Changing faces of war and war-like situations have led in recent years to new forms of military deployment. They range from the so called "war on terrorism" with e.g Operation Enduring Freedom or humanitarian interventions (e.g. Kosovo 1999) to deployments within disaster relief missions as lately in Haiti. These pose not only moral, legal, and organizational challenges to states and the international community but also put individual soldiers and military (medical) personnel in situations that their classical formation (...) does not prepare them for. For they face (i) situations not sufficiently covered/ regulated by international humanitarian (IHL) law and/or (ii) tasks that are not within the range of the "classical soldier". These changing needs require new forms of education in the military and highlight the role of ethical education as many of the dilemmas cannot be resolved by sole reference to the IHL. In addition to a solid knowledge of the law of armed conflict (LOAC), military personnel should therefore acquire fundamental skills of ethical reasoning in dilemma situations. Our article aims at (i) outlining the goals of a military medical ethics education that responds to these needs and the practical challenges of present-day military deployment and (ii) present how the ICMM tries to integrate these goals in its educational program. (shrink)

Military medical ethics is garnering growing attention today among medical personal in the American and other armies. Short courses or workshops in “battlefield ethics” for military physicians, nurses, medics, social workers, and psychologists address the nature of patient rights in the military, care for detainees, enemy soldiers and local civilians, problems posed by limited resources, ethical questions arising in humanitarian missions, as well as end-of-life issues, ethics consultations, care for veterans, advance directives, (...) and assisted suicide. Although many of these issues are the core subjects of any bioethics curriculum, military medical ethics presents unique challenges to bioethics educators. (shrink)

The goal of military medicine is to conserve the fighting force necessary to prosecute just wars. Just wars are defensive or humanitarian. A defensive war protects one's people or nation. A humanitarian war rescues a foreign, persecuted people or nation from grave human rights abuse. To provide medical care during armed conflict, military medical ethics supplements civilian medical ethics with two principles: military-medical necessity and broad beneficence. Military-medical necessity designates (...) the medical means required to pursue national self-defense or humanitarian intervention. While clinical-medical necessity directs care to satisfy urgent medical needs, military-medical necessity utilizes medical care to satisfy the just aims of war. Military medicine may therefore attend the lightly wounded before the critically wounded or use medical care to win hearts and minds. The underlying principle is broad, not narrow, beneficence. The latter addresses private interests, while broad beneficence responds to the collective welfare of the political community. (shrink)

United States military medical ethics evolved during its involvement in two recent wars, Gulf War I (1990–1991) and the War on Terror (2001–). Norms of conduct for military clinicians with regard to the treatment of prisoners of war and the administration of non-therapeutic bioactive agents to soldiers were set aside because of the sense of being in a ‘new kind of war’. Concurrently, the use of radioactive metal in weaponry and the ability to measure the health (...) consequences of trade embargos on vulnerable civilians occasioned new concerns about the health effects of war on soldiers, their offspring, and civilians living on battlefields. Civilian medical societies and medical ethicists fitfully engaged the evolving nature of the medical ethics issues and policy changes during these wars. Medical codes of professionalism have not been substantively updated and procedures for accountability for new kinds of abuses of medical ethics are not established. Looking to the future, medicine and medical ethics have not articulated a vision for an ongoing military-civilian dialogue to ensure that standards of medical ethics do not evolve simply in accord with military exigency. (shrink)

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. (shrink)

When militaries mention loyalty as a value they mean loyalty to colleagues and the organisation. Loyalty to principle, the type of loyalty that has a wider scope, plays hardly a role in the ethics of most armed forces. Where military codes, oaths and values are about the organisation and colleagues, medical ethics is about providing patient care impartially. Being subject to two diverging professional ethics can leave military medical personnel torn between the wish (...) to act loyally towards colleagues, and the demands of a more outward looking ethic. This tension constitutes a test of integrity, not a moral dilemma. (shrink)

Medical ethics prohibits caregivers from discriminating and providing preferential care to their compatriots and comrades. In military medicine, particularly during war and when resources may be scarce, ethical principles may dictate priority care for compatriot soldiers. The principle of nondiscrimination is central to utilitarian and deontological theories of justice, but communitarianism and the ethics of care and friendship stipulate a different set of duties for community members, friends, and family. Similar duties exist among the small cohesive (...) groups that typify many military units. When members of these groups require medical care, there are sometimes moral grounds to treat compatriot soldiers ahead of enemy or allied soldiers regardless of the severity of their respective wounds. (shrink)

Bioethics, Volume 36, Issue 6, Page 731-732, July 2022.

Military doctors and nurses, working neither as pure soldiers nor as merely doctors or nurses, may face a ‘role conflict between the clinical professional duties to a patient and obligations, express or implied, real or perceived, to the interests of a third party such as an employer, an insurer, the state, or in this context, military command’. This conflict is commonly called dual loyalty. This chapter gives an overview of the military and the medical ethic and (...) of the resulting dual loyalty problem for medical personnel working in the military. It considers how dual loyalties relate to being a professional, something medical personnel are the paradigmatic examples of, but also something military personnel claim to be. Against that background, the chapter elaborates on the medical rules of eligibility used in Afghanistan, and on the policies concerning military involvement in local healthcare, to see what the existing rules and policies are, and whose interests they serve. (shrink)

In 12 narratives, medical workers from Afghanistan, Darfur, Gaza, Iraq, Israel, Myanmar, and Ukraine describe the day-to-day challenges of providing quality medical care in austere conflict zones. Faced with severe shortages of supplies, overwhelmed by sick and injured civilians and soldiers, and subject to constant attacks on medical personnel and facilities, the contributors to this collection confront difficult dilemmas of justice, medical impartiality, neutrality, burnout, and moral injury as they struggle to fulfill their duties as (...) class='Hi'>medical professionals, military officers, and conscientious citizens. (shrink)

Military physicians are often perceived to be in a position of ‘dual loyalty’ because they have responsibilities towards their patients but also towards their employer, the military institution. Further, they have to ascribe to and are bound by two distinct codes of ethics, each with its own set of values and duties, that could at first glance be considered to be very different or even incompatible. How, then, can military physicians reconcile these two codes of (...) class='Hi'>ethics and their distinct professional/institutional values, and assume their responsibilities towards both their patients and the military institution? To clarify this situation, and to show how such a reconciliation might be possible, we compared the history and content of two national professional codes of ethics: the Defence Ethics of the Canadian Armed Forces and the Code of Ethics of the Canadian Medical Association. Interestingly, even if the medical code is more focused on duties and responsibility while the military code is more focused on core values and is supported by a comprehensive ethical training program, they also have many elements in common. Further, both are based on the same core values of loyalty and integrity, and they are broad in scope but are relatively flexible in application. While there are still important sources of tension between and limits within these two codes of ethics, there are fewer differences than may appear at first glance because the core values and principles of military and medical ethics are not so different. (shrink)

This book challenges the World Medical Associationâ (TM)s (WMA) International Code of Ethics statement in 2004, which declared that â ~medical ethics in armed conflict is identical to medical ethics in times of peaceâ (TM). This is achieved by examining the professional, ethical, and legal conflicts in British Military healthcare practice that occur in three distinct military environments. These are (i) the battlefield, (ii) the operational environment and (iii) the non-operational environment. As (...) this conflict is exacerbated by the need to achieve Operational Effectiveness, this book also explores the dual loyalty conflict that Military Health Care Professionals (MHCPs) encounter between following military orders and professional codes of practice. The method used to challenge the WMAâ (TM)s statement and explore these conflicts is the use of real-life problem-solving vignettes, which mirror actual ethical and professional conflicts and dilemmas that may occur in the three environments. The areas of law analysed similarly reflect the difficulties that MHCPs face when caring for the sick and wounded in violent locations when under attack. In particular, the book questions whether it is right for a MHCP to owe their patients a duty of care in hostile environments. This leads on to questioning if any MHCP could be protected by combat immunity where no duty of care is owed to fellow soldiers in the battlefield. The book also questions whether the standard of care should be variable in hostile environments. It also explores the dual loyalty conflict of a wounded senior officer refusing treatment from a junior officer. In addition, it examines the difficulties of a doctor maintaining patient confidentiality when a soldier refuses treatment for a psychological injury but wishes to redeploy to the battlefield. The book successfully challenges the WMAâ (TM)s statement. It also concludes by suggesting that neither a military-focused approach nor a professional healthcare-focused approach towards military healthcare is the best way to solve the dual loyalty conflict. (shrink)

In order to maximize human performance, defence forces continue to explore, develop, and apply human performance enhancement (HPE) methods, ranging from pharmaceuticals to (bio)technological enhancement. This raises ethical, legal, and societal concerns and requires organizing a careful reflection and deliberation process, with relevant stakeholders. We discuss a range of ethical, legal, and societal aspects (ELSA), which people involved in the development and deployment of HPE can use for such reflection and deliberation. A realistic military scenario with proposed HPE application (...) can serve as a starting point for such an iterative and participatory process. Stakeholders can discuss this application, modify its features, and design appropriate processes around it – for instance, procedures for informed consent. We propose that organizing aspects into these three categories – ethical, legal, and societal – can help involve appropriate interlocutors at different moments: legal aspects with people in strategy or management roles, from the start of a project; ethical aspects with people in operations and medical roles, during development; and societal aspects with people in communication and personnel roles, during deployment. Notably, we developed and discussed this framework and the three aspects in close collaboration with personnel from the military. (shrink)

A mass casualty (MASCAL) event is different to a major incident. The crux of this difference is that in a major incident, by the adoption of special measures, normal or near-normal standards of care can be maintained. In a MASCAL, irrespective of what special measures are instituted, standards of care inevitably drop. This is a, currently unmet, challenge for medical planning and planning policy. Twenty-First century weaponry is capable of producing thousands of causalities a day over a period of (...) several days in peer-on-peer conflict. In this chapter, we propose that medical planning for military events on this scale should include the following: explicit acceptance that ‘gold standard’ care cannot be given to patients who are triaged for treatment, a better understanding how to identify those patients who will not be triaged for treatment, a focus on ensuring patient flow (which includes diversion, self-care and remote monitoring), and implementation of the principle that care should be given by the lowest capable provider. We attempt to begin to develop some principles for planners to consider drawing on historical precedents and explore some of the ethical implications of our proposals. (shrink)

Little research has explored the perceptions of military medical providers in the deployed environment and how their perceptions may change over time across an extended military conflict. To our knowledge, no studies have examined military medical providers’ opinions on readiness for their roles in the post-9/11 contingency operations. What has been published indicates that, during the height of Operation Iraqi Freedom, military medical providers often deployed with little notice and minimal formal training. The (...) present report examines data obtained from multiple cohorts of military medical providers (N = 321) deployed to Iraq between 2005 and 2009. Despite varying degrees of support from the U.S. public, our findings indicate that U.S. Air Force military medical providers’ support for the people of Iraq, their belief in the mission, and their ability to influence change did not vary with time. (shrink)

Although knowledge of torture and physical and psychological abuse was widespread at both the Guantanamo Bay detention facility and Abu Ghraib prison in Iraq, and known to medical personnel, there was no official report before the January 2004 Army investigation of military health personnel reporting abuse, degradation, or signs of torture. Mounting information from many sources, including Pentagon documents, the International Committee of the Red Cross, Amnesty International, Human Rights Watch, etc., indicate that medical personnel failed to (...) maintain medical records, conduct routine medical examinations, provide proper care of disabled and injured detainees, accurately report illnesses and injuries, and falsified medical records and death certificates. Medical personnel and medical information was also used to design and implement psychologically and physically coercive interrogations. The United States military medical system failed to protect detainee's human rights, violated the basic principles of medical ethics and ignored the basic tenets of medical professionalism. (shrink)

Background As part of its response to the 2014 Ebola outbreak in west Africa, the United Kingdom government established an Ebola treatment unit in Sierra Leone, staffed by military personnel. Little is known about the ethical challenges experienced by military medical staff on humanitarian deployment. We designed a qualitative study to explore this further with those who worked in the treatment unit. Method Semi-structured, face-to-face and telephone interviews were conducted with 20 UK military personnel deployed between (...) October 2014 and April 2015 in one of three roles in the Ebola treatment unit: clinician; nursing and nursing assistant; and other medical support work, including infection control and laboratory and mortuary services. Results Many participants reported feeling ethically motivated to volunteer for deployment, but for some personal interests were also a consideration. A small minority had negative feelings towards the deployment, others felt that this deployment like any other was part of military service. Almost all had initial concerns about personal safety but were reassured by their pre-deployment 'drills and skills', and personal protective equipment. Risk perceptions were related to perceptions about military service. Efforts to minimise infection risk were perceived to have made good patient care more difficult. Significantly, some thought the humanitarian nature of the mission justified tolerating greater risks to staff. Trust in the military institution and colleagues was expressed; many participants referred to the ethical obligation within the chain of command to protect those under their command. Participants expected resources to be overwhelmed and ‘empty beds’ presented a significant and pervasive ethical challenge. Most thought more patients could and should have been treated. Points of reference for participants’ ethical values were: previous deployment experience; previous UK/National Health Service experience; professional ethics; and, distinctly military values. Conclusion We report the first systematic exploration of the ethical challenges face by a Western medical military in the international response to the first major Ebola outbreak. We offer unique insights into the military healthcare workers’ experiences of humanitarian deployment. Many participants expressed motivations that gave them common purpose with civilian volunteers. (shrink)

Medical Officers serving with their national contingents in peacekeeping operations are faced with difficult ethical decisions in regard to their obligations to the local civilian population. Such populations may be under-resourced in regard to medical care, and vulnerable to abuse and exploitation. Though the medical officer may support the local medical services, he/she should never undermine these resources. Adopting a human rights approach and observing the requirements of ethical medicine, aids the doctor in prioritising his/her duties. (...) At times there may be conflict with one’s own military superiors. It is wise to discuss potential difficulties prior to setting out on the mission. Human rights abuses cannot be ignored. The medical officer has a duty to do his/her best to report their observations so as to prevent abuse or to bring it to an end. (shrink)

Medical ethics needs to be on its guard against those in military or political power who would seek to subvert its most basic tenets in order to serve their own endsEmergencies and warlike situations often force medical personnel to follow orders and perform actions or duties pertaining to their field of expertise in flagrant violation of their professional code of ethics. Opposing such orders may be contextually impossible, or elicit unduly high personal costs. Medical (...) ethics, while lamenting these impositions, is often reduced to passive and silent disagreement. In recent years, however, biomedical ethics has become active in accepting and supporting these estrangements from accepted standards and values of the healthcare professions, coming up with justifications of torture; suggesting non-treatment of the wounded, depending on their combatant status; prompting collaboration in the development of biological weapons, and disregarding informed consent.Physicians’ participation in torture has been unanimously condemned and, although acknowledging that such conduct “is the result of the displacement of their medical vocation by the doctrine of ‘national security’”, such an “ideological substrate” has nevertheless been deemed untenable.1 Perpetrators were found to have committed their deeds in an ethical void2; this was recognised, but in no way did it serve to excuse physicians from the duty of opposing induced suffering and assuaging its effects to the best of their abilities.Torture in its “humane” form has been defended on utilitarian grounds,3 using weak arguments that are unable to justify physicians’ active participation in torture. For the most part, professional ethics has remained adamant in its undaunted disapproval of medical non-therapeutic involvement in violent scenarios such as war, terrorism, and even torture. Nobody would have thought, in earlier times, that medical ethics could take any other position than to unrelentingly reject physicians’ participation in torture, …. (shrink)

Advances in medical capability should be accompanied by discussion of their ethical implications. In the military medical context there is a growing interest in developing prophylactic interventions that will mitigate the effects of trauma and improve survival. The ethics of this novel capability are currently unexplored. This paper describes the concept of trauma prophylaxis and outlines some of the ethical issues that need to be considered, including within concept development, research and implementation. Trauma prophylaxis can be (...) divided into interventions that do not and those that do have medical enhancement as an unintended side effect of their prophylactic action. We conclude that type 1 interventions have much in common with established military medical prophylaxis, and the potentially enhancing qualities of type 2 interventions raise different issues. We welcome further debate on both interventions. (shrink)

The profession of medicine has developed codes of ethical conduct for thousands of years. From the Hippocratic Oath of ancient Greece onward to modern times, a universal and central element of such codes has expressed the imperative that a physician shall “Do no harm.”.

This article begins with three problems of “dual loyalties” in medicine, the supposed fact that military physicians are, as medical officers, sometimes required to do what violates ordinary medical ethics—for example, ignore medical need in order to treat their own wounded before civilians or wounded enemy, help make chemical or biological weapons more deadly, or assist at a rough interrogation. These problems are analyzed as special cases of a problem that could arise in any profession, (...) a problem easily resolved using a theory of professional ethics absent from medical ethics until now though common outside. Employing a physician—rather than an ordinary officer, some other kind of healer, or scientist—is to enter a sort of “Ulysses contract” requiring the physician’s professional standards to preempt obligations otherwise applying to an employee. In this way, the article also illustrates the benefits that might accrue to medical ethics from drawing on other fields of practical ethics. (shrink)

On October 25, 1946, three weeks after the International Military Tribunal at Nuremberg entered its verdicts, the United States established Military Tribunal I for the trial of twenty-three Nazi physicians. The charges, delivered by Brigadier General Telford Taylor on December 9, 1946, form a seminal chapter in the history of medical ethics and, specifically, medical ethics in war. The list of noxious experiments conducted on civilians and prisons of war, and condemned by the Tribunal (...) as war crimes and as crimes against humanity, is by now more or less familiar. That list included: high-altitude experiments; freezing experiments; malaria experiments; sulfanilamide experiments; bone, muscle, and nerve regeneration and bone transplantation experiments; sea water experiments; jaundice and spotted fever experiments; sterilization experiments; experiments with poison and with incendiary bombs. What remains less familiar is the moral mindset of doctors and health care workers who plied their medical skill for morally questionable uses in war. In his 1981 work, The Nazi Doctors, Robert Jay Lifton took up that question, interviewing doctors, many of whom for forty years continued to distance themselves psychologically from their deeds. The questions about moral distancing Lifton raised have immediate urgency for us now. Military medical doctors, psychiatrists and psychologists serve in U.S. military prisons in Guantánamo, Abu Ghraib, Kandahar, and, until very recently, in undisclosed CIA operated facilities around the world where medical ethics are again at issue. Moreover, they serve in top positions in the Pentagon, as civilian and military heads of command, who pass orders and regulations to military doctors in the field, and who are in charge of the health of enemy combatants, as well as U.S. soldiers. Because we recently marked the sixtieth anniversary of the judgment at Nuremberg, I want to awaken our collective memory to the ways in which doctors in war, even in a war very different from the one the Nazis fought, can insulate themselves from their moral and professional consciences. (shrink)

A novel method of teaching military medical ethics, medical ethics and military ethics in the Israel Defense Force (IDF) Medical Corps, essential topics for all military medical personnel, is discussed. Very little time is devoted to medical ethics in medical curricula, and even less to military medical ethics. Ninety-five per cent of American students in eight medical schools had less than 1 h of (...) military medical ethics teaching and few knew the basic tenets of the Geneva Convention. Medical ethics differs from military medical ethics: the former deals with the relationship between medical professional and patient, while in the latter military physicians have to balance between military necessity and their traditional priorities to their patients. The underlying principles, however, are the same in both: the right to life, autonomy, dignity and utility. The IDF maintains high moral and ethical standards. This stems from the preciousness of human life in Jewish history, tradition and religious law. Emphasis is placed on these qualities within the Israeli education system; the IDF teaches and enforces moral and ethical standards in all of its training programmes and units. One such programme is ‘Witnesses in Uniform’ in which the IDF takes groups of officers to visit Holocaust memorial sites and Nazi death camps. During these visits daily discussions touch on intricate medical and military ethical issues, and contemporary ethical dilemmas relevant to IDF officers during active missions. (shrink)

Since the mid-1800s, clergy, doctors, other clinicians, and military personnel who specifically facilitate their work have been designated “non-combatants”, protected from being targeted in return for providing care on the basis of clinical need alone. While permitted to use weapons to protect themselves and their patients, they may not attempt to gain military advantage over an adversary. The rationale for these regulations is based on sound arguments aimed both at reducing human suffering, but also the ultimate advantage of (...) the nation-state fielding non-combatant staff. However, this is sometimes not immediately apparent to combatant colleagues. Clinicians in the armed force are also military officers, owing a “dual loyalty” that can create conflict if their non-combatant status is not well understood. Historical examples of doctors breaching their responsibilities include prioritisation of combat capability over the rights of individual soldiers (as occurred when scarce medical resources were allocated to soldiers more likely to return to battle in preference to those most likely to die without them), use of physicians to facilitate prisoner interrogation, medical research or treatment to enhance physical performance at the expense of health, application of Medical Rules of Eligibility according to factors other than clinical need, provision of treatment contingent upon support for military objectives, and use of medical knowledge to enhance weapons. However, not being a combatant party to a conflict does not imply that the non-combatant clinician cannot act in the national interest. Indeed, by adhering to the same universal ethics as their civilian colleagues, military clinicians provide optimal care to their own troops, facilitate freedom of action in host nations, and build positive international relationships during the conflict and in the post-conflict state. (shrink)

In the context of military medical care, Eisenstein and colleagues have introduced the notion ‘left of bang intervention in trauma’, which refers to interventions administered before trauma to reduce morbidity and mortality after injury. This paper responds to Eisenstein and colleagues’ ethical analysis of such interventions, highlighting the difficulty in distinguishing between purely prophylactic and enhancing interventions. This response also addresses legal issues that arise from left of bang interventions under human rights law and the law of armed (...) conflict, in particular the questions as to whether the consent of service members would need to be obtained and whether the adversary would as a consequence be authorised to resort to more injurious weapons. (shrink)

Outbreaks of epidemics like Ebola trigger difficult ethical challenges for civilian and military health care personnel. This book offers theoretical reflections combined with reports from recent military and NGO missions in the field. The authors of this volume focus on military medical ethics adding a distinct voice to the topic of epidemics and infectious diseases. While military health care personnel are always crucially involved during disaster relief operations and large-scale public health emergencies, most of (...) the current literature treats ethical issues during epidemics from a more general perspective without taking into account the specifics of the military context. The contributions in this volume provide first-hand insights into some of the ethical issues encountered by military health care personnel in missions during the Ebola outbreak in 2014/2015. This practical perspective is complimented by academic analyses and theoretical reflections on ethical issues associated with epidemics. (shrink)

Fifty-nine years ago, Dr Leo Alexander published his now famous report on medicine under the Nazis. In his report he describes the two major crimes of German physicians. The participation of physicians in euthanasia and genocide and the horrible experiments performed on concentration camp prisoners in the name of science. In response to this gross violation of human rights by physicians, the Nuremberg military tribunal, which investigated and prosecuted the perpetrators of the Nazi war crimes, established ten principles of (...) ethical conduct in medical research in 1949. Foremost among them was the need for voluntary consent of the human subject and that the experiment be conducted to avoid all unnecessary physical and mental suffering. Notwithstanding all these important efforts and impressive achievements in understanding the ethical failings of Nazi physicians, the bioethical community has almost completely ignored the moral challenges facing the victims of the atrocities. These dilemmas and their responses have continued relevance for modern medicine. (shrink)

Because the goal of military medicine is salvaging the wounded who can return to duty, military medical ethics cannot easily defend devoting scarce resources to those so badly injured that they cannot return to duty. Instead, arguments turn to morale and political obligation to justify care for the seriously wounded. Neither argument is satisfactory. Care for the wounded is not necessary to maintain an army's morale. Nor is there any moral or logical connection between the right (...) to health care (a universal human right) and the duty to defend one's nation (a local political duty). Once badly wounded, soldiers enjoy the same right to medical care as any similarly ill or injured individual. National health care systems grasp this point and offer few additional health care benefits to veterans. In the United States, however, lack of universal health coverage skews the debate to focus on special entitlements for veterans without considering the health care rights that other citizens enjoy. (shrink)

The contemporary operating environment for deployed United States military operations largely focuses on deployments to predominantly Islamic countries. The differences in cultural values between d...

The military might of the modern era poses devastating threats to humankind. Wars result from struggles for material or ideological power. In this context the probability of flouting agreements made during peaceful times is great. The rights of victims and the rights of medical personnel are vulnerable to State and military momentum in the quest for sovereignty. Scholars, scientists and physicians enjoy little enough influence during times of peace and we should be sanguine about their influence during (...) war. But we also must avoid becoming co-opted by partisan political forces. The universal ideals for which we strive, need to be cherished and kept central in our field of vision if we are to rise above man's basest instincts and if we are to preserve professional integrity, individuality and humanitarian concern for the sanctity of life — even the lives of our foes who are engaged in battle against us. Such compassion also recognizes the coercion implicit in recruiting persons into wars they detest and which pits them against their own image. Man's inhumanity to man, most evident during war, must not be allowed to pervade the sanctuary of medical care. Health professionals must constantly be encouraged to serve humankind with empathy and compassion and great social effort needs to be expended to facilitate this role globally and under all conditions. (shrink)

Battlefield euthanasia, the purposeful killing of wounded soldiers (or even civi- lians) in order to hasten their foreseeable death, has been an issue in military medicine and in soldiers’ moral codes at all times. During conflicts since anti- quity, there have been severely wounded who would not die immediately but whose fate seemed clear, nevertheless. But can it ever be morally justified to kill those wounded out of mercy in order to end their suffering? Can death ever be the (...) better option? And if so, what conditions have to be fulfilled? This paper investigates some of the moral aspects of battlefield euthanasia. Analogies to physician-assisted suicide in civil settings will be drawn and contrasted with the additional aspects that the military environment adds to the problem. (shrink)

Some doctors and nurses played a key role in Nazism. They were responsible for the sterilization and murder of people with disabilities. Nazi doctors used concentration camp inmates as guinea pigs in medical experiments that had military or racial objectives. What we have learnt about the behaviour of doctors and nurses during the Nazi period enables us to reflect on several issues in present-day medicine. In some authors' opinions, the teaching of the medical aspects of the Holocaust (...) could be a new model for education relating to professionalism, Human Rights, Bioethics and the respect of diversity. Teaching Medicine and the Holocaust could be a way of informing doctors and nurses of violations of Ethics in the past. Moreover, a Study Trip to Holocaust and Medicine related sites has a strong pedagogical value. Visiting Holocaust related sites, T4 centres and the places where medical experiments were carried out, has a special meaning for medical students. Additionally, tolerance, anti-discrimination, and the value of human life can be both taught and learned through this curriculum. The following article recounts our experiences of organizing and supervising a study trip with a group of medical students to some Holocaust and medicine-related sites in Berlin and Hadamar. The study tour included lectures at universities in Düsseldorf and Berlin. (shrink)

BackgroundFrench military doctors are currently deployed in the Sahel to support the armed forces of Operation Barkhane, in medical or surgical units. As well as supporting French soldiers, their other missions are diverse and complex: medical assistance to civilians and persons under control (PUC), advice to commanding officers. These tasks can create ethical dilemmas when decisions are forced upon doctors that may be in conflict with medical values or fundamental principles. Little is known about the specific (...) dilemmas experienced by French military doctors in overseas operations. We therefore conducted a qualitative study among doctors and surgeons recently deployed to the Sahel to explore and better understand this question.MethodSemi-structured, face-to-face interviews were conducted with 20 French military doctors or surgeons deployed since January 2016 in medical or surgical facilities in Mali and Chad.ResultsAll interviewed doctors reported having faced several ethical dilemmas during missions. All reported dilemmas involved the treatment of civilians (while delivering community medical assistance) or of PUC. The dilemmas involved choices as to which patients to treat, the use of care as a means to an end by military authorities, and the level of care attainable in the absence of any possible hospital follow-up. Questions of delivering care at the risk of their own safety or the mission’s and of treating openly hostile patients were also brought up. Several dilemmas stemmed from the dual loyalty problem, namely the conflict between military doctors’ duty of care to patients and to the military institution, but this was not the only factor involved. Contextual factors (restricted resources and security constraints) and psychological factors (especially hostility towards the enemy) were also associated with many of the reported dilemmas.ConclusionThis is the first reported study focusing on the ethical dilemmas encountered by French military doctors in overseas operations. It provides unique insights into their ethical experiences and should prove useful in improving operational training for healthcare personnel deployed on overseas missions. (shrink)

This paper presents an overview of the key ethical questions of performing gene editing research on military service members. The recent technological advance in gene editing capabilities provided by CRISPR/Cas9 and their path towards first-in-human trials has reinvigorated the debate on human enhancement for non-medical purposes. Human performance optimization has long been a priority of military research in order to close the gap between the advancement of warfare and the limitations of human actors. In spite of this (...) focus on temporary performance improvement, biomedical enhancement is an extension of these endeavours and the ethical issues of such research should be considered. In this paper, we explore possible applications of CRISPR to military human gene editing research and how it could be specifically applied towards protection of service members against biological or chemical weapons. We analyse three normative areas including risk–benefit analysis, informed consent, and inequality of access as it relates to CRISPR applications for military research to help inform and provide considerations for military institutional review boards and policymakers. (shrink)

This article briefly outlines what the medical duty is, and its special role in international law, before discussing the problems resulting from the dual role as doctor and soldier, which military doctors can expect to meet conceptually, and unfortunately in reality as well. With arguments based on international humanitarian law and ethics, this article shows that greater weight should be given to the medical role.

The growing area of military bio-technologies, especially the use of cogniceuticals, raises several ethical concerns for military physicians. These include the role of military physicians in prescr...

In emergency situations and while medical resources are sufficient, doctors are expected to prioritize and treat patients according to medical criteria only. In MASSCAL situations and when medical resources become insufficient, patient selection and prioritization changes. Rules of triage are applied with the aim of getting the best result possible under the circumstances, e.g., saving the largest number; collective health outweighs individual health. Still, according to the standard ethical principles, non-medical criteria should never influence the doctors’ (...) decision of who will be treated. In military contexts, so-called medical rules of eligibility (MROE) provide rules that include non-medical criteria. This chapter aims to analyze if, why, and under what circumstances it may be ethically acceptable to prioritize patients according to non-medical criteria. (shrink)

Confidentiality is a core value in medicine and public health yet, like other core values, it is not absolute. Medical ethics has typically allowed for breaches of confidentiality when there is a credible threat of significant harm to an identifiable third party. Medical ethics has been less explicit in spelling out criteria for allowing breaches of confidentiality to protect populations, instead tending to defer these decisions to the law. But recently, issues in military detention settings (...) have raised the profile of decisions to breach medical confidentiality in efforts to protect the broader population. National and international ethics documents say little about the confidentiality of detainee medical records. But initial decisions to use detainee medical records to help craft coercive interrogations led to widespread condemnation, and might have contributed to detainee health problems, such as a large number of suicide attempts several of which have been successful. More recent military guidance seems to reflect lessons learned from these problems and does more to protect detainee records. For the public health system, this experience is a reminder of the importance of confidentiality in creating trustworthy, and effective, means to protect the public's health. (shrink)

There is considerable support for the idea that an atmosphere of safety can foster learning in groups, especially during ethics training courses. However, the question how safety dynamics works during ethics courses is still understudied. This article aims to investigate safety dynamics by examining a critical incident during a military ethics train-the trainer course during which safety was threatened. We examine this incident by means of a four-factor analysis model from the field of Theme-Centered Interaction (TCI). (...) We show that during ethics training courses a safety paradox can occur, involving a tension between honesty and openness to other perspectives and values. Finally, we discuss how trainers can foster safety during ethics training. (shrink)