Medical Ethics for the Military Profession

This paper summarizes medical ethics in the military profession to raise military leaders’ awareness of Military Medical Ethics (MME) and the ethical issues that may impact their medical services and personnel. First, it summarizes core concepts, including the four principles of medical ethics (autonomy, beneficence, non-maleficence, and justice), the two legal frameworks for the use of military force in war, jus ad bellum and jus in bello, and the concept of dual loyalty. It then examines MME issues during conflict, in garrison healthcare, and during the COVID-19 epidemic. Finally, it concludes by arguing that MME is an important domain of military ethics that should be taught to military leaders to complement the detailed education of MME for military medical professionals.

Thematic Analysis of Military Medical Ethics Publications From 2000 to 2020—A Bibliometric Approach

ABSTRACT Introduction There has been external criticism of the compliance of military health personnel with internationally agreed principles in military medical ethics (MME). In response, a number of authors have called for clarity on the principles and topics within the domain of MME. This complements an increased acknowledgment of the need for education in MME for military health personnel. Our paper utilizes bibliometric techniques to identify key themes in MME to inform the development of a curriculum for this subject. Materials and Methods We designed a search strategy to find publications over the period January 1, 2000-December 31, 2020 in the domain of MME from the three databases, PubMed, Web of Science, and Scopus, using the search string (ethic* OR bioethics* OR moral*) AND military AND (medic* OR health*). We obtained a total of 1,115 publications after duplication removal. After exclusion based on topic, year, and study design, we analyzed a total of 633 publications using Scopus’s embedded analysis tool and the software VOSViewer. We generated a co-occurrence word map from the abstracts of each of the publications. We deduced themes of MME based on the clusters shown in the word map, and we categorized each publication into one of these themes to analyze the change of themes over time. Results We observed a 10-fold increase in annual publications on MME between 2000 and 2020. The majority of papers were written by U.S. (72%) and UK (13%) authors, although a total of 15 countries were represented. After using VOSViewer to identify co-occurring keywords in titles and abstracts from these publications, nine themes were identified: biomedical research, care to detained populations, disaster/triage, mental health, patient-focused foundations, technology, dual loyalty, education/training, and frameworks. The relative proportion of each of these themes changed over the study period, with mental health being dominant by the end. Conclusions This study has identified key themes that might inform the development of a curriculum for teaching MME. It is noticeable that the majority of themes cover MME from the perspective of professional practice on military operations; noting, the research and technology themes also pertain to the generation of knowledge for military operations. There were a limited number of publications covering practice in the non-deployed or garrison settings, and these were codified under the themes of “framework” and “dual loyalty”. The results are skewed toward English-speaking countries and exclude non-academic publications. Further work will search for other open-source information and non-English publications. To our knowledge, this exploratory bibliometric analysis on MME in the academic literature is the first of its kind. This article has demonstrated the use of bibliometric techniques to evaluate the evolution of knowledge in MME, including the identification of key themes. These will be used to support further work to develop a curriculum for the teaching of MME to military medical audiences.

Military Medical Ethics and Just War

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.

Moral Reasoning in Military Medical Ethics

Applied ethics must resolve moral dilemmas, because, at the end of the day, medical personnel and military commanders must act. Reaching a defensible ethical decision requires moral agents to define the military and medical mission clearly and answer the following questions. Is the proposed operation or policy an effective and necessary means to attain the mission’s goals? Are the costs proportionate, keeping in mind that costs include military, medical, and moral costs? Finally, is the deliberative forum appropriate? Military medical ethics entails private (doctor-patient) and public discourse. Public discourse or deliberation engages the political community and its institutions. It requires widespread participation, well-reasoned arguments, reasonable pluralism, and, ultimately, responsive public policy.

Introduction

“Can military medicine be ethical?” is one question that may puzzle readers whose knowledge of medical ethics since 9/11 is colored by the prisons of Abu Ghraib and Guantanamo Bay. To address these and other challenges, Military Medical Ethics in Contemporary Armed Conflict explores controversial topics that include preferential care for compatriot warfighters, force feeding detainees, weaponizing medicine to wage war, medical experimentation, and neural enhancement for warfighters. Less controversial but no less compelling concerns direct our attention to postwar justice: the duty to rebuild war-torn nations and the obligation to care for war-torn veterans.

Conclusion

Rounding out Military Medical Ethics in Contemporary Armed Conflict, the conclusion first highlights the signposts that lead the reader to understand how the ethics of war is inseparable from the ethics of military medicine. Military medicine must serve just war. Historically, just wars are defensive or humanitarian. But things may change. So next, we look to the future. Past wars do not necessarily predict coming conflicts. Future wars will see novel weapons and new adversaries drawing from nation-states, nonstates, criminals, and unknown assailants. Nevertheless, the experience of recent wars, particularly those in Iraq and Afghanistan, offers important lessons to guide military medicine as war evolves into ways we can anticipate and in ways we cannot.

Military Medical Ethics in Contemporary Armed Conflict

Beleaguered countries struggling against aggression or powerful nations defending others from brutal regimes mobilize medicine to wage just war. As states funnel medical resources to maintain unit readiness and conserve military capabilities, numerous ethical challenges foreign to peacetime medicine ensue. Force conservation drives combat hospitals to prioritize warfighter care over all others. Civilians find themselves bereft of medical attention; prison officials force feed hunger-striking detainees; policymakers manage health care to win the hearts and minds of local nationals; and scientists develop neuro-technologies or nanosurgery to create super soldiers. When the fighting ends, intractable moral dilemmas rebound. Postwar justice demands enormous investments of time, resources, and personnel. But losing interest and no longer zealous, war-weary nations forget their duties to rebuild ravaged countries abroad and rehabilitate their war-torn veterans at home. Addressing these incendiary issues, Military Medical Ethics in Contemporary Armed Conflict integrates the ethics of medicine and the ethics of war. Medical ethics in times of war is not identical to medical ethics in times of peace but a unique discipline. Without war, there is no military medicine, and without just war, there is no military medical ethics. Military Medical Ethics in Contemporary Armed Conflict revises, defends, and rebuts wartime medical practices, just as it lays the moral foundation for casualty care in future conflicts.