ETHICS UNDER FIRE

Abstract

As medical students we are taught medical ethics from the very beginning of our training, chiselled into us through interview prep and situational judgement tests. We then apply them throughout our training as doctors, sometimes in a high-pressure environment.Now imagine the same duress whilst in the back of a mobile surgical unit, with the whirring of drones overhead threatening to expose you to enemy fire, miles from the nearest hospital. In both settings doctors abide by the same professional code: to care, to do no harm and to put the patient first. But military medicine creates an environment where these values are placed under immense strain. Is this relevant to us? The BMA seems to think so: three recent BMJ cover pages emphasise the strengthening link between global conflict and health. Admittedly, conflict ethics is only one part of that, but if you are that medic, it is essential to get it right.

On top of being guided by the GMC’s GoodMedical Practice, British military doctors(Medical Officer or MOs) are also bound by the Laws Of Armed Conflict (LOAC): namely the Geneva conventions. These laws protect medics but also limit what they can do. All medical personnel are protected by beingcategorised as non-combatants; they cannot be targeted by enemy forces. Even when captured, doctors have a protected status and must be allowed to continue impartial care. But with these protections come ethical constraints.  For example, MOs are in the military, but are they allowed firearms? Surely this is an obvious clash with, ‘Do No Harm’.Would use of such weapons undo everything the Hippocratic oath we swear by stands for?The current consensus is that a doctor may use a small personal weapon to defend themselves and their patients. No other use of force is permitted and any breach of this forfeits their protected status (and is a war crime). This isthe first ethical tension: when and how to use firearms while upholding the principles ofmedical ethics. ​

    Furthermore, the Geneva conventions require doctors to treat everyone impartially, based purely on clinical need. For example, anMO is treating a wounded soldier in an ambulance and is attacked. The team return lawful fire and the doctor critically wounds the attacker. Once the area is made safe, that same attacker is now ‘hors de combat’ – no longer a threat – and is now the doctor’s patient. ​

This commitment to impartiality underpins trust in the medical profession itself. In essence, treating the enemy ethically upholds the widespread integrity and neutrality in the medical profession. ​

Scenario Three. Dual loyalty – mission or medicine? ​

MOs serve two masters: their patients and their commanders. Dual loyalty describes the moral conflict when the welfare of the individual clashes with the objectives of the mission.​

For example, a soldier with a knee injuryis given a week of reduced duties. However, his unit is at high readiness in a time of political tension, and a frustrated commander comes in demanding the injured soldier returns to duty, as the operational effectiveness of the unit has been compromised. ​

What should the MO do here? The GMC requires that “a doctor’s first concern must be the care of their patient.” The challenge for a MO is ensuring that operational necessity never compromises this duty. Ethical leadership, and the courage to occasionally stand firm against the chain of command are central to maintaining both military effectiveness and medical professionalism. In such cases, the ethical code safeguards both the medic and the patient.​

Scenario Four. Ethics of mass casualty.​

In mass-casualty situations, triage replaces equality with necessity. The principle is to save the greatest number of lives with limited resources — even if that means some patients receive delayed or no treatment. ​

Consider a scenario of a nine casualties in a truck that hits a land mine and explodes.In the truck is five allied soldiers, two detained enemies and two civilians.Regardless of background, all must be categorised and treated; the doctor must put all loyalties and relationships aside. The two enemies are treated first as their injuries are most critical, whilst the five soldiers, some of whom the MO knows and is friends with, must wait. The MO determines one of the civilians has a significant traumatic brain injury - in this environment he is expected to die.Consequently, the other casualties requiring intervention must be prioritised, even though said patient could have stood a chance if in hospital.​

Triage decisions are emotionally and ethically taxing. They require balancing utilitarian reasoning with compassion, often in seconds. Military medics use structured algorithms, but behind each decision lies the same GMC principle of acting in the patient’s best interests, given the circumstances.​

To summarise, military medicine stretches medical ethics to its very limit, creating challenging clashes between compassion, command and loyalty. The lesson learnt is no matter where a doctor is, military or not, sticking to the ubiquitous values outlined to us are paramount to maintaining worldwide trust in the medical profession. Ironically, war paradoxically refines medicine to its moral core, preserving life and dignity amid  chaos and destruction. Wow that got deep thanks for reading! ​

Aidan is a third-year medical student at Glasgow and Strathclyde Officers Training Corps with an interest in military health and ethics.