Proceedings of the 4th ICMM Workshop on Military Medical Ethics · PDF file · 2018-02-03Proceedings of the 4th ICMM Workshop on Military Medical Ethics ... Another case study is

Military Medical Ethics Series

Proceedings of the 4th ICMM Workshop

on Military Medical Ethics

edited by D. Messelken and D. Winkler

International Committee of Military Medicine

Comité international de Médecine Militaire

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Editors D. Messelken and D. Winkler. http://melac.chPremedia Zentrum elektronische Medien, ZEMCopyright SFBL; individual chapters: the contributors.

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ISBN 978-3-905782-94-3

04.15 500eng 860327358

Military Medical Ethics SeriesEdited by AFLO, Medical Services Directorate

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Proceedings of the 4th ICMM Workshopon Military Medical Ethics

Edited by D. Messelken and D. Winkler

2015



5

Table of Contents

Introduction (D. Messelken and David Winkler) 6

Chapter 1

Medical Neutrality

(Paul Gilbert) 11

Chapter 2

Experiences of a Medical Officer as Healer and Killer

(Mustafa Pasha) 25

Chapter 3

Ethical Issues In Civilian Medical Assistance Programs

(Sheena M. Eagan Chamberlin) 47

Chapter 4

The Humanitarian Imperative

(Peter Schaber) 67

Chapter 5

Clashing values in humanitarian action: the challenges of reconciling

two worlds

(Caroline Clarinval) 77

Chapter 6

Medical ethical issues in earthquake relief by Chinese Armed Forces

(Min YU) 91

Chapter 7

E-learning at ZEBIS – or how theory is put into practice

(Veronika Bock & Kristina Tonn) 103

ABOUT THE AUTHORS 117


Proceedings of the 4th ICMM Workshop on Military Medical Ethics

6

Introduction

Daniel Messelken & David Winkler

About the workshop

The annual ICMM Workshops on Military Medical Ethics, which are organized

by the Swiss Armed Forces Medical Services Directorate together with the ICMM

Centre of Reference for Education on International Humanitarian Law and Ethics

(http://www.melac.ch/), have become a regular and appreciated forum for dis-

cussions.

The idea of this workshop series, which started in 2011, is to bring together peo-

ple from different professional backgrounds and to offer them a space to exchange

on topical issues and dilemmas from the field of military medical ethics. The par-

ticipants of the workshops not only include medical officers serving in armed

forces all over the world, but also academic experts in international humanitar-

ian law or military medical ethics, and representatives from several internation-

al organizations like the ICRC and MSF. As a result, discussions during the past

workshops were not only led on a high academic level, but were also grounded

in practice and enriched with reports and case studies from the field.

The goal of these three day workshops is to facilitate an open discussion and to

agree on common positions on how to (re)act in future situations comparable to

the cases and problems discussed during the sessions. The conferences there-

fore give large room for group and plenary discussions, formally and informal-

ly.

The Contributions of this Volume

The first three chapters of this volume treat the questions of medical neutrality

and the role of medical personnel in the armed forces from different points of

view: a philosophical analysis of the principle of neutrality is complemented by

the case reports of an officer who reflects on the challenges that medical officers

may face in the real world. The third chapter provides again a theoretical ana-

lisis of so-called medical assistance programs that also challenge medical neu-

trality.

In the first chapter, Professor Paul Gilbert discusses the moral arguments for the

principle of medical neutrality. This principle, which is also a fundamental norm


7

of international humanitarian law, obligates military physicians to be neutral

when treating the wounded, only according to their medical needs and without

distinguishing friend from foe. In return, medical personnel are granted immu-

nity from attack. In recent conflicts, this principle has been criticised and it has

been suggested that the fact that military doctors also have a military role could

sometimes lead them not to act neutrally. Gilbert maintains that such a position

misunderstands the doctors’ role in the armed forces. He also discusses an alter-

native approach, according to which the armed forces would not employ doc-

tors who are bound by medical ethics, but rather «medical technicians» who

could obey military orders without being bound by medical ethics. Gilbert con-

cludes however that such personnel would usually have to follow the same pri-

orities than full medical personnel if they adhere to the principles of IHL. Thus,

the paper ends with an argument about the importance of upholding the pres-

ent system of neutrality also in contemporary (asymmetric) conflicts.

In the second chapter, Brigadier General Mustafa Pasha draws from his own

experience in counter-insurgency missions and contrasts the theoretical account

of the first chapter. According to his experience, young medical officers often un-

knowingly violate principles of military medical ethics. The reason for such (mis-)

conduct often can be found in a lack of adequate knowledge about ethical prin-

ciples and the lack of an adequate support system. Among the ethical issues med-

ical personnel in the armed forces experience are those of performing a dual role

(soldier and physician), the question of how to implement the biomedical prin-

ciples of «informed consent» and «patient autonomy», or also the question of

how to perform medical duties in an interrogation cell. Pasha emphasises the

need to educate medical officers in military medical ethics and also to prepare

them for their tasks by enabling them to deal with ethical dilemmas. Such an ap-

proach should, according to him, also include a monitoring system in order to

continuously learn from experiences.

A more theoretical approach is again found in the third chapter on Ethical Issues

In Civilian Medical Assistance Programs, contributed by Dr. Sheena M. Eagan Chamberlin. Civilian medical assistance programs question medical neutrality

insofar as they propagate the use of medicine as a strategic tool within the mil-

itary. This can for example be the case when strategic military goals are priori-

tized in medical missions and that to the detriment of the core medical objectives.

Such a prioritization highlights the complicated field of work of the physician-sol-

dier, who is forced to practice only limited medicine in such «win the hearts and

minds» missions. Ethically therefore such missions are highly problematic.

Chamberlin’s paper offers a historico-ethical perspective on medical assistance

programs by beginning with the Vietnam War and moving forward to contem-

Introduction



8

porary missions. Specifically, she focuses on two US-American military programs:

Medical Civic Action Programs (MEDCAP) and Medical Readiness Training Ex-

ercises (MEDRETE).

The chapters 4-6 of this volume switch the focus to a different issue and all treat

ethical challenges related to humanitarian missions (or humanitarian aid more

generally). Again, we contrast philosophical reflections (Schaber, chapter 4) with

experiences and reports from the field (Clarinval and Yu, Chapters 5 and 6).

In chapter 4, Professor Peter Schaber discusses the ideal of the humanitarian

imperative that guides humanitarian workers. This imperative most important-

ly includes the duty to help (all) people in need. However, such help sometimes

may only be delivered by, at the same time, contributing to the wrongdoings of

others in the same context. The ethical question then is whether the humanitar-

ian aid is still good, as long as and if it leads to more overall goodness than over-

all badness. Schaber argues, in his provocative paper, that humanitarian aid can

indeed sometimes be morally wrong. According to him, humanitarian aid can

become morally problematic if it only follows the humanitarian imperative be-

cause it then remains impartial and neutral between wrongdoers and innocent

people. Helping wrongdoers (in need), however, can also mean contributing to

their wrongdoing.

The fifth chapter by Dr. Caroline Clarinval is inspired by her experience from

ICRC missions and enriched by research done during a PhD in ethics. The out-

come of this combination is a tool or framework for ethical decision making

which is specifically adapted to the non-standard ethical environment of hu-

manitarian missions. Clarinval presents this framework and applies it to a case

in which humanitarian medical personnel are confronted with local cultural cus-

toms that clash with their professional ethos.

Another case study is presented in the sixth chapter by Senior Colonel Min Yu.

He reports two examples of ethically difficult decisions during a disaster relief

mission (earthquake) in China and reflects on the ethical principles involved in

such situations. These included decisions between saving lives and treatment

quality, patients’ right of knowing their medical condition and being involved in

treatment decisions, or questions of resource allocation. In his paper, Yu analy-

ses two real cases and concludes that it is necessary to conduct more research

in medical ethics and disaster relief ethics in order to enhance the training, ac-

quire the knowledge, and successfully perform disaster relief missions.

The seventh and last chapter of this volume presents recent efforts in Germany


9

to build up an e-learning tool that supports the ethics education of soldiers. Dr.

Veronika Bock and Kristina Tonn, both from the center for ethical education

in the armed forces (ZEBIS - Zentrum für ethische Bildung in den Streitkräften), re-

port about the challenges faced during the setup and enhancement of their on-

line teaching portal. The portal offers material for education in various disciplines:

law (international and national), politics, history, intercultural communication

and ethics. The challenge in ethical education for soldiers is to combine theory

with practice, or rather to make abstract theory accessible and applicable to sol-

diers. This article gives answers to the questions of whether and how an online

teaching portal can support ethics teaching and does so based on the experienc-

es gained with the teaching portal for character guidance training at ZEBIS. The

challenges and demands of ethical education are discussed with particular re-

gard to military ethics.

Acknowledgements

We would like to thank the Secretary General of the ICMM, Major General

Roger Van Hoof and the Swiss Surgeon General, Major General Andreas Stettbacher, for their continuous support of the ICMM workshop series and the

work of the ICMM Center of Reference for Education on IHL and Ethics. Further,

we would like to thank the Logistic Steering Committee of the Medical Services

Directorate of the Swiss Armed Forces who once again took over the whole or-

ganizational aspect of the workshop and did a perfect job.

We are indebted to all authors who delivered us their manuscripts and to all par-

ticipants for an open and fruitful input during the workshop discussions. We

would like to thank Shazia Islamshah who, during her short stay at the Center

for Ethics in Zurich, enormously helped us with the editorial work of this volume.

More information: http://workshop.melac.ch/

Introduction


Abstract

Under international law military doctors are expected to be neutral in the sense of treating the wounded in accordance with their medical needs alone irrespective of which side they are on, and military staff enjoy immunity from attack in consequence. But it has been objected that their military role should sometimes lead them to act otherwise.

The paper maintains that this misunderstands the doctor’s role in the armed forces, but the objection does raise the question of why the forc-

es employ doctors with their strict ethical code rather than medical technicians who would just obey orders rather than following purely medical priorities. The paper claims that this is because adherence to the principles of discrimination and proportionality would result in such staff usually being ordered to act in accordance with the same

priorities as doctors proper. The immunity from attack of medical staff can be derived from the same principles. Possible exceptions and the

applicability of the present system of neutrality to contemporary con-flicts are discussed.



11

Chapter 1

Medical Neutrality

Paul Gilbert

1. Introduction

I shall start with a story. An injured man is helped into a doctor’s surgery. The

doctor recognises him as one of her patients. But before she can begin treating

him someone rushes in shouting, «There are many people down the road in a

worse state than him» – pointing to the injured man – «and he’s the one who

caused this disaster. Come and help them. Please!» We can readily imagine that

the doctor would respond to this appeal, considering that the apparently grea-

ter medical needs of the unknown people down the road take precedence over

that of her patient.

We might think of several possible civilian contexts for this scenario, but I want

instead to paint in a military background for the story. The doctor is a military

physician at a field hospital. The injured man brought in is a soldier from her

own side wounded in a street battle. The people in a worse state down the road

are civilians from the enemy side injured when he fired a rocket propelled gre-

nade at a house from which there had been sniper fire. Might these circumstan-

ces change the doctor’s priorities regarding whom she should treat from those

that are operative in a civilian context? Does she face a dilemma special to the

military situation, bearing in mind that if promptly treated the soldier may be

able quite soon to return to fighting?

It is a cardinal principle of international humanitarian law as set out in the 1949

Geneva Convention that wounded soldiers from either side are to be treated wi-

thout distinction as to their affiliations, but only in accordance with medical pri-

orities, and in the 1977 Additional Protocols this principle is extended to the

treatment of injured civilians. In recognition of the fact that military medics must

be neutral in the way that they select patients for treatment they are accorded

immunity from attack – medical neutrality in the legal sense. They are regarded

as non-combatants and enjoy protected status in the same way as if they were

civilian doctors because they are expected to act like them. Legally, then, it seems

clear the military doctor in our scenario ought to do whatever her counterpart

in the civilian context would do. Yet, we may ask, is this ethically the case also?



12

2. The role of a military doctor

In recent years there have been several suggestions to the effect that the situa-

tion of the military doctor is more complicated than that of the civilian one, in

particular in view of the fact that the former occupies two roles, both a military

and a medical role (see e.g. Allhoff 2008). This has led to the conclusion that an

army medic should sometimes act otherwise than in accordance with purely

medical priorities on account of the divergent ethical requirements of the mili-

tary role. But the supposition that the requirements of the two roles may conflict

is, I want to argue, false since it fails to allow that the armed forces, like other em-

ployers, employ doctors just as doctors, not in some other sort of role for which

their knowledge and skill equips them. The role of doctor is self-standing, like

that of a philosopher, say, in the sense that pursuing the calling is possible out-

side of an institution. When it is part of an institution’s workings the institution

treats the role as ready-made and plays no part in shaping what is involved in

performing it. Connected to its self-standing status are two further features of

the doctor’s role. First, it is pervasive in that a doctor is expected to give medical

assistance in an emergency even outside of his or her employment. Second, it is

autonomous in that the doctor is solely responsible for the medical judgments

on which he or she acts and should not be ordered to act otherwise by an em-

ployer for non-medical reasons.1

If this is right then it is evident that a military doctor will have to act on his or

her medical judgment alone when acting as a doctor, and this will imply neu-

trality in the treatment of the wounded, for enemy wounded may demand more

immediate treatment than the doctor’s comrades. It is not for the doctor, except,

as I shall later allow, in the most desperate circumstances, to make a moral judg-

ment about what it is best to do all things considered. It is not for the doctor to

take account, say, of the military consequences of the medical priorities decid-

ed upon, of the relative deserts of the wounded or of any other non-medical fac-

tor. One way to express this is to say that the doctor’s role gives its occupant a

reason not to act in situations where medical judgment is required otherwise

than for medical reasons, that is to say that it excludes acting from non-medical

considerations, and thus occupying the role constitutes having what Joseph Raz

terms an exclusionary reason (Raz 1990). Medical neutrality in the sense of treat-

ing patients irrespective of whether they are friend or foe is simply a consequence

1 For development of these points see Gilbert 2013.


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Proceedings of the 4th ICMM Workshop on Military Medical Ethics · PDF file · 2018-02-03Proceedings of the 4th ICMM Workshop on Military Medical Ethics ... Another case study is