Military Medical Ethics in Contemporary Armed Conflict
Mobilizing Medicine in the Pursuit of Just War
Michael L. Gross, PhD
Introduction
In an age of Twitter brevity, introductions are vital but dangerous. If they summarize the arguments too well, they might deter all but the most intrepid from reading on. If they don’t summarize the argument well enough, even the intrepid may balk. The trick is to pique the reader’s curiosity without giving away the show.
Let’s start with this. Anyone searching “military medical ethics” in the decade or more following revelations of torture and abuse at Abu Ghraib prison in Iraq (2003-4) will be overwhelmed with such harrowing titles as A Stain on Medical Ethics (Wilks 2005); Unspeakably Cruel (Annas 2005); Oath Betrayed (Miles 2006); Science in Dachau’s Shadow (McCoy 2007); The Hippocratic Myth (Bloch 2011) and Ethics Abandoned (Rubenstein and Thomson 2013).” Comments like “Military medicine has always remained on the borderline of ethics… (Fox 2013: 275)” or “The post-9/11 ‘war on terror’ has deformed military medical ethics in the US (Annas and Crosby 2019: 303),” are not uncommon. The upshot is clear: military medical ethics is hardly deserving of its name; it is ethics more honored in the breach than the observance.
This book repudiates that notion entirely. Medical ethics must certainly address things that must not be done and suffer rebuke if it does not. But Abu Ghraib and Guantanamo Bay are not the only provinces of moral inquiry. Military medical ethics also tackles a perplexing mix of things that must be done but may not; things that can be done but need not, and things that should be done but are not.
Things that must be done but may not
Consider war injuries first—over three million American and international troops deployed to Iraq and Afghanistan since 2003. There, medical workers faced devastating multi-system injuries unencountered in any previous war. Improvised explosive devices (IEDs), not the gunshot wounds or booby traps of Vietnam, were the chief culprit. Hemorrhage, exsanguination, and traumatic brain injury were the primary causes of death among the more than 8,500 Coalition soldiers who lost their lives. These numbers are low. And in a time where Americans and Europeans see pandemic deaths multiply into the tens of thousands in a matter of weeks, the numbers of dead and injured warfighters in Iraq and Afghanistan risk becoming a footnote. But these numbers are low for a reason. Despite the ferocity of the fighting and the severity of the injuries, fewer service personnel died of wounds than during any other war in history. Dedicated, innovative medicine, speedy evacuation, body and vehicle armor, and technological development combined to conserve fighting strength and enhance mission success.
But isn’t this claim tone deaf? Since when are force conservation and mission success the metrics of good medicine? What about lives saved or lost? Certainly, the devastation of war reached far beyond the relatively low casualties of allied forces. Many tens of thousands of contractors, local allies, police, enemy combatants, and civilians suffered violent death, injury, accident, and disease. These numbers are very far from low. Yet, military medical facilities are often the only provider as wars ramp up. Military planners do not look past what is required to attend to their own needs. Their perspective is not unusual. In war, medical resources are scarce by design, and local nationals clamoring for care may soon overwhelm the system. Here, then, is the first and most tenacious of ethical dilemmas: Who gets what, when, and where?
The challenge of allocating scarce resources is not new to medical ethics. For civilian or peacetime medical ethics, the “what” is medical attention; the “when” is as medical need dictates, and the “where” is in the facility best able to meet a patient’s need. In military medical ethics, things immediately go awry precisely because force conservation and mission success are its metrics. Still, the answer starts the same. The “what” is medical attention, but the “when” is as military necessity dictates and the “where” can be in an in-theater combat support hospital, a poorly equipped and understaffed Iraqi or Afghan facility or, if you happen to wear the uniform of a Coalition soldier, a first-class hospital in Bethesda, Maryland; Landstuhl, Germany or Birmingham, England. Military necessity usurps medical need as the fundamental criterion of allocating treatment in wartime. As a result, a patient’s identity or affiliation rather than a patient’s medical need determines the extent and kind of care he or she will receive.
A pediatrician deployed to a war zone tells me the following story. But before I continue, ask yourself this: Who takes pediatricians to war? Anyway, he winds up managing admissions in a combat support hospital. Every day, mothers mob the front gate hoping someone will care for their children. Some were caught in the crossfire; others just sick and injured in the way kids are. Most are turned away; there is only room for military casualties. But someone asks: What about the kids we hurt? What about our “collateral” damage? Shouldn’t we at least tend them? So the doctor asks: How many of you were hurt by our gunfire, missiles, or bombs? They all raise a hand. So a few get in, but not many. The rest, despondent, just leave. Telling the story back home, people wonder: What kind of pediatrician sends away sick children? “But we needed the beds for our own,” comes the answer. “Our own?” comes the response. “Our own are grown men and women.” Showing no patience for the bald demands of military necessity, civilian medicine embraces impartiality and vigorously repudiates any notion of treating the sick and wounded based on the uniform they do, or don’t, wear. So he stops telling his story. People want to hear M*A*S*H, but it’s not that at all.
Military medical ethics, then, has considerable work to do. Establishing the permissible criteria of differential medical care across patients who are combatants, detainees, and civilians are the subject of Section II: Caring for the Wounded of War.
Nearly two decades of post 9/11 warfare in Iraq and Afghanistan provide much of the raw material for this study. So Section II opens with a road map of military medicine during these conflicts. In Chapter 4 and those following, we see how multinational forces, led by the United States and Great Britain, rapidly ended a conventional war against Taliban and Iraqi regular forces with medical assets to spare. In short order, however, a protracted insurgency soon engulfed Coalition forces. With less than 300 beds to service nearly 200,000 troops in Iraq, there is precious little for anyone else. Multinational forces receive the best care, detainees the second best, and local nationals the dregs. Complicating things further, scarce medical resources prove useful for other reasons. Highly prized, medical attention lends itself to gathering actionable intelligence and gaining, as the Swedes put it, “force protection.” Pediatric care, in particular, delivers some of the most valuable information and the best force protection. Saving kids generates enormous goodwill and some handy side-benefits too. A quid pro quo? Maybe. Something that must be done but may not? Maybe not.
More things that must be done but may not; one that can be done but need not
Now, think about weaponizing medicine to serve the aims of war. This is the broad subject of Section III: Medicine as a Weapon of War. Civilian healthcare serves only the ends of medicine: saving lives and improving their quality. During armed conflict, medicine serves the ends of war: saving lives and improving their quality. They sound identical but are not. To save lives in peacetime, one must prevent death and cure. To save lives in war, one must pursue death and kill. Military medicine, no less than any other military means, serves war by ensuring warfighters are fit to kill.
There are many ways to kill in war and many ways for doctors to participate. The most obvious is their strenuous efforts to patch up wounded soldiers so they can fight another day. This duty requires some thought but is not overly disturbing unless troops run riot and kill gratuitously once they have recovered. But when troops do their job as they should, there is good reason to nurse them to health. When doctors, nurses, and medics fail, there is good reason to look for new ways to help. Medical experimentation is one answer. While a staple of medical science, “experimentation,” carries considerable baggage owing to Nazi and Japanese pseudo-research that brutalized civilians and prisoners of war. In fits and starts since then, medical research has trodden carefully in wartime. Perhaps too carefully, with the result of inhibiting lifesaving research on the battlefield (Chapter 8).
For all its challenges, healing remains the goal of experimentation. Sometimes, however, physicians experiment to help build bombs. Bomb building is less than therapeutic and prompted modest soul searching when the US and Britain recruited medical doctors into their fledging biological and chemical weapons (BCW) programs after World War II. But international laws put the brakes on BCW and most programs closed by 2000. In their place, some clinicians abandoned their therapeutic vocation to partner with military scientists to chemically, biologically, and neurologically enhance the human fighting machine. The moral context is not quite the same as weapons development but raises some compelling similarities. In each case, medicine serves war directly.
Lost in the debate is another crucial question: Does anyone need a neural interface implant? More generally, do enhanced warfighters meaningfully enhance warfighting? Many people think they do. Think of modern-day gladiators fortified by exosekeltons and hard wired into a computer interface embedded in their brains, cyborg-like. Strong, ever alert, super decisive, and exceptionally lethal, they’re the perfect Special Forces operative. Right? Not really. Most gladiators went the way of Spartacus. To get their job done, what Special Forces really need today is quick language acquisition. Enhancement can help, but it is not sexy. The sexy stuff is often a complicated and sometimes dangerous medical procedure we can do but may not need. A more thorough answer to these questions occupies Chapter 9.
Non-lethal, but no less benign weaponization finds its mark in medical diplomacy. Successful diplomacy is to convince others of one’s purpose. Diplomacy is a vital wartime enterprise when civilian loyalties are torn between insurgents and government forces. What better way to bring civilians over than to offer them timely and sophisticated medical care? Intuitively, this sounds like mercenary medicine, something that medical ethics should forbid. Trading favors for medical attention is corrupt. And, in peacetime, it may be. But in wartime, one asks different questions: can medical diplomacy get the job done, offer greater military benefits than costs, and avoid egregiously violating anyone’s fundamental human right to medical care? For the answer, see Chapter 10.
Things That Should Be Done but Are Not
War fatigue plagues every conflict. Countries run out of men, materiel, money, ideological fervor, and patience. They just want to go home. When they do, post-war justice suffers. The first thing victorious armies neglect is their obligation to rebuild a war-torn nation’s essential infrastructures. Chief among them is healthcare. Attention falls aside because post-war reconstruction is not a constant duty. These duties occupy Section IV, Post-War Justice and the Responsibility to Rebuild. Typically, a victorious defensive army has no obligation to rebuild the nations it traverses and tramples. But humanitarian armies do. Defensive armies go to war to protect their compatriots while humanitarian armies go to war to protect others. So it would be exceptionally counterproductive for humanitarians to leave for home before their job is finished. But the cost is high, so high that everyone looks for a way out (Chapter 11).
Finding the way out of foreign entanglements does not offer a way out of domestic entanglements. What do we do with all those vets that fill Chapter 12? They did their duty but, then, do not always reintegrate well. Others are just sick, injured or otherwise damaged. Still, others fall into poverty, suicide, divorce, and alcoholism. How a nation treats its veterans is the final reckoning of war. Often, the solution is just to forget them once the bands die down, and the confetti is swept away. As veterans, too, are swept aside, post-war justice fails at home as badly as it fails abroad. These things should not be done. But the cost of post-war justice is enormous, so much so that the inability to allocate sufficient funds for post-war reconstruction and veteran care before commencing war may proscribe war from the get-go. The projected cost of veteran healthcare and disability payments in the United States exceeds $700,000,000,000. Add to that the many billions of reconstruction, and pretty soon you’re talking real money.
But what about theory?
Books about theory and practice, like this one, begin with theory even though some people skip these sections. I end here with some remarks about theory to disabuse readers of that temptation. Applied ethics is dynamic. Moral discourse works from ethical principles to medical practice and back again. Back again is to think more carefully and, when necessary, amend or abandon first principles. The back again peeps out of each chapter and settles in the conclusion of this book. Chapters 1 and 2 explain the moral terms and ethical principles used throughout this book as they pertain to the rights and duties that military and medical ethics accord soldiers, civilians, detainees, and patients. But not all the theory chapters are theoretical. Chapter 3 is a how-to chapter and explains how to implement the principles of military medical ethics to disentangle its conundrums and dilemmas. The upshot of these three chapters is to place military medical ethics squarely in the ambit of just war.
As a weapon of war, military medicine enjoys no forbearance unless the war it supports is just. To prosecute a just war, one must kill permissibly. Now we are beginning to see how radically military medical ethics differs from civilian medical ethics and how intimately military medical ethics is tied to the conduct of war. Absent just war, military medicine loses its ethical moorings. Absent morally informed medical practice, just war is similarly cast adrift. Military medical ethics, then, is not just about repudiating torture and vivisection. Rather, military medical ethics is about ensuring fair and equitable treatment when resources are scarce, maintaining mission readiness while respecting any patient’s rights, weaponizing medicine while preserving its therapeutic function and, ultimately, saving lives to take them.
Crossing and combining military and medical disciplines to address these questions, some of the accompanying terms may be unfamiliar to single-minded readers of medical or military ethics (spoiler alert). Associative duties, for example, refer to special obligations of care that friends, family, and, as I will argue, soldiers owe one another. The distinction between impartiality and neutrality may be fuzzy for some. I try to explain each clearly before I torpedo both. Readers of medical ethics may be less than familiar with some basic principles of just war and international humanitarian law (IHL). These include the principles of necessity (adopting the least harmful means to accomplish a mission), distinction (the obligation to distinguish among military and civilian targets), proportionality (the duty to avoid excessive civilian casualties), and collateral harm (unintentional, incidental civilian death or injury).
Other concepts are unique constructions. These include military-medical necessity and broad beneficence. Each is similar but not identical to its roots. Military-medical necessity refers to the medical means required to achieve military goals. Broad beneficence invokes the collective good, that is, the best interests of an entire political commonwealth. In contrast, narrow beneficence turns on an individual patient’s best interest.
If Section I integrates military medical ethics and the principles of just war, it does not mean that I think the wars in Iraq and Afghanistan are necessarily just. Just wars are either defensive or humanitarian. A defensive war turns on an aggressor who invades, subjugates, or plunders a peace-loving nation. Germany’s invasion of Poland in 1939 is the classic example, but most others offer less certitude. Who defended and who invaded in the Falklands/Malvinas (1982), Iraq-Iran (1980), Israel-Lebanon (2006)? A humanitarian war confronts a regime that brutalizes its people who, in one form or another, invite foreign forces to rescue them. Humanitarian wars and the accompanying responsibility-to-protect and responsibility-to-rebuild are new phenomena. Examples are sparse, effective interventions more so. NATO’s demolition of the Kaddafi regime in Libya (2011) and UN and African Union troop deployments to save Darfur (2007) are two examples. The best example is probably the one that wasn’t: Western intervention in Syria (2011 ongoing). Each archetype of war, whether defensive or humanitarian, provides the context for the theory and practice of military medical ethics.
A Brief Methodological Note
Before moving on, a brief methodological note is appropriate. I noted that Chapter 3 explains how applied ethics confronts theoretical ethical principles with real-life military medical practice. Each chapter is an exercise of applied ethics. The normative principles outlined in Chapters 1 and 2 draw from moral philosophy and international law. The practice of military medicine that occupies the rest of the book emerges from varied and voluminous literature by doctors, nurses, lawyers, military commanders, politicians, and policymakers since the turn of the 21st century.
In the course of recent wars, physicians and nurses published substantial research, surveys, clinical guidelines, and case studies in military and nonmilitary medical journals that engaged the fundamental question of medical care in an austere environment. An overview of this publication activity appears in Chapter 8. The United States, Britain, NATO, and the defense departments of other multinational forces circulated handbooks, policy papers, legal opinions, and lessons-learned reports about military and health doctrine, strategy, equipment, and protocols across their services. Special Inspectors General for Iraq and Afghanistan Reconstruction audited Coalition operations regularly since the early years of these wars. International organizations were equally energetic. The United Nations, World Health Organization, International Committee of the Red Cross, and numerous health and human rights NGOs did their best to keep an eye on belligerents and offer guidance and reproach as needed.
The result is a panoply of independent actors, sometimes cooperating and other times working at odds with, or ignorant of, one another. The data are not always consistent. Agencies report their findings in different ways, and the numbers do not always reconcile. Later versions of military and field manuals replace the earlier editions leaving guidelines of the war years to sometimes vanish into irretrievable archives. Rarely did anyone engage their moral qualms directly. But the material for ethical discourse is there if you look closely.
Despite the range of sources enlivening the following chapters, this book is neither an empirical nor exhaustive study of military medicine or just war since 2000. Rather, it uses the data that military, governmental and nongovernmental sources supply to exemplify medical practice, illustrate the shortcomings of military medical ethics, and suggest modest resolutions. Before beginning in earnest, one more story.
During World War II, doctors bandage up a soldier named Yossarian to masquerade as another who recently died of wounds. It’s a gesture to the family coming a long way to see their dying son. After a few Helleresque interlocutories, a brother wants to know;
Did you have a priest?'
'Yes,' Yossarian lied, wincing again.
That's good,' the brother decided. 'Just as long as you're getting everything you've got coming to you. We came all the way from New York. We were afraid we wouldn't get here in time.'
'In time for what?'
'In time to see you before you died.'
'What difference would it make?'
'We didn't want you to die by yourself.'
'What difference would it make? (Heller 1955: 177).
In real life, insurgents ambush a French military convoy in Afghanistan. Fighting off gunfire, the French squad weaves a ring around two catastrophically burned soldiers to afford the medic room to work. Medical attention is futile; the wounded men have no chance of survival. Nevertheless, the medic depletes his stock of medicinals, leaving precious little if attacked again. But their goal is closely focused: to send the two soldiers home before they die.
What difference would it make?
Indeed.