Complexities of autonomy in military medical ethics: A brief report.

ABSTRACT: The first Fallen Surgeons Military Educational Symposium was convened in conjunction with the the American Association for the Surgery of Trauma (AAST) 23 meeting, under the guidance of the AAST Military Liaison Committee. The daylong session included a 1.5-hour segment on military medical ethics in combat and its unique challenges. Medical ethical issues arise frequently within the military across a range of varied circumstances, from the day-to-day operations of stateside forces to the complexities of deployed troops in theaters of conflict. Given the scope of these circumstances, preparation and advanced planning are the key to addressing and resolving the ethical issues that occur. The goal of this session was to present illustrative cases, not to prescribe solutions, and to make the attendees aware of some of the challenges they may encounter when deployed.

When Medical Ethics and Military Ethics Collide.

In 12 narratives, medical workers from Afghanistan, Darfur, Gaza, Iraq, Israel, Myanmar, and Ukraine describe the day-to-day challenges of providing quality medical care in austere conflict zones. Faced with severe shortages of supplies, overwhelmed by sick and injured civilians and soldiers, and subject to constant attacks on medical personnel and facilities, the contributors to this collection confront difficult dilemmas of justice, medical impartiality, neutrality, burnout, and moral injury as they struggle to fulfill their duties as medical professionals, military officers, and conscientious citizens.

Short Communication: Combining Ethics With Efficiency-Israel Defense Forces' Experience in Clinical Trials During the Coronavirus Disease 2019 Pandemic.

The coronavirus disease 2019 (COVID-19) pandemic, first reported in China, soon spread worldwide, has evolved into one of the most complex global public health crises the world has encountered in the last several decades. Conducting military medical research is vital to study the unique influences of military service conditions on soldiers' health and to improve the medical response in various emergency periods. The Israel Defense Forces (IDF) Medical Corps maintains an Institutional Review Board (IRB) which reviews clinical studies conducted within the IDF. During the COVID-19 pandemic, the IRB of the IDF had to rapidly implement procedural modifications in order to comply with expanding urgent demands for research without compromising ethical standards. The ethical dilemmas and the IDF policy and perspective are outlined in this article.

Burn wound care of civilians in Sahel region by French military surgical teams: ethical challenges and future training requirements.

The primary mission of the French military surgical teams deployed in external operations in the Sahel is to provide support for combatants. However, many of their activities and of the limited human and material resources allocated to them are devoted to providing free medical assistance to the local population. The French military surgical teams are very often expected to take care of serious burns for the benefit of civil populations because of the absence of dedicated civilian medical structures. Surgical teams are faced with a necessary triage of patients to be taken care of because of the discrepancy between the high demand for care and the means at their disposal. But the triage can lead to ethical dilemmas when the values that come into play in the decision contradict each other or when they run up against the quota of available human and material resources, as well as the interests of the military institution. The challenge is then to become aware of these dilemmas in this particular context. A discussion of these ethical dilemmas would help carers to avoid developing fatalistic attitudes or developing chronic pathologies due to unresolved or unconscious predicaments. Solutions are proposed that place ethical reflection at the heart of the practices during external operations by the French surgical teams. The ethics of discussion must bring together all players in care management and also the military authorities, before, during and after the missions. Training programmes for ethical reflection would benefit surgical teams and help them approach and become aware of the dilemmas they will necessarily face.

Creating a 'Father Confessor': the origins of research ethics committees in UK military medical research, 1950-1970. Part II, origins and organisation.

Using a major ethics crisis as a methodological approach to study secret science environments, part II examines the origins and organisation of the Applied Biology Committee (ABC), the first independent research ethics committee (REC) at Porton Down, Britain's biological and chemical warfare establishment since the First World War. Although working in great secrecy, the UK military, and Porton in particular, did not operate in a social, political and legal vacuum. Paradigm shifts in civilian medical ethics, or public controversy about atomic, chemical and biological weapons, could thus influence Porton's self-perception and the conduct of its research. The paper argues that the creation of the first REC at Porton in 1965, that is, the ABC, as the ' father confessor ' inside the UK's military research establishment reflected a broader paradigm shift in the field of human research ethics in the mid-1960s.

Bioethics of military performance enhancement.

Biological interventions to improve performance, such as amphetamines, have a long history of military use, and in the future may include more advanced biotechnologies. This article discusses the ethics of using biomedical enhancements in the military. The article begins by describing the distinction between biomedical enhancements and interventions intended to prevent, treat or mitigate disease. It then sets forth three principles to guide the ethical use of bioenhancements-proportionality, paternalism and fairness. The article applies these principles to concerns raised by military bioenhancement: safety, fairness in access to military reward, carryover effects to civilian life, whether service members can be ordered to use bioenhancements and when they may be permitted to do so voluntarily.

Is the four quadrant approach to military medical ethics a cargo cult? A call for more unity between philosophers and practitioners.

Moral theory should be practically useful, but without oversight from the philosophical community, the practical application of ethics by other institutions such as the military may drift into forms that are not theoretically robust. Ethical approaches that drift in this way run the risk of becoming 'cargo cults': simulations that will never properly fulfil their intended purpose. The four quadrant approach, a systematic method of ethical analysis that applies moral principles to clinical cases, has gained popularity in the last 10 years in a variety of medical contexts, especially the military. This paper considers whether the four quadrant approach is a cargo cult or whether it has theoretical value, with particular reference to the more popular four principles approach. This analysis concludes that the four quadrant approach has theoretical advantages over the four principles approach, if used in the right way (namely, with all four quadrants being used). The principal advantage is that the four quadrant approach leaves more room for clinical judgement, and thus avoids the charge of being too algorithmic, which has been levelled at the four principles approach. I suggest that it is the fourth quadrant, which invites the user to consider wider, contextual features of the case, which gives the approach this key advantage. Finally, I make a more general proposal that theoretical ethicists should work closely with those practitioners who apply ethics in the world, and I call for a symbiotic relationship between these two camps.

Legal framework versus moral framework: military physicians and nurses coping with practical and ethical dilemmas.

Within military operations, military physicians and nurses experience a dual loyalty to their professional identities. The moral frameworks of the medical and military professions are not similar, and require different kinds of choices and action from its members. But above all, the legal framework in which the healthcare personnel has to operate while deployed is different from the medical moral standards. Military necessity is prioritised over medical necessity. In debates on dual loyalty, legal frameworks should be considered as a more decisive factor in ethical decision-making processes. Legal frameworks, both general and mission-specific, support this prioritisation of military necessity, complicating the work of military physicians and nurses. During the post-Cold War era, in which neutrality and moral supremacy have served as legitimising factors for military peacekeeping or humanitarian missions, this misalignment between the moral and the legal framework is problematic. What is legally correct or justifiable may not be morally acceptable to either the medical professional standards or to the general public. The legal framework should be given more prominence within the debates on dual loyalty and military medical ethics. This paper argues that the misalignment between the legal and moral framework in which deployed healthcare personnel has had to operate complicated ethical decision-making processes, impeded their agency, and created problems ranging from military operational issues to personal trauma and moral injury for the people involved, and ultimately decreasing the legitimacy of the armed forces within society.

US military medical ethics in the War on Terror.

Military medical ethics has been challenged by the post-11 September 2001 'War on Terror'. Two recurrent questions are whether military physicians are officers first or physicians first, and whether military physicians need a separate code of ethics. In this article, we focus on how the War on Terror has affected the way we have addressed these questions since 2001. Two examples frame this discussion: the use of military physicians to force-feed hunger strikers held in Guantanamo Bay prison camp, and the uncertain fate of the Department of Defense's report on 'Ethical Guidelines and Practices for US Military Medical Professionals'.

Ethical rationales for past and present military medical practices.

This paper reviews changes in the ethical challenges that have arisen in military medicine over the past four decades. This includes the degree, if any, to which providers during the Vietnam conflict have carried out what we now refer to as harsh interrogation measures in an attempt to extract information from captured enemy soldiers, the extent, if any, to which the USA used medicine as a means to try to win over the hearts and minds of civilians in occupied territory and how providers should treat service members who return from the front with combat fatigue. An issue that arose during the first Gulf War in 1991 is discussed, namely US service persons being required to take botulism vaccine without their consent. Finally, present challenges are discussed including interrogation measures such as waterboarding and the ethical issues posed in the recent past by the exclusion of gay service members and those posed presently by the inclusion of transgender members. Two ethical values are suggested that have remained constant, namely giving priority to the individual needs of service personnel over those of the unit when there are no urgent combat needs and the reliance on individual virtue when what they should do is morally unclear.

Dual loyalty in military medical ethics: a moral dilemma or a test of integrity?

When militaries mention loyalty as a value they mean loyalty to colleagues and the organisation. Loyalty to principle, the type of loyalty that has a wider scope, plays hardly a role in the ethics of most armed forces. Where military codes, oaths and values are about the organisation and colleagues, medical ethics is about providing patient care impartially. Being subject to two diverging professional ethics can leave military medical personnel torn between the wish to act loyally towards colleagues, and the demands of a more outward looking ethic. This tension constitutes a test of integrity, not a moral dilemma.

Military health outreach on Exercise ASKARI SERPENT: a discussion of clinical and ethical challenges.

Exercise ASKARI SERPENT (Ex AS) is an annual British Army medical exercise that sees the deployment of a medical regiment to rural Kenya. The exercise involves the delivery of health outreach clinics and health education to the civilian population alongside Kenyan governmental and non-governmental organisations. This article includes a post hoc analysis of the ethical and clinical challenges that clinicians faced during Ex AS, applying a four-quadrant approach to ethical decision-making. This article intends to stimulate further debate and discussion on how to best prepare clinicians for clinical challenges and ethical decision-making on future exercises and operations. We conclude that our experiences on Ex AS can provide an insight on how to develop predeployment training for clinicians. Furthermore, the universal nature of the challenges faced on Ex AS can be applied to training for future contingency operations.

The safety paradox in ethics training: a case study on safety dynamics within a military ethics train-the-trainer course.

There is considerable support for the idea that an atmosphere of safety can foster learning in groups, especially during ethics training courses. However, the question how safety dynamics works during ethics courses is still understudied. This article aims to investigate safety dynamics by examining a critical incident during a military ethics train-the trainer course during which safety was threatened. We examine this incident by means of a four-factor analysis model from the field of Theme-Centered Interaction (TCI). We show that during ethics training courses a safety paradox can occur, involving a tension between honesty and openness to other perspectives and values. Finally, we discuss how trainers can foster safety during ethics training.

Military physicians' ethical experience and professional identity: a Canadian perspective.

Military physicians can experience ethical tensions and encounter important dilemmas when acting at the same time as healers, soldiers and humanitarians. In the literature, these are often presented as the result of pressures, real or perceived, from the military institution or role and obligation conflicts that can divert physicians from their primary duty towards their patients. In this article, I present the ethical experiences of 14 Canadian military physicians who participated in operational missions, particularly in Afghanistan. Interestingly, although some dilemmas discussed in the academic literature were raised by Canadian physicians, ethical tensions were less frequent and numerous than what might have been expected. Instead, what emerged were distinctions between the ethical experiences of physicians: generalists experienced more frequent and different ethical challenges than specialists, and these also varied by context, that is, garrison versus on deployment. The main dilemmas during deployment were similar to those encountered by humanitarian physicians and concerned inequalities in the provision of care between coalition soldiers and Afghans (soldiers and civilians), as well as the lack of resources. Surprisingly, participants were evenly divided with regards to how they perceived their professional identity: one group clearly prioritised the medical profession (ie, doctor first and foremost), while the other group identified themselves as military physicians, but without prioritising one profession over the other.

The 'peace role ' of healthcare during war: understanding the importance of medical impartiality.

This article argues that medical personnel of armed forces occupy a ' peace role ', which continues and dominates their professional ethos during armed conflict. The specific role and its associated legal and ethical obligations are elaborated, and on that basis arguments are provided why and how the work of military healthcare providers is interpreted as a continuation of peace during war.

Military medical research in Britain and the USA: the challenge of informed consent.

Military medical research requires informed consent from test subjects, which is difficult to obtain for deployed (in-theatre) or prehospital studies where patients are incapacitated and legal representatives are not available. Although US and UK regulations make provisions for exceptions to informed consent, these are rarely used, thereby hindering trauma research and prospective experimental studies of new devices, surgeries or drugs. In their place, a survey of research articles published in the Journal of the Royal Army Medical Corps and Military Medicine between 2004 and 2018 shows how researchers turned to clinical surveys and retrospective, case or animal studies instead. The reluctance to enrol military personnel in interventional studies stems from past instances of abuse and current misperceptions of soldiers as a particularly vulnerable class of research subjects. Increasing the pool of research subjects to facilitate interventional studies to improve combat casualty care requires honing military medical ethics in two ways. First, it is important to implement existing informed consent regulations without special regard for the status of service personnel. This will expedite approval of waivers of informed consent. Second, aggressively recruiting civilians for military-related medical research increases the number of subjects available for trauma research. Community consultation and public discourse are the proper venues to deliberate on each recommendation.

Revisiting Desmond Doss (1919-2006): Merging Combat Medicine and Benevolence on the Battlefield.

Conscientious objectors are typically defined only by their unwillingness to serve in the armed forces. Desmond Doss participated in World War II as a combat medic and a conscientious objector by providing emergency medicine on active battlefields while refusing to handle a weapon or harm another human being. Born and raised with humility, Doss developed spiritually as a Seventh Day Adventist. Although fixated on the Ten Commandments and "Thou shall not kill," Doss felt a call to serve and voluntarily enlisted in the U.S. Army with aspirations of becoming a combat medic. Throughout his training he was met with physical, spiritual, and political obstacles as his superiors unsuccessfully tried to convince him and eventually to force him out of the military or to take up arms and fight. Doss was granted his request as a combat medic, was not required to handle a weapon or fight, and was deployed with the 307th Infantry Regiment overseas. His heroism on the battlefield saved hundreds of lives and earned him the Medal of Honor. A thorough yet concise examination of Doss' formative years, the obstacles presented by the country he aimed to serve, how he evolved from a conscientious objector to a combat medic worthy of emulation, and his lasting legacy is a necessary reminder of what we risk when courageous people are limited by outdated and potentially unconstitutional policies and perceptions.