Abstract
A Military Physician is expected to fulfill the dual role of a humane physician and a patriotic soldier. But both these professions are principally very different from each other, a soldier above all is supposed to have utmost loyalty towards his country and protect national security at all costs. Whereas a doctor has moral obligations towards his patients and is required to treat ill or wounded irrespective of caste, creed, or nationality. Military physicians bridge these two professions based on the principles of humanity, impartiality, and neutrality. The present paper attempts to explore the challenges faced by military physicians in adhering to professional ethos especially during an armed conflict and provides an overview of various regulations and declarations in vogue for guiding military physicians in times of ethical and obligatory dilemmas.
Keywords: Military physicians, Military medical ethics, Dual loyalty, Bioethics in conflict zones
Introduction
The painting (Fig. 1) aptly sums up the moral dilemma a military physician faces while delivering his duties as a doctor and a military officer. The military physician on one hand should uphold the medical ethics and provide medical care to those who require it, irrespective of whether they are fellow combatants, civilians or from the enemy forces. On the other hand, his patriotism as a uniformed soldier and the military environment prevents him to provide services to the enemy forces. As has been fittingly put by Sidel et al. that “We believe the role of the physician–soldier to be an inherent moral impossibility because the military physician, in an environment of military control, is faced with the difficult problems of mixed agency that include obligations to the “fighting strength” and … “national security.”2 Thus, the military physician has dual obligation i.e., obligation to the patient and obligation to his nation, such a situation is referred to as “mixed agency,” in which the ethical choice is more complex and challenging. Thus, though doctor and soldier are contrasting professions, yet these both are required a society to thrive, just as laws and moral direction. The military physician bridges these two professions. Doctors uphold medical ethics in all situations (war or peace) and provide care to the defenseless including ensuring unbiased triage among the wounded from severely wounded to mildly wounded, battle casualties vs non-battle casualties, citizens vs prisoners of wars.
Fig. 1.
Hippocrates refuses the gifts of Artaxerxes (It depicts the emissaries of Artaxerxes, the king of Persia, offering gifts to Hippocrates to persuade him to treat Persian soldiers suffering from plague. It is said that Hippocrates responded by: “Tell your master I am rich enough; honor will not permit me to succor the enemies of Greece”).1
This article attempts to explore the challenges faced by military physicians in adhering to professional ethos especially during an armed conflict, where as opposed to neutral physicians, military physicians are desired to align themselves with needs of the mission and do what it takes to achieve success. As well as we kindle the debate regarding the physician's dual loyalty conflicts and patient's rights in the armed conflict zones.
“Inter arma enim silent leges”
(“In times of war, law falls silent.”)
Marcus Tullius Cicero (Pro Milone, 52 BC)
History
The greed of human beings has since time memorial proved that wars cannot be avoided. Over 2000 years ago Cicero quoted “In times of war, the law falls silent” and over the centuries many conflicts across the globe have proved Cicero correct. Time has shown that conflict is less cruel than the other. The two world wars and many other conflicts have proved to mankind that war brutalizes everything and destroys humanity. Large numbers of people have been killed in armed conflicts either as combatants or as non-combatant victims of violence. A famous historical example of importance of triage and dilemmas faced by military physician was witnessed in 1943, when the invading British troops marching to Italy were found to have contracted STD after visiting the local prostitutes. The moral question that arose was whether to save the penicillin stock required to treat these same soldiers if injured during war or to exhaust the stock while treating them for STD. Another more recent example lies in the military doctrine, “traditionally countries combat casualty care is directed towards casualties of own troops first, allies second, civilians third, and the enemy fourth”. This overrides the basic medical ethical and moral principles where the most seriously injured casualty should be attended first irrespective of his/her status.3 These issues are dealt with in the “International Humanitarian Law (IHL)” that has developed out of the traditional “The Law in Waging War”.4 The rules of IHL are to be applied in armed conflicts, even if the conflict is not regarded as a war in the conventional sense by the parties to the conflict. Similarly, after Dunant witnessed the devastating consequences of war at a battlefield in Italy, he argued successfully for the formation of the civilian relief corps which respond and relieves human sufferings during conflict, and for rules to set limits on how war is waged, this ultimately led to the birth of The Red Cross and the Geneva Conventions.5
Under the Geneva conventions, medical professionals and health care facilities are accorded special status; they are considered immune from attack and should be repatriated immediately if captured. In return, medical personnel are expected to fulfill following obligations.6,7
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1.
“Regarded as “non-combatants,” medical personnel are forbidden to engage in or be parties to acts of war”.
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2.
“The wounded and sick soldiers and civilian friends and foe must be respected, protected, treated humanely, and cared for by the belligerents”.
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3.
“The wounded and sick must not be left without medical assistance and the order of their treatment must be based on the urgency of their medical needs”.
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4.
“Medical aid must be dispensed solely on medical grounds, “without any adverse distinction founded on sex, race, nationality, religion, political opinions, or any other similar criteria.”
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5.
“Medical personnel shall not exercise any physical or moral coercion of any kind against the civilians, particularly to obtain the information from them or the third parties”.
Thus the Geneva Convention urges the member nations to recognize medical expertise in true letter and spirit, and paves way for accord of special privileges to medical personnel during armed conflict. But, in return it asserts certain binding legal and moral obligations on the medical personnel.
Humanitarian function during armed conflict
“Humanitarian function criteria” is applied to medical professionals which includes three principles viz. humanity, impartiality and neutrality. It is these three pillars which form the fundamental basis of various regulations whether National or International. Neutrality and impartiality are not synonymous and are often poorly applied which leads to loss of faith in humanity. Neutrality means to gain confidence by remaining aside from political, religious, racial or other dividing ideologies. Whereas impartiality means that the circumstances may differ for everyone under different conflicts but the rights are same for all human beings.8 Thus, if applied in true sense all provisions of IHL regarding military medical personnel become transparent.
Dual loyalty
Complete loyalty towards the patients is the ultimate mandate for international code of ethics. In real world scenario, health care professionals have sense of obligation and are inclined towards the employers, insurance companies, family members, and governments which may clash with their undivided devotion towards the patients. Dual loyalty thus emerges as role conflict between the fidelity of health care professional towards a patient which is expressed or implied, real or perceived as compared to the interests of a secondary motive, military command in this context. In more practical terms, dual loyalty exposes the conflict between two very different professions, military physician is a soldier who has loyalties to his country and he is also a doctor who has obligations towards his patients’, thus these obligations and duties (dual role) many times clash in irresolvable ways.
One of the most common dilemmas faced by military physicians in the conflict zone is whom to treat first? Many physicians without a second thought treat their compatriots first irrespective of the severity of the condition. This decision is based on purely military perspective; here to care for its own troops and return them to active duty promptly takes precedence over medical ethics. However, Geneva Conventions clearly states that: “Each belligerent must treat his fallen adversaries as he would the wounded of his own army”.9 From this standpoint, it would be incorrect to base priority of care on military necessity. But at the same time military necessities to provide care to compatriot cannot be ignored. This conflict between military and pure medical ethics drive the impasses of dual loyalty particularly in zones of Armed conflicts. Dual loyalty conflicts also occur in variety of other situations such as involvement of military medical professionals in torture wherein medical skills are used to cause pain, physical or psychological harm on an individual that is not a legitimate part of medical treatment. In general, under strain of military command structures, health care professionals face significant conflicts of dual loyalty when performing examinations for legal or administrative purposes that have grave consequences for victims' human rights.
Identification and definition of associated quandary
During counter-terrorism operations, military doctors often run into three kinds of potential medical ethics conflicts. They may be asked or even ordered to assist in the questioning of apprehended suspected terrorists. Medical personnel may be asked to somehow ensure forcible food intake by those refusing all feeding. Doctors are also often forced to certify combat personnel as fit for duties even if that contradicts their professional assessment. As far as questioning of suspects goes, there is no ambiguity that medical personnel cannot have any part or use their medical knowledge in any action involving torture or cruelty.10,11 The second issue of force feeding a prisoner on hunger strike can also be adequately justified, as a physician cannot allow someone to die out of starvation hence has minimal civil rights implications. However, the third issue is rendering a soldier fit that will go back to war, especially when it comes to context of military psychiatry; the soldier may be physically fit after treatment but may be a victim of post-traumatic stress disorder, depression and so on. This also exposes the aspect of combat fatigue, military physicians if excuse relatively fatigued soldiers from further combat duties, they are consciously or unconsciously exposing other soldiers to higher stress and fatigue. Thus, in many circumstances military physicians in spite of being aware of the stress and burn-out levels have to forcibly give orders to soldiers to return to combat.12,13
Pharmaceutical bioethics in conflict zones
Bioethics issues are simpler in resource poor scenarios where ‘‘needs of the many vs the need of one” takes preference.14 However, in resource abundance settings bioethics issue continue to be complex if military medical personnel remain adamant to their overriding duties to treat only their own troops regardless of their ethical obligation to treat the wounded irrespective of caste, creed or nationality.15 This unending conflict between military, legal and ethical obligations is bread-and-butter bioethics, and is yet to be resolved. Another bioethical issue typical to the war zones is without consent use of experimental drugs/immunizing agents to protect, enhance or promote early recovery of the fighting troops. A few notable examples are, use of Pyridostigmine bromide by US troops in 1990 following Iraq’s invasion of Kuwait, as “pre-treatment” for the effects of nerve agents.16, 17, 18, 19 Similarly, without proven efficacy use of anthrax vaccine by US troops during the Persian Gulf war.20 These instances are in violation of many ethical codes of conduct which prevent use of experimental drugs in human beings without consent. But notwithstanding the ethical considerations, these actions are justified by governments on the basis of war exigencies.
Military medical ethics in treatment of civilians
Military Health care professionals operate in situations with scarce resources (of both material and personnel) due to which they cannot provide the same level of care as in civilian settings and are forced to triage patients so that they can only admit selected patients to their facilities. Consequently, selection and admission criteria are followed and in military environment the chain of command influences the rules of medical eligibility by either imposing nonmedical criteria or by simply demanding prioritized treatment of patients for strategic nonmedical reasons.21 Thus, medical personnel are confronted with external pressure regarding how and for whom the resources should be used. Other issue is offering different standards of care, acting beyond one's own competences (e.g., treating children when no pediatrician is available), and providing suboptimal care. A second area of ethical challenge arises when medicine becomes an instrument for nonmedical purposes. On one hand, this can happen in so-called “winning hearts and minds” campaigns, when medical care is provided to a population with the intention to gain acceptance or support for the military. Medical care thus becomes a means to an end, which itself has nothing to do with medicine. On the other hand, the issue of complicity in abuse of medicine can arise when medicine or the trust usually placed in physicians is abused to achieve nonmedical aims such as gaining intelligence.
Hard law vs soft law
Hard law
The Law of Armed Conflict (LoAC), popularly known as International Humanitarian Law (IHL), governs all international and non-international armed conflicts. The IHL regulations have been developed to reflect moral principles and are thus, heavily influenced by ethical reflections.4 Thus, acting in accordance to its provision should always be the highest priority. Even if not applicable in a certain situation or conflict, it gives important insight into the moral principles that govern individual and collective conduct during conflict.
Soft law
These are rules of professional medical conduct as laid out by the World Medical Association or National Medical Associations. In addition, during UN-mandated international missions, “Rules of engagement (RoE) are the internal rules or directives for military forces (including individuals) that define the circumstances, conditions, degree, and manner in which the use of force, or actions which might be construed as provocative, may be applied”.4 The RoE document defines the conduct that is expected during internationally mandated missions and serves as framework on which the moral code of conduct is formulated with regard to missions. The RoE derives its fundamentals from Universal Declaration of Human Rights, which accords fundamental rights to all human beings at all times.4 In the military context, most relevant human rights treaties is the “Convention on the Prevention and Punishment of the Crime of Genocide” and the “United Nations Convention Against Torture”.
To summarize, compared to IHL and other bodies of hard law, the rules of engagement and professional ethics are seen as a form of “soft law” with secondary validity. Generally, human rights law and international humanitarian law have a stronger relevance and stand higher in the hierarchy when it comes to evaluating conduct during armed conflict. National law, the rules of an army, or professional rules of conduct have a subsidiary character and can be relied upon when there is a need for more detailed regulations or in very specific situations.
World Medical Association – declarations relevant to military medical ethics
Declaration of Geneva (1948)
The declaration has evolved over the years as the means of warfare have changed and the latest amendment was done on 14 Oct, 2017 in Chicago.22 It gives modern vision to the 2500 years old Hippocratic oath which laid down the fundamental ethics which all physicians should follow.
Declaration of Tokyo (1975)
It provides guidelines for medical doctors concerning torture and other cruel, inhuman or degrading treatment in relation to detention and imprisonment.23
Declaration of Malta (1991, revised in 1992)
Related to Hunger Strikes.24
Declaration of Taipei
Related to ethical considerations regarding health databases and biobanks.25
Conclusion
The paramount ethical principals of practice of medicine are “concern for the welfare of the patient” and “primarily do no harm.” Whereas the fundamental guiding principals of military service are “concern for the effective function of the fighting force” and “obedience to the command structure”.26 In practical terms, medicine seeks to help individuals remain healthy, or to restore them to health, and to allay suffering. The Armed Forces, on the other hand are very often required to use violent destructive force and weapons in order to impose the will of the State or ensure protection of its own people. These two very different professions are bridged by military physicians. However, more often than usual in armed conflict zones military physicians are faced with ethical and obligatory dilemmas. There are no straight forward answers as role of military, medical ethics and national security are intricately intertwined. There are regulations and guidelines available on both military and medical ethics, but the onus rests upon political leaders, international bodies, military generals and bioethicists to engage in constant dialog and ensure that no combatant or civilian right is violated and right to medical care is upheld irrespective of individual status. As above all, it is the collective responsibility of all nations to safeguard the humanity in adversity.
Disclosure of competing interest
The authors have none to declare.
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