The suicide of an Iraq war veteran in Eastern Washington has highlighted an ethical dilemma confronting the Department of Veterans Affairs and the military: how far to go in protecting patient confidentiality as troubled veterans are called back to front-line duty.

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Tim Juneman went to a Department of Veterans Affairs psychiatrist in January 2008 to talk about his recurrent thoughts of suicide.

The 25-year-old Washington State University student was an Iraq war veteran who had survived a year of tough fighting that left him with a twin diagnosis of post-traumatic stress disorder (PTSD) and traumatic brain injury.

His biggest worry, according to notes taken by the VA psychiatrist, was a looming call back to active duty by the Washington National Guard. The order would have sent the specialist back to Iraq.

A VA psychiatrist hospitalized Juneman but never notified the National Guard unit of his patient’s distress over redeployment. Juneman was released that month, then missed follow-up appointments.

In early March 2008, Juneman hanged himself in his Pullman apartment. His body was discovered some 20 days later, The Spokesman-Review newspaper reported.

His death underscores an unsettling new reality for VA health-care providers. Unlike in decades past, they now often treat veterans headed back to war. And this can pose an ethical challenge for VA doctors if they think PTSD, traumatic brain injury or other unhealed wounds could put a patient or others at greater risk on the front line.

Confidentiality rules generally prevent them from informing active-duty commanders of a veteran’s medical problems, unless the veteran signs a release.

In some instances, veterans may resist signing a release, even when they have serious cases of PTSD and traumatic injury.

These veterans might be floundering in civilian life and look forward to a return to combat, seeing that as a way of putting their lives back on track. Or their sense of duty makes them balk at opting out of service, even if they are reluctant to return to the war.

VA officials say they must comply with privacy rules and are not required to share a veteran’s health status with the Defense Department, according to a statement released by the VA in response to a Seattle Times inquiry.

But VA rules do allow disclosure under certain limited circumstances. These exceptions include “to assure the proper execution of a military mission,” according to a VA privacy statement. But VA officials define such exceptions narrowly, and the patient information typically is released only if the military requests it.

“It’s not broad brush; it’s a very rare thing,” said David Bayard, a VA spokesman.

Jacqueline Hergert, Juneman’s mother, says the VA should have contacted the National Guard about her son’s plight.

“In Tim’s case,” Hergert said, “he had already been placed under suicide watch, and somebody should have told his unit. Perhaps doing that would have saved my son. What he really needed was for the VA to be an advocate for him.”

As a growing number of combat veterans head back to war zones, the gaps in knowledge about the mental health of reservists are a concern to some National Guard leaders.

“The VA is very protective of this information, as they should be,” said Lt. Col. Carol Munsey, deputy state surgeon for the Washington Army National Guard. “But if you’re talking about a person who is not doing well, then the command needs to know about it.”

A different military

Young men drafted into past wars usually returned to civilian life free of obligations to continue serving in the Reserves or the National Guard.

But things have changed as an all-volunteer military, whose numbers represent less than 1 percent of the nation’s population, has become responsible for fighting two long-running wars.

Each enlistee typically has an eight-year service obligation. The active-duty portion might involve multiple tours in a war zone, and returning soldiers face more years of possible call-up to Reserve or National Guard units that remain a key part of the military campaigns in Iraq and Afghanistan.

That means soldiers’ medical care can be fragmented: VA doctors treat them when they return to civilian life; they’re back to Army doctors if they are called up again.

Army doctors and commanders generally do not have access to VA medical records that might help them assess whether a veteran should return to front-line duty.

Instead, it’s largely up to the veteran to decide what — if anything — should be disclosed to commanders.

At a VA Puget Sound counseling session last year for veterans with PTSD and traumatic brain injury, the topic aroused intense debate, said Mark McPherson, a Washington National Guard veteran from Seattle.

“I had a very strong discussion with one of these guys and told him he wasn’t doing any favors to himself or others by not disclosing,” McPherson said. “But he was a sergeant, and he wanted to go. For a lot of these guys, the only part of their identity that seems to make sense anymore is the one that fits into the uniform.”

For VA officials, confidentiality is an important part of their outreach effort to help persuade veterans to seek treatment.

A 2008 study by the Rand Corp. found that nearly 20 percent of men and women who served in combat reported symptoms of post-traumatic stress disorder. Yet nearly half had not sought treatment, with many fearing that could harm their military careers, according to the study.

VA officials worry that number would rise even higher if confidentiality standards were loosened.

Munsey, the state’s deputy surgeon, says some Washington Guard veterans do volunteer to release VA information about PTSD and other health issues. The state Guard also has all soldiers headed for deployments fill out a health checklist.

When issues are disclosed, some soldiers still are able to deploy if doctors conclude they won’t put themselves or others at undue risk.

“It’s all self-reporting,” Munsey said. “All the soldiers are required to go through the process. But how do I know they are telling the truth?”

Planning new start

When Tim Juneman first sought help from the VA in early 2008, he was trying to leave the military behind and fashion a new career as a speech pathologist.

Serving with the Fort Lewis-based Stryker Brigade had put him into the thick of the Iraq war. His brigade was slammed by more than 1,380 roadside bombs during a year in Mosul, according to a brigade tally.

After four years in the Army, Juneman opted to finish his military commitment by serving in the Washington National Guard.

He thought the Guard would grant him at least two years stateside, according to his mother. In 2007, he enrolled at Washington State University. He struggled with headaches, insomnia and other problems, but his studies appeared to be going well.

Then, in the fall of 2007, he learned that his National Guard unit would be sent to Iraq the following summer.

“He was coping the best he could, but I think this overwhelmed him,” Hergert said. She said she was unaware of her son’s suicidal thoughts.

But Juneman apparently was forthright with the psychiatrist.

Juneman was having strong thoughts of suicide, which included a plan to hang himself, the psychiatrist wrote in notes from a Jan. 5, 2008, appointment obtained by Juneman’s family. Juneman said he learned of his deployment a couple of months ago and believed that was the trigger for the worsening of his depression, the psychiatrist wrote.

Hergert said copies of the notes were found in her son’s apartment. She wondered if he intended to show them to his commanding officers. She doesn’t know if he ever considered signing the form to allow his medical records released to the Guard.

Hergert said that would have been a difficult decision for her son who, despite his problems, felt a profound duty to serve.

At his National Guard unit in Spokane, no one had seemed aware of the depths of Juneman’s despair.

“It breaks our heart to lose somebody the way we lost that soldier,” said 1st Lt. Keith Kosik, a spokesman for the National Guard. “Had we had any indication that he was struggling with those kinds of things, we would have done everything we could have to get him help.”

Hal Bernton: 206-464-2581 or