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‘Medical ethics in times of armed conflict is identical to medical ethics in times of peace’. So states the first line of the World Medical Association’s (WMA) Regulations in Times of Armed Conflict and Other Situations of Violence,1 which can also be found in the WMA International Code of Medical Ethics.2 Is this bold statement a universal truth, to be accepted at face value by both civilian and military healthcare professionals (MHCPs), or is it simply a lofty, aspirational principle issued by an international body perhaps unfamiliar with the real-life ethical challenges of front line military medical practice?
In theory, MHCPs should adhere to this principle, as in an ideal world it would remain the same regardless of context and present no challenges to ethical decision making. However, MHCPs rarely encounter an ideal world, and in practice, it becomes more difficult to keep standards the same during conflict, for a number of reasons. These might include issues such as scarce resource allocation, dual-loyalty conflict, the concept of military necessity, the Medical Rules of Eligibility for the treatment facility, two-tiered care and complications of impartiality and neutrality. Some of these topics are discussed in this very issue.
The question then becomes, though MHCPs ought to follow the WMA’s guiding principle, can we actually follow such a principle? The unique and complex ethical considerations of front line military medical practice often lead to competing demands in ethical decision making, which cannot always be resolved to the satisfaction of all. In other words, someone will typically lose out. Recent research in this field has demonstrated that ethical decision making on combat and humanitarian deployment, in practice, is anything but straightforward, for the reasons alluded to above.3 4 Some international commentators also disagree with this WMA notion of equitability, though none justify their positions as neatly as Vollmar.5 He states that medical ethics in times of armed conflict can never be identical to medical ethics in times of peace, because the ‘exigencies of battle pose unique challenges incomparable to the civilian context because of the scale of the threats to life, unpredictability and levels of violence’.
The field of military medical ethics (MME) is an exciting, relatively young hybrid of military ethics and medical ethics, resulting in a narrow and specialised subset of both. It uses ethical theory to promote the practical application of ethics by MHCPs to dilemmas in deployed military clinical environments, be they combat oriented or humanitarian in nature. Patient groups in these situations may be any combination of friendly forces, enemy personnel or civilians who may or may not have been affected by military operations. MME is an important field of research for MHCPs, as the findings can help them to identify, understand, rationalise and normalise ethical issues in context. The research can also help to both inform MHCPs of new ideas and approaches and mitigate against the potential for morally questionable or unethical practice, as well as assist in refining their ethical decision-making skills.
The need for MHCPs to receive more exposure to ethical decision-making education was identified in a training needs analysis conducted during the Op TELIC and Op HERRICK era. This decision resulted in specific medical ethics sessions being written into entry officer courses, the Military Operational Surgical Training course, General Practitioner Specialty Training courses, senior trainees study periods and the Captured Persons practitioner course among others. There have also been requests from field units to provide case/scenario-based learning for their troops prior to deployment, as well as ethical scenarios increasingly being written into mission-specific assessment/validation plans. Until recently, ethics training has largely focused on the situations encountered in protracted, large-scale deployments like Iraq and Afghanistan. These operations generally had a high clinical tempo and an enduring or semipermanent treatment facility, fully stocked with an international blend of specialists and equipment.
In the contingency era, however, we are told that we are likely to be engaging in shorter duration operations with a smaller footprint than in the Telic/Herrick era. This type of deployment will undoubtedly bring ethical challenges of a different kind, such as those already observed on Op GRITROCK and Op TRENTON. For example, there are ethical tensions (particularly for MHCPs) inherent in having a medical treatment facility, which has a very low patient throughput, located very close to a refugee camp, with the obvious medical needs therein. From a professional rather than a military viewpoint, no doctor or nurse likes to see empty beds when there is so much human suffering close at hand. It is the humanitarian concerns, advancing technology and the ever-changing character of conflict discussed in this issue that will define and shape the ethical actions of MHCPs in the future. Going some way to address these issues and help prepare the ethically minded MHCP of the future, the International Committee of Military Medicine runs an annual MME course and regular workshops in Switzerland. These are highly recommended for those who are interested in furthering their knowledge. These events are organised and run by Dr Daniel Messelken, one of the authors in this special edition.
With all this renewed ethical focus, and the number of global military operations undertaken by North Atlantic Treaty Organization and UN Forces, MME has enjoyed something of a renaissance in the international academic world in recent years. As a result, for some time now, it has been an aspiration of the Journal of the Royal Army Medical Corps to create a special edition in MME. Accordingly, this edition makes that aspiration a reality, bringing together an eclectic collection of fascinating, engaging and highly topical papers within the field of MME. These papers have all been written by a combination of both established, widely published experts and up-and-coming international academics, all with a strong interest in MME. Both Lt Cdr Brockie as guest editor of this issue on MME, and the editor in chief Lt Col Breeze, wish to acknowledge the efforts, engagement and enduring sense of humour of all the people who have made this special issue possible.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient consent for publication Not obtained.
Provenance and peer review Commissioned; internally peer reviewed.
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