Sir: Military psychiatry is, as Greenberg et al (Psychiatric Bulletin, June 2002, 26, 227-229) suggest, a unique national resource. I agree (Psychiatric Bulletin, July 1997, 21, 418-421) that it should focus on those areas in which it can justly claim expertise.

Greenberg et al state that military psychiatry is essentially occupational and they mention its ‘ethical and moral’ challenges. As a serving Officer, I was certainly aware of ethical tensions. On the whole, service personnel came to see me as a psychiatrist, not as an occupational physician. The occupational role, however, meant that under certain circumstances I had to act, not primarily in the best interests of the patient, but to safeguard the military. This possibility was not made explicit. Yet, military patients had few options but to be seen by military psychiatrists.

In civilian life, we can make more autonomous decisions concerning whom we see. The role of the occupational physician is explicit. Doctors only normally act against the wishes of their patients when there are substantial risks associated with not doing so. This is not always the case in the military, because the rules relating to mental illness are attuned to the needs of the organisation, not to personal needs. For understandable (but none the less stigmatising) reasons, the military environment is intolerant of what it perceives as mental illness. So, there can be an ethical tension between the occupational role and the therapeutic inclination. This ethical dilemma is another unique feature of military psychiatry and one that it would be interesting to see addressed.