Wartime Medical Ethics

Abstract

To the Editor: Michael Gross raises many important and controversial issues in his article, "Bioethics and Armed Conflict: Mapping the Moral Dimensions of Medicine and War" (HCR Nov-Dec 2004), not least in his principle conclusion that "Medical ethics in times of war are fundamentally different from those in times of peace." If the basic ethical principle for a physician is always to do the best he can for his patients, Hippocrates could be said to share Gross' view; according to Plutarch's Lives, "he would never put his skill at the service of barbarians who were enemies of Greece." The issue comes down ultimately to the human rights of the individual versus the necessities of the state. Modern medicine is evidence-based, but evidence cannot settle ethical disputes. Perhaps, though, a change of circumstances can. Some doctors are pacifists; in countries permitting conscientious objection to military service, they are unlikely to serve in war. Others may refuse to serve in certain combats, or may feel that specific orders breach their ethical code. For health workers as for others, to obey an order which is illegal under the Geneva Conventions is not a defense to a charge of committing a war crime. The most radical proposal was made by J.A. Ryle, professor of physic at Cambridge University, in his preface to The Doctor's View of War, almost seventy years ago: "By withholding service from the Armed Forces before and during war, by declining to examine and inoculate recruits, by refusing sanitary advice and the training and command of ambulances, clearing stations, medical transport, and hospitals, the doctors could so cripple the efficiency of the staff and aggravate the difficulties of campaign and so damage the morale of the troops that war would become almost unthinkable." Perhaps group loyalty--patriotism when you favor it, nationalism when you do not--makes this solution impossible. But many physicians in many countries now support organizations such as International Physicians for Prevention of Nuclear War. They are working to end all war. Douglas Holdstock Editor, Medicine, Conflict and Survival To the Editor. Concerning Michael Gross's excellent paper, two points: First, the Pentagon's argument that it is not feasible to obtain informed consent for the use of investigational drugs during war is unpersuasive if (1) an accurate, concise, and readable disclosure document can be crafted and distributed with the medication, (2) records can be kept, and (3) there is no evidence that key personnel would opt out. I believe all three conditions are met (as do military physicians with whom I have spoken). Second, the misnomer "non-lethal weapon" distracts from the sometimes lethal consequences of using these items (such as the anesthetic agent used in the Moscow theater hostage situation). In addition, their use is not likely to be confined to deterrent operations but will almost certainly include quasi-policing procedures, as has been contemplated in Iraq. Medical scientists who consider participating in the development of such weapons should not be comforted by the labeling. …