Beneficence requires that any procedure is provided with the intention of doing good for the patient involved

Justice requires that burdens and benefits are equally distributed

The patient must have Autonomy of thought, intention, and action when making decisions regarding their health care procedures

Non-maleficence requires that a procedure does not harm the patient involved or others, or at least promotes more good than harm

INTRODUCTION

Who should be picked up by medical evacuation helicopters? Should I withdraw treatment from a child burned in a cooking accident to free up an intensive care bed for a military patient? Should I declare a soldier unfit to deploy because she refuses to take anti-malarials? Should I order a doctor to treat infectious disease patients? Should I tell the Commanding Officer of the soldier who has declared his addiction to alcohol? Should I downgrade a senior non-commissioned officer whose medical condition precludes deployment and prevent their promotion? Should I administer a vaccination that I think is unnecessary? Should I train my medics to operate crew-served machine guns? These are just some of the types of decisions that may face a military healthcare worker that have ethical and legal implications.

Ethics is the set of moral principles than govern a person’s activities or behaviours. Reaching from the Hippocratic Oath, there is a long history of prescribing the ethical standards by which doctors and other healthcare professionals practice their art. Medical ethics starts with the underlying principle of ‘first do no harm’. This contrasts with the ‘profession of arms’ whereby the explicit intent is to do harm to one’s enemies. However, even in war, there should be limits to the use of violence. These are expressed as the ‘laws of armed conflict (LOAC)’ or ‘International Humanitarian Law (IHL)’. Military ethics covers the practice of military art based on IHL and all other behaviours in employment in the armed forces. Military medical ethics lies at the intersection of medical and military ethics. It is underpinned by the principle that medical facilities and personnel are fundamentally humanitarian actors afforded protection under IHL. Medical personnel (encompassing all healthcare workers and personnel assigned to medical duties) are not parties to conflict and thus have rights and duties. These extend from conflict into the wider military environment and reflect the application of medical ethics into the unique context of the armed forces. As argued in an editorial by Withnall and Brockie in BMJ Military Health, there is an operational imperative that all healthcare personnel of the armed forces are taught the principles of IHL, the limitations on the use of violence and its application towards protected persons. Military healthcare personnel also need specific education in military medical ethics so that they understand their duties to both their profession (medicine, nursing and allied healthcare) and their military employer – so called ‘professional dual loyalty’.

MEDICAL ETHICS

Medical ethics is underpinned by the 4 principles of autonomy (the right of an individual to self-determination), beneficence (the best interests for a patient), non-maleficence (first do no harm), and justice (fairness at an individual and population level in decisions about allocation of care). These are often expressed as a list of professional behaviours that form the basis of regulation by professional bodies that grant qualifications and licence to practice. These lists may cover behaviours towards patients, behaviours towards oneself, and behaviour towards colleagues and the public. There are special provisions for circumstances where there could be an imbalance of power between healthcare professionals and patients such as consent, research, financial and personal relationships.

Professional regulation is usually linked to organisations that grant licences to practice for defined professions such as doctors, nurses and specified allied health professionals (pharmacists, opticians, biomedical scientists, paramedics etc). These organisations control approval of educational programmes, examinations, investigations of malpractice and professional sanctions (the UK General Medical Council is one example). . For military health professionals, their licence to practice granted by their professional regulating body is more important than the contract with their military employer . There are often clauses in military laws that constrain the application of military rules to protect the professional duties of healthcare workers (e.g. protect the right of confidentiality between the doctor and the patient, except for specific circumstances). The oversight of medical ethics by professional regulating bodies is usually under the authority of national laws. However, international bodies such as the United Nations (and its subordinate agencies, such as the World Health Organisation) and the World Medical Association provide internationally agreed principles for medical ethics.

MILITARY ETHICS

Military ethics covers, but is not limited to, the principles of LOAC. This covers both the legal basis by which states decide to go to war (jus ad bello) and then conduct during war (jus in bello). Many militaries provide training on LOAC to their personnel (e.g. UK Joint Service Manual on Law of Armed Conflict ). This includes general instruction to all personnel, concentrating on rules of engagement and protected persons and property. Training for senior leaders is likely to cover targeting, proportionality and discrimination, oversight and legal advice, and difficult decision-making. Military ethics also covers behaviours during military operations outside a formal declaration of war including humanitarian and disaster relief operations, internal security, peace-keeping and peace-enforcement operations. This includes compliance with international agreements on trafficking, slavery, sexual and gender-based violence, child soldiers and other breakdowns in societal behaviour during conflict and insecurity.

Many armed forces also set values and standards for military personnel as part of their normal duties outside conflict (e.g. the Values and Standards for the British Army ). These will both reflect societal norms (such as anti-discrimination laws) and also reflect the unique obligations and commitments of the armed forces to society, such as courage and selfless commitment. Military medical personnel are subject to military law in the course of their employment. They will be bound by military ethics though will need to understand the specific obligations and protections afforded to their profession through IHL. Wider military values and standards may impose additional constraints on their behaviours in their professional and personal lives compared to their civilian counterparts (e.g. freedom to speak to the press).

MILITARY MEDICAL ETHICS

Military medical ethics are founded upon the duties and protections afforded to medical personnel and units for the relief of suffering due to war that are enshrined within the Geneva Conventions. Whilst they wear the uniform of the armed forces, they also entitled to wear the Red Cross and are classes as non-combatants. This separation of medical personnel from parties to conflict is inviolable whilst they are a member of a protected profession. The behaviours of military medical personnel should reflect the humanitarian principles of humanity and impartiality . However, they cannot be neutral or operationally independent because they are employed by a state . Medical personnel serving in the military must understand and accept the ultimate role of the armed forces. If this contravenes their conscience, they must resign.

The Geneva Conventions and wider IHL specify the duties of parties to armed conflict in regard to distinction and proportionality in the use of violence. These also specify the roles and responsibilities of medical personnel that are additional to normal principles of medical ethics. As a result of increasing evidence of transgressions of these international agreements, the World Medical Association (WMA), the International Committee of Military Medicine (ICMM), the International Council of Nurses (ICN) and the International Pharmaceutical Federation (FIP) have published ‘Ethical Principles Of Health Care In Times Of Armed Conflict And Other Emergencies’ as a summary of the obligations of healthcare personnel . These principles emphasise the enduring nature of medical ethics and the primary task of health-care personnel as to preserve human physical and mental health and to alleviate suffering with humanity and without discrimination. The document lists the rights of the patient to emergency care, self-determination, dignity, privacy, and confidentiality, all without discrimination. It also re-iterates the obligations of all parties to enable patients to access to health care and to protect health facilities, transport and personnel.

Military medical ethics extends beyond conflict and provides guidance in circumstances where the dual loyalties of the military and medical professions may conflict. This includes relationships with patients , consent , force health protection measures (such as vaccinations ), confidentiality , research , and police investigations . A military medical practitioner is likely to need a broader and deeper understanding of the applications of ethics within their employment compared to their civilian counterparts because of these complexities.

SUMMARY

This short paper has introduced military medical ethics as a unique blend of both medical ethics and military ethics as applied to the professional practice of healthcare workers during armed conflict and when serving in the armed forces. Healthcare workers are regulated by the standards of their professional bodies and this determines their scope and licence to practice. Healthcare workers employed in the armed forces need to be taught the law of armed conflict/international humanitarian law in order to be able to understand and apply their obligations as protected persons working in protected facilities. They also need to understand the application of medical ethics within their unique employment circumstances of the armed under military law.

General further reading

Medical Ethics:

Medical Ethics Manual. Manual for physicians about the role of ethics in medicine. World Medical Association at: https://www.wma.net/what-we-do/education/medical-ethics-manual/

Military Ethics:

Collected resources at the Centre for Military Ethics. At: https://militaryethics.uk/en/resources

A Soldier’s Values and Standards. British Army. At: https://www.army.mod.uk/who-we-are/our-people/a-soldiers-values-and-standards/

Joint Service Manual of the Law of Armed Conflict. JSP 383. UK Ministry of Defence. At: https://www.gov.uk/government/collections/jsp-383

Military Medical Ethics:

BMJ Military Health. Military Medical Ethics Special Issue. At: https://militaryhealth.bmj.com/content/165/4

Fundamentals of Military Medicine. Borden Institute. 2019. Chapter 5 Military Law and Ethics and Chapter 6 Law of Armed Conflict and Military Medicine. At: https://www.cs.amedd.army.mil/borden/bookDetail.aspx?ID=a875991f-3640-4cab-afa5-66f02f917333%20&pageTitle=Fundamentals%20of%20Military%20Medicine

Withnall R, Brockie A. Military ethics: an operational priority. BMJ Military Health 2019;165:219. http://dx.doi.org/10.1136/jramc-2019-001262

Olsthoorn, Peter. (2019). Dual loyalty in military medical ethics: A moral dilemma or a test of integrity?. Journal of the Royal Army Medical Corps. 165. 282-282. 10.1136/jramc-2018-001131. Available at: https://www.researchgate.net/publication/329801888_Dual_loyalty_in_military_medical_ethics_A_moral_dilemma_or_a_test_of_integrity/citation/download

International Code Of Medical Ethics. World Medical Association. 9 Jul 2018. Available at: https://www.wma.net/policies-post/wma-international-code-of-medical-ethics/ Accessed: 21 Jun 20

General Medical Council. https://www.gmc-uk.org/

Annas GJ. Military medical ethics--physician first, last, always. N Engl J Med. 2008;359(11):1087-1090. doi:10.1056/NEJMp0805975

Global Health Ethics. World Health Organisation. https://www.who.int/health-topics/ethics

World Medical Association. https://www.wma.net/

Strengthening of co-ordination of humanitarian emergency assistance of the United Nations. UN General Assembly 46/182 dated 19 Dec 1991. At: https://undocs.org/A/RES/46/182

Tobin J. The challenges and ethical dilemmas of a military medical officer serving with a peacekeeping operation in regard to the medical care of the local population. Journal of Medical Ethics 2005;31:571-574.

Common ethical principles of health care in conflict and other emergencies. At: https://www.icrc.org/en/document/common-ethical-principles-health-care-conflict-and-other-emergencies

R. Vollmuth. Healthcare Professionals between Medical Ethics and Military Duties. Medical Corps International Forum. 2016. https://military-medicine.com/article/3198-healthcare-professionals-between-medical-ethics-military-duties.html

Nathanson, V. (2013). Medical ethics in peacetime and wartime: The case for a better understanding. International Review of the Red Cross, 95(889), 189-213. doi:10.1017/S1816383113000775. https://international-review.icrc.org/sites/default/files/irrc-889-nathanson.pdf

John D. Grabenstein, Phillip R. Pittman, John T. Greenwood, Renata J.M. Engler, Immunization to Protect the US Armed Forces: Heritage, Current Practice, and Prospects, Epidemiologic Reviews, Volume 28, Issue 1, August 2006, Pages 3–26, https://doi.org/10.1093/epirev/mxj003

Gibson T, Coker WJ. Medical Confidentiality: The Right Of A Commanding Officer To Know.

BMJ Military Health 2002;148:130-136. http://dx.doi.org/10.1136/jramc-148-02-05

McManus J, Mehta SG, McClinton AR, De Lorenzo RA, Baskin TW. Informed consent and ethical issues in military medical research. Acad Emerg Med. 2005;12(11):1120-1126. doi:10.1197/j.aem.2005.05.037

Physician Participation in Interrogation. Code of Medical Ethics Opinion 9.7.4. American Medical Association. At: https://www.ama-assn.org/delivering-care/ethics/physician-participation-interrogation