War Ethics: The Physician vs Nationalism
Dr. Priyanka Manghani
“Non-violence leads to the highest ethics, which is the goal of all evolution. Until we stop harming all other living beings, we are still savages.”
– Thomas.A.Edison
War. A term so common now, that every day we‘re embroiled in a variety of news of death, dismay, and destruction. Syrian Civil War, War against Taliban, Vietnam War… are just a few names to begin with. War is a term human civilization is so obsessed with, that there isn‘t a single nation or fundamentalist / radical group not willing to start one. War means loss of life and health. The role of a military physician here is extremely crucial. However, doctors also face a dozen ethical dilemmas during the war, which not only tests the noble profession of medicine and humanity but also puts many lives at risk.
During times of war, physicians are sometimes faced with the conflict of their professional duties to ensure the ethical principles of beneficence, non-maleficence, patient autonomy, and self-determination, within the framework of the proper ethical conduct in the practice of medicine, and the obligation and duties placed upon the physician by the state in times of war. Many ethical dilemmas may occur for the physician on the battlefield or elsewhere in the war region, including the treatment of detainees and the priority of treating wounded enemy soldiers or civilians first. Prejudiced, Nationalism, or Humanitarian Medicine, it‘s a close call for anyone serving on the field. Somewhere, all of us aim to be the Doctor without any border, but how far can we actually go beyond nationalist views or communist thoughts? The discourse of international humanitarian law does not furnish detailed road maps for negotiating this complex terrain of war and preparation for war. Nor does the discourse of human rights supply answers on how to proceed with scientific advances across large and disparate populations. But these two strands of thought, together with established principles of medical ethics, have since the end of the Second World War provided the rules and standards by which the international community has determined that medicine, science, and government must all be held accountable.
Ethical dilemmas can be intensified in humanitarian contexts by insecure environments, lack of optimum care, language barriers, potentially heightened power discrepancies between care providers and patients, differing cultural values, and perceptions of patients, communities, and medical staff. Time constraints, stressful conditions, and lack of familiarity with ethical frameworks can prevent reflection on these dilemmas, as can frustration that such reflection does not necessarily provide instant solutions. Lack of reflection, however, can be distressing for medical practitioners and can reduce the quality of care. Speaking from an ethicist point of view, such discrepancies can highly affect the future of international health and humanitarian medicine as well as the protection of refugees and allied people during the war.
Case Scenario 1:
In the war on terror, military physicians have faced at least three major challenges to medical ethics: orders that they help to interrogate terrorist suspects, force-feed prisoner hunger strikers, and certify soldiers as fit to be redeployed to Iraq or Afghanistan. The medical ethics rule in the first two instances is clear and is reinforced by international human rights standards: no physician can take part in any action involving torture or cruel or inhumane treatment or use medical knowledge or skills for punishment. Nonetheless, the DOD’s post-9/11 interrogation policy required physicians to certify prisoners as fit for interrogation, and instructions issued in 2006 explicitly authorize physicians to certify prisoners as fit for ―punishment‖ and even administer the punishment if it is ―in accordance with applicable law,‖ as interpreted by the DOD’s civilian lawyers.
Case Scenario 2:
Force-feeding hunger strikers at Guantanamo has been justified on the basis of military necessity, and military physicians have been ordered to force-feed prisoners ―for the good of the country.‖ Additional rationales are that the prison is an extension of the battlefield, that hunger strikers are engaged in asymmetric warfare, that allowing them to die by starvation would be widely viewed as a military failure in the war on terror that could force the closure of Guantanamo, that physicians should not allow their patients to die by starvation, and that the prisoners are incapable of making either an informed refusal (because they are incompetent) or a voluntary refusal (because of peer pressure). Current DOD instructions on force-feeding directly contradict the explicit ethical positions of both the American Medical Association (AMA) and the World Medical Association (WMA). 4,5Yet supporters of the practice have argued that force-feeding, even with restraint chairs, is consistent with civilian medical ethics as applied in the U.S. federal prison system — a justification that recognizes that there are no special medical ethics for the military but fails to acknowledge that many aspects of medical care in prison in the United States may also violate basic standards of medical care and ethics.
Case Scenario 3:
A third example of such an ethical conflict is provided by military psychiatry. The durations of the wars in Iraq and Afghanistan and the shortage of troops have required that more troops receive mental health treatment for serious mental disorders than in previous wars. Increasingly, soldiers’ depression, post-traumatic stress disorder, and anxiety are being treated with newer psychotropic medications, especially selective serotonin-reuptake inhibitors (SSRIs). There is no military doctrine on the use of SSRIs in combat situations, but some military psychiatrists have recommended that their colleagues in Iraq ―should consider having one SSRI in large quantities, to be used for both depressive disorders and anxiety disorders. . . to [in the words of the motto of the Army medical corps] conserve the fighting strength.6 This strategy is consistent with medical ethics only if the treatment is part of an overall treatment plan, is medically indicated, and is provided with the voluntary and informed consent of the soldier–patient.
Ethicist’s Debate:
The battlefield conflict is one that shall always remain and probably sub duded by the feeling of dual loyalty. But the boundary of the doctor-patient relationship should never lose its sanctimony. Basic human rights violations, including torture, inhumane treatment, and experimentation without consent, can never be justified. Other conflicts should be analyzed as possible exceptions in extremis to the rule that medical ethics are universal. The ―physician’s first‖ guidance is only half the story; the other half should be ―last and always. Medicine is a very noble profession and humanitarian medicine comes with its limitations, but it cannot substitute political actions in any way! Be the physician first and the Nazi later.
