The tragedy of war has been common throughout human history and is presently raging worse than ever. The ethical or moral dilemmas encountered by physicians in combat are difficult to resolve since they have pledged their loyalty to the Hippocratic Oath. The military corps has other priorities that involve serving the interest of a state or a nation. Even though there may be actual orders as to how to treat prisoners or enemy soldiers, and civilians, these considerations take a backseat to the protection of national interests. Consequently, a physician must choose between being loyal to their pledge to save lives against obeying a state or a nation’s efforts to save their national interests even if it means killing civilians or soldiers “hors de combat.”
Bioethics for Medical Doctors in the Army
War is a tragedy whose existence is riddled with ethical challenges and paradoxes that no one likes to talk about. Perhaps the only way these ethical questions may be considered is if we think of them through a veil of humor. This was the basis of the series “MASH”, one of the most famous and successful television program, portraying life in a MASH, a medical mobile unit with nurses and surgeons who took care of wounded soldiers during the Korean War. The popularity of the show was due to the two main characters B.J. and Hawkeye whose adventures illustrated these ethical and moral dilemma doctors go through when in the Army, and especially at war. MASH made us laugh at the absurdity of the ethical dilemmas B.J. and Hawkeye had to deal with on a daily basis. However, some episodes could not make us laugh because the level of tragedy involved in the story was too deep. Many times, B.J. and Hawkeye found themselves in situations when they had to make a choice between being soldiers or being doctors. Their choice always tended to be in favor of being a doctor first, even if it meant that they would be disciplined for disobeying orders. One may think that the choice is clear, either way, but as this discussion will show that it is not the case. The scope of this paper is to explore these issues by defining what ethics are, what background doctors as well as military men come from, ,and what may happen if you mix both in one person. The scenarios invoked to discuss this topic are when the country is either at peace or at war.
ETHICS AND BIOETHICS
What can be said about ethics, and specifically bioethics? In the first place, ethics are the analysis and the application of moral concepts dealing with Good, Evil, Right, Wrong, Responsibility. The reason why ethics are so hard to grasp is because even though, we may be able to break down ethical questions as morally good or evil, right or wrong, it is rarely that obvious or clear cut. The context of the ethical dilemma is as important as the question itself since the question cannot be defined without the context of the problem. It is a mistake to reduce an ethical question to a one-dimensional problem because it may very well lead us into making the wrong decision as to what we really stand for thereby promoting feelings of guilt or regrets for our actions. Another possibility is that we may be overconfident that we are right thereby hurting or arming others by our self-inflicted blindness. The goal of making ethically acceptable decisions is to fully commit to the idea that ethical dilemmas are multi-dimensional and deal with it. (Carol Levine, 2006)
Medical ethics contend with the evaluation of merits, risks, and social concerns of actions made in medicine. When a student goes to medical school or nursing school, they are given a list of principles as guides for making an ethical and moral decision. The Hippocratic Oath is the solemn pledge to practice medicine as it was intended to be by Hippocrates:
“I will remember that I remain a member of society, with special obligations to all my fellow human beings, those sound of mind and body as well as the infirm. If I do not violate this oath, may I enjoy life and art, respected while I live and remembered with affection thereafter. May I always act so as to preserve the finest traditions of my calling and may I long experience the joy of healing those who seek my help.” (Lasagna L, 1964/2001)
The main principles are the following: salus aegroti suprema lex or the most important law is to act in the best interest of the patient, primum non nocere or first, do no harm, Voluntas aegroti suprema lex or the most important law is for the patient to be able to choose his or her treatment, justice or making choices as to who would get first treatment in the event of scarcity of resources, dignity for both patients and doctors, the patient should not be lied to and deserves the right to know all the facts about their illness and treatment. Again, these guiding principles by themselves do not give a miracle answer, but they may be applied within the multi-dimensional context of the situation without forgetting that these principles in some cases may interfere with each other in particular cases. (Gillon, 1994)
BEING IN THE MILITARY
Becoming a soldier is a commitment to serve the country and its ideals. The training is geared towards breaking independence and making everyone obedient to the same orders. A soldier must obey to his or her superiors, no argument, just obedience. A soldier who argues with his or her superior officers will be disciplined and can even undergo court martial, which may be the end of his or her military career and may also get him or her, a jail sentence, depending on the offense. Independent thinkers do not make it in the Army and if you notice there are not any. There are two ways a doctor can be s soldier: on one hand, he or she was trained as a doctor by the Army, or on the other hand, he or she might have joined after finishing medical school as a civilian. These two scenarios may impact the behavior and ethical choices that a physician may face. Presumably and generally speaking, someone who has done his or her entire medical training in the Army as an army recruit may feel more loyalty towards the Army and its thinking. However, someone who never was in the Army to begin with or imagined that he or she would be in the Army may feel a weaker loyalty to the ideals of obedience that the Army holds. In the MASH example, B.J. and Hawkeye were civilian doctors who became military men as a result of the Korean War effort. Their loyalty and ethical values remained far away from military thinking. (Murray, 2004)
WHEN MILITARY OBEDIENCE STRUGGLES WITH MEDICAL ETHICS
The difficulties outlined in the definition of ethics as well as medical ethics above are especially applicable in times of war. Michael Gross establishes that there is no correspondence between being a physician in the army at war and being a physician in the army at peace. He states: “Armed conflict augments the general principles of bioethics with those peculiar to the conduct of war.” (Gross, 2004) The fundamental difference between military ethics and medical ethics are the focus of intent. Medical ethics focus on the patient or patients and the care associated with their medical condition. By contract, military ethics focus on the rights and the interests of three types of groups: the combatant, noncombatants, and the state. Gross gives a first step to approach a solution. The notions of life, liberty, and dignity that we saw earlier in the principles of medical ethics above can conflict one another. Gross tells us that we need to use a “utility maximizing” principle to make further progress as to determine a priority. Medical ethics does not place utility above any other principles, but simply places it at the side of others whereas military ethics heavily rely on utility that may overrun other principles because in effect, the utility principle allows the military to kill moral constraints on military action, so to speak. War tramples an individual’s right to life and automatically to medical care. Specifically, the consideration of an enemy soldier’s life and right to medical care is denied if they still pose a threat to our side. However, if the soldier is “hors de combat”, then the risk of threat is null thereby granting the enemy soldier medical treatment and life. More subtle is the use of medical expertise to develop lethal or non-lethal weapons. Gross’s conclusion is that the laws of humanity and the physician’s duty of beneficence are not synonymous, implying that this is a sort of loophole that one person can use to justify injuring another or withdrawing medical care. Therefore, a physician can also be a soldier.
Bioche and Marks speak of recent events in the Iraq War where U.S. medical personnel have been caught not reporting accounts of prisoner abuses, degrading treatments, and even murders. Their premise starts with their statement: “When military forces go into combat, they are typically accompanied by medical personnel (physicians, physician assistants, nurses, and medics) who serve in non-combat roles. These professionals are bound by international law to treat wounded combatants from all sides and to care for injured civilians.” (Bioche & Marks, 2005) By contrast, Gross extensively explained the subtleties of military ethics against medical ethics in the first part of his article, introducing the notion that physicians may not feel bound by international law and/or the Geneva Convention since his or her concept of beneficence can be adapted to his or her personal circumstances in a conflict. In fact, Bioche & Marks state clearly that physicians are obligated to act according to international law to care for all patients as they are accompanying the Military. There seems to be no hesitation in their tone and no ambiguity in their understanding of international law.. In addition, their points are based on the current events in Iraq where scandals have erupted of prisoner abuses by wardens. These abuses were known to exist, not only by regular service men inside the prison, but also by medical personnel. Their position is that such abuses should have been reported to military commanders because physicians as well as nurse serve in non-combatant roles, implying that they take no part in fighting, thereby representing neutrality. The Geneva Declaration is an international standard for medical ethics that physicians also pledge their allegiance to: “I will maintain the utmost respect for human life.” “I will not use my medical expertise to violate human rights and civil liberties, even under threat.” (World Medical, 1949/2006) After reading these pledges, can we argue that a physician’s duty is to his or her patient first? Can we say that if an enemy soldier still pose a threat, but he or she is injured that the physician from the other side has the choice to let this person die? If the physician lets the enemy soldier die, then he or she violates the Hippocratic Oath, but fulfills their allegiance to their nation. So, the important point becomes how important is the allegiance to one’s nation over their duty as a doctor who heals and does not kill? Gross’s expose seems tedious in his effort to take every action or position apart as a philosopher would. It is important to define the context of the ethical dilemmas and analyze the multi-dimensional aspects of a choice, but Gross loses sight of the main points to be considered in this debate by over analysis. If we go back to his idea of utility, the doctor places utility along other principles, Gross said. However, in the Iraq situation, utility has no bearing on a physician’s ethical choices on denouncing abuses that have nothing to do with military victory or loss to benefit a state or a nation. In fact, these prisoners have no value as informers. In addition, the Geneva Convention, the Geneva Declaration, and the International Human Rights are supposed to be upheld by the nations who signed them. Even though these rules are imperfect and contradict one another as Gross said, this is no excuse for physicians to kill or let patients die since they are bound by greater principles that address life and the preservation of life. Gross’s statements that the physician’s pledged duty is only applicable to individual patients is a convenient interpretation that allows him to confuse the issue of life preservation in general.
In conclusion, a physician or a nurse has the responsibility to preserve life and care for all patients, regardless of their origin, whether it be friend or foe. Ethical dilemmas are multi-dimensional problems, but it should not cloud the basic issues at stake: can the Hippocratic Oath be overridden by nationalistic loyalty? Multi-dimensionality in this example is the extent a physician should go to in order to care for enemy patients. The extent is subjective, meaning that basic care might just be enough to preserve their life and protect their health without any abuses. In addition, a physician has no authority to pass judgment on the political as well as military status of prisoners or injured civilians. “The fact that a person acted pursuant to order of his Government or of a superior does not relieve him from responsibility under international law, provided a moral choice was in fact possible to him.” (The Nuremberg, 1945/1950)
Bioche, M. G., & Marks, J. H. (2005). When doctors go to war. New England Journal of Medicine, 352(1), 3-6.
Carol Levine. (Ed.). (2006). Does military necessity override medical ethics? [Special issue]. Taking Side: Clashing Views on Controversial Bioethical Issues, 11(17).
Gross, M. L. (2004). Bioethics and armed conflict: mapping the moral dimensions of medicine and war. In Hastings Center Report (Bioethics and Armed Conflicts No. 6, pp. 22-30). Garrison, N.Y: The Hastings Center.
Gillon, R. (1994). Medical ethics: four principles and attention to scope. Bioethics Medical Journal, 309, 184.
Lasagna L. (2001). The Hippocratic Oath Modern Version. . (Original work published 1964) Retrieved December 12, 2006, from NOVA PBS Web site: http:/?/?www.pbs.org/?wgbh/?nova/?doctors/?oath_modern.html
Murray, K. R. (2004). Training at the Speed of Life Volume One – The Definitive Textbook for Police and Military (1st ed., Vol. 1). Gotha Florida, US: Armiger Publishers.
The Nuremberg Principles (1st ed., Vol. 2). (1950). . (Original work published 1945) Retrieved December 12, 2006, from Wikipedia Encyclopedia Web site: http:/?/?en.wikipedia.org/?wiki/?Nuremberg_Principles
World Medical Association International Code of Medical Ethics. (2006). . (Original work published 1949) Retrieved December 12, 2006, from The World Medical Association Web site: http:/?/?www.wma.net/?e/?policy/?c8.htm
 I am assuming that there is an equivalence of the terms ethics and morals in this discussion, but it may be argued in others that they are not quite the same. Nonetheless, I will use the terms interchangeably since the point of the discussion is to argue actions within a context.