “I
will not permit considerations of religion, national-
ity, race, party politics or social standing to intervene
between my duty and my patient; and I will maintain
the utmost respect for human life, from the time of its
conception, even under threat, I will not use my medi-
cal knowledge contrary to the laws of humanity.”46
Inspired by the Declaration of Geneva, in 1949,
the WMA published its International Medical Code
of Ethics (latest revision 2006).47 In an eort to meet
international standards of medical practice, the CMA,
in the 1956 revision of its own medical code of ethics,48
added the WMA Geneva Declaration Physician Oath
as an appendix. The dierent versions of the CMA
Code of Ethics focused primarily on physicians’ duties
towards their patients, their colleagues, and the medi-
cal profession.49 Whether in the Hippocratic inspired
codes of ethics, or in the Geneva Oath, there is clearly
an individual/patient-centered approach to the prac-
tice of medicine such that the physician’s first obliga-
tion is invariably, if not always, towards their patient.50
The civil rights movement of the 1960s and 1970s,
increasing attention to issues associated with immi-
gration and multiculturalism, and the rise of the field
of bioethics and attention to issues associated with
research and the impact of technology on individu-
als, led the CMA — along with other national medical
associations, such as the American Medical Associa-
tion (AMA) — to re-evaluate the core ethical prin-
ciples and values found in its code of ethics.51 Codes
of ethics built around medical paternalism gave way
to those aimed at respecting the autonomy of the
patient, and a less individualistic and more collectivist
perspective emerged.52 More recently, there has been a
tendency in international and national codes of ethics
to recognize physicians as social actors.53 For example,
according to the WMA, “Medicine is now more than
ever before, a social rather than a strictly individual
activity. It takes place in a context of government and
corporate organisation and funding. It relies on public
and corporate medical research and product develop-
ment for its knowledge base and treatments.”54
Responsibilities of physicians towards society were
included for the first time in the 1970 revision of the
CMA Code of Ethics,55 with three articles stating that
an ethical physician had the responsibility to (1) “strive
to improve the standards of medical services in the
community” and “accept his share of the profession’s
responsibility to society in matters relating to public
health,” (2) “recognize his responsibility to assist the
court in arriving at a just decision” when acting as a
witness, and (3) “support the opportunity of his con-
freres to obtain hospital privileges in his community
appropriate to their personal and professional quali-
fications”. In a major revision in 1996,56 these articles
were included as part of a complete numbered list,
along with other articles requiring physicians to “use
health care resources prudently” (article 32) and “to
promote fair access to health care resources” (article
31), thus integrating notions of public health among
physician responsibilities.
Physician Roles
Building on a classification proposed by Pedro Lain
Entralgo, Pellegrino57 identified four different but
sometimes overlapping roles that physicians can
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The Journal of Law, Medicine & Ethics, 44 (2016): 639-651. © 2016 The Author(s)
have in relation to their patients: (1) the technician
who sees the patient mechanically; (2) the researcher
(knowledge); (3) the ocial of an institution; and (4)
the businessman who is looking for profit. Pellegrino
adds to this list a fifth item, namely the role of the phy-
sician as employee of the state who must, above all,
consider the well-being of the population, rather than
solely that of the patient. These various roles imply
“a dierent theory of medicine, a dierent interper-
sonal relationship between physician and patient, and
a dierent ethics.”58 While Pellegrino recognized that
medicine is a “multivaried societal phenomenon” and
that physicians play dierent roles, for him the fact
remains that “one of these roles, the role of healer, is
primary; the others are subsidiary” because medicine
is “a special kind of human activity with its own inter-
nal morality.”
In recognizing these dierent roles, and the various
pressures on (or interests on the part of ) physicians
that limit a more traditional patient-centered orienta-
tion, Pellegrino and others have raised concerns about
the threat to the core values of the medical profession58
and argued for a return to a professional patient-cen-
tered medical practice; this view is clearly articulated
in the 2002 Physician Charter60 and in calls for a more
virtue-based medical ethics.61 The Physician Charter,
for example, identifies three core principles (primacy
of patient welfare, patient autonomy and social jus-
tice) and concludes that “professionalism is the basis
of medicine’s contract with society.” Of note, the Physi-
cian Charter values were integrated in the most recent
2004 revision of the CMA Code of Ethics.62
This focus in codes of ethics — and in medical eth-
ics more generally — on the appropriate behavior of
Table 1
Comparison of Military and Medical Ethics
Canadian Military Canadian Physicians
Values • Integrity
• Loyalty
• Courage
• Stewardship
• Excellence
• Loyalty
• Integrity
• Disinterest
• Respect for life, individual and for dignity
Principles and
Duties
• Respect the dignity of all persons
• Serve Canada before self
• Obey and support lawful authority
• Have an irreproachable behavior
• Promote education and training
• Maintain skills
Obligations Of CF members:
• Abide by DND and CF code of ethics and
demonstrate in action and behavior
Those with leadership roles must:
a. exemplify the values in the code
b. create a healthy ethical climate
All DND and CF employees also have an obliga-
tion to report serious breaches of the code
• Quality of the professional relationship
• Freedom of choice and consent
• Support and Monitoring
• Quality practice
• Independence, impartiality, integrity
• Records and fees
• Relationships with other professionals and the
College/Association
Ethical Authorities • Society (Canadian Constitution, Charter of
Rights and Freedoms)
• Queen’s Regulation and Orders
• Defense Ethics Programme
• Canadian Forces
• National laws
• International humanitarian laws
• Canadian Medical Association
• Provincial College of Physicians
• Professional Codes
• Charter of ethics of Faculties of Medicine
• World Medical Association
• International Declaration of Human Rights
Differences • Virtue ethics, value-based
• Defence of social rights
• Compliance with authority
• Military sanctions
• Possibility for legitimate use of force and
resulting harm to others
• Ethics based on duties
• Defence of human rights
• Professional autonomy
• Professional and civil sanctions
• Principle of “do no harm”
Drawn from the Canadian Defence Ethics Programme,63 the Statement of Defence
Ethics,64,the DND and CF Code of Values and Ethics,65 and the CMA Code of Ethics.66
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physicians, however, is not without its limits. In par-
ticular, the complex ethical issues facing clinicians
working in different specialties and contexts (e.g.,
general medical practice vs humanitarian work), as
well as broader societal issues such as those related
to abortion, euthanasia, or organ donation may not
be adequately (if at all) addressed in medical codes of
ethics. This is arguably the case for the Statement of
Defence Ethics, the DND and CF Code of Values and
Ethics, and the CMA Code of Ethics. These codes of
ethics necessarily have a broad scope and aim to cover
all aspects of the professional practice that they seek
to govern, but in so doing, they pay little attention to
the particular challenges and work context of military
physicians.
Discussion: Comparing Codes of Ethics
In light of the above-mentioned critiques by Pel-
legrino and others, and following our presentation
of the Canadian military and medical codes of ethics,
one might conclude that there is a fundamental and
intractable contradiction between the military and
the medical worlds in Canada, and that their respec-
tive values and codes of ethics are simply incompat-
ible. However, we argue that a closer analysis of the
professional ethics values of Canadian physicians (as
inscribed in the CMA Code of Ethics) reveals that they
are quite similar to those of members of the Canadian
military (as articulated in the Statement of Defence
Ethics and the DND and CF Code of Values and Eth-
ics). In Table 1, we compare the core values, principles
and obligations that are explicitly articulated in the
CAF and CMA codes of Ethics.
In both the Canadian military and medical codes of
ethics, for example, loyalty and integrity are proposed
as core values. Courage, stewardship, and excellence
are specific to the military while disinterest (objectiv-
ity/impartiality) and respect for life are particular to
medicine. Excellence, which is a core value in the mili-
tary, is also found in the medical code of ethics, listed
under two dierent categories: principles and duties.
The two codes of ethics recognize that their members
will have to deal with various ethical authorities at dif-
ferent levels (national and international) and the rules
of their home institution (DND, hospital, private clin-
ics, etc.), and may thus be faced with challenges, and
even contradictions, at dierent levels; this is referred
to as the “multiplicity problem” of codes of ethics.67
Further, both the CMA Code of Ethics and the DND
and CF Code of Values and Ethics are very broad in
scope, and so are intended for use by a diversity of
actors. Indeed, the CMA Code of Ethics covers dierent
medical specialties, some of whom may not feel that
their reality is suciently well addressed (e.g., psy-
chiatry and public health). For its part, the DND and
CF Code of Values and Ethics is intended for all DND
and CAF personnel, thus including both combatants
(e.g., frontline soldiers and senior sta ocers) and
non-combatants (e.g., clinicians, lawyers, engineers,
administrative sta). As such, it is clear that these
codes of ethics cannot specifically address the diver-
sity of ethical challenges or situations in which their
members will find themselves. Without adequate
profession/specialty-specific guidelines and training,
each group will arguably have a tendency to focus
more on legal obligations (what is permitted, how to
avoid being sued) over ethical obligations (what one
“ought to do” as a professional), i.e., the “legalization
problem” with codes of ethics.68
What is also evident from Table 1 is that for the
Canadian military, principles and values take prece-
dence over other aspects. Indeed, as described above,
the Statement of Defence Ethics and the DND and CF
Code of Values and Ethics require all sta to respect
three principles and five values. The three principles
of “respect for human dignity,” “serve Canada before
self,” and “obey and support the authority” are more
“universal” and focused towards humanity, society,
and legal authorities. These principles and obligations
are presented in a clear hierarchical fashion such that
it is more important to respect human dignity (the
first principle) than to follow orders (third principle),
and if one has to choose, the first has precedence over
the others.69 This ranking is rather unique to Canada’s
military. In most military institutions, the first rule is
usually to serve one’s country and follow lawful orders.
The five ethical obligations that CAF/DND members
must refer to in their ethical decision-making are
‘integrity,’ ‘loyalty,’ ‘courage,’ ‘stewardship’ and ‘excel-
lence,’ and expected behavior for each of these values
are defined in DND and CF Code of Values and Eth-
ics. For example, courage is described as: (1) Facing
challenges, whether physical or moral, with determi-
nation and strength of character; (2) Making the right
choice amongst dicult alternatives; (3) Refusing to
condone unethical conduct; and (4) Discussing and
resolving ethical issues with the appropriate authori-
ties. In 2013, the DND and CF Code of Values and Eth-
ics added ‘stewardship’ and ‘excellence,’ adding to the
value of ‘duty’ found in the earlier Statement of Defense
Ethics and the DEP. Stewardship reflects a new con-
cern for government employees to “eectively and e-
ciently using the public money, property and resources
managed by them.”70 This value is also found in CMA
Code of Ethics under article 44, which asks physicians
to “use health care resources prudently.”71
The CMA Codes of Ethics, contrary to that of the
DEP, is more duty-oriented: “Its focus is the core
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activities of medicine — such as health promotion,
advocacy, disease prevention, diagnosis, treatment,
rehabilitation, palliation, education and research. It
is based on the fundamental principles and values of
medical ethics, especially compassion, beneficence,
non-maleficence, respect for persons, justice and
accountability.”72 It comprises three main sections: (1)
fundamental responsibilities; responsibilities to the
patient; (2) general responsibilities such as initiating
and dissolving a patient-physician relationship, com-
munication, decision making and consent, privacy and
confidentiality, research; (3) responsibilities towards
society, the profession and oneself.
The CMA Code of Ethics is more focused on the phy-
sician’s relationship with the patient and the medical
community, so it is in general more individualistic than
the DEP which recognizes from the start the social role
of the military and its responsibility towards society.
As already mentioned, the CMA code now recognizes
that physicians participate in the organization of care
and so defines certain responsibilities towards soci-
ety (article 41 to 45). Under Article 44, for example,
a physician has the responsibility to use prudently the
resources devoted to health care. In addition, Article
4, under “fundamental responsibilities,” states that the
physician must “consider the well-being of society in
matters aecting heath.”73 Nonetheless, these broader
social responsibilities are not as clearly elaborated or
as explicit as are the ethical responsibilities towards
patients (respect for autonomy, confidentiality, etc.).
It is simply noted that physicians must consider the
social context as an important factor in the health of
the individual, the obligation to become involved in
matters aecting public health, testify in court pro-
ceedings, and promote equitable access to resources.74
Medical ethics and research ethics have traditionally
been concerned with the relationship between health
professionals and patients/research participants,75 but
the associated individual-centered norms or ethical
frameworks are now recognized as dicult to apply
to the social concerns of public health and the prob-
lem of resource allocation.76 HIV/AIDS in the 1990s
highlighted the tensions that emerge when individual
rights and common good are in conflict77 and as Chil-
dress and colleagues noted “sometimes, in particular
cases, a society cannot simultaneously realize its com-
mitments to public health and to certain other general
considerations, such as liberty, privacy, and confiden-
tiality.”78 The subordination of individual interest in
favor of the collective interest which is sometimes nec-
essary in public health policies or for national security
may thus conflict with traditional medical and profes-
sional client/patient-centered ethics. Similarly, recog-
nition of social and structural determinants of health
(poverty, racism, sexism) clearly shows that medical
ethics must also open up to a broader view of medi-
cine and not focus primarily on principles of respect
for patient autonomy. Thus, the tension between what
seems to be a fundamental dierence in military and
medical ethics, i.e., individual interest versus collec-
tive interest, is also found within contemporary medi-
cal ethics and professional practice.
Both the military and medical professions have
many laws, rules and codes to refer to, both at a
national and international level. Members of the
Canadian military are guided explicitly by the Cana-
dian Constitution and the Charter of Rights and Free-
doms, because as government employees they must
behave in accordance with the Values and Ethics Code
for the Public Sector (VECPS) — adapted in the DND
and CF Code of Values and Ethics — and must respect
international laws regarding the conduct of war and
military missions (i.e., international humanitarian
laws). Apart from the CMA Code of Ethics, Canadian
physicians have to respect their provincial regulations,
provincial laws for professional conduct, the Charters
of Ethics of Faculties of Medicine, and at an interna-
tional level, the WMA, the Declaration of Helsinki and
the UN Declaration of Human Rights.
Military physicians are bound by all of these dier-
ent codes, laws, and declarations which may some-
times become overwhelming, not just because of the
potential contradictions in interpretation, but also
because of the volume of information that has to be
understood and integrated. The CMA Code of Ethics
recognizes that “physicians may experience tension
between dierent ethical principles, between ethical
and legal or regulatory requirements, or even their
own ethical convictions and the demands of other
parties.”78 As such, CMA members are encouraged to
pursue training in ethical analysis. By contrast, the
Statement of Defence Ethics, and the more recent DND
and CF Code of Values and Ethics, have from the very
beginning (1997) been embedded within the DEP,
such that ethical decision-making processes are pre-
sented to all members through an ongoing training
program, and explained alongside the code of ethics.
The biggest dierence between the two codes is
in the fundamental value of medical practice for the
respect for human life. The military identifies “respect
for the dignity of persons” as a principle, while it is a
central if not an absolute value in medical ethics. Evi-
dently, the value of human life cannot be the same for
the military as it is in medicine, when society recog-
nizes that soldiers have the right to kill under certain
circumstances specified in international laws. In ethi-
cal terms, the notion of preserving human life does not
have the same weight in medicine as in the military,
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since it is the first priority and ultimate goal of medi-
cine. So while both military and medical codes of eth-
ics share many values, principles, and responsibilities,
the distinction in terms of respect for human life may
be viewed as source of irreconcilable dierence. Yet, it
is also worth asking if in fact “respect for life” in medi-
cine is as universal or fundamental a value as it once
was. Important ethical discussions surrounding issues
such as euthanasia, assisted suicide, abortion, and
resource allocation must bring nuance to our under-
standing of this principle.
In the same manner, the principles of “do no harm”
and “respect individual liberty” could be seen as con-
trary to the legitimate use of force that is allowed in a
military context. But this is a false dichotomy that does
not reflect the military and medical realities of today.
The principle of “do no harm” in medicine is increas-
ingly recognized as being intimately related to other
principles such as beneficence and autonomy (i.e., in
debates about euthanasia and assisted suicide). In the
same way, the use of force (and so doing harm to oth-
ers) by soldiers is heavily circumscribed and controlled
by international laws (i.e., regarding the proportionate
use of force) and needs to be understood in relation to
beneficence. For example, recent international peace-
keeping missions have been heavily criticized for not
allowing soldiers to intervene when witnessing rape,
murder, and even genocide (e.g., in Rwanda or the
Democratic Republic of Congo), because of restricted
Rules of Engagement (i.e., if a peacekeeping mission
does not operate under Chapter VII of the UN Char-
ter, soldiers cannot use force). These kinds of situation
have shown that the appropriate use of force needs to
be evaluated in relation to other principles (e.g., pre-
venting harm to civilians, justice) and so is not by defi-
nition negative or wrong.
The Canadian military has frequently been involved
in dierent kinds of operations, i.e., peacekeeping mis-
sions (Haiti, Somalia, Rwanda, and Kosovo to name
a few), humanitarian missions (e.g., Philippines, Sri
Lanka, Haiti, Pakistan) with the Disaster Assistance
Response Team (DART), and as part of military inter-
national coalition forces such as in Afghanistan or
more recently in Mali, with the French Army. So the
military mandate can sometimes be to help, protect,
and save lives and when it does, it generally involves
health professionals. Finally, even during armed con-
flicts, soldiers have an obligation, under international
humanitarian laws, to protect civilians, and the same
is true for physicians. There are contexts where a phy-
sician’s responsibility towards society and the common
good can outweigh their responsibility towards their
individual patient, such as in public health emergen-
cies (e.g., requiring obligatory notification of some ill-
nesses, quarantine) or the disclosure of cases of child
abuse.80
In summary, it is overly simplistic to
oppose the military and medical profes-
sions as if they have fundamentally oppo-
site and incompatible goals, principles,
and values.
Conclusion
The main dierences between the medi-
cal and military codes of ethics in Canada
come from choices regarding the core values and prin-
ciples of the two professions: the CMA code is more
focused on duties and responsibilities, while DND and
CF code is focused on core values. Another dierence
relates to professional autonomy: physicians have
much more autonomy (although it is more limited in
a context of scarce resources) than soldiers who are
in a hierarchical organization that relies on obedience
(chain of command) and has the power of coercion
(threat of court martial). Further, it is clear that in
armed conflicts — where tension, stress, and insecu-
rity are the norm — that it can be much more dicult
to make ethical decisions. In fact, a study81 concluded
that while the DEP is well suited for administrative
and organizational issues, it may be less eective in
the case of military operations. The ethical approach
of the program requires a level of ethical analysis that
is conceptual and can become dicult to implement
when issues are complex, stress is high and time is
limited.
The general principles and values that are present in
a code of ethics — whether that of the CMA or the CAF
— are important as they cover a diversity of key issues,
are broad in scope, and so can be widely accepted by
the members of the profession. But the lack of speci-
ficity in codes becomes a challenge for those who are
trying to “make decisions on the ground,” and all the
more challenging when they are professionals work-
ing in institutions, i.e., the military, who are drawing
on apparently conflicting codes of ethics. As noted by
Hunt and colleagues, looking at the context of human-
itarian work, “Existing articulations of ethics for
healthcare practice, including professional codes of
In summary, it is overly simplistic to oppose
the military and medical professions as
if they have fundamentally opposite and
incompatible goals, principles and values.
Rochon and Williams-Jones
health reform • winter 2016 649
The Journal of Law, Medicine & Ethics, 44 (2016): 639-651. © 2016 The Author(s)
ethics, are often insuciently adapted for the context
of healthcare practice in development and humanitar-
ian work or the range of issues experienced by clini-
cians.”82 Further, some scholars have questioned the
usefulness of codes of ethics in guiding ethical deci-
sion-making by healthcare professionals, because of
three main problems: (1) an “interpretation problem”
that comes from the inevitable gap between a rule and
what is done in practice, and so implies a need for eth-
ical competency; (2) the “multiplicity problem,” where
professionals are confronted by a large number of dif-
ferent documents that each dictates particular duties
and rules; and (3) the “legalization problem,” where
members replace ethical reflection by legal interpreta-
tion.83 These problems were also identified in both the
medical and military codes of ethics.
An interesting example of how to respond to the
problem of scope can be found in the work of the
Canadian Psychiatric Association (CPA), who in the
late 1970s wrote an annotated version of the CMA
Code of Ethics.
Some ethical problems which arise in psychiatric
practice are rarely experienced by other medical
specialities, although the principles of medical
ethics are the same. The Canadian Psychiatric
Association (CPA) has recognized this problem
which it has attempted to solve by annotating for
psychiatrists the Canadian Medical Association
(CMA) Code of Ethics.84
The CPA continued in the same vein with regards
to the 1996 CMA Code of Ethics, explaining how the
dierent articles applied to the particular field of psy-
chiatry.85 This approach of accepting a “general” medi-
cal code of ethics, and then annotating this code to
address the particularities of a field such as psychiatry,
is particularly interesting. It recognizes that clinicians
will inevitably seek out diverse ethical landmarks or
sources of ethical inspiration to complement but not
replace their initial professional code of ethics.
Unlike the CMA Code of Ethics, the Statement of
Defence Ethics and the DND and CF Values and Eth-
ics Code are embedded within the DEP, a broad and
comprehensive program of ethics education that aims
to build on the codes of ethics to provide a range of
practical ethical tools to members of the CAF and
DND. What is still lacking, however, is the “military
physician annotated version” that explains how medi-
cal ethics values and principles fit within a broader
context of civil service and military ethics as articu-
lated in the DEP. Similarly, the CMA Code of Ethics
would benefit from an annotated version for military
physicians to show how military values and principles
can also be congruent with medical ethics. A promis-
ing example of specific and practical ethical guidance
for military physicians is the British Medical Associa-
tion’s (BMA) 2012 guide, Ethical Decision-making for
Doctors in the Armed Forces.86 This guide warrants
further analysis and testing to see what lessons could
be learned for other military medical contexts, such as
that in the CAF.
While expecting a full harmonization between
Canadian military and medical ethics might be
overly optimistic, it should be possible to work with
the key stakeholders involved (e.g., physicians, the
CAF/DND, the CMA) to build practical and context-
specific ethical resources (e.g., case studies, targeted
and situation-specific ethics training) that are: (1)
adapted to the working environment of military phy-
sicians (and other health professionals), and (2) that
address those situations where there may be impor-
tant contradictions in obligations and responsibili-
ties. As we have hopefully demonstrated through our
comparison of the Canadian military and medical
codes of ethics, there are arguably fewer dierences
than may appear at first glance between the military
and medical professions because the core values and
principles of military and medical ethics are not so
dierent.
Note
The research for this article was supported by a scholarship to
Christiane Rochon from the Quebec Fonds de recherche sur la
société et la culture (FRQ-SC), and funding to Bryn Williams-
Jones, Lisa Schwartz and Matthew Hunt from the Ethics Oce of
Canadian Institutes of Health Research (CIHR).
The authors confirm that there are no financial interests or
connections, direct or indirect, or other situations that might raise
questions of bias in the work reported or the conclusions, implica-
tions, or opinions stated in the present article.
Acknowledgments
We are grateful to Professors Matthew Hunt (McGill University)
and Jeff Blackmer (University of Ottawa & Canadian Medical
Association) and Colonels Hugh Mackay and Michel Robitaille
(Canadian Armed Forces) for their constructive comments and
suggestions on early drafts of this article.
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