A Moral Analysis of Military Medicine

This paper offers a brief examination of the moral status of military medicine. Military physicians assume one set of obligations as physicians, including obligations of beneficence, nonmaleficence, and respect for autonomy. They assume another set of obligations as members of an armed service, such as maintaining combat readiness and maximizing the fighting strength of the force. These different obligations may come into conflict, but so may the obligations of civilian physicians in a variety of practice settings. In military service, however, both patients and physicians give up a greater measure of autonomy over their choices and actions than they do in most other settings. Because of both their increased risks and their decreased ability to make choices, military personnel can be viewed as a vulnerable population. Military physicians' ability to act on their behalf, however, is limited by the physicians' obligations to pursue military goals and to obey the lawful orders of superior officers. A physician's decision to enter military service is thus a morally weighty one that bears reflection on the practices of the military service to which one is pledging obedience. Introduction Physicians in military service have participated in a wide variety of activities in the 20th century. Scholars have recounted the notorious misdeeds of Nazi military physicians! and the less well known offenses of Japanese military physicians in occupied Manchuria," two dark chapters in the recent annals ofmilitary medicine. Military historyalso includes significant episodes ofvalorand self-sacrifice bymtlttary physicians who risked theirown livestosave thelives ofothers.3 Incontrastto these dramaticstories, military physicians practicing in peacetime mayfmd that their activities are almostIndistingutshable from those oftheir civilian colleagues. Given such diverse experiences, can wemakeanygeneral observations about the moral status ofmilitary medicine? Only a few authors, most notably Victor Sidel4 - 6 and EdmundHowe,7,8 havediscussedthe moral status ofmilitary medicine. This paperwill offer additional observations, focusing on conflicts ofobligation in military medicineand on limits to the autonomy ofmilitary physicians. We begin with an example. In a short story by Pearl Buck entitled 'The Enemy." a Japanese military surgeon in World War II discovers an American prisoner of war who was shot while escaping and has somehow washed up on the beach behind the physician's home. Although both the surgeonand his wife once studied in the United States, they have no love for Americans. They consider throwing the gravely wounded man backintothe sea, but insteadcarryhimintotheirhouse,where the surgeonoperateson his bulletwound. Thesoldier survives, Department ofMedical Humanities, EastCarolina University School ofMedicine, Greenville, NC 27858. An earlier version of this paper was presented at the Third World Congress of Bioethics, SanFrancisco, CA, November 22-24, 1996. This manuscript wasreceived for review in April 2003 and was accepted for publication in June 2004. Reprint & Copyright ©byAssociation ofMilitary Surgeons ofU.S., 2005. but the family's servantsleave the surgeon's home to protest their employer's harboring ofthe enemy, a criminal offense. The surgeon contemplates turning the prisonerover to the authoritiesforprobable execution, but eventually helpshimto escape by sea. "Strange," the surgeon thinks to himself as the story ends, "I wonder whyI could not kill him?" In this story, Buck's surgeon wrestles with a conflict between his desire to heal the wounded enemy soldier and hisfelt dutyas a military physician and a loyal subjectofJapan to tum himover to the authorities. The story offers a dramatic illustration of some of the moral duties and dilemmas ofmilitary physicians. Conflicting Obligations It shouldbe notedat the outset that virtually all physicians, be they military officers or civilians, specialists or generalists, private practitioners or public servants, assume multiple obligations to patients, patients' families, their own families, colleagues, the profession, employers and employees, and society at large. 10 These multiple obligations can, and oftendo, come into conflict, and a major task of medical ethics is to help physicians decide howto proceed in the face ofsuch conflicts. Although conflicts ofobligation are unavoidable formostmembers of complex societies, it also seems clear that we ought to avoid assumingobligations that weknow orshouldknow will be in frequent or irreconcilable conflict. For example, a physician should not assume a responsibtlity to care for a newpatient if doing so would force him or her to abandon other patients already under his or her care.We can begin an analysis ofthe moral situationofmilitary physicians byreviewing some oftheir fundamental obligations and then considering whether these obligations create especially difficult orirreconcilable conflicts, There is, first ofall, a set ofobligations assumed by military physicians simply as physicians, members ofthe medical profession. Perhapsbest known and mostwidely accepted among these are basic obligations expressed in medical oaths and codes of ethics, especially duties of nonmaleficence ("do no harm") and beneficence ("act for the good of the sick"). These obligations form the basis for conceiving the physician-patient relationship as a fiduciary relationship inwhich the physician is expected to act in the best interestsofthe patient.11 Contemporary commentators alsoascribeto physicians a basicobligation to respect the autonomous choices of patients.12,13 More specific obligations, including confidentiality, truthfulness, and compassion, among others, are often grounded in these fundamentalobligations. In addition to their obligations as physicians, military physiciansacceptanotherset ofobligations as members ofthe armed services oftheircountry. Military physicians commit themselves toserving military goals determined bytheircommanders. Some of these goals may be virtually identical to nonmilitary goals, such as the provision of quality medical care to individuals. Others may be entirely different, such as the maintenance of forces at combatreadiness in peacetime and whatissometimes Military Medicine, on 18 February 2022 A Moral Analysis of Military Medicine called "the conservation of the fighting strength" in wartime.8 Military physicians agree to subjectthemselves tothe command structure to achieve these goals. There is obviously potentialforconflict between thesetwo sets ofobligations assumedbymilitary physicians. Ordersto divulge medical Information about a patientforsome military purpose, forexample, mayconflict withone'sobligation to maintainthat patient's confidentiality. It remainsan openquestion, however, whetherconflicts such as this oneare soserious, sointractable, or so frequent as to conclude that the roleofthe military physician is inherently morally problematic or untenable. Let us consider this question in greaterdetail. Conceptually, the simplest wayto dealwithconflicts between medical and military obligations would be to insist that oneset ofobligations shouldalways take precedence over the other. In a number of articles on military medicine, for example, Victor Sidel comes close to defending the view that in order to honor their professional medical obligations, physicians should not entermilitary service.4,5 Sidel emphasizes both an obligation to care for individual patients and an obligation to prevent the human suffering and death caused by war; he refers to an observation by John Ryle that the universal refusal by physicians to serve in the military would so undermine the organizationand themorale ofthe troopsas tomakeit extremely difficult or impossible fornations to wage war.13 Ifphysicians' medical obligations do always take precedence over conflicting military obligations, then physicians could serve in the military only on the condition that all conflicts between medical and military goals would be resolved in favor ofthe former, a condition that military authorities are highly unlikely to accept. Thus, establishingan absolutepriority ofmedical over military obligations would make the position ofthe military physician morally untenable. In directcontrast to the above position, onemightclaim that military obligationsshouldalways takeprecedence over medical obligations formilitary physicians. Dr.Ugur Cilasun, Executive Director of the Turkish Medical Association, for example, describesthe former situationin Turkey as follows: "Mer legislative changes in the aftermathofthe 1980military coup, a military school of medicine was established for the purpose of training doctors solely for the military. In a ceremony at this military school, the head of the junta, addressing the soldier students, said: 'You are first and foremost soldiers, and only afterthat, doctors.' Thiswasevidence that military doctors were expected and obliged to give priority to the chain-of-command, above and over the medical code ofethics.,,14 Ifmilitary physicians should always give priority to military over medical obligations, any conflicts between the two they might encounter could be resolved easily and withno moral qualms. Neither ofthese two polarpositions is likely to attract a large numberofadherents.Ashas beennoted, eachposition requires absolute allegiance to one set of obligations over another. The valuesfostered by medical obligations, such as individual and public health and well-being, are genuine, fundamental, and deeply held, but so are the valuesoffreedom and securitythat underlie military obligations. Assuming that there are genuine conflicts between them,there seemsto be no compelling wayto establishthe absolute priority of either set ofvalues and obli77 gations over the other.Thus,wemust recognize the primafacie legitimacy ofboth, and tum our attention to more specific instances ofconflict. Atthis stageofthe analysis, onemightbetempted toconclude that the role ofmilitary physicians is no more morally problematic than a variety of other well-established types of medical practice, including occupational medicine, sports medicine, medicine in penalinstitutions, and even medicine in managed careorganizations. Ineachofthesepractice settings, physicians assume obligations to an institutional employer or contractor that can and do conflict with the professional obligation to promote the best interest ofindividual patients. For example, prisonphysicians maybe required to provide psychophannacological treatment to mentally disturbed death-row inmates to restorethem to sanityand thereby allow their executions to go forward, 15 Ahealth-maintenance organization (HMO) physician may be required to prescribe a less effective drug to treat a patient'sillness becausea more effective (andmore expensive) alternative is not included in the HMO's formulary. In some of these settings, such conflicts can be mitigated by informing patients that the physician's actions in this particular setting are directed to goals otherthan or in addition to that ofbenefiting the patient, and allowing the patient to opt out of the relationship ifhe or she objects. 10 Ifthe informed patientagrees to continue the relationship, then he orsheis giving tacitpermissionto the physician's or the institution's pursuitofthosegoals. The recent growth ofmanaged care and the ongoing debate over the moral implications of managed care strategies and techniques havehighlighted the existence and pervasiveness of physician conflicts ofinterest and obligation. 16 In lightofthese developments, it is becoming more difficult to maintain that physicians should adhere to a single-minded commitment to individual patient benefit and should ignore the interests of thosewho payforhealthcare,otherpotential recipients ofcare, orsociety at large. Thus, it mayseemthat the conflicting interests and obligations ofmilitary physicians are not significantly different from those ofmany, if not most, of their civilian colleagues. Such a conclusion would be premature, however. Patient and Physician Autonomy There are morally significant features of military medical practice that distinguish it from other types ofpractice. These features have to do not with the mere existence of conflicts of obligation in military medicine, but with the ability of the patients and especially physicians to decide howto addressthem. In other words, they have to do with the locus of control over decision making in the military. Both patients and physicians give up a greatermeasure of autonomy over their choices and actionswhen they enter military service than they do in most other practice settings. Consider, first, the area ofpatient autonomy. Few if any patients enjoy complete freedom in theirhealthcarechoices. Most are limited byprevious choices, such as the choice ofajoboran HMO, by lack of resources, by availability ofservices, and in various other ways. At least some of these limitations can be overcome: patients can consult different physicians, change jobs or health plans, or move to a different city. Members ofan armed service typically confront a number of additional constraints. Some voluntarily choose to enterthe military, whereas Military Medicine, Vol. 163, February 1998 Downloaded from https://academic.oup.com/milmed/article/163/2/76/4831825 by guest on 18 February 2022 78 others are conscripted into seIVice. Once inductedintomilitary service, one is not free to leave without the approval of the propermilitary authorities. While in the service, oneis obligated to obey alllawful ordersofone'ssuperiors, and oneis subjectto disciplinary action for failure to do so. Military personnel are subject to hazardous duty, including life-threatening assignments in war. With regard to health care, members of armed seIVices mayhavelittleor no control over whoprovides care for them or what treatments theywill receive. Awell-known recent example of mandatorytreatment was the administration ofan experimental anti-chemical warfare agent without informed consent to U.S. troops stationed in the Middle East during the GulfWar. 17 Theconfidentiality rights ofarmedseIVices personnel in the United States are also limited; for example, the U.S. military does not recognize testimonial privilege of confidential medical information. 18 Because of both their increased risks and their decreased ability to make choices in health care matters, military personnel can be viewed as a vulnerable population, similarin a number of respects to other vulnerable groups such as children, prisoners, and the mentally infirm. In the case of the latter groups,the United States and other countrieshaveestablished special protections against mistreatment and exploitation in medical therapy and research.19,20 In contrast, members of armedservices, althoughtheyoftenreceive health carefrom the military, typically have not more but fewer of the protections, such as confidentiality and informed consent, that civilians enjoy. The reason for these limitations on the personalfreedom of members ofthe armed seIVices is not mysterious: political and military leadersdeemit necessarytoorganize themilitary in this wayto maintaina highly effective fighting force. Most physicians whochoose to entermilitary seIVice will be in substantial agreement with the need for an effective military force, but, as physicians,theywill presumably alsobe concerned about the effect ofmilitary decisions on health and well-being, especially ofthe service personnel who are their patients. Although they will likely endorse the central mission and structure of the armed services, they may not accept the necessity of every military decision and maywishtocompare a decision's military rationale againstits effects onthe healthand well-being ofthe troopsorof the society at large. Military physicians' ability to act on such comparisons, however, is constrainedby the factthat they,too, have limited autonomy and are obliged to obey military regulations and the orders oftheir superior officers. As we have noted above, physicians in a variety of practice settings haveinstitutionaland other obligations that maylimit their ability to act solely on behalf of their patients. Like patients, however, physicians mayovercome someofthese limitations by challenging institutional rules or by changing jobs. Military physicians havesomewhat fewer options. Like nonmedicalservice personnel, theymaybe draftedintomilitary service, they may not leave without the approval ofthe properauthorities, and they must obey the orders ofsuperior officers or face disciplinary consequences. Military medical officers, in other words, are not always free to choose howtheywill respondto a conflict between theirmilitary and medical obligations; superior orders may take the decision out oftheir hands. This may not always, or evenoften, be the case;military medical officers may Military Medicine, Vol. 163, February 1998 A Moral Analysis ofMilitary Medicine be granted wide discretion in making health care decisions about individuals or groups under their care. Nevertheless, whenregulations or ordersdemandit, military physicians may be forced to give their military obligations priority, no matter howstrong their moral conviction that medical considerations should take precedence in a particular situation. In this way, military physicians give up a portion of their decision-making authorityand therebyassume a somewhat greatermoralrisk of beingforced to act in opposition to their convictions than their civilian colleagues. Options for Military Physicians The moral situation ofmilitary physicians is actuallysomewhatmorecomplex than the previousstatementindicates. Ifthe actions of military physicians were absolutely determined by their superiors' orders, we might praise or blame the superior officers and their decisions, but not the physicians' actions, becausetheyhad nocontrol over thoseactions. Infact, however, military physicians do have some, albeitlimited options. First, military physicians are generally obliged to obey only lawful orders, not any orders a superiormightgive. Thus, militaryphysicians mayrefuseto obey an ordertheydeemunlawful and request adjudication of the matter by a court-martial." Military physicians who take this step will, if the authorities decide to prosecute, face the somewhat daunting task of convincing militaryjudgesthat theirinterpretation ofthe applicable law, and notthat oftheircommanding officer, is correct. Towhat lawsmaya military physician appeal in challenging an order? Presumably these includemilitary regulations themselves and the positive lawsofone's country, including international treaties such as the Geneva Convention that one's own nation has ratified. Thus, the scope ofa military physician's right to resist orders depends on what regulations and laws one's military servtce and one's nation have adopted and may vary significantly from one nation to another. For example, it would be highly significant to military physicians whether one's nation had ratified international conventions banning the development,testing, production, or use ofbiological or chemical weaponsifonewere ordered to assist in the development or testingof such weapons. Military physicians mightalsoappealdirectly to international laws, but unless such laws have been adopted by one's own nation, they are unlikely to be recognized by military judges. Even if nations have officially recognized an international law, theymaynot enforce it.Turkey, forexample, appears to permit widespread torture despiteits acceptance ofinternational laws prohibiting that practice." In situations in whichan orderviolates international but not nationallaw, military physicians confront an unenviable choice between probable prosecution and disciplinary actionby one's own military and possible future prosecution and punishment by a foreign or internationaltribunal. Military physicians may alsochoose not to obey an orderthat theyconcede islawful but that theybelieve tobe unethical. Insuch a case,the physician is expressing a willingness to accept the military's punishment rather than carry out an unethical order. Inaddition to the protection ofnationaland international law, professional medical associations have sought to defend the medical obligations ofphysicians byformal condemnations and Downloaded from https://academic.oup.com/milmed/article/163/2/76/4831825 by guest on 18 February 2022 A Moral Analysis of Military Medicine sanctions against certain practices, including physician participation in torture and executions. In response to reports of physician participation In torture in Turkey and Uruguay, for example, the national medical associations of those countries condemned the practice of torture and the Turkish Medical Association refused membership to military physicians. 14,22 Conclusion What, then, is the underlying moral difference between military and civilian medical practice? It is, I believe, the fact that the military demands a more nearly total commitment to its goals and procedures than other employers and, as a result, military physicians have less individual freedom to make their own moral choices. Some military goals, such as the protection of citizens and their way of life, are highly desirable; other possible goals, such as aggression against other nations, are highly morally suspect. Some military practices and procedures, such as strict discipline and rigorous training, are necessary and defensible means to achieving military goals; others, such as torture, genocide, and mistreatment of one's own soldiers, prisoners ofwar, or civilians, are highly problematic. Upon entering military service, physicians assume obligations to pursue military goals and abide by military procedures, with only limited freedom to resist these on medical or other grounds. Thus, the decision to enter military service is a morally weighty one that bears significant reflection on the practices and regulations of the military service to which one is pledging obedience. In closing, let us return briefly to Pearl Buck's Japanese surgeon. I strongly believe that he made the right decision, despite his misgivings, to provide care for the American prisoner of war (POW) and to help him escape. In fact, failure to provide assistance would likely have been a violation of the Geneva Convention's protections for POWS.23 Suppose, however, that the surgeon had chosen to throw the POWback into the sea or to tum him in to be executed. Howstrongly should we condemn him? By helping the POW, the surgeon was risking his career, his own freedom, his family's well-being, and perhaps his own life. Such are the personal and moral hazards that may be encountered by military physicians. 79 References 1. Lifton RJ: The Nazi Doctors. New York, Basic Books, 1986. 2. 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