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The doctor’s role in battlefield medicine

Treatment decisions are made based on what’s possible. US Air Force

Doctors working in an environment of armed conflict face situations where patients have overwhelming injuries. There is often limited access to medical resources to provide treatment. And the doctors themselves may be in danger.

While doctors are bound by their own professional ethics and the Geneva Conventions, the legal, moral and ethical tenets under which they operate can be seriously challenged.

At first glance, doctors and soldiers seem to have opposite aims: doctors seek to relive suffering, to help and to heal; soldiers to kill and conquer.

This dilemma is even more apparent when considering the role of uniformed doctors serving within an organisation designed to produce casualties.

So how do doctors deal with these inconsistencies?

While International Humanitarian Law covers all participants in conflict, it singles doctors out as a group that has a unique and specific code of conduct applied to them.

In essence, there are three obligations that make their ethical position different to that of other serving soldiers:

  • Firstly, they may not partake in acts of war (although they may use weapons to protect their patients);

  • Secondly, they must treat all casualties equally, based on medical need and ignoring nationality, enemy status, religion etc;

  • Finally, they are required by law to speak out against atrocities committed by either side.

The ethical complexities facing doctors generally increases the closer they are to combat. Doctors serving with soldiers in the front line have a different role and tend to face different challenges to those in hospital facilities.

In hospital facilities, decisions are really more about what treatment is or isn’t appropriate, and when it is futile to continue such treatment.

In some ways, these decisions are familiar and the practitioner can draw on civilian experience. For example, when should resuscitation be stopped following non-survivable vehicle accident injuries?

The difference is that in war, there may other considerations such as the resources available, the security situation as well as the capacity to deal with other medical priorities.

Treatment may not be technically or physically possible, and there may be no option to transfer care to other facilities.

For example, if an Australian is injured and left with no arms or eyesight they would receive sophisticated rehabilitation, prosthetics and support services. But for a civilian wounded in warzone with limited health resources, there may be no quality of life at all with such disabilities.

Decisions about whether use military resources to treat a local child on a ventilator – when there is no ability to support that child later – are equally complex.

The reality is that, while our own military personnel and other designated nationals will be afforded strategic retrieval to a highly sophisticated health facility, locals in warzones have no such option.

They are likely to be repatriated at the earliest opportunity to a very basic indigenous facilities where their recovery and even survival may be unlikely. For this reason care is different, however much we may like to think otherwise.

Direct or indirect involvement in euthanasia is a rare and extreme example of the ethical predicament that may confront a doctor in war.

There are a number of historical examples where doctors have been caught up with battlefield euthanasia. These include the World War II accounts of Jewish physicians in the face of their patients being captured/executed by the enemy, and the accounts of Australian Colonel John Masters faced with leaving severely injured soldiers to the mercy of the advancing Japanese.

In these cases, the role of the doctor was indirect – that is, the doctor did not actually kill the patient(s) himself, despite being involved in the decision to do so.

The recent account of an Australian surgeon’s involvement in the death of a mortally injured woman in Kosovo highlights a more direct and unambiguous act.

This raises the ultimate dilemma – a doctors’ role to “relieve suffering” and whether, in the face of certain death, or capture by the enemy and (presumed) torture, it is acceptable to expedite death.

The mode of death is also relevant. For example, is it more “acceptable” that a patient is shot, rather than use limited supplies of morphine for palliation, that might otherwise be used to treat the wounded?

Central to this argument is the unique position, trust and responsibility of the doctor and whether such an act violates their ethical obligations. This is a clear distinction from the issue of soldiers conducting “mercy killings” on the battlefield.

The complexities of war have few civilian parallels except for the mass casualties generated from terrorist events and natural disasters.

Doctors in a war zone are affected by their environment. They too may face risk to their own lives, and the effects of working with constant fatigue and dealing with horrific injuries contributes to “compassion fatigue”.

It requires great maturity to exist within a culture of “us” and “the enemy” and yet be able to maintain neutrality, compassion and professionalism when dealing with wounded enemy soldiers, prisoners, children and known insurgents or terrorists.

The events at Abu Graib prison demonstrate clearly what happens when doctors are drawn into military “counter cultures” and fail to fulfill their obligations.

Doctors too need to understand that the effects of their interventions are broader than simply patient care. All interventions by foreign military and civilian doctors risk undermining confidence in local doctors and facilities, and can create unrealistic expectations in these communities.

Doctors can also find themselves unknowing players in the use of health to “reward” or “punish” communities. For example, as an occupying force doctors might provide treatment to “reward” important political figures to encourage their support, while being unable to provide for those with greater medical need.

Indeed, as General Sir Michael Rose observed in Bosnia – “There is no such thing as impartial humanitarian assistance”.

Doctors have a very important role in war: to heal those injured and harmed by conflict. The challenges of conflict medicine are different from those in civilian practice and it is imperative that those doctors who intend to serve in war zones endeavour to understand the unique ethical complexity they may face.

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