Specific Topic(s):

Ethics of triage and resource allocation, military necessity

Key references:

‘Ethical principles of health care in times of armed conflict and other emergencies’ – ‘In armed conflict or other emergencies, health-care personnel are required to render immediate attention and requisite care to the best of their ability. No distinction is made between patients, except in respect of decisions based upon clinical need and available resources’.

Geneva Conventions: Rule 110. The wounded, sick and shipwrecked must receive, to the fullest extent practicable and with the least possible delay, the medical care and attention required by their condition. No distinction may be made among them founded on any grounds other than medical ones. https://ihl-databases.icrc.org/customary-ihl/eng/docs/v1_rul_rule110

Discussion:

Review of the question: this question highlights the challenge of allocating military medical capacity for the immediate needs of casualties from conflict when the medical capacity is likely to be exceeded as a result of a mass casualty incident in which triage decisions are made on ability to benefit from simple interventions. This is different from a major incident in which casualties are treated in the order of clinical severity.

Interpretation of the principles/policy from the references: In all circumstances the casualties should be treated solely on the basis of clinical need without discrimination. However, Article 12, third paragraph, of the 1949 Geneva Convention I provides: “Only urgent medical reasons will authorize priority in the order of treatment to be administered.” Therefore, there is no obligation on military forces to treat non-urgent civilian cases. The two academic references below provide a framework for deciding whether international military medical units should provide care for other populations including local security forces, and local civilians. This framework has been called ‘medical rules of eligibility’. Gross argues that military forces may decide to ‘keep beds empty’ to ensure capacity for future military operations on the grounds of military necessity. The ‘military necessity’ decision can only be made by a military (not medical) commander supported by legal advice.

Framework for answering the scenario/question:

• What are obligations for caring for patients?

• What is the difference between ‘normal’ and mass casualty situations?

• Why might it be necessary to retain a ‘medical reserve’?

• What tensions might exist between medical ethics and military necessity?

• Who has ultimate authority to decide?

Further issues for consideration:

• Is this argument different for ‘an occupying power’ rather than an international partner to a sovereign nation?

• Is this argument different if military commanders want to use medical support to care for civilian patients as part of a ‘hearts and minds’ task?

• Is this argument different for different parts of the medical evacuation system (ambulance evacuation from an incident, field medical care, surgical capacity, intensive care, evacuation out of country)?

Gross ML. Saving Life, Limb, and Eyesight: Assessing the Medical Rules of Eligibility During Armed Conflict. Am J Bioeth. 2017;17(10):40‐52. doi:10.1080/15265161.2017.1365186

Bricknell MC, dos Santos N. Executing Military Medical Operations. BMJ Military Health 2011;157:S457-S459. Republished at: https://www.military-medicine.com/article/3072-executing-military-medical-operations.html