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Solomon R. Benatar, MBChB, DSc(Med) and Ross E. G. Upshur, MD, CCFP, FRCPC

Both authors are with the Joint Centre for Bioethics, University of Toronto, Toronto, Ontario. Solomon R. Benatar is also with the Bioethics Centre, Department of Medicine, University of Cape Town, Cape Town, South Africa.

Correspondence: Requests for reprints should be sent to Ross E. G. Upshur, Joint Centre for Bioethics, University of Toronto, 88 College St, Toronto, Ontario, M5G 1L4, Canada (e-mail: ross.upshur{at}utoronto.ca).

The concept of the dual loyalty physicians may have to both a patient and a third party is important in elucidating the obligations of physicians. The extent to which loyalty may be deflected from a patient to a third party (e.g., an insurance company or a prison commander) is greatly underestimated and has not attracted significant scholarly analysis.

We examined dual loyalty in civilian and military contexts and used the principles of public health ethics to construct a framework for determining the legitimacy of physicians' obligations. We illustrate the application of these principles to problems physicians encounter regarding communicable diseases, elder abuse, and driving fitness. In the complex military context, independent ethics tribunals should be created to adjudicate loyalty conflicts.

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