Medical Ethics In Military Conflict

In recent years, there have been numerous recorded accounts of United States medical personnel neglecting to report evidence of detainee abuse. The contrast between war and peace time is of great importance when discussing the idea of medical ethics. The ideals that are traditionally associated with physicians, physicians assistants, nurses and medics, in a time of war, classifies them as noncombatants. This classification prohibits them from taking part in any form of armed combat or taking any such action that would result in harming another individual, be he/she friend or foe. Still, in a world plagued by unconventional warfare, medical personnel are faced with a dilemma in which their traditionally held roles are brought into question. In order to properly address the issues at hand first the issue of how military necessity and medical ethics are held in tension, i.e. the question, does military necessity override medical ethics? Secondly, one must address the more complex question of, should/ought military necessity override medical ethics? The answer lies in the complex understanding of what it means to be a medical physician. I argue that at our current state medical ethics are subject to the whims of military necessity, but that this is in and of itself flawed. Military necessity must not be the basis for how we dictate what rules medical personnel are allowed to violate.

The dilemma of medical noncombatants on the battlefield has found many hurdles that have had to be overcome. One of the main concerns is that of immoral and unethical physicians and how they treat prisoners. For example, the atrocities by the Nazi doctors in the concentration camps of World War Two. Their torture and inhumane experimentation is something that has been banned and would cause them to relinquish their rights as a noncombatant. As a result of this sort of behavior, in 1949 the Geneva Conventions, a series of international agreements signed by over sixty nations, set out to establish a code of conduct for dealing with “naval warfare, the treatment of prisoners, and the protection of civilians from deportation, hostage taking, torture, and discrimination in treatment” (Levine, 289). This agreement revolutionized the way that medicine would be applied to war. However, although the Geneva Conventions brought what little humanity and civility can be brought to war, the art of war has changed drastically over the course of the previous fifty years. Guerrilla warfare has blurred the lines between civilian and combatant and in doing so it has created a problem for medical ethicists and military leaders alike. The question thus begs to be asked, if warfare has changed, does that mean that military medicine has changed with it?

Many view the events that transpired in the American held detention facilities in Guantanamo Bay, Cuba, an American naval base, and in Abu Ghraib prison in Iraq as perfect examples of how military necessity has overridden the physician’s moral obligations to the detainees. One must also take into consideration that many of the inhabitants of the Guantanamo Bay facility were not deemed classifiable as “prisoners of war” and thus were not afforded the rights provided by the Geneva Convention. Military physicians were placed in a very precarious position by their superior officer and high ranking facility officials. They were asked to support their nation and “fight terrorism” by not revealing what was occurring during interrogations and in doing so violate their Hippocratic Oath. Under normal, supervised, peacetime interrogations suspects interrogations have a system of checks and balances that ensure the persons’ rights and liberties are upheld. This may be the case for nonmilitary criminals, but the question at hand, one may observe, pertains to those captured by means of military conflict. Even detainees are not supposed to be subject to what the Geneva Convention deems as, “physical or mental torture, nor any other form of coercion, may be inflicted on prisoners of war to secure from them information of any kind whatsoever” (Bloche and Marks, 300). Documents show that physicians played an active role in the development of interrogation plans for those detained at the two facilities. These plans included the implementations described in the Bloche and Marks essay, “’dietary manipulation’ – minimum bread and water. . ., ‘environmental manipulation’ – i.e., reduced A.C. [air conditioning] in the summer, lower[ing] heat in winter; ‘sleep management – for 72-hour time period maximum, monitored by medics’; ‘sensory deprivation – for 72-hour time period maximum, monitored by medics’; ‘isolation – for longer than 30 days’; ‘stress positions’; and ‘presence of working dogs’” (298). Each of these, in some way, falls under what some may view as a breach of the Geneva Convention. These violate the rules that the agreement had lain forth concerning basic human rights in a prison environment.

In order to answer the question of “should/ought,” one must begin by finding himself in the “no-man’s land” between two passionate and powerful camps. On one hand many ethicists view that the change in military ethics has greatly altered medical ethics, and that this transformation is both evident and needed. They argue that military medicine, by its very nature, is separate and distinct from what one may find in medicine practiced during times of peace. Their argument is based on the nature of medicine and how it is practiced in combat. Using a “utility” method that is separate from what traditional ethics would perceive it as, they are able to determine a persons worth. As Gross writes of the dilemma, “Military ethics . . . elevates utility in a way that may run roughshod over other fundamental principles, as utility allows military necessity to trump other moral constraints on military action” (291). Many like Gross argue that medical ethics must change because the value of human life must change during combat. He creates an hourglass theory to a combatant’s right to life when he writes, “Combatants lose their right to life as they gain the right to kill” (292). This concept seems rather general when discussing armed engagement, but Gross wishes to take the idea one step further when he applies the same principle to medical treatment. Thus he concludes that as an individual gains the right to kill, he further loses his right to medical treatment and care. He remarks, “Deprived of their right to life, enemy combatants have no intrinsic right to medical care” (292). Further, Gross places boundaries on the rights of medical personnel to provide care for their own soldiers based on what he call “salvage value,” i.e. the chance that a wounded individual has to return to the fighting and thus continue to serve a purpose. In this scenario, personal autonomy falls to the wayside in favor of a more restricting form of paternalism.

Contrary to the belief that medical obligations and responsibilities must change during and in the face of impending combat, others argue that medical ethics are above and beyond the control of government and individual states. These people assume the premise that medicine exists separately from the military and operates next to and not subordinate to combat operations. In other words, the obligation of a physician to treat any and all humans in need is not dictated by the changing political or social environment, but instead remains a constant. They tend to counter the argument proposed by Gross with a call to recognize each individual, regardless of personal allegiances, as deserving dignity. Dignity, Gross admits, is often lost in the current system that places military necessity superior to medical ethics. From a Kantian standpoint an argument against the current system can easily arise. The way that soldier, therefore people, are used in combat is as a means to an end, the end of conflict. This, according to Kant would be unacceptable. Furthermore, the utility principle has become elevated above and beyond the other ethical principles and in doing so many of the other valuable methods of solving difficult and controversial dilemmas are lost. To outright neglect these concepts, Bloche and Marks would argue, is an abomination. They also believe that “physicians should not use drugs or other biologic means to subdue enemy combatants or extract information from detainees, nor should they aid others in doing so” (Bloche and Marks, 300).

The concept of “should” is very delicate. In reviewing the arguments made, one striking point becomes very clear. Thinkers, such as Gross, that are in favor of neglecting medical ethics in favor of military necessity base much of their argument of why it should be permissible to do so, on the basis that it is currently being done. They even admit to the neglect for personal dignity by interrogators. This neglect is one of the many flaws with their argument. Those apposed to that view believe that the individual should never be made a means to an ends. The physician should respect the dignity and self worth of all individuals, regardless of position. They also hold fast to the belief that allowing medical professionals to pick and choose when and where medical ethics should be applied opens the door for a slippery slope to begin. Through an observation, even the most slight, it is evident that those opposed to neglecting medical ethics in favor of military necessity present the stronger, more valid argument.

I have found myself in quite a conundrum because both of the positions presented are valid, in their own way. On one hand national security often dictates that person liberties be relinquished in order for the common good of society to be fully protected. Still, the most compelling argument comes from side that seeks to establish a solid ethical mold for what a physician should be, regardless of whether it is in an office in Portland or in a detention facility in Iraq. One of the key arguments is that a slippery slope emerges when one is allowed to suspend the person rights of another, more specifically the right to health care. When the concept of utility is the singular guiding principle I believe that many important and vital concepts are left out, namely Kant’s view that humans are an ends in and of themselves. As one begins down a path that allows doctors to remove themselves from the moral constraints of their Hippocratic Oath, the worries of inhumane treatment, such as that in Nazi run occupation camps, becomes an ever growing possibility. It is understood that war has changed since the adoption of the Geneva Convention, however, that does not mean that the rules set forth from those conferences are no longer valid. It appears to me that in a world where medical ethics are often shaped and molded to meet popular demand, there must be a solid bright line that is visible for all to see. This line must keep the medical professional from having to make the decision of neglecting their sworn duty. There must be character present, even in times of war or when one may view torture as an acceptable means to secure national security. It may appear that I appeal more to virtue ethics than those that present the case. This may be true, but to neglect virtue ethics would be as large a travesty as placing a utilitarian view of the discussion supreme to all others.
I believe that it is vital that medical ethics to be separate and not influenced by military necessity. Doctors and other physicians must not be put in a position to abandon their oath of beneficence. Although each side presents arguments in their favor, the argument against allowing medical ethics to be subdued is far to compelling and far more logical. If we are to grow as human beings we must be looking to improve upon that which we have already created and developed. Allowing such travesties to occur as those at Guantanamo Bay and Abu Ghraib is a sin against humanity and must be stopped.