II. MEDICINE AND WAR

Ethical conflicts occur whenever medicine and war intersect. This entry discusses four general types of ethical conflict: (1) conflict between the military obligation of physicians and other medical personnel to provide care to members of the military force in which they are serving and the medical obligation to serve others, such as members of opposing military forces and civilians, who need their care; (2) conflict between the obligation of military medical personnel to "conserve the fighting strength" and the medical obligation to respond to the special needs or rights of individual military personnel under their care even if that response hinders the fighting strength; (3) conflict between the combatant and noncombatant roles of medical personnel; and (4) conflict between the national obligation to serve one's country through service in a military force and the international obligation to prevent war or prevent specific actions by the military force of one's country.

The history of physicians' involvement with military forces is a long one. Homer praised the efforts of the sons of Asclepios to provide surgical care before the gates of Troy, and Hippocrates, recognizing that the battleground was an important training ground for surgeons, urged that "he who would become a surgeon should join an army and follow it" (Vastyan, 1978, p. 1695).

However, physicians and other medical personnel had relatively little aid to offer to military casualties until the eighteenth century. Since that time developments in military weaponry and concurrent advances in medical technology and techniques for the evacuation of casualties have made the deployment of medical resources increasingly important to armies and their commanders. To the armies of the czar, for example, Peter the Great brought the feldsher, modeled after the feldscherer (field barber-surgeon) of the Prussian armies. In the New World deplorable medical care during the American Revolution caused political conflicts over the management of hospitals and healthcare for soldiers. The increase in the number of military casualties during the wars of the nineteenth century and the extraordinary increase in military and civilian casualties during those of the twentieth century, together with dramatic improvements in the ability to treat casualties successfully, led to changes in the types of ethical issues that arise in the context of war and an increase in their number.

Military Obligations Versus Medical Obligations

As a member of the military forces of a nation a military physician is charged with protecting the strength of that force. As a member of the medical profession, however, a physician generally is obligated to care for all the sick and wounded who need his or her services and to set priorities for providing those services on the basis of the urgency of medical need and the effectiveness of medical care.

Hippocrates, often called the father of medicine, apparently rejected the principle that physicians have an obligation in war to succor "enemies" as well as "friends." The evidence for this appears in Plutarch's Lives in a reference to "Hippocrates' reply when the Great King of Persia consulted him, with the promise of a fee of many talents, namely, that he would never put his skill at the service of Barbarians who were enemies of Greece" (Plutarch, p. 373).

Just before the start of the U.S. Civil War the American Medical Association (AMA) selected as the model for a commemorative stone carving for the Washington Monument, then being built in the District of Columbia, the painting Hippocrates Refuses the Gifts of Artaxerxes, portraying Hippocrates's dismissal of the emissaries of the king of Persia. The inscription the AMA selected was Vincit Amor Patriae, "Love of Country Prevails" (Stacey).

In a time of "unjustifiable and monstrous rebellion," a phrase used by one of its leaders, the AMA probably intended by its use of the painting and the inscription to applaud the refusal to provide medical services for enemies. Indeed, no evidence can be found that in the pre–Civil War United States there was a great deal of sympathy for evenhanded medical care in time of war (Sidel, 1991b).

PHYSICIANS AS IMPARTIAL HEALERS. A physician's responsibility to treat those in medical need on both sides did not burn itself into public or medical consciousness until the late 1860s, in the aftermath of the Crimean War and theU.S. Civil War. Leadership in increasing the new consciousness was assumed by the nonphysicians Florence Nightingale, who served as a nurse in Turkey and the Crimea from 1854 to 1856, and Dorothea Dix, whose work in bringing humane care to mental patients in the United States led President Abraham Lincoln to invite her to organize theU.S. Army Nursing Corps and become the first superintendent of nurses in the U.S. Army.

Henri Dunant, a Swiss banker who was an eyewitness at the Battle of Solferino in 1859, organized medical services for the Austrian and French wounded. In 1864 he helped initiate an international conference in Geneva that led to the founding of the International Red Cross and its national affiliates. The conference adopted a Convention for the Amelioration of the Condition of the Wounded and Sick in Armed Forces in the Field. Fourteen signatory nations pledged to regard the sick and wounded, as well as personnel, facilities, and transportation for their care, as neutrals on the battlefield. For his efforts Dunant was awarded the first Nobel Peace Prize.

Two contemporaneous events in the United States influenced future codifications and applications of international law and their bearing on medicine. Francis Lieber, a German-born philosopher, lawyer, and historian, was commissioned by the Union forces to draft a code of conduct for armies in the field. The resultant Lieber Code was promulgated in May 1863 as General Order No. 100 by the Union Army. Closely related to that development was the 1865 trial of Captain Henry Wirz, a physician who served as the commandant of the infamous Confederate prison at Andersonville, Georgia. Wirz was charged with a series of offenses involving inhumane treatment of the prisoners under his charge. His plea that "superior orders" mitigated the negligence of duty with which he was charged was disallowed, and Wirz was convicted and sentenced to be hanged.

During the eighty years after the first Geneva treaty on the treatment of war casualties three other related international agreements were negotiated in the Hague and in Geneva. The Convention for the Amelioration of the Wounded, Sick, and Shipwrecked Members of Armed Forces at Sea dealt with the care of casualties of naval warfare. The Convention Relative to the Treatment of Prisoners of War regulated the treatment and repatriation of prisoners. The Convention Relative to the Protection of Civilian Persons in Time of War prohibited deportation, the taking of hostages, torture, and discrimination in treatment. Those three agreements, along with the original Geneva accord, were codified in a single formal document in Geneva in 1949; together they are called the Geneva Conventions. Agreed to at that time by sixty nations, the 1949 conventions were declared binding on all nations according to "customary law, the usages established among civilized people … the laws of humanity, and the dictates of the public conscience" (Geneva Conventions of 1949).

Under the conventions medical personnel are singled out for certain specific protections by an explicit separation of the healing role from the wounding role. Medical personnel and treatment facilities are designated as immune from attack, and captured medical personnel are to be repatriated promptly. In return for that treatment, specific obligations are required of medical personnel:

1. Because they are regarded as noncombatants, medical personnel are forbidden to engage in or be parties to acts of war.
2. The wounded and sick—soldier and civilian, friend and foe—must be respected, protected, treated humanely, and cared for by the belligerents.
3. The wounded and sick must not be left without medical assistance, and only urgent medical reasons authorize any priority in the order of their treatment.
4. Medical aid must be dispensed solely on medical grounds, "without distinctions founded on sex, race, nationality, religion, political opinions, or any other similar criteria."
5. Medical personnel shall exercise no physical or moral coercion against protected persons (civilians), in particular to obtain information from them or from third parties.

Those duties are imposed clearly with no exceptions and are given priority over all other considerations. Thus, the Geneva Conventions formalized the recognition that although professional expertise merits special privileges, it incurs very specific legal as well as moral obligations (Vastyan, 1978). That special role of physicians has been incorporated in the public expectations and the ethical training of doctors in most societies. It also is embedded in the World Medical Association's Declaration of Geneva, which is administered as a "modern Hippocratic Oath" to graduating classes at many medical schools.

There is, however, evidence of deviation from those principles. An example of the erosion of the principle of equal medical care for "enemies" occurred in the United States during the Cold War. The medical society of Maryland and the AMA refused to criticize a Maryland psychiatrist who testified voluntarily before the Un-American Activities Committee of the U.S. House of Representatives in 1960 about information he had obtained while treating an employee of the National Security Agency (NSA). His patient, together with another NSA employee with whom the patient allegedly had had a sexual relationship, later defected to the Soviet Union. The psychiatrist, clearly without his patient's permission, provided to the committee information given to him by that patient, and the material was leaked to the press by the committee. In response to a petition by a group of Maryland psychiatrists and other physicians asking that the psychiatrist be censured, the medical society stated that "the interests of the nation transcend those of the individual" (Sidel, 1961).

Obligations to Enhance Military Strength Versus Personnel Needs

Military physicians must accept priorities different from those of their civilian colleagues (Vastyan, 1974). The primary role of a military physician is expressed in the motto of the U.S. Army Medical Department: "To conserve the fighting strength" (Bellamy). In describing that role, a faculty member of the Academy of Health Sciences at Fort Sam Houston in 1988 cited as "the clear objective of all health service support operations" the goal stated in 1866 by a veteran of the Army of the Potomac in the Civil War: "[to] strengthen the hands of the commanding general by keeping his Army in the most vigorous health, thus rendering it, in the highest degree, efficient for enduring fatigue and privitation [sic], and for fighting" (Rubenstein, p. 145).

Principles of triage that are unacceptable in civilian practice may be required in war, such as placing emphasis on patching up the lightly wounded so that they can be sent back to battle. For example, "overevacuation" (the presumed excessive transfer of personnel to a safe area rather than back to the military operation) is cited as "one of the cardinal sins of military medicine" (Bellamy). Violation of patient confidentiality, which is unacceptable in civilian practice, may be required. Medical personnel may be required to administer experimental drugs or immunizations to troops without their free and informed consent (Annas).

Combatant Versus Noncombatant Roles for Medical Personnel

Perhaps the most dramatic attempt to meld these conflicting obligations was made by the Knights Hospitallers of Saint John of Jerusalem, a religious order founded in the eleventh century. With a sworn fealty to "our Lords the Sick," the knights defended their hospitals against "enemies of the Faith," becoming the first organized military medical officers. They were "warring physicians who could strike the enemy mighty blows, and yet later bind up the wounds of that same enemy along with those of their own comrades" (Vastyan, 1978, pp. 1695–1696).

A more recent example of the erosion of the distinction between combatant and noncombatant roles was demonstrated in a U.S. Army exhibit at the 1967 AMA convention. It was titled "Medicine as a Weapon" and featured a photograph of a Green Beret (Special Forces) aidman handing medicine to a Vietnamese peasant (Liberman et al.). Dr. Peter Bourne, who had been an army physician working with the Special Forces in Vietnam, wrote that the primary task of Special Forces medics was "to seek and destroy the enemy and only incidentally to take care of the medical needs of others on the patrol" (Liberman et al., p. 303).

In 1967 Howard Levy, a dermatologist drafted into theU.S. Army Medical Department as a captain, refused to obey an order to train Special Forces aidmen in dermatological skills. He refused specifically on the grounds that the aidmen were being trained predominantly for a combat role and that cross-training in medical techniques would erode the distinction between combatants and noncombatants. Levy was charged with one of the most serious breaches of the Uniform Code of Military Justice: willfully disobeying a lawful order. Tried by a general court-martial in 1967, Levy admitted his disobedience, saying that he had acted in accordance with his ethical principles. The physicians who testified for the defense "argued that the political use of medicine by the Special Forces jeopardized the entire tradition of the noncombatant status of medicine" (Langer, p.1349). They agreed with Levy that physicians are responsible for even the secondary ethical implications of their acts and that they must not only act ethically but also anticipate that those to whom they teach medicine will act ethically as well. Although Levy was a medical officer, the court-martial panel did not include a physician. Levy was given a dishonorable discharge and sentenced to three years of hard labor in a military prison. His appeals were not successful (Glasser; Langer).

Inside or outside the armed forces medical personnel may be involved in war-related research and development such as work on biological weapons or the radiation effects of nuclear weapons. In that work it is said to have been common practice to concentrate physicians into "principally or primarily defensive operations" (Rosebury). However, work on weapons and their effects can never be exclusively defensive, and at times the distinction is arbitrary. The question arises whether there is a special ethical duty for physicians, because of their medical obligation to "do no harm," to refuse to participate in such work or whether in non-patient-care situations physicians only share the ethical duties of all human beings (Sidel, 1991a).

The noncombatant role of a physician in military service is ambiguous even if frank combatant activities are eschewed. Military physicians, like all members of the armed forces, are limited by the threat of military discipline in the extent to which they can protest publicly against what they consider an unjust war. The issue of what is a just war has been debated for more than two millennia (Seabury and Codevilla; Walzer). It generally is thought that there are two elements in a just war: jus ad bellum (when is it just to go to war?) and jus in bello (what methods may be used in a just war?). Among the elements required for jus ad bellum are a just grievance and the exhaustion of all means short of war to settle that grievance. Among the elements required for jus in bello are the protection of noncombatants and the proportionality of force, including avoiding the use of weapons of mass destruction such as chemical, biological, and nuclear weapons and the massive bombing of cities. Membership in the armed forces, even in a noncombatant role, usually requires self-censorship of public doubts about the justness of a war in which the armed forces are engaged.

In 2003 the United States, with the support of the United Kingdom, initiated an attack on Iraq that those countries alleged was permissible under international law as a "preventive" or "preemptive" war. The action was not approved specifically by the Security Council of the United Nations. Many lawyers and physicians argued that because there had been no attack or imminent attack on the United States, the requirements for jus ad bellum had not been met and the "collateral damage" to civilians caused by the attack exceeded the ethical test of jus in bello. Although there were protests from Physicians for Social Responsibility and other medical groups, U.S. service members, including medical personnel, evinced no public protest.

The U.S. military used depleted uranium as a casing for armor-piercing shells in the 1991 Gulf War, its actions in Kosovo and Afghanistan, and the 2003 Gulf War. Uranium is both toxic and radioactive, and its use is seen by many experts as a violation of the United Nations Charter, the Geneva Conventions, the Conventional Weapons Convention, and the Hague Conventions. There was no public protest by military physicians.

In addition, medical personnel, like other people, may consider themselves pacifists. "Absolute pacifism" opposes the use of any force against another human being even in self-defense against a direct personal attack. The argument underlying this position for many of its adherents is that the use of force can be ended only when all people refuse to use it and that acceptance of one's own injury or even death is preferable to the use of force against another person. More limited forms of pacifism, such as "nuclear pacifism," hold that the use of certain weapons of mass destruction in war is never justified no matter how great the provocation or how terrible the consequences of failure to use them. It has been suggested ("maternal pacifism") that because of their nurturing roles women have a special responsibility to oppose the use of force (Ruddick).

When a group is threatened with genocide, which the Nazis attempted in World War II, many who otherwise might adopt a pacifist or limited pacifist position believe that force may be justified. Their shift in position is based on the threat to the survival of the group, a threat that makes the pacifist argument that current failure to resist will lead to a future diminution in violence seem untenable.

There is considerable debate whether physicians, because of a special dedication to the preservation of life and health, have a special obligation to serve or to refuse to serve in a military effort. That position is made more complex by the physician's role as a military noncombatant. Many military forces permit physicians, like other military personnel, to claim conscientious objector status. In the United States conscientious objection is defined as "a firm, fixed, and sincere objection by reason of religious training and belief to: (1) participation in war in any form; or (2) the bearing of arms." Religious training and belief is defined as "belief in an external power or being or deeply held moral or ethical belief to which all else is subordinate and … which has the power or force to affect moral well-being" (U.S. Department of Defense). A person who claims conscientious objector status must convince a military hearing officer that the objection is sincere.

Obligations to Serve in War Versus Obligations to Prevent War

As wars kill an increasing percentage of civilians with socalled conventional weapons and as threats of the use of weapons of mass destruction continue, what form of service is appropriate for an ethical physician? One response was suggested in the late 1930s by John A. Ryle, then Regius Professor of Physic at the University of Cambridge:

It is everywhere a recognized and humane principle that prevention should be preferred to cure. 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 (p. 8).

During the Vietnam War more than 300 American medical students and young physicians brought Ryle's vision a step closer to reality by signing the following pledge:

In the name of freedom the U.S. is waging an unjustifiable war in Viet Nam and is causing incalculable suffering. It is the goal of the medical profession to prevent and relieve human suffering. My effort to pursue this goal is meaningless in the context of the war. Therefore, I refuse to serve in the Armed Forces in Viet Nam; and so that I may exercise my profession with conscience and dignity, I intend to seek means to serve my country which are compatible with the preservation and enrichment of life (Liberman et al., p. 306).

Ryle's vision is a variation on that of Aristophanes in his comedy The Lysistrata, which was written in 411 b.c.e., just before the probable time of Hippocrates's refusal to treat the Persians (circa 400 b.c.e.). The title character, an Athenian woman, ends the second Peloponnesian War by organizing the wives of the soldiers of both Athens and Sparta to refuse sexual intercourse with their husbands while the war lasts. The Athenians and Spartans make peace quickly and go home with their wives (Aristophanes).

Some physicians and other medical personnel have refused to support war by serving in the armed forces. In one of the most dramatic examples Yolanda Huet-Vaughn, a captain in the U.S. Army Medical Service Reserve, refused active duty in the Persian Gulf. In her statement she explained her actions:

I am refusing orders to be an accomplice in what I consider an immoral, inhumane and unconstitutional act, namely an offensive military mobilization in the Middle East. My oath as a citizen-soldier to defend the Constitution, my oath as a physician to preserve human life and prevent disease, and my responsibility as a human being to the preservation of this planet, would be violated if I cooperate (Sidel, 1991b, p. 102).

The reasons Huet-Vaughn gave for her action were quite different from the reasons given by Levy. Levy refused to obey an order that he believed required him to perform a specific act that would violate the Geneva Conventions; Huet-Vaughn refused to obey an order that she believed required her to support a particular war that she felt to be unjust and destructive to the goals of medicine and humanity.

One of the questions Huet-Vaughn's action raises is whether physicians have a special ethical responsibility, in view of their obligation to protect the health and lives of their patients and the people in their communities, to refuse to support a war they believe will cause major destruction to the health and environment of both combatants and noncombatants (Geiger; Sidel, 1991b). If a physician considers service in support of a particular war unethical on the grounds of sworn fealty to medical ethics, may—or must— that doctor refuse to serve even if that objection does not meet the criteria for formal conscientious objector status? Is there an ethical difference if the service is required by the society—as in a "doctor draft"—or if the service obligation has been entered into voluntarily in return for military support of medical training or for other reasons? Is military service a voluntary obligation if enlistment, as it is for many poor and minority people, is prodded by lack of educational or employment opportunities or, as for many doctors, by the cost of medical education or specialty training that in other societies is provided at public expense?

Although few physicians are willing or able to take an action such as that taken by Huet-Vaughn, other actions are available to oppose acts of war that are considered unjust, oppose a specific war, or oppose war in general. One is acceptance of a service alternative consistent with an ethical obligation to care for the wounded or maimed without simultaneously supporting a war effort. Opportunities for service in an international medical corps such as Médecins du Monde and Médecins sans Frontieres are limited, butU.S. physicians may wish to demand that their nation redirect some of the billions of dollars it spends annually on preparation for war to the United Nations or the World Health Organization to help fund an international medical service to treat the casualties of war.

Other physicians may work, as individuals and particularly in groups, to help prevent war by contributing to public and professional understanding of the nature of modern war, the risks of weapons of mass destruction, and the nature and effectiveness of alternatives to war. Among the groups organized for that purpose are the International Physicians for the Prevention of Nuclear War, whose U.S. affiliate is Physicians for Social Responsibility. If the world is to survive, physicians may need to consider new forms of national service and contribute in a broader sense to their nations and their planet (1986).

In the broader context of medical ethics it is widely accepted that opposition to war does not permit an ethical physician to refuse medical care to victims of war he or she is in a position to serve and that that care does not presume the physician's support of the war being fought. Ethical dilemmas arise when a physician actively supports the war effort through membership in a military medical service or by assigning priority to patient care on the basis of military demands rather than patient needs. These issues and those associated with the role of the physician in peacemaking and peacekeeping, which often are distorted by the fervor that may accompany war and preparation for war, require dispassionate analysis and action in times of peace.

victor w. sidel (1995)

revised by author

SEE ALSO: Care; Conflict of Interest; Conscience; Justice; Medical Codes and Oaths: Ethical Analysis; Obligation and Supererogation; Profession and Professional Ethics; Prisoners, Healthcare Issues of;Triage; and other Warfare subentries

BIBLIOGRAPHY

Annas, George J. 1992. "Changing the Consent Rules for Desert Storm." New England Journal of Medicine 326(1): 770–773.

Aristophanes. 1979. The Lysistrata. In Aristophanes, vol. 3, trans. Benjamin Bickley Rogers. Cambridge, MA: Harvard University Press.

Bellamy, Ronald F. 1988. "Conserve the Fighting Strength." Military Medicine 153(4): 185–186.

Geiger, H. Jack. 1991. "Conscience and Obligation: Physicians and Just War." PSR Quarterly 1: 113–116.

Geneva Conventions of 1949. 1983. In Human Rights Documents: Compilation of Documents Pertaining to Human Rights. Washington, D.C.: U.S. Government Printing Office.

Glasser, Ira. 1967. "Judgment at Fort Jackson: The Court-Martial of Captain Howard B. Levy." Law in Transition Quarterly 4: 123–156.

Homer. 1990. The Iliad, trans. Robert Fagles. New York: Viking.

Langer, Elinor. 1967. "The Court-Martial of Captain Levy: Medical Ethics v. Military Law." Science 156(3780): 1346–1350.

Liberman, Robert; Gold, Warren; and Sidel, Victor W. 1968. "Medical Ethics and the Military." New Physician 17(11): 299–309.

Lown, Bernard. 1986. "Nobel Peace Prize Lecture: A Prescription for Hope." New England Journal of Medicine 314(15): 985–987.

Plutarch. 1914. "Marcus Cato." In Lives, vol. 2, trans. Bernadotte Perin. Cambridge, MA: Harvard University Press.

Rosebury, Theodor. 1963. "Medical Ethics and Biological Warfare." Perspectives in Biology and Medicine 6: 512–523.

Rubenstein, David A. 1988. "Health Service Support and the Principles of War." Military Medicine 153(3): 145–146.

Ruddick, Sara. 1989. Maternal Thinking: Toward a Politics of Peace. Boston: Beacon Press.

Ryle, John A. 1938. "Foreword." In The Doctor's View of War, ed. Horace Joules. London: George Allen & Unwin.

Seabury, Paul, and Codevilla, Angelo. 1989. War: Ends and Means. New York: Basic Books.

Sidel, Victor W. 1961. "Confidential Information and the Physician." New England Journal of Medicine 264(22): 1133–1137.

Sidel, Victor W. 1991a. "Biological Weapons Research and Physicians: Historical and Ethical Analysis." PSR Quarterly 1(1): 31–42.

Sidel, Victor W. 1991b. "Quid Est Amor Patriae?" PSR Quarterly 1(1): 96–104.

Sidel, Victor W. 2003. "Earth Penetrating Nuclear Weapons, Nuclear Testing, Depleted Uranium Weapons and Medical Consequences and Implications for Compliance with the Nuclear Non-Proliferation Treaty." Testimony before the Preparatory Committee for 2005 Review Conference of the Nuclear Non-Proliferation Treaty.

Stacey, James. 1988. "The Cover." Journal of the American Medical Association 260: 448.

U.S. Department of Defense. 1982. Air Force Regulation 35–24. Washington, D.C.: Author.

Vastyan, E. A. 1974. "Warriors in White: Some Questions about the Nature and Mission of Military Medicine." Texas Reports on Biology and Medicine 32(1): 327–342.

Vastyan, E. A. 1978. "Warfare: I. Medicine and War." In Encyclopedia of Bioethics, vol. 4, ed. Warren T. Reich. New York: Macmillan.

Walzer, Michael. 1977. Just and Unjust Wars: A Moral Argument with Historical Illustrations. New York: Basic Books.