AMA Journal of Ethics®

Illuminating the art of medicine

Journal of Ethics Header

AMA Journal of Ethics®

Illuminating the art of medicine

Virtual Mentor. October 2007, Volume 9, Number 10: 715-717.

Medicine and Society

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Physician-Soldier

The roles of the military professional and the medical professional sometimes conflict, but this author seeks to reconcile the ethical ideals of both.

Gary Schwartz, MD

The seasoned and effective soldier and doctor are similar in one respect-they share a keen sense of intuition honed by years of experience. The professional who succeeds on the battlefield and in the wards applies insight that is not teachable even in the best of training facilities, only learnable by rigorous life experience.

Learning ObjectiveUnderstand the ethical arguments that support participation by physicians in military medicine.

But these professional roles differ from each other in many ways, so much so that some have questioned whether serving in both professions at the same time is ethically possible. Might doing so even be reproachable? Are physicians, given their duty to preserve and restore physical and mental health, obligated to attempt to banish war and warriors from the earth? As defenders of health and human life, ought physicians be held responsible for promoting-if not guaranteeing-the prevention of injury? If so, this should exclude their participation in or support of war in any form.

Intuitively, this argument appears sound. The physician's professionally imposed obligation to heal entails a duty to prevent injury when possible, a duty obviously violated during times of war. The principle of prevention of harm can be seen either as an extension of the obligation of beneficence included in the Hippocratic Oath or as a separate and superior obligation-in fact, the modified Hippocratic Oath taken by the majority of physicians in this country includes the clause "I will prevent disease whenever I can, for prevention is preferable to cure" [1].

But this argument assumes that the ethical obligation to heal (do good) necessarily entails an obligation to prevent harm, an obvious example of which is war. In reality, doing good (beneficence) and preventing harm (maleficence) are not always compatible ends, and conflict with each other at times.

The tension between the principles of beneficence and nonmaleficence is not always obvious in the one-on-one clinical encounter. Proposed treatments for a given patient can usually be predicted to either benefit the patient or do harm. Even here, though, there are instances in which an intervention may cause both good and harm and the benefits and risks must be weighed before a treatment decision is made. When more than one individual is involved, the balancing and decisionmaking become more complicated. The principle of promoting the greater good clashes with the intent to prevent individual harm. In general, the former, utilitarian approach is deemed the more practical, since qualitative "good" is quantified by considering the number of individuals affected, and the action that benefits most often becomes the ethically endorsed action.

In the case of war, individual rights are frequently violated in the interest of the greater good. Examples here range from the restrictions on individual rights that soldiers accept upon joining the military, to the deprivation suffered by families of dead soldiers, and restrictions placed on supplies available to civilians. While unjustifiable militant action is obviously morally reprehensible, these infringements of individual rights for the potential benefit of many may be justifiable and even warranted.

The distinction between the good of the individual and the good of the many applies to the question of the physician's role in denouncing war. If no war is justifiable, the physician is obligated to condemn all acts of war. But if military action can prevent more widespread morbidity or mortality, then not only should it not be condemned, it should be supported by the international community of health care professionals. Such an extreme movement existed during the conflict in Kosovo in the late 1990s, when the international organization Physicians for Human Rights called upon President Clinton to intervene with ground forces to prevent the massacre of innocent victims [2]. Judgments about the justness of and "need" for war are extremely value-laden and tied to the perspective of the decisionmaker. Those who undertake the calculus of how much wrongdoing justifies war, with the infringement of individual rights and bloodshed that come with it, venture into moral minefields. They must have knowledge from many sources and the support of many before committing lives to this "least bad" course of action.

The dual role of the military physician is demanding. Physicians must fulfill their obligation to heal and ease the suffering of all parties involved, while acting ethically in the conflict situation. Despite supporting a military intervention against an oppressive regime, physicians on the battlefield are obligated to treat even those soldiers who commit inhumane actions; not doing so would breach the fundamental humanitarian duty of the physician [3]. This obligation is based on the World Medical Association's International Code of Medical Ethics, adopted in 1949, stating that the physician must not allow ethnic origin, nationality, or political affiliation to intervene between his duty and his patient [4]. On the battlefield, t he physician's clinical responsibility is the patient, irrespective of the actions that got him or her there and the utilitarian goals of the war.

There are social needs without which civilization would crumble. One of these is the promise of protection and security without which people would be unable to go about their pursuit of society's goods. Protection and security are fostered through the rule of law, through politics and diplomacy, and sometimes through war, when the utilitarian goals of such action can be justified for the sake of society. Yet, even in wartime, the ideals of humanity must be considered by the medical community as superior to all others [5], which in practice translates to a policy of providing medical care for both friend and foe.

It is the physician's responsibility to recognize that tutti fratelli, they are all our brothers [6]. The physician is obligated to provide comfort to the suffering and healing to the injured, while leaving the politics to diplomats.


References

  1. Gabriel B. A Hippocratic Oath for Our Time. Oath of Lasagna, 1964. http://www.aamc.org/newsroom/reporter/sept2001/hippocraticoath.htm. Accessed September 1, 2007.
  2. Fink SL. Physician groups and the war in Kosovo: ethics, neutrality, and interventionism. JAMA. 2000;283(9);1200.
  3. Russbach R, Fink D. Humanitarian action in current armed conflict. Med Glob Surviv. 1994;1(4):188-199.
  4. World Medical Association. International Code of Medical Ethics. Adopted 1949; amended 1968, 1983. http://www.wma.net/e/policy/c8.htm. Accessed September 1, 2007.
  5. Conklin E. The doctor's dilemma or medical ethics in peace and war. Science. 1944;99(2567):187-190.
  6. In June, 1859, a Genevan tourist named Jean-Henri Dunant observed a battle between the armies of France and Austria in Castiglione, Italy. At the war's end, Italian doctors and nurses cared for the injured soldiers of both sides, saying "tutti fratelli," they are all our brothers. Koch T. Weaponising medicine: "Tutti fratelli," no more. J Med Ethics. 2006;32(5):249-252.

Gary Schwartz, MD, is a second-year surgery resident at St. Luke's-Roosevelt Hospital Center in New York City. His areas of interest include minimally invasive gastrointestinal surgery and surgical oncology.

The Physician as Healer, Citizen, and Soldier, October 2007

A Moral Obligation for Military Medical Service in the United States, October 2007

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