by Martin CM Bricknell CB OStJ PhD DM MBA MA MedSci
Military Medical Ethics has been a subject of significant academic debate over the first two decades of the twenty-first century covering topics such as medical rules of eligibility for care in military field hospitals, the duty of health professionals in the care of prisoners of war or detainees, and the ethics of human performance enhancement for military purposes. The recently published book, Military Medical Ethics in Contemporary Armed Conflict by Michael Gross, provides an excellent summary of these issues. He places particular emphasis on the potential clash between the duties of military healthcare personnel as members of the armed forces and their duties as registered healthcare practitioners accountable to their professional regulatory bodies, so called Dual Loyalty.
The book opens by summarising the professional foundations of military and medical ethics, extending this to the rights of patients being cared for by military health systems alongside the duties of healthcare practitioners. The first section closes with a chapter on moral reasoning as applied to conundrums in military medical ethics. He particularly introduces the possibility that the ‘military necessity’ argument that underpins military ethical decision-making may justify a military order that would be contrary to pure medical ethics. This is an important, but contentious, perspective that has been insufficiently debated in the academic literature thus far.
The second part covers military medical ethics as applied to caring of the wounded from war on the battlefield. This provides an overview of the academic literature that originates from the experience of NATO and coalition forces during the military campaigns in Iraq and Afghanistan. There are chapters on combat casualty care (concentrating on medical rules of eligibility), detainees and prisoners of war, and, care and compensation for civilian victims of war. These chapters provide an excellent description of the evolution of opinions and policy in the application of military medical ethics amongst the military medical services which supported the multinational and national forces in these theatres. This particularly identifies the political and professional pressures that led to many nations revisiting the professional guidance provided to military medical personnel in the light of examples of behaviours and practices that may have been illegal.
The third part considers the potential use of biomedical technologies as a weapon of war. The first chapter in this part considers ethics as applied to clinical biomedical research to improve survival and clinical outcomes of military patients. This highlights the importance of independent ethical review of military medical research to ensure that issues of consent and confidentiality are properly addressed. The next chapter extends the discussion into the potential use of biomedical technology to modify human performance for military purposes either by increasing resistance to biological threats (e.g. infectious disease or chemical/biological weapons) or by enhancing human performance by exceeding innate biological capacity (e.g. drugs to enhance alertness or human-machine interfaces that speed up decision-making). This particularly highlights the ethical conundrum for health professionals of using biomedical knowledge to enhance the combat effectiveness for the armed forces. The final chapter in this part looks at medicine as a diplomatic tool to enhance strategic relationships between states; which predicted the use of ‘mask’ or ‘vaccine’ diplomacy by adversaries during the recent COVID crisis.
The final part considers the ethics of post-war reconstruction and the care of Veterans with ongoing heath problems as a result of their military service. These two chapters extend the concept of military medical ethics into the duties and obligations of governments to ensure that the long-term consequences of conflict are mitigated at both the state level and the human level. The book concludes by considering the character of future wars and potential effects of conflict in the cyber and space domains alongside the traditional physical domains of land, sea and air. The consequent harms to human security of unconstrained conflict in these new domains have the potential to impact non-combatants and civilians on a global scale, far beyond any physical battlefield.
Overall, this book provides an excellent and up to date summary of military medical ethics by providing a comprehensive review of the issues across many individual topics. It will be especially interesting to military health practitioners (doctors, nurses and allied health professionals) but is also highly relevant for ethicists from both a purely military and purely health background. The text is extensively referenced, indeed the book is worth purchasing just for the bibliography. It benefits from having a single author to create a consistent logic across the book. The author is non-military and is not a citizen of the nations that have attracted criticism in the practice of military medical ethics, so providing an independent and unconstrained analysis of the issues. However, some of the perspectives presented in the book are contentious, especially the potential justification for military necessity to take precedence over medical ethics. While the book provides a highly accessible introduction to the subject, military healthcare professionals will need to seek additional sources of policy or guidance before applying the observations from this book into their own personal, professional practice.