Fighting military doctors

Ethics and military

Wars and violent conflicts not only lead to the destruction of material goods, but also always mean death, suffering and injury for the soldiers or fighters involved and the civilian population affected in the conflict area. The suffering of those injured in the war was described prominently and impressively by Henri Dunant, who provided the inspiration for the Geneva Conventions and the Red Cross movement, in his memories of Solferino. Doctors and medical staff have an important role to play in such situations, as they can use their knowledge and commitment to help alleviate the suffering caused. Armies have long also used doctors to provide their soldiers with the prospect of rapid medical care in the event of an injury.

This article briefly introduces the medical task and its special role in international law and then discusses the problem arising from the double role of doctor and soldier, which is expected of military doctors conceptually and unfortunately also in reality. Based on international law and ethical arguments, this article shows that the medical role must be given more weight.

Humanity despite war

With the first Geneva Conventions in the 19th century and in the current international humanitarian law, medical activity and the group of people entrusted with it are given a special position: Although military doctors are part of the military, they are considered non-combatants and enjoy immunity from attacks. This special role goes hand in hand with obligations, because as protected personnel, on the one hand, they are not allowed to take part in combat operations and, on the other hand, they must treat all injured and needy people equally - regardless of nationality, rank, gender and other non-medical distinctions. Medical care should only be committed to the principle of humanity and should therefore be neutral. Humanity as "principe essentiel“(According to Pictet) of international law is to be understood as a counterweight to the logic of military necessity.

The double role of the military doctor

In the profession of the military doctor, who is at the same time a soldier and a doctor, the conflict between military necessity and the principle of humanity is revealed in a special way. Because the fighting and thus also hurtful role of the soldier stands in opposition to the healing and nurturing role of the doctor. In a certain way, the military doctor is conceptually expected to fulfill two roles, which, however, are not always compatible with one another and thus lead to role conflicts or contradicting role obligations in one person (dual loyalties1) being able to lead. If the differences between the two roles are blurred in practice and thus in the experience of military doctors, there is a risk that these differences will be increasingly less and no longer adequately reflected. The mixing of the two roles is promoted in today's conflicts by the "embedding" of medical personnel in fighting units in order to ensure their rapid medical care.

Different role ethics

Anyone who is actually supposed to fill two roles at the same time is also confronted with the question of which role ethic is to be regarded as the (re) relevant one. It is true that the ethical rules for different roles do not necessarily and constantly conflict; in the case of military ethics for soldiers and medical ethics for doctors, however, contradicting professional ethics obligations must be assumed.2 Military doctors are also often obliged to take two oaths: the Hippocratic one and the soldier one.

On the one hand, there are military ethical obligations and rules. They are mostly derived from the just war tradition. For soldiers, the rules of the ius in bello relevant, according to which violence can only be directed against combatants and must be proportional. So violence is subject to rules even in war. What is decisive, however, is that according to these rules, soldiers are morally entitled in certain situations to attack soldiers on the opposite side. You can then also use (potentially) fatal force - without necessarily finding yourself in a situation of individual self-defense. A soldier's oath or a corresponding pledge obliges soldiers to serve their country; military virtues are often mentioned as obedience, bravery and comradeship.

In the tradition of the Hippocratic oath, doctors swear to devote their lives and work to the health of their patients, to promote their recovery and not harm them. In modern medical ethics, medical action is usually measured according to the most influential approach based on four principles: respect for patient autonomy, non-harm, benevolence and (distributive) justice. Either way, the focus of medical ethical considerations usually lies in promoting the well-being of individual patients. (Exceptions to this are sometimes found in research ethics and the Public health-Ethics made in which the health of a larger group is considered - without, however, completely losing sight of the individual patient.)

Soldiers and doctors are bound by fundamentally different professional ethics. To put it bluntly, one could say: soldiers defend their country and their fellow citizens; Doctors heal their patients. While medical ethics follows an individual logic that focuses on the patient's well-being, military ethics takes a collective perspective. It therefore follows a collective logic and aims at national security and the survival of a group.

Problematic dual role in reality

If it is not clear for the professional group of military doctors whether they are committed to military or medical ethics, in practice they quickly find themselves in a role conflict with loyalties for both roles. In the end, it is irrelevant whether this role conflict actually exists or whether it is “just” perceived as such in individual cases. In any case, in recent years it has been shown in a number of cases that the (perceived) dual role and the uncertainty with regard to belonging have in reality led to significant moral problems or even to violations of international humanitarian law. In this context, mention should be made of the participation (or even the presence) of doctors in interrogations who are immoral or illegal in themselves or due to the methods used; but also questionable triage criteria and non-medical principles for patient selection (rules of eligibility).3

The alleged need to arm the medical staff and their vehicles with more weapons has been repeatedly discussed recently, because they are often attacked in current operations. Attacks on medical facilities in conflict are undoubtedly a problem. However, the question must be asked whether they can be prevented by arming the medical personnel or whether the increasing embedding of medical personnel in military patrols and thus the mixing of combat and medical roles even favors such attacks. It is not without reason that an appropriate spatial distance between protected units and combatants is required from an international law perspective (1st Geneva Convention, Art. 19).

Another problematic mixing of medical and military roles can be in such a way specified Winning Hearts and Minds-Campaigns are found in which medical action is instrumentalized for non-medical goals. Finally, it seems at least less likely that doctors will take a neutral perspective on documenting war crimes and protecting the rights of people, as is often assumed, if they perceive themselves more as soldiers.

Significance and weight of the medical role

The examples mentioned make it clear that the overlapping of the medical and military roles is to be viewed as problematic from an ethical point of view. Such an assessment is also reflected in international legal regulations and other important guidelines that require a clear separation of roles and assign medical staff their medical role. According to this logic, military doctors are first doctors and, accordingly, obliged to comply with professional medical ethics (even if they are employed and paid within the military). There is no need to justify why they are medical professionals and if they are acting in accordance with the rules for doctors, but justifying why they are to deviate from this role.

This becomes clear, for example, in Article 16 (Additional Protocol I) and Article 10 (Additional Protocol II) to the Geneva Conventions. These stipulate that no one "may be punished for having performed a medical activity that is in accordance with the medical code of honor, regardless of the circumstances and for whose benefit it was carried out." in rule 26 of the compiled by the International Committee of the Red Cross (ICRC) International Customary Law:

"Punishing a person for performing medical duties compatible with medical ethics or compelling a person engaged in medical activities to perform acts contrary to medical ethics is prohibited."

Under international law, military doctors are clearly bound in their actions to comply with medical ethical standards. Interestingly, the authors of international humanitarian law explicitly require military doctors to comply with medical ethical (and thus non-legal) standards. In other words: How military doctors and medical personnel should behave in war is not only found in international law, but primarily in the regulations of medical ethics.4 It can therefore be assumed that the medical role has priority.

This naturally leaves the question of which medical ethical standards apply and whether these differ from civil standards in the event of a conflict. The best-known answer to this question is provided by the World Medical Association (WMA) in the so-called Havana Declaration. There it says in the first sentence:

"Medical ethics in times of armed conflict are no different from medical ethics in peacetime."

This statement (or this requirement) has been discussed a lot and is often criticized for its generality. The direct transferability of civil clinical standards to conflict situations is disputed. In individual cases and especially in extreme cases, deviations can certainly be unavoidable. However, this does not call into question that no other professional ethical standards and ethical principles should be applied to doctors in war or conflict situations.5 A number of important international organizations (including the ICRC and the International Committee of Military Medicine, ICMM), which this year a joint document too Ethical Principles in Health Care in Times of Armed Conflict and Other Emergencies want to say goodbye. The draft document explicitly states that the principles and foundations of medical ethics remain unchanged in a military context (or in general in emergency situations).

Closing remarks

In the figure of the military doctor, two roles meet, which are tied to conflicting role ethics. This role conflict is not only of a theoretical nature, but also shows itself in reality (as the examples above make clear). The current tendency to see more and more soldiers with special skills in military doctors are clearly opposed by international humanitarian law and (medical) ethical principles, both of which accord the medical role a greater importance and special status.

The mixing of soldier and medical roles is particularly problematic when it is ultimately the responsibility of the individual military doctor to weight the roles, possibly even depending on the situation. Conversations show that military doctors with less experience or in embedded operational situations partially suppress their ethical and legal medical obligations and perceive themselves (primarily or exclusively) as soldiers. Group dynamics in small units can reinforce this tendency.

It is important that the special role of military doctors from a military perspective, with its obligations and limitations, is known and recognized at all levels and also among non-medical personnel. It must also be systematically taken into account when planning operations. This requires the (political) will to respect and protect medical personnel and their independent and neutral medical task in accordance with the principle of humanity. Ultimately, this is also in the interests of the combatants: This is the only way to guarantee that military doctors can firstly meet their moral and legal obligations and, secondly, are available as military doctors in an emergency when their comrades in combat or other victims of violence and suffering need medical help in a conflict.