When Medical Ethics and Military Ethics Collide

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 medical professionals, military officers, and conscientious citizens.

The safety paradox in ethics training: a case study on safety dynamics within a military ethics train-the-trainer course

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.

Ethical Issues of Using CRISPR Technologies for Research on Military Enhancement

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.

Left Of Bang Interventions in Trauma: ethical implications for military medical prophylaxis

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 (Left Of Bang Interventions in Trauma) 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 (type 1) and those that do (type 2) 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.

Saving Life, Limb, and Eyesight: Assessing the Medical Rules of Eligibility During Armed Conflict

Medical rules of eligibility permit severely injured Iraqi and Afghan nationals to receive care in Coalition medical facilities only if bed space is available and their injuries result directly from Coalition fire. The first rule favors Coalition soldiers over host-nation nationals and contradicts the principle of impartial, needs-based medical care. To justify preferential care for compatriots, wartime medicine invokes associative obligations of care that favor friends, family, and comrades-in-arms. Associative obligations have little place in peacetime medical care but significantly affect wartime medicine. The second rule suggests liability for collateral harm that is unsupported by international law and military ethics. Absent liability, there are pragmatic reasons to offer medical care to injured local civilians if it quells resentment and cements support for Coalition forces. In contrast to peacetime medicine, military necessity and associative obligations outweigh distributive principles based on medical need during war.

Complicity and torture

One of the great merits of On Complicity and Compromise is that it wades into specific swamps where ordinary theorists fear to slog. It is persuasive that in general it can be right sometimes to be complicit in wrongdoing by others through causally contributing to the wrongdoing, but not sharing its purpose, if by being involved one can reasonably expect to lessen the extent of the wrong that would otherwise be suffered by the victims. I focus on whether the book's general thesis is applicable to torture, which depends on what torture and the torture situation are in fact like. I focus on the case to which the chapter several times refers: the innovative CIA paradigm of torture. First, to the extent that the paradigm, which is predominantly mental, or psychological, torture succeeds in its goal of producing regression to a compliant state, the physician would be unable to rely on the torture victim's expressions of preferences or interests as authentically his own. Second, since disorientation plays such a large role in the CIA's style of torture (adopted at Guantanamo by the military), the authorities would refuse to allow a stable relationship to be built up with any one doctor by any victim, making comprehension of the victim's preferences difficult. Third, even if the doctor could somehow judge what the victim's genuine interests were, the control of the situation is much too totalistic to allow the physician any action independent of what the torture regime requires.

Following professional codes of practice and military orders in austere military environments: a controversial debate on ethical challenges

In 2004, the World Medical Association's International Code of Ethics claimed that 'medical ethics in armed conflict is identical to medical ethics in times of peace'. This paper challenges this notion and suggests that the hostile, austere and diverse environments in which military doctors and nurses serve are significantly more problematic and different to a civilian healthcare environment. It debates that there may be some incompatibility and challenges between following military orders such as the protocols written down in a Medical Rules of Eligibility matrix and professional codes of practice in these environments. This is either where fighting takes place or where the mission is for humanitarian purposes.

Neuromodulation research and application in the U.S. Department of Defense

BACKGROUND

Modern neuromodulatory techniques for military applications have been explored for the past decade, with an intent to optimize operator performance and, ultimately, to improve overall military effectiveness. In light of potential military applications, some researchers have voiced concern about national security agency involvement in this area of research, and possible exploitation of research findings to support military objectives. The aim of this article is to examine the U.S. Department of Defense's interest in and application of neuromodulation.

METHODS

We explored articles, cases, and historical context to identify critical considerations of debate concerning dual use (i.e., national security and civilian) technologies, specifically focusing on non-invasive brain stimulation (NIBS).

DISCUSSION

We review the background and recent examples of DoD-sponsored neuromodulation research, framed in the more general context of research that aims to optimize and/or rehabilitate human performance. We propose that concerns about military exploitation of neuromodulatory science and technology are not unique, but rather are part of a larger philosophic debate pertaining to military application of human performance science and technology. We consider unique aspects of the Department of Defense research enterprise--which includes programs crucial to the advancement of military medicine--and why it is well-situated to fund and perform such research. We conclude that debate concerning DoD investment in human performance research must recognize the significant potential for dual use (civilian, medical) benefit as well as the need for civilian scientific insight and influence. Military interests in the health and performance of service members provide research funding and impetus to dual use applications that will benefit the civilian community.

The new military medical ethics: legacies of the Gulf Wars and the War on Terror

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.

Primary care provider reflections on context-specific quandaries from special issue on ethical quandaries when delivering integrated primary care

Comments on the articles by Robinson & Rickard, (see record 2013-11498-007), Dobmeyer, (see record 2013-11498-008), Mullin & Stenger (see record 2013-11498-009), and Rosenberg & Speice (see record 2013-11498-010) regarding the topic of context-specific quandaries for the special issue on ethical quandaries when delivering integrated primary care. The current author provides brief reflections on each article.

Physician involvement in torture: an ethical perspective

Evidence proves that physician involvement in torture is widely practiced in society. Despite its status as an illegal act as established by multiple international organizations, mandates are routinely unheeded and feebly enforced. Philosophies condemning and condoning torture are examined as well as physicians' professional responsibilities and the manner in which such varying allegiances can be persuasive. Physician involvement in torture has proven detrimental to the core values of medicine and has tainted the field's commitment to individuals' health and well-being. Only when this complex issue is addressed using a multilevel approach will the moral rehabilitation of medicine begin.

Comradery, community, and care in military medical ethics

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.

Gray matters: a deployed physician's perspective on combat medicine in Iraq

A female physician who was serving as a first-year medicine resident in Manhattan in September 2001 writes this paper. It details her experience of signing up for military service as a result of the September 11th attack on the United States. She lays out the surroundings, atmosphere, and reactions of those around her during the attack and details her own personal motivations for joining the military, her need to take control and help those in need heal while also trying to heal herself. Grateful, yet haunted by her experience, she provides an intimate glimpse into her time serving as a combat physician at a trauma hospital in Balad, Iraq during the 2007 military surge. A trained geriatrician and palliative care physician she recounts the stories of several patients that have forever shaped her life and explores the contradictions and ethical challenges she faced while caring for them ultimately struggling with the uncertainty of whether what she was truly doing was good for those she served or herself.

Neglect of medical evidence of torture in Guantánamo Bay: a case series

BACKGROUND

In the wake of the September 11, 2001 attacks on the US, the government authorized the use of "enhanced interrogation" techniques that were previously recognized as torture. While the complicity of US health professionals in the design and implementation of US torture practices has been documented, little is known about the role of health providers, assigned to the US Department of Defense (DoD) at the US Naval Station Guantánamo Bay, Cuba (GTMO), who should have been in a position to observe and document physical and psychological evidence of torture and ill treatment.

METHODS AND FINDINGS

We reviewed GTMO medical records and relevant case files (client affidavits, attorney-client notes and summaries, and legal affidavits of medical experts) of nine individuals for evidence of torture and ill treatment and documentation by medical personnel. In each of the nine cases, GTMO detainees alleged abusive interrogation methods that are consistent with torture as defined by the UN Convention Against Torture as well as the more restrictive US definition of torture that was operational at the time. The medical affidavits in each of the nine cases indicate that the specific allegations of torture and ill treatment are highly consistent with physical and psychological evidence documented in the medical records and evaluations by non-governmental medical experts. However, the medical personnel who treated the detainees at GTMO failed to inquire and/or document causes of the physical injuries and psychological symptoms they observed. Psychological symptoms were commonly attributed to "personality disorders" and "routine stressors of confinement." Temporary psychotic symptoms and hallucinations did not prompt consideration of abusive treatment. Psychological assessments conducted by non-governmental medical experts revealed diagnostic criteria for current major depression and/or PTSD in all nine cases.

CONCLUSION

The findings in these nine cases from GTMO indicate that medical doctors and mental health personnel assigned to the DoD neglected and/or concealed medical evidence of intentional harm.

Ethical dilemmas for physicians in time of war

During times of war, physicians are sometimes faced with the conflict of their professional duties to ensure the ethical principles of beneficence, non-maleficence, patient autonomy, and self-determination, within the framework of the proper ethical conduct in the practice of medicine, and the obligation and duties placed upon the physician by the state in times of war. Many ethical dilemmas may occur for the physician on the battlefield or elsewhere in the war region, including the treatment of detainees and the priority of treating wounded enemy soldiers or civilians first. When physicians are faced with a conflict between following state or national policies and following international principles of humanitarian law and medical ethics, the physician should opt for the latter. Physicians should not participate in any way in human rights abuses of detainees or prisoners when deployed in a war zone. Physicians must maintain the principles and standards and ethical considerations of their noble profession at all times.

Military medicine and the ethics of war: British colonial warfare during the Seven Years War (1756-63)

This article examines 18th-century European warfare, tracing the first formal codifications of conventions of war, frequently introduced by military physicians and initially regarding the treatment of the sick and wounded. It outlines to what extent these conventions were followed in practice, particularly in the challenging environment of American irregular warfare, with a focus on the most well-known incident of "biological warfare" in the period: the deliberate spread of smallpox by British officers among Amerindians in 1763. More broadly, it demonstrates that the history of military medicine provides a fruitful method with which to uncover assumptions about the ethics of war.

The prisoner as model organism: malaria research at Stateville Penitentiary

In a military-sponsored research project begun during the Second World War, inmates of the Stateville Penitentiary in Illinois were infected with malaria and treated with experimental drugs that sometimes had vicious side effects. They were made into reservoirs for the disease and they provided a food supply for the mosquito cultures. They acted as secretaries and technicians, recording data on one another, administering malarious mosquito bites and experimental drugs to one another, and helping decide who was admitted to the project and who became eligible for early parole as a result of his participation. Thus, the prisoners were not simply research subjects; they were deeply constitutive of the research project. Because a prisoner's time on the project was counted as part of his sentence, and because serving on the project could shorten one's sentence, the project must be seen as simultaneously serving the functions of research and punishment. Michel Foucault wrote about such 'mixed mechanisms' in his Discipline and punish. His shining example of such a 'transparent' and subtle style of punishment was the panopticon, Jeremy Bentham's architectural invention of prison cellblocks arrayed around a central guard tower. Stateville prison was designed on Bentham's model; Foucault featured it in his own discussion. This paper, then, explores the power relations in this highly idiosyncratic experimental system, in which the various roles of model organism, reagent, and technician are all occupied by sentient beings who move among them fluidly. This, I argue, created an environment in the Stateville hospital wing more panoptic than that in the cellblocks. Research and punishment were completely interpenetrating, and mutually reinforcing.