How do you analyze the present state of military medical ethics?

Medical ethics and bioethics rarely engage topics in military medicine, policy or biosciences. Of the 140,000 articles on bioethics and medical ethics listed in PUBMED from 2000 through 2010, only .75% (less than 1000) discuss topics in military medicine. More than a third of these were devoted to the controversy about the United States’ use of physicians and psychologists to supervise abusive interrogation. Absent that controversy, .5% of bioethics and medical articles address military medicine and military bioscience. This amounts to about seven articles per month. To put this in perspective ten ethics articles per month are published on the much more theoretical issue of stem cells.

To delineate the issues covered by this literature, I reviewed the titles of most recent 100 articles, editorials, and letters in PUBMED (excluding papers on United States clinicians’ complicity with the mistreatment of war on terror prisoners). This very low-resolution analysis of the .5% of bioethics papers addressing military issues showed the following.

22% of medical ethics/bioethics papers discussed the general ethics of war or historical events, such as the Crimean War or Nazi Medicine.

16% examined the effect of war on civilians, such as the duty to provide medical care to non-combatants, to ensure that civilian medical facilities are operating, to prevent rape during war, to ensure public order, to protect media representatives etc.

16% addressed matters pertaining to the development and proportionate use of weapons of mass destruction including nuclear, biological and chemical weapons.

13% examined military research and experimentation on soldiers or prisoners. This includes for example, interrogational experiments and the use of untested vaccines or drugs on deployed soldiers

9% addressed issues in post-war reconciliation, truth commissions, and reparations.

8% considered how to teach military medical ethics and bioethics to military and civilian clinicians, researchers, and public health students.

6% addressed the war crime of torture.

5% addressed issues of war ethics for clinicians. This share would have been much larger if I had not excluded the controversy over United States’ use of clinicians to oversee torture during interrogations. However, it one looks at the pre-Abu Ghraib period, this share of writings was even smaller.

5% addressed topics in the medical humanities, such as war imagery in Goya’s paintings.

Although a larger sample of articles would have included more papers on any specific issue, it is unlikely that the proportionate share of the covered issues would have changed a great deal. For example, the six articles debating the policy implications of excess childhood mortality from caused by trade sanctions predate the 100 title sample, but when those articles were published little else published in the category the ethics of protecting civilians caught up in war and siege. Given such miniscule attention, many bioethics issues pertaining to military conduct have not received any significant analysis. Bioethicists largely leave the debate about the bioethics dimensions of military policies to generals, political scientists and NGOS.

In your opinion, how will the situation likely evolve over the next five years?

There are political and conceptual barriers that impede medical ethicists and bioethicists from addressing military issues.

Politically, military programs and activities are imbued with notions of patriotism and politics. In this sense, those who attempt to reflect on the ethics dimensions of military programs may be seen as expressing anti-nationalism or as simply promulgating political opinions.

Conceptually, bioethics lacks both a definition of military ethics or even a reasonably complete outline of issues to foster the creation of such a definition. Relying on the current canonical topics (torture, experimentation, nuclear war, etc.) risks relegating ethics scholarship to the ethics of past wars. New issues have to be able to get on the table. For example,

•Can a duty require countries or forces that deploy non-deactivating land mines to pay for demining and rehabilitation of civilian casualties be articulated and put into international law? Does this matter fall within bioethics?

•Can a duty of stewardship with regard to the storage of the smallpox virus be defined? If any one party holding this dangerous material does not meet duties for safe stewardship, should all parties be required to destroy stores under UN supervision? Is this bioethics?

•Is it a disqualifying conflict of interest for a defense department to determine if exposure to potentially biotoxic weapons made with “depleted uranium” causes a service-connected disability for which supplemental veteran’s health care would be due? Is this bioethics?

1. •Who is responsible for ensuring that trade sanctions (a form of siege) do not interdict supplies that are needed to operate public water systems in a manner that causes non-combatants to die? Is this bioethics?
   

It would seem that a conceptual definition of a military bioethics issue would meet two special criteria. First, the bioethics problem would have to be engendered by the unique political role of the military (defending national security, maintaining territorial integrity, etc.). Second, the bioethics problem would have to arise because of the military sector’s special authority (i.e., command structure) OR powers (use of weaponry, tactical interrogation of war prisoners, control of foreign territory, etc.). This definition excludes problems that occurred within a military organization but were separable from these criteria. For example, routine informed consent for surgery in a veteran’s hospital falls outside both criteria. Compulsory (unconsented) administration of untested vaccines to deployed soldiers meets both criteria. The iterative refinement of this definition against a fuller list of topics requires considerable work. Such refinement will necessarily be highly politicized.

To secure the autonomy of bioethics from military policy and command, bioethicists must rehabilitate the concept of “dual loyalty ethics.” Traditionally, dual loyalty ethics was used to analyze situations where a physician’s obligation to a patient’s well being conflicted with duties to another party. It works best when the patient’s health interest is safeguarded but where a personal interest (e.g., privacy) is compromised for an institutional priority (e.g., not certifying a pilot with alcoholism as fit to fly). Today, military authorities largely have carte blanche to subordinate personal health interests to mission aims. Deployed soldiers are required to accept untested drugs or vaccines whose effects are largely unmonitored. In more than eighty countries, interrogatees are savaged under medical supervision in a largely vain pursuit of information. A rehabilitated concept of dual loyalty ethics could revitalize military medical ethics by affirming the centrality of a clinician’s or public health expert’s duty to the well-being of soldiers, prisoners, and non-combatants at least within the framework of human rights and international law. Such an advance could serve as a foundation for strengthening codes of ethics for military clinicians, military education, and reforming military policies.

What are the structural long-term perspectives?

Structurally, there is little foundation for multidisciplinary collaborative scholarship between civilian and military medical ethicists. Few scholars are prepared for these issues. Medical ethics and bioethics societies devote little conference time to military matters. The few journals on these matters speak to small audiences. Medical ethicists who work for defense departments have produced solid scholarship that largely defers to the exigencies of military command rather than elevating civil society’ frameworks of human rights. The World Medical Association, comprised of representatives of national medical societies, is not constituted to support the voices of a scholarship of dissent.

There are compelling reasons why bioethics must effectively engage military policy. Military-related activities pose unique issues for public health, human experimentation, and clinical ethics. War affects public health. It causes .3% of all deaths, a third as many as are caused by murder. Today, war makes more than forty million people a year either refugees or internally displaced persons. This roughly equals the number of people who die of heart attacks, infections, cancer and injuries put together. The health of displaced persons, disabled veterans, disabled civilians and structurally delayed national development from war challenge bioethics. Many politicians are ill equipped to study these issues or place them in broad perspectives of human rights. As part of academia, bioethics (like the press, international organizations, NGOs, and civilian government) is part of the civil society oversight of military activities. Bioethics must create and nurture forums to develop expertise and dialogue on problems arising from military bioethics.

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Steven H. Miles, MD, is Professor of Medicine and Bioethics at the University of Minnesota in Minneapolis, USA. His most recent book is Oath Betrayed: America's Torture Doctors (University of California Press; 2010; Random House, 2006).  He has also writen The Hippocratic Oath and the Ethics of Medicine (Oxford University Press, 2004). He serves on the Board of the Center for Victims of Torture in Minneapolis, Minnesota. His website: www.ahc.umn.edu/bioethics/facstaff/miles_s/ He has no conflicts of interest to disclose.

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