To the uninitiated, the phrase “military medical ethics” probably signals triage (methods for sorting casualties) and the neutrality of medical personnel in battle zones. There is, however, a lot more to it than that, as this excellent book by Michael L. Gross shows. Gross is a professor in the Department of Political Science at the University of Haifa and has published extensively in bioethics and the ethics of war.
The central question of Gross' book is whether medical ethics in war is different from medical ethics in peace. In contrast to, among others, the World Medical Association, Gross argues that it is different, and sometimes very much different. He gives two main reasons: First, standard peacetime bioethics emphasizes a number of core principles, among them are the right to life and autonomy. These principles are absent or abridged in military contexts. For instance, soldiers' right to life is conditional, and their autonomy is circumscribed. Second, bioethical principles may be overridden by principles of just war. In contrast to standard bioethical principles, which typically concern the rights of individual patients, the principles of contemporary just war theory leave considerable room for considering collective or aggregate utility.
Nevertheless contemporary just-war theory and bioethics share a conceptual background, Gross notes. They both reflect liberal ideals and emphasize principles that grew out of the Enlightenment, such as autonomy, right to life, and utility. Furthermore, during the last hundred years, both medical ethics and the ethics of war have had to adapt to vast and rapid technological and social change. To see this, we only need to think of machine guns, aircraft, and penicillin.
After two remarkably clear introductory chapters, Gross turns to specific problems of military medical ethics. He begins with a fundamental and perhaps somewhat surprising question: Should we care for the wounded and, if we should, why? “After all, if a soldier is sent to die, why is it necessary to care for him or her when wounded?” (p. 66). Gross claims that there is no obvious answer to the question. He discusses three standard arguments for treating wounded soldiers and claims that none of them withstand scrutiny: (1) salvaging manpower, (2) maintaining morale, and (3) the duty of the state to care for those who risk their lives on its behalf. The first two arguments are utility arguments, and Gross rejects the empirical premises on which they rest. Salvage of manpower, he argues, is best achieved by sanitation and preventive measures, such as vaccination and, perhaps, by providing basic care for the lightly wounded. Severely wounded soldiers who require advanced care usually do not return to fighting when and if they recover, and caring for the wounded also requires a lot of manpower, so that, on balance, the net effect might be the opposite of salvaging manpower. As regards morale, there is no obvious direct morale-boosting effect of advanced medical care. The third argument is rejected for reasons of justice. Gross' conclusion is that the state has a duty to provide care for its soldiers, but that soldiers do not have a particular right to care. A possibly provocative example concerns the number of American neurosurgeons in Vietnam during the Vietnam War. Could they not have been of more use back home? And would it not have been more just to offer American civilians the same chances of receiving treatment as the soldiers had, particularly as many head injuries in Vietnam would have been preventable, if the soldiers had cared to use their helmets? Whether one agrees with Gross' conclusion or not, the question is certainly worth asking.
In Chapter 4, Gross discusses patients' rights for soldiers. He argues that soldiers' patient rights are sometimes abridged and yield to military necessity. The reason is that some of their other basic rights, such as the right to life, are restricted by the very nature of their being soldiers.
One of the most interesting chapters of the book is Chapter 5, on wartime triage. Here, Gross digs into the oft-discussed example of penicillin triage during World War II. It is sometimes described as a dilemma between giving penicillin to soldiers wounded in battle and those wounded in brothels, that is, suffering from venereal disease. If restoring an army's fighting strength is a prime concern, curing gonorrhoea is more efficient than curing infected battle wounds, because a soldier with gonorrhoea can return to fighting more or less immediately after a shot of penicillin. This is reportedly what some military decisionmakers did in World War II. However, Gross widens the perspective considerably. There are more dilemmas lurking behind the scarce vials of penicillin in the 1940s. For instance, how to allocate penicillin between civilians and soldiers? Furthermore, one way of preventing gonorrhoea would be to allow closely monitored prostitution. Should one do that? The overarching question is, of course, whether there are alternatives to triage—a question that is as important today as it was in World War II.
There are several parallel problems in wartime military triage and civilian disaster or emergency triage, for instance, in a pandemic flu situation with scarcity of antivirals and/or vaccines. Gross' arguments are well worth reflecting on for those interested in civilian triage as well. And, possibly, Gross' discussion would have been even more interesting had he himself developed these parallels a little more in depth. This could have shed even more light on at least two important distinctions. The first is the one between conventional triage and mass casualty triage. “The former distributes medical care based on need, while the latter appeals solely to salvage and utility” (p. 144). The second distinction is between macrolevel allocation (policy decisions) and microlevel allocation of resources. On the battlefield, medical personnel allocate available resources mainly through triage. But macrolevel allocation of resources—how many medics per company, how transport is organized, and so on—is carried out by military commanders and not exclusively by medical personnel. Obviously, the situation is very much similar in civilian care settings.
A topic to which there are much fewer parallels in peacetime medicine, however, is the subject of Chapter 5—the neutrality of medical personnel and the related problem of “medical stability operations.” Such operations were carried out in Vietnam, among other places, and aimed at improving the image of the government and gaining public support. Gross also discusses the problems of maintaining medical impartiality and/or immunity in low-intensity conflicts and counterinsurgency warfare.
The argument of Chapter 5, and subsequent ones, is along the following lines: Bioethics and its established principles sometimes conflict with civic morality, and war puts those principles to test. If a physician's sticking to principles of medical ethics severely hampers the efforts of her state in a just war, shouldn't she abandon them? The participation of medical personnel in torture and torturelike interrogation procedures (Chapter 7) and in preparation for chemical and biological warfare (Chapter 8) are instances of this, and Gross' discussion certainly shows that the issues are not as simple as they may seem at a superficial glance. Gross charts the dilemmas rather than solves them, but does so very effectively. Controversy is likely to remain, however, because many of the dilemmas boil down to the age-old conflict between deontological and consequentialist approaches to ethics.
If one decides to stick, strictly, to the established principles of medical ethics, one possible position is to regard medicine as a pacifist profession. This is the subject of the book's penultimate chapter (Chapter 9). Gross rejects the idea that medicine is a pacifist profession, but holds that it is “imbued with principles of pacifism” (p. 318). The last chapter of the book (Chapter 10) summarizes the arguments of the previous chapters.
Bioethics and Armed Conflict covers a number of topics, and each chapter is more or less self-contained. Nevertheless, the book as a whole is well held together, and Gross' prose is highly readable. Another excellent feature of this book is the generous amount of background provided. For instance, the topics of nuclear deterrence and civil disobedience are clearly and concisely introduced. This makes the book reasonably accessible also for readers with little or no background in either bioethics or the ethics of war. There is a fair amount of history of military medicine as well. It can thus be recommended for use as a textbook, for philosophers as well as for health professionals and military personnel. If there is room for only one work of military medical ethics in your bookshelf, this is certainly a good choice.
