Military Medical Ethics for the 21st Century

Michael L. Gross, Don Carrick

• Publisher: Routledge
• Year: 2016
• ISBN:
  9781317096092
• Edition: 1
• Topic: Philosophie
• Subtopic: Éthique et philosophie morale

As asymmetric 'wars among the people' replace state-on-state wars in modern armed conflict, the growing role of military medicine and medical technology in contemporary war fighting has brought an urgent need to critically reassess the theory and practice of military medical ethics. Military Medical Ethics for the 21st Century is the first full length, broad-based treatment of this important subject. Written by an international team of practitioners and academics, this book provides interdisciplinary insights into the major issues facing military-medical decision makers and critically examines the tensions and dilemmas inherent in the military and medical professions. In this book the authors explore the practice of battlefield bioethics, medical neutrality and treatment of the wounded, enhancement technologies for war fighters, the potential risks of dual-use biotechnologies, patient rights for active duty personnel, military medical research and military medical ethics education in the 21st Century.

PART I
Battlefield Ethics

Chapter 1
Military Medical Ethics: Experience from Operation Iraqi Freedom1

Jacob Collen, Patrick O’Malley, Michael Roy and Laura Sessums

Introduction

Military physicians face numerous pressures during deployment in peace-keeping and wartime operations. In the current counterinsurgency operations in Afghanistan (and formerly in Iraq), military physicians provide care for US military personnel and government contractors, a myriad of local nationals (civilian non-combatants, local national military and law enforcement personnel) working in parallel with US forces, detainees and insurgents. In addition to providing clinical expertise, physicians may interface with the local population in medical operations to improve military relations and establish goodwill in the community.

Currently, most US military physicians experience their first deployment soon after completion of postgraduate training. While those trained in surgical specialties typically deploy to upper echelons of care (such as combat support hospitals) to provide emergent surgical support, most physicians, whether primary care or subspecialists, are deployed as battalion or brigade surgeons, and work in forward deployed medical facilities.

In the forward deployed environment, challenges include providing effective triage and care for battle injury, as well as managing non-battle illness and injuries. Decisions about who to evacuate to upper echelons of care can dramatically impact mission readiness (that is, loss of manpower), and safety of soldiers (when movement is over hostile territory). Triage and treatment must factor in the operations tempo, adequacy of supplies, capability of transport, safety of personnel, bioethics, and military and international laws for medical engagement. An additional challenge for forward deployed physicians is their utilization for medical operations in the local community, which may be for humanitarian intent, as well as to generate goodwill and promote cooperation for intelligence gathering (Rice and Jones 2010).

In this complex environment, ethical challenges abound. Many challenges are rooted in the conflict of dual agency (Howe 2003). Military healthcare providers serve dual roles as military officers and medical professionals, which may come into conflict. Dual agency can be defined as a clinical role conflict between the professional duties to a patient and duties to a third party (military, state, employer, insurer) (Singh 2003). These conflicts are much more difficult to resolve when the two loyalties are in equal balance or in very rapidly evolving circumstances (Sessums et al. 2009). Often, deployed physicians are trained inadequately to manage the demands of their competing roles.

While all medical schools offer some training in medical ethics, physicians in training often focus on enhancing their medical knowledge, and medical ethics may ‘take a back seat’. Civilian medical school curriculums generally lack militarily relevant medical ethics, so most military physicians deploy with a weak foundation in pertinent medical ethics. Training and education in medical ethics immediately prior to deployment is rare, as most physicians transition from their primary assignment in a clinic or hospital to the forward deployed environment with little notice, and, at most, a brief training course in combat casualty care. There is not a standard military course prior to deployment for medical ethics and rules of engagement for the care of local nationals. As such, physicians risk ethical compromise when dilemmas arise.

This chapter reviews several scenarios, including some encountered by deployed medical personnel during Operation Iraqi Freedom (2004–2005), which serve to highlight relevant literature and ethical principles. While an in-depth analysis of the ethical principles discussed here is beyond the scope of this chapter, it is our hope that these scenarios will provoke further discussion and analysis.

Civil Affairs

Case 1: Civil Affairs Missions during Deployment

Your command wants you, the battalion surgeon, to prepare a grant to procure medical supplies for local clinics in the area. The goal is to obtain $100,000 worth of medications and supplies, to be turned over to local authorities. In the past, cash-only grants obtained for medical supplies have been used by enemy combatants against your military. You are concerned that supplies may be easily sold and the proceeds again used against the military. You voice your concerns to the command but they fall on ‘deaf ears’.

Militaries can have civil affairs units that reach out to local populations and engage in missions that minimize the impact of military operations on civilians. Such units may include experts from many different fields, such as lawyers and engineers. Physician involvement in civil affairs during military operations is common, yet most physicians have no training in civil affairs, knowledge of the needs of the local medical community, or contacts with local physicians. The medical needs of the civilian population in a war-torn region can be substantial and are often unmet by local resources. Military leaders may see medical care and health programmes as a simple way to befriend the local population and improve public opinion of the military operation (‘winning hearts and minds’) (Rush et al. 2005). You are worried that the proposed civil affairs mission will not accomplish its stated goal of providing medical supplies, could reduce your ability to otherwise provide medical care to the local population, and may result in funding for local insurgents.

Civil affairs medical missions are, at their core, public health, focused on improving the health of populations rather than individuals. Governments usually include public health activities in civil affairs missions. ‘Public health has affirmative obligations to improve the public’s health and, arguably, to reduce certain social inequities’(Kass 2001: 1776–82). In the above situation, however, it does not appear that the mission will likely accomplish either of these goals. To analyse explicitly the ethical issues in public health programmes, Kass has proposed an ethical framework of six questions (Kass 2001):

1. What are the public health goals of the proposed programme?

2. How effective is the programme in achieving its stated goals?

3. What are the known or potential burdens of the programme?

4. Can burdens be minimized? Are there alternative approaches?

5. Is the programme implemented fairly?

6. How can the benefits and burdens of a programme be fairly balanced?

Policy considerations (such as the ‘hearts and minds’ argument) may diverge from conclusions reached using the above ethical framework. However, physicians and other health professionals must act in ways that allow them to retain their professional integrity and the public trust. The World Medical Association Regulations in Times of Armed Conflict affirms that ‘medical ethics in times of armed conflict is identical to medical ethics in times of peace’ (http://www.wma.net/en/30publications/10policies/a20/) (World Medical Association). Accordingly, the physician’s duty in this scenario is to review the available facts to determine if the scheme the command has outlined has a reasonable likelihood of improving public health without unduly burdening particular persons or groups of persons. If the answer is no, the physician should articulate this to the commander in order to help optimize the medical piece of the mission. If there are no acceptable alternative schemes to accomplish the goal, and the current task involves the physician acting beyond their professional expertise and abilities, then the physician should explain to the commander that they cannot participate in good faith under their professional obligations.

Even if the proposed civilian affairs mission appears consistent with bioethical principles, given most physician’s lack of expertise in this area, seeking the assistance of a military civilian affairs unit (if available) or partnering with a non-governmental organization (NGO) (if acceptable to your command) that has local contacts and expertise can be a preferable way for the military to achieve its policy objectives. These groups work directly with local populations regularly and have knowledge of local customs and activities which better positions them to avoid the pitfalls of those uninitiated in civil affairs activities. This solution avoids enmeshing health care professionals in a project that may be unlikely to achieve its stated goal (Brookes 2011) and conflicts with their obligations to individual patients.

In the scenario outlined above, the brigade procured $50,000 in pharmaceuticals and delivered them to a local national clinic as a display of goodwill. The next day a foot patrol from the unit discovered that all the medications had vanished overnight from the clinic, and intelligence suggested they had been sold to provide funds for the insurgency. Similar scenarios occurred throughout the combat theatre, and this type of mission was discontinued as it became clear that such efforts were inadvertently aiding the insurgency. Direct involvement of an NGO running and staffing a local clinic or medical operation might prevent such a scenario from occurring, and avoid compromise to military personnel.

Medical operations during war can serve several purposes, including demonstrating goodwill and humanitarian intent, influencing the local population and gathering intelligence (Rice and Jones 2010). Unfortunately, deployed physicians have variable skill sets, typically limited to their medical specialty, that are not applicable to effective implementation of larger scale medical missions, or the use of medical care as a commodity (Rice and Jones 2010) to influence the local population. As a military physician, it is likely that you will be asked to participate in such missions. As the onsite medical expert, it is your responsibility to provide feedback to the commander on potential pitfalls of such missions, ways to improve them and the limits of your professional capabilities. In order to maintain physician integrity, it is important that you confine your activities to providing medical care only. Under the GCs, medical personnel are entitled to respect and protection in all circumstances but only if exclusively engaged ‘in the search for, or the collection, transport or treatment of the wounded or sick, or in the prevention of disease’ (International Committee of the Red Cross 1976). Gathering intelligence and similar military activities are clearly outside the scope of medical expertise and patient care and physicians must avoid any involvement in them.

Care for Local National Civilians

Case 2: Injured Civilians and Mission Safety

You are a passenger in a convoy that drives past the aftermath of a roadside bomb. Several local nationals are clearly wounded, and in need of emergent care. The driver in the lead vehicle refuses to stop to allow you to provide aid.

At first glance, it may seem like this is an easy decision to make. There are seriously injured civilians who need first aid at the scene, and transport to more definitive care. You have the personnel and resources to provide this. If this scenario occurred in the United States, or in an allied country where there is not a significant concern that one would be jeopardizing one’s own welfare by stopping to provide assistance, it would be an easy decision to do so. Even in a deployed setting where one might be on a humanitarian or peace-keeping mission, there are clear advantages to stopping and providing assistance. As medical providers, we are accustomed to serving those in need, and would rarely think twice about providing aid. To a bystander, the failure of the military convoy to stop and care for the wounded would appear callous and inhuman. This may be the first contact with Americans that some at the scene have and, if they see the convoy just drive by, it is unlikely that they will ever feel positively toward Americans again. Instead of ‘winning the hearts and minds’, failure to stop would create new animosity, and perhaps win converts to our opponents.

What argument, then, can be made for driving past those in need instead of stopping to provide assistance as our societal norms and medical ethics would seem to dictate? The answer is that it could pose a significant security risk to the unit. Remaining stationary out in the open for a period of time while providing first aid could place the safety of the entire convoy in jeopardy, and could further hinder the accomplishment of the mission that was the purpose of the convoy. In fact, an enemy force might deliberately cause mass casualties in a civilian population on a convoy route in order to induce the convoy to stop. The enemy forces could then easily ambush the stopped convoy, causing greater damage and loss of life. The greater the confidence the enemy might have that the convoy would actually stop to provide assistance, the more resources they might choose to devote to the destruction of the convoy, making an argument for at least being cautious – if not unpredictable – in deciding whether to provide aid in such a situation.

The Geneva Conventions provide protection for medical units and their methods of transport, as well as the wounded and those caring for them. Though the GCs explicitly address medical units, both fixed and mobile, their protections would less clearly apply to a military convoy stopping to provide medical aid. Further, those in the convoy may reasonably have little confidence that the enemy would follow the Conventions.

If, as convoy leader, you choose to stop to provide medical assistance, you might consider using the GCs as a justification, in addition to the moral and ethical arguments in favour of stopping. The GCs state that, ‘Whenever circumstances permit, and particularly after an engagement, each party in the conflict must, without delay, take all possible measures to search for, collect and evacuate the wounded, sick and shipwrecked without adverse distinction’ (http://www.icrc.org/customary-ihl/eng/docs/v1_rul_rule109) (Henckaerts et al. 2005). Rather than an absolute obligation in all circumstances, this obligation applies only when ‘circumstances permit’. Accordingly, providing assistance is means dependent, based on appropriate judgement in the light of given circumstances and available resources.

The immediacy of the medical needs of the wounded and the capabilities of you and your medical personnel affect the decision to stop and provide aid. Ultimately, it comes down to a judgement call, with significant weight on mission safety. One must assess, in a split second, what are the perceived risks and benefits of stopping – as opposed to passing by – the wounded civilians? How safe is the area thought to be, and how secure a perimeter can be established quickly to try to maintain safety while providing first aid? How easy would it be for the hostile forces to have established an ambush and how susceptible would the unit be?

A physician’s obligation to provide medical care despite personal risk is well known in the setting of communicable disease or natural disasters. ‘This ethical obligation holds in the face of greater than usual threats to their own safety, lives, or health. However, the physician workforce is not an unlimited resource and physicians should balance immediate benefits to individual patients with the ability to care for patients in the future’ (Bostick et al. 2008: 3–8). Ethical codes note the need for physicians in the civilian world confronted with violent patients or those with communicable diseases to make every attempt to meet both their obligation to care for the patient but also to protect their own safety (World Medical Association). The military physician has arguably accepted a higher risk to personal safety based on the inherent nature of armed conflict. Asymmetric warfare has increased the risk to physician safety even further. How this altered playing field impacts ethical decision-making for physicians is still unclear, but may mean it is more difficult to provide care to the wounded without significantly compromising personal safety.

After considering the risks of providing care, it is important to determine if the means to provide care are available. How many wounded local nationals appear to be present? Based on initial assessment, likely made while the convoy is still in motion, how dire is the need for medical assistance, and how likely is survival without assistance? Thus, the initial ethical principle to apply is utilitarianism, weighing the number of casualties expected to benefit from halting the convoy against the number harmed if the convoy were ambushed in doing so. Simple application of this principle alone may lead to the conclusion that one should not stop the convoy. However, the balance could easily shift in favour of stopping to provide aid if one believes that the likelihood of an ambush is low and the expected benefits of medical care to injured local nationals is high.

One additional issue to consider in this situation is that the convoy will almost certainly be led by a non-physician who might take a utilitarian approach to conclude that stopping is not worthwhile. However, what if you, as the physician riding in an ambulance with the convoy, believe that you have an ethical duty to stop to care for the wounded, yet the commander has ordered everyone to keep driving? You do not have a duty to obey an unlawful order, but it is hard to argue that the order is truly unlawful, and to halt without the protection of the rest of the convoy seems foolish and hazardous. Unless one can rapidly make a persuasive argument to the commander, it appears more judicious to follow the commander’s lead, forgoing the opportunity to provide medical assistance. Ultimately, placing a priority on safety in wartime is critical – both for soldiers and medical personnel – and the commander’s risk assessment should dictate the course of action.

In the above case, the deployed physician asked the convoy commander for permission to stop to assess the accident scene and render care. The convoy was travelling down a road that was commonly targeted with improvised explosive devices and a source of frequent casualties. The convoy commander deemed the scene un...

Table of contents

• Cover Page
• Title Page
• Copyright Page
• Contents
• List of Figures and Table
• Notes on Contributors
• Acknowledgements
• Introduction
• PART I BATTLEFIELD ETHICS
• PART II MILITARY MEDICAL ETHICS AND NEW TECHNOLOGIES
• PART III PATIENT RIGHTS, RESEARCH ETHICS AND MILITARY MEDICAL ETHICS EDUCATION
• Index