MILITARY MEDICINE 2002; 167, Suppl. 3: 26 - 31

Medical Ethics in Peace and in
the Armed Conflict

Guarantor: LTC Andreas G. Schapowal
Contributors: LTC Andreas G. Schapowal, German Armed Forces; COL Hans-Ulrich Baer, Swiss Armed Forces


Global medical ethics on the basis of the General Declaration of Human Rights by the United Nations is a key subject for the 21st century. World Health Organization's new definition of health includes "spiritual health", a term that has to be defined in international consensus despite different anthropologies, cultures, and religions. Old issues in medical ethics such as assisted suicide are still waiting for global consensus among the "pro-life" and "pro-choice" parties. So far the Netherlands and Belgium are the only countries where euthanasia has been legalized, whereas the U.S. Supreme Court has denied a right of medically assisted suicide. The respect of nature is also the basis for guidelines in new issues in medical ethics such as gene therapy and human cloning, which are controversially discussed. Military medical ethics should provide regulations for morally correct decisions in armed conflicts including the war against international terrorism and in peacekeeping missions. Triage of the wounded, distribution of medical aid, and critical incident stress debriefing for soldiers and their relatives are key issues.

Introduction: Definition of Ethics

Ethics is the branch of philosophy concerned with the study of those concepts we use to evaluate human activities, in particular the concepts of goodness and obligation. Philosophical schools can be divided into schools that regard ethical language as being descriptive and those that regard it as being prescriptive. Descriptive theories of ethics seek to define the meaning of good either in terms of non-moral characteristics (naturalism) , in terms of metaphysical constructions, or in terms of moral notions that are considered to have a special and peculiar character of their own. Important among the prescriptive theories is the view that ethical language is used to appeal not to the intellect, but to the emotions, showing that a person's moral feelings arouse and are designed to arouse similar feelings in others. Other prescriptive theories are those that define ethical terms as carrying mandatory force, enjoined by some kind of authority, divine or otherwise. A special case was Emmanuel Kant's theory of the categorical imperative, according to which the prescriptive force of moral action hinges on the criterion of whether the principle involved could become a universal maxim. So far there is no global consensus in philosophy for a definition of "good”.
In our opinion, in identifying the meaning of a human action, the intention is decisive. From this viewpoint we are able to distinguish in moral philosophy between good - bad, right - wrong, helpful - harmful, wholesome - unwholesome.

Global Ethics for a Global Community

At the beginning of the 21st century, we are realizing that the world has grown smaller and the world's people have become almost one community interdependent in large multinational groups, in global economy, industry, and trade with worldwide communications eliminating nearly every ancient barrier of distance, language, and face. We also share the same grave problems: overpopulation, dwindling natural resources, environmental pollution threatening our air, water, and food, and the elimination of life forms minute by minute.
There is a common ethical basis of all world religions in which believers of different religions and also nonbelievers or agnostics can agree: respect of nature and humanity. No matter whether we believe in the sayings of Confucius, the discourses of Buddha, the Torah, the Sermon on the Mount, or any other religion or pseudo-religion, we as human beings all desire happiness and do not want suffering. Furthermore, each of us has an equal right to pursue these goals.
In Europe, this was reflected in the philosophical discussions before and during the French Revolution and expressed in the Declaration of Human Rights in 1789, renewed worldwide in the General Declaration of Human Rights of the United Nations.

Definition of Health

The World Health Organization (WHO) defines health in its preamble as "a state of complete physical, mental, and social well-being, not merely the absence of disease or infirmity. The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being." In January 1998, the WHO Executive Board adopted a resolution requesting that this definition of health be changed to "Health is a dynamic state of complete physical, mental, spiritual, and social well-being and not merely the absence of disease or infirmity." The WHO General Assembly has still to agree to extend the definition of health to the spiritual level [1].

Globalization of Health Ethics

Moral commitments to protect individual health go back thousands of years to ancient Hindu Samihita medical ethics, the Japanese Rhi-Shu code of medicine, and the Greek Hippocratic Oath. In Hippocratic medicine, the therapeutic relationship was grounded on the moral principle of philanthropia: "where there is love of man (philantropia), there is the love of the art of healing (philotechnia)”. The link between religious beliefs and medical ethics also has well-established historical roots. For instance, Buddhist scriptures frequently referred to the Buddha as the "Great Physician”. In the bible, Christus Medicus acts very much in the same way. Contemporary bioethics are based on the Ethical Guidelines of the World Medical Association, examples of which are the Declaration of Geneva and the Declaration of Helsinki [2-4].
Presuming that it is every medical doctor's task and aim to maintain, improve or restore his patients' health using aIl possible efforts, this new definition of health has many implications for the education, ethics, and daily practice of doctors no matter in which field or country they are working.

Physical Level

Our universities and medical schools offer a high standard of medical education. The medical student's obligation is to study hard and gain as much knowledge of the human body and its functions, as well as of pathogenesis and salutogenesis as possible. The qualified doctor has a duty that is to consider himself an eternal student and must ensure that by reading scientific journals and attending scientific meetings and postgraduate courses, he maintains a high standard of the increasingly subtle body of knowledge, at least in his field of specialization.

Mental Level

Doctors must know about the mind and its functions as well as about the interdependent relationship between the body and the mind. This is every doctor's obligation. Leaving the mental level to the psychiatrist would allow only a very poor and limited understanding of the human being, in general, and the patient's needs, in particular.

Social Level

In the developing world, addressing the basic health needs of a country's poorest citizens is the first step toward reducing the level of poverty. Tuberculosis, malaria, and human immunodeficiency virus remain the most pressing global challenges in the context of diseases that are caused by poverty. How can medical doctors, businesses, governments, and international organizations join together to attack the diseases that continue to afflict the poor and that prevent greater socioeconomic development?
In the developed countries, with the arrival of genetic screening, gene technology, and telemedicine, health care practices are set to change considerably in the next few years. What real advances can we expect from new methods and treatments? Will new health care systems further empower patients or diminish their influence?
Social commitment should be an integral component of the medical profession. Social responsibility ranges from such goals as commitment to a fair health system in one's own country, to the involvement in the improvement of working conditions, to questions of global distribution of health resources, and the commitment for a healthy environment suitable for human beings, animals, and plants [5, 6].
Within the WHO, there is a movement towards globalization of public health ethics [7]. The WHO works for continued and strengthened application of ethics to health policy, research and service provision, implementation of equity-orientated policies, and incorporation of a gender perspective into health policies and strategies. Doing good in public health would include investment in global research, surveillance, and development aimed at protecting aIl from infectious diseases, and controls on exports of products hazardous to health, in particular tobacco, hazardous wastes, contaminated food products, hazardous chemicals, illegal drugs, and weapons [8].

Spiritual Level

Spirituality seeks the ultimate truth beyond our superficial material world. In different cultures and nations, mankind has devised various religions with their different anthropologies. All religions can agree on global ethics [9]. Global medical ethics can be accepted as well by doctors who do not feel affiliated with any religion. Indeed, it is the support for universal values that is the core of an major religions and also agnostics that links us together through the whole world community. Common to that core is the injunction expressed clearly by all major religions and philosophical schools as well that “we should not do unto others as we would not have them do unto us" [10 – 12].
Good medical and good scientific judgement requires much more than scientific and medical knowledge, analytical, and surgical skills. It also needs every doctor’s and scientist's integrity, which comes with courage and character on the right ethical basis. To try to implement the right medical ethics in each single medical student, ethics should be part of the medical curricula at all universities worldwide.
Three features are needed to be a good doctor or scientist committed to improving the state of health: altruism, wisdom, and compassion.

Altruism

The mental faults of ignorance, hatred, and greed should be erased from one's mind. The medical doctor should be happy and thankful for the opportunity to help and serve other beings, which makes his profession one of the most precious of all.

Wisdom

To seek the best possible knowledge of medicine and to develop a peaceful and altruistic mind is the right basis to maintain or restore health in patients. This includes a clear understanding of the basis of suffering, death, and life after death. An important quality in this context is mindfulness, being aware of the consequences of our decisions and actions.

Compassion

Loving kindness should be the basis of a doctor's behaviour. The motivation should not be to become well-known, respected, famous, rich, or whatever other worldly values could be achieved but exclusively to help others as best as possible. The ongoing discussion in western countries about the salary of medical doctors is counterproductive. Working continuously for the well-being of others will bring much more benefit to one's own spiritual continuum than anything else. By not giving priority to selfish and monetary aspects, doctors will recover lost ground in their patients esteem and make a very good first step toward a health care system affordable for the global interdependent society.

Actuality of Medical Ethics

In the 20th century and right now we can note significant scientific advances in the fields of natural sciences and medicine. Nevertheless, the sum of diseases seems to have remained the same. Many people watch with growing sorrow the endangerment of their living conditions not only by less stringent requirements for a healthy environment, the unlimited exploitation of non-renewable resources, rapid increase in population, but also newly appearing pathogens such as human immunodeficiency virus and prions. After the World Trade Centre and Pentagon tragedy on September 11, 2001, there is a new quality and quantity of anxiety because of the globalization of terrorism and the physical and mental war against this phenomenon.
Unsolved problems in the history of medicine such as abortion and euthanasia, new challenges such as organ transplantation, fertilization, gene research, technology, and therapy up to human cloning are waiting for answers of medical ethics. In all industrialized countries, the explosion of costs in the health services led to financial problems and to increased state regulation not only in the area of clinical medicine hut also more and more in the field of outpatient medical care. In a mechanized world doctors must fight against allowing the medical profession to degenerate to a repairer of the biological "human machine". Doctors have to learn from the history of Hitler Germany to never again let ourselves fall into a "medicine without humaneness" - as the German philosopher Alexander Mitscherlich put it, to become accomplices of criminal human experiments and industrialized mass extermination ordered by the state and obviously tolerated by the majority of the population. We should never forget that during the Holocaust in the “Third Reich" by the state doctrine of forms of life without any worth for the German race over 6,000,000 million Jews, Gypsies, and many others including 70,273 patients from German psychiatric clinics have been killed. There are always new powerful leaders misguided by their egoism and insane suffering from megalomania showing up like Slobodan Milosevic or Osama bin Laden as recent cases.

Genetic Revolution

It is one of the greatest achievements of last century's science to decode herbal, animal, and even the human genome and in cloning everything in every possible way. We are looking forward to be able to clone organs like kidneys, livers, lungs, hearts, and skin from the individual patient's own cells. We do hope to be able to heal gene-related diseases like cystic fibrosis. In the pharmaceutical industry, vaccines against acquired immunodeficiency syndrome, malaria, and tuberculosis, reproducible in the highest standard, unlimited amounts, reasonable costs, and the distribution worldwide in terms of health for all are hopefully at the horizon. Genetically modified food resistant to parasites, bacteria, viruses, and moulds are advertised by the food industry.
Yet there are, with good reason, public fears watching the advances of the genetic revolution. Will we have blood tests and gene mapping right after birth? We know that over the course of the last 10 years hundreds of thousands genetically mutated animals have been born. What about human genes added to cows, sheep, rabbits, and fish? What about mice genes in medication produced by recombinant techniques? What about retroviruses? What about, to mention the worst case, the serious and recently successful attempts made to clone humans? Will designer families be the reality for tomorrow? Will we even have soldiers cloned some not too far times? Think of the nightmare of Aldous Huxley's Brave New World to become true in this century!
Respecting nature is the key answer to all ethical reasoning in this field, and the public eye has to watch the advances and proceedings in genetic engineering as actually in stem cell research. The aim must be to maintain the integrity of the human genome for our as well as future generations. There is a need of:

  • international consensus on ethics, which will lead to international guidelines,
  • making national laws on the basis of these international guidelines, and
  • transparency in public via media.

The actual discussion and recent laws in Switzerland may be a good example: Swiss Gene Lex

  • checks every single case,
  • respects nature and biodiversity, and
  • makes the producer responsible for any adverse event for mankind or environment for 30 years, which of course raises questions of economical risks, insurance rates, rentability, and industrial options of doing research and production abroad where there are either no regulations or more permissive ones.

Conflict between "Pro-Life" and "Pro-Choice" Parties

Another very important field to watch and to carefully consider is the ongoing discussion of euthanasia and its regulation in the Netherlands allowing medically assisted death to a far extent, whereas there are much more cautious discussions, legal regulation, and court decisions for example in the United States and the United Kingdom [13].
The "Pro-Life" party defines life as a divine creation or a gift from the universe to the individuals to be respected like every form of life and nature. Religious and natural law they say are protecting human life from the beginning before birth and until natural death. In the extreme position any form of action intended to abbreviate life, even under a justification of ending unrelievable suffering, is banned.
The "pro-choice" party favors the individual deliberate choice to govern the physical dignity of ones own life and death without being bound to any collective ethics but only to the individual moral capability of free decision-making.
The Dutch position in this matter is that medically assisted death is allowed under the following conditions [14]:

  • requests for euthanasia must come only from the patient and must be entirely free and voluntary,
  • the patient's request must be well considered, explicit, enduring, and persistent,
  • the patient must be experiencing intolerable physical, mental, or other suffering with no prospect of amelioration,
  • euthanasia must be a last resort, alternatives to alleviate the patient's condition having been considered and found wanting, such as by the patient's refusal,
  • euthanasia must be performed by a physician, and
  • the physician must have consulted with an independent physician who has relevant experience.

So far no medical association, other than the Dutch and Belgian, considers it appropriate for doctors to assist, either directly or indirectly, with suicide.
In 1973, the U.S. Supreme Court was asked to rule on the legality of a Texas State Statute that made it a criminal offense for physicians to perform abortions unless the mother's life was in danger. After reviewing the matter of Roe v. Wade, 410 U.S. 113 (1973), a majority of the members of the Court determined that within the Bill of Rights to the U.S. Constitution there exits a "right of privacy” [15]. A majority of the members of the Court further determined that this "right of privacy" left the decision whether to terminate a pregnancy through abortion up to the woman after consultation with her physician. A series of "individual rights" cases followed Roe, including Cruzan v. Director, Missouri Department of Health, 497 U.S. 261 (1990), in which the U.S. Supreme Court held that an individual had a right to require medical authorities to withdraw life-sustaining treatment. The Court emphasized that its determination was based on the ancient AngIo American principle that "at common law, even the touching of one person by another without consent and without legal justification was a battery”. Cruzan, 497 U.S., at 269. The court further noted that medical treatment typically requires informed consent and that generally a competent individual has a right to refuse treatment. In 1994, applying the same type of logic, the Supreme Court used in Roe, as well as their interpretation of Cruzan, a group of terminally ill patients filed suit in the U.S. District Court in Western Washington seeking to nullify a Washington State Statute that prohibited assisted suicide. The District Court struck down the statute, holding that it was an unconstitutional intrusion into "individual rights" guaranteed by the U.S. Constitution. On appeal, the District Court decision was reversed by a three-judge panel of the U.S. 9th Circuit Court of Appeals. That decision was appealed to the full membership of the 9th Circuit, which by a majority vote, overruled the original three-judge panel, thus, reinstating the original District Court decision. The State of Washington then appealed to the U.S. Supreme Court (Washington v. Glucksberg, 521 U.S. 702, 1997). The U.S. Supreme Court noted that for over 700 years AngIo-American common law has punished (through loss of all property to government) or prohibited suicide in same fashion. The Court further noted that the Washington State Statute expressly allowed for the withdrawal or withholding of life-sustaining treatment, thus it complied with the requirements of Cruzan. In the end the Court overruled the lower Courts, deciding in essence, that although there are "individual rights" in which the government cannot intrude, the government may "discourage" the activity by prohibiting others from assisting.
On the other hand, there is a widespread agreement in ethical guidelines of medical associations that doctors have a duty to try to provide patients with a peaceful and dignified death with minimal suffering, which is of course contradictory to the Dutch position of a doctor's role deliberately to kill patients at their request. In this context, one has to be aware of the fact that reducing pains by very potent drugs from classical morphine up to more potent drugs like Fentanyl can lead to the abbreviation of life as well.
Another widely discussed problem is the one of prolonging life in patients who are forever completely unaware in a persistent vegetative state beyond any hope of recovery and whose life therefore can only be prolonged by continuous medical care, treatment. and artificial nutrition. Britain's highest court, the House of Lords, decided in the case of Anthony Bland in 1993 by majority vote that prolongation of his life by these means served none of his interests. The key argument was the denial of present and future characteristics of "personhood" to Anthony Bland because of severe neurological damage. Withholding medical care in those cases is dependent on the high court decision of the country and needs always to be adapted to the individual case [16].

Military Medical Ethics

An important outcome of the Nuremberg Doctors' trials were ethical codes in medicine, including not only the Nuremberg Code but also the Geneva Convention and The Helsinki Declaration as well as subsequent resolutions. We now have bioethics sections in many medical textbooks. Ethics committees at state, scientific society, and university level constitute a solid foundation for conducting research projects on animals and humans in an ethically responsible way. However, there is no special military medical ethics, and there are merely no ethical sections in the handbooks of military medicine.
The question "Why military medical ethics?" should be answered by analyzing the real sources of armed conflicts. In a world where social, cultural, and religious differences are in fact the abundant source of armed conflicts, ethical considerations that transcend these differences are called for. With military actions against dictators like Iraq's President Saddam Hussein, Mr. Slobodan Milosevic, and the al Qaeda terrorists, new forms of armed conflicts have arisen in recent years. Right now, the war against international terrorism focuses our attention on an area of warfare that traditionally has not been addressed by international law. Military medical ethics in this context and understanding is an actual and global key issue. As the law is always behind political events, conflicts, and changes in a society's morals, ethical considerations should have a stable foundation in humanity on the one hand and calculate and disclose possible future issues in advance. In a global view, the question "What kind of morals for the military?" should not be based on interest groups or even national political leaders, whom, because of the nature of politics, sometimes act only because of their immediate political needs; rather, there should be binding regulations in international rules and law, the best of which would be on the level of consensus of the United Nations General Assembly.
There are special issues in military medicine in the armed conflict qualitatively different to medical ethics in general: the doctor-patient relationship, the triage of the wounded, and the interface between stress-related disorders of soldiers and ethics.

Doctor-Patient Relationship and Triage

In medical ethics, the old paternalistic doctor-patient relationship seeing all the knowledge and competence and therefore the decision making as well on the doctor's side has been replaced. Medical ethics focused on patient's autonomy and developed a setting of partnership of equals between doctor and patient.
In the armed conflict with clear rules, ranks, and orders, the doctor-patient partnership is generally not working or merely impossible. The paternalistic setting is the rule. As hierarchy matters in military, staff officers, and even more generals are as a matter of fact privileged. For the most part it is the doctor or the doctors' team that

  • chooses between comparable treatment options, of course also on the issue of resources often limited in the armed conflict compared with peacetime possibilities,
  • decides on life-threatening treatment, and
  • makes decisions about life-sustaining technology.

Another main difference between the weIl-known principles of triage in civilian catastrophes and in the armed conflict is that the medical officer often faces the dilemma that he/she by understandable emotion and sympathy likes to give priority in treatment to his/her own party's patients and to sidetrack the others. From an ethical point of view however the military medical officer should give priority to medical aspects only, meaning that he/she should not (even not when ordered) give priority to his own party or make distinctions between military ranks.
The previous discussion of "pro-life" versus "pro-choice" parties is very relevant in the armed conflict and triage, too. Under all circumstance, there should be no mercy killing of severely wounded or dying soldiers but above all very sufficient action against pain, which might of course result in shortening of life as a side effect.

Stress Disorders

Killing people in the armed conflict, seeing people killed, or facing the possibility to loose one's own life every second is a profound source of stress. Stress, dysfunctional responses, and ethical conflicts flow into each other. The adverse and the own party as weIl as family and friends at home are involved and play a role. The dysfunctional responses vary from minimal - like brief emotional reactions and cognitive distortions to severe psychiatric decompensation like autoaggression, severe depression, and even suicide.
Good strategies of coping with stress disorders should be present in every military medical officers mind and should not be an exclusive obligation for psychiatrists who in many armies are not present to the needed extent in the field. A distinction between mild and moderate disorders, especially diagnosing the beginning psychiatric disease, should be trained to reach a high amount of right situational diagnosis. The cooperation between medical officers in the field, psychiatrist, and psychologist, also with priests from different religions should be as good as possible. A hierarchy of necessary interventions according to personal and technical resources should be present.
Ethics, law, and order are closely intertwined in the practice of the armed conflict. Legalism, to an even greater extent strategic and tactical military needs, is commonly used by commanders to both obscure and resolve ethical dilemmas. Therefore, a special training for commanders in law of the armed conflict, which is already mainly the role, in ethics and in critical incident stress debriefing is critical. Despite the best training, however, the daily necessities and ad hoc solutions in the armed conflict may place an enormous burden on the individual soldier. The dilemma and the inner conflict remain and quite often the problems are displaced, never outspoken, never solved for a lifetime. The answer should be a foIlow-up after the conflict to identify and to help in mislabelled cases or in detecting the hidden ones.

Conclusion

Resolutions of moral conflicts are at best based on global ethical consensus on guidelines rather than on doctrinaire prohibitions backed by criminal or other sanctions. Tolerant laws respecting the dignity of life and distinct medical ethical codes can be responsive to individual moral choices. At the end of life, all means of palliative care should be used to secure human dignity and to prevent suicide or the demand for medically assisted death. In abortion, education and financial support, in particular, in prevention of unplanned pregnancy should be considerably increased as weIl as financial and social support for childbirth and adoption.
Providing health for all in the 21st century is WHO's main aim. As a body of 191-member states throughout the world, WHO recognizes that it has a unique mandate and responsibility to guide all partners involved in global governance of heath toward the attainment of health for all. Promoting international collective action that benefits all countries, and by responding to global threats to health, however, needs the strongest possible political support of the United Nations, including actions against poverty and repression. Equity in all levels of health and health care has to be considered and understood as a basic human right and the prior condition for enduring freedom and lasting peace.
As far as military medical ethics is concerned, a military ethics committee could be an international advisory council that gathers together competent medical officers from different medical fields, religions, nations, and military alliances. Of course it should include people from other faculties like jurists, scientists, theologians, philosophers, and politicians. This ethics committee would be endowed neither with administrative authority nor juridical powers but would have a strictly advisory role. The committee by its existence and efforts could trigger the ethical discourse in medical corps worldwide and help to bridge the gaps in favour of partnership for peace. Reflecting on Franz Kafka's observation that "to prescribe pills is easy, but to reach an understanding in people is very hard”, why not give military medical officers an active role not only in maintaining and restoring the physical level of health but also the social, mental, and spiritual levels. The first important step would be to assume the obligations of dialogue by respecting each other and taking each other's views seriously without any prejudice in nationality, culture, and religion or anthropology.
It is obvious that ethical codes once hopefully achieved on global consensus per se are not satisfactory. History often has shown undesirable trends and malfeasance despite ethical regulations. To achieve the high aim of peace and freedom, the ethical sensitivity and moral integrity of the individual, in our context of doctors, group of doctors, and ideally of the entire medical profession, are more important than written ethical codes. There is a special role for medical doctors to participate as individuals as weIl as a collective in these efforts by continuously working for health in every aspect, including spiritual health, and to try to decrease egoism and ignorance in one's own mind in the best possible way and above all to extinguish hatred and to build up tolerance, humaneness, and respect of nature.

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Authors

LTC Andreas Schapowal MD, Swiss Academy of Medicine and Ethics, Hochwangstrasse 3, CH- 7302 Landquart; E-mail: andreas.schapowal@medizin-ethik.ch.
COL Hans-Ulrich Baer, Associate Professor of Surgery, Digestive Surgery Institute, Witellikerstrasse 40, CH-8029 Zürich, Switzerland; E-mail: hans.baer@profbaer.ch.
Correspondence: LTC Schapowal.

This manuscript was received for review April 2002. The revised manuscript was accepted for publication in April 2002.
Reprint & Copyright @ by Association of Military Surgeons of U.S., 2002.