Medical Diplomacy and the Battle for Hearts and Minds

Medical diplomacy leverages health care to win hearts and minds, pacify war-torn communities, and gather intelligence. Charging that medical diplomacy exploits vulnerable patients, critics chastise military medicine for repudiating the neutrality it requires to deliver good care. Military medicine, however, is not neutral. But it must be effective and looking at the wars in Vietnam, Iraq, and Afghanistan, medical diplomacy does not usually offer good care. MEDCAPs (Medical Civic Action Programs) and PRTs (Provincial Reconstruction Teams) fail to provide civilians with quality treatment. Suggestions for improvements abound and if medical diplomacy proves effective, then humanitarian force may utilize medicine for military advantage, pacification, and stabilization during armed conflict. At the same time, humanitarian war requires close cooperation between military forces and civilian-relief NGOs (nongovernmental organizations). Ideally, the former provides security and funding, while the latter work with local officials and stakeholders to build health care infrastructures and restore confidence in the government.

Military Medicine in Contemporary Armed Conflict

In the Iraq and Afghanistan wars (2001 and ongoing), military medicine saved more wounded than in any previous conflict. Improvised explosive devices (IEDs) injured tens of thousands of the more than three million warfighters deployed. Prominent wounds included multisystem injuries, traumatic brain injuries, limb loss, and post-traumatic stress (PTSD). To care for wounded service personnel, multinational forces established in-theater facilities for lightly and moderately wounded, while evacuating the critically injured to Europe and the United States. Coalition facilities could not offer comprehensive medical attention to host-nation allies or civilians. As the fighting progressed, multinational forces teamed up with local government agencies to slowly rebuild local medical infrastructures through Medical Civic Action Programs (MEDCAP) and Provincial Reconstruction Teams (PRT). As the conflicts wind down, Coalition nations face their responsibility to rebuild each country and to tend discharged veterans at home. Both tasks prove daunting.

Military Medical Research and Experimentation

Medicine is often unprepared for the physical and psychological wounds of modern war. Military medicine requires urgent research to treat traumatic brain injury, develop resuscitation techniques, upgrade surgical procedures, and acquire effective drugs. Retrospective, observational, and survey studies dominate the literature. However, clinically controlled experimental studies, the gold standard of medical research, are rare in military medicine. Stringent informed consent requirements to protect service members from coercion and undue influence make it difficult to enlist them for in-theater clinical studies. When a research subject is unconscious and his representative is unavailable to give consent, investigators can request waivers. But due to concerns about patient vulnerability, waivers are rarely granted to allow researchers to recruit injured soldiers in the field. Easing informed consent requirements to match those of civilian medical research, and intensifying efforts to recruit civilian research subjects during war will improve the prospects of clinical research.

Postwar Healthcare Reconstruction

Following humanitarian wars, multinational forces incur an obligation to rebuild. As international donors and local authorities rebuilt healthcare services in Iraq and Afghanistan, life expectancy and vaccination rates increased while infant and maternal mortality decreased. Using health to enhance state-building, however, was less successful. State-building is an ambitious undertaking that requires legitimacy, governance, essential services, and human security. Although health care can foster trust between the government and its citizens, Iraq and Afghanistan show only slight progress toward constructing secure, stable nations. War-torn countries, however, are not the only eligible recipients for reconstruction aid. Any severely fragile and destitute state has a claim for assistance and healthcare aid against the international community. To get the most of their resources, therefore, donor states must apportion aid to those states with the best chances of providing their citizens with a decent and dignified life.

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.

Care and Compensation for Civilian Victims of War

Lacking bed space, Coalition military hospitals in Iraq and Afghanistan declined to admit any civilian except those injured by multinational forces. There are, however, no firm moral grounds for granting collateral casualties a special right to medical attention. Military necessity justifies preferential care for civilians who can contribute to a counterinsurgency, not those suffering collateral damage. Money, not medicine, is a better vehicle to assuage resentment among wounded civilians. Considering the rights of compatriots, allies, civilians, and detainees, five ethical principles govern the distribution of medical care during war: military-medical necessity, associative duties, liability for collateral or accidental harm, beneficence, and urgent medical need. Judging by the number of patients each principle reaches, the cost of care, and the feasibility of implementation, necessity and associative duties best serve military medicine. Once patients assemble by identity and military status, urgent medical need governs care within each group.

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.

Veteran Health Care

Afterwar, embattled countries often forget their veterans. The rule is simple: nations must offer wounded veterans the same medical care other citizens enjoy. Nevertheless, veterans have no special rights to preferential or priority care. Virtuous or villainous conduct is an unacceptable criterion of medical attention. Just as the innocent victim of a traffic accident enjoys no stronger right to health care than the inattentive driver who ran the light, soldiers enjoy no exclusive right to medical treatment. Nor can discharged veterans appeal to military necessity to afford them the privilege of priority care. Despite provisions in the United States, the United Kingdom, and Australia to carve out special rights for veterans, they are without a firm moral foundation. Instead, each nation may reward military service with public recognition and financial compensation, while providing every citizen with the high level of care that each deserves by right.

Warfighter Enhancement: Research and Technology

To improve warfighter performance, medical science seeks pharmacological, surgical, genetic, and neurological technologies to make soldiers smarter, faster, stronger, and more alert. The sought after soldier is a gladiator or Jedi knight. Scientific research, however, is unwarranted if superfluous, and there are grave doubts about the usefulness of super soldiers in modern warfare where warfighters need language and cultural skills rather than strength and endurance. Beneficial enhancement research, therefore, focuses on learning, information analysis, and organizational efficiency that do not require invasive, irreversible, or surgical interventions. Utilizing noninvasive technologies such as wearables or neuroplasticity training carry few risks and enable research subjects to give fully informed consent. Nevertheless, medical scientists are not conducting therapeutic research to ameliorate pain and suffering. They are building weapons of war. As a result, enhancement researchers and providers jeopardize their immunity on the battlefield and leave themselves liable to defensive killing in war.