Clinical Ethics in Anesthesiology. A Case-Based Textbook
6. Anesthesiologists, the state, and society
47. Triage and treatment of wounded during armed conflict
Craig D. McClain and David B. Waisel
The triage physician at a forward clearing station receives two wounded enemy enlisted men, an injured local villager, and a wounded friendly solider. The enemy soldiers appear to have serious but not life-threatening internal bleeding and may require blood transfusion. The triage physician estimates that short operations will stabilize both enemy soldiers. It is unlikely they have any useful military intelligence. The villager’s open femur fracture will require surgical treatment and a blood transfusion under normal circumstances. He has a hematocrit of 25% and a compression dressing has effectively limited his rate of bleeding. The friendly soldier has a vascular injury in his groin. He is conscious, mildly hypotensive and his hematocrit is 18%. The triage physician is concerned that this operation will consume extensive resources both during the operation and postoperatively. Many additional casualties will arrive within the hour. The triage physician estimates that treating all four patients will deplete the unit’s blood supply, and she is aware that no further personnel or material resources are expected.
“It is forbidden to kill; therefore all murderers are punished unless they kill in large numbers and to the sound of trumpets.”(Voltaire)
Military medicine intertwines the military and medical professions. Under most circumstances, the military physician serves primarily as a physician, and to a lesser extent as a member of the military. However, on occasion, the two positions can battle each other for ascendency. In Greek mythology the sons of Asclepius were both healers and warriors. However, in modern times, military physicians do not take up arms to confront the enemy unless their own lives – or those of their patients – are under threat. In fact, many of the ethical challenges met by the modern military physician are not encountered in civilian settings, and as such, it may not always be appropriate – or practicable – to apply the principles of civilian medical ethics to military medicine.
The underlying discrepancy between civilian and military medical ethics can be attributed to their respective goals and how they are to be achieved. Civilian physicians, in most circumstances, concentrate on primary medical goals, while military physicians must adhere to the organizational objective of defeating the enemy. As such, military physicians must occasionally subordinate other values to achieve defeat of the enemy.
This is the origin of the core ethical quandary with which military physicians must wrestle: finding a balance between giving absolute priority to the principle of military necessity – and its attendant obligations as a military officer – with that of lending moral weight to their patients’ interests according to the traditional principles of civilian medical ethics. Indeed, military physicians may have to choose to sacrifice their patients’ autonomy and best interests when required to fulfill the military mission of protecting their society. Physicians trained within modern medical ethics in which an individual patient’s rights are paramount may have difficulty balancing those views with their duty to place the needs of the military before those of his/her patients.
Triage is a system of sorting patients according to need when resources are insufficient for all wounded to be treated. Military medical ethics becomes even more complex and challenging in the arena of armed conflict when triage of the wounded involves friendly soldiers, “enlisted” enemy soldiers, and local civilians.
International guidelines for ethical conduct of physicians engaged in armed conflict
In response to wartime outrages, international organizations codified the conduct of armed conflict. Statements from the Geneva Conventions,a International Committee of the Red Cross, the UnitedNations, and the US military1 have proposed that war can be conducted in an orderly fashion by adhering to certain guidelines. The World Medical Association’s (WMA’s) resolution entitled “Regulations in Times of Armed Conflict” typifies these statements2*:
Medical ethics in times of armed conflict is identical to medical ethics in times of peace, as stated in the International Code of Medical Ethics of the WMA. If, in performing their professional duty, physicians have conflicting loyalties, then their primary obligation is to their patients; in all their professional activities, physicians should adhere to international conventions on human rights, international humanitarian law and WMA declarations on medical ethics.
The primary task of the medical profession is to preserve health and save life. Hence it is deemed unethical for physicians to … give advice or perform prophylactic, diagnostic or therapeutic procedures that are not justifiable for the patient’s health care.
While codifying wartime behavior sounds ironic, these principles are accepted by most of the international community. Indeed, modern bioethical priority of respect for autonomy is promoted by the WMA’s prohibition against performing procedures that would not benefit the soldier-patient. Both independence from controlling influence and capacity for intentional action are essential for making an informed choice regarding medical treatment.
During state-sponsored armed conflict, however, the goals and needs of the state often supersede the rights of individuals. Combatants, by definition, are members of a state-controlled military force actively participating in armed conflict. By joining the military, soldiers have willingly accepted some level of controlling influence from the state, particularly during combat. Using this standard, it may be necessary for individuals to make willing or unwilling sacrifices – including that of their health and survival – for the benefit of the state.
Triage is the dynamic process of prioritizing treatment for casualties in a resource-poor environment. Tables 47.1 and 47.2 illustrate the complexity and imprecision of triage. Table 47.1 describes theoretical and practical triage categorization. Table 47.2 describes the multiple known and unknown factors that affect the otherwise discrete categorization of the wounded. But this oversimplification is belied by the demand for in-the-moment functional use of these categories.b
The goals of combat medicine are to return the greatest possible number of wounded soldiers to combat and to preserve life. These sometimes conflicting goals necessitate tough decisions. Faced with an impending attack, physicians may try to quickly stabilize critically wounded soldiers while focusing most resources on returning the less seriously wounded soldiers to fighting. If speedily returning soldiers to combat is less essential, then combat physicians may devote most of their resources to treating the critically wounded.
Soldiers may receive care during triage that they would not receive in a resource-rich environment. For example, rather than performing limb salvage surgery on a soldier with a neurovascular injury, the physician may amputate the arm in order to conserve time and other resources. In his article, Gross crystallizes the sacrifices soldiers accept in regard to triage:
… (military) medical personnel bear an obligation to salvage soldiers and return as many to duty as quickly as possible. Salvage speaks to a specific and objective measure of quality of life distinct from the patient’s own subjective evaluation. Salvageable soldiers may not invoke quality of life to refuse treatment, however painful or onerous, if it will return them to military duty. Those beyond salvage, on the other hand, may not appeal to any right to life to secure medical care when resources are scarce.3
Clashing demands of patient and state may cause cognitive dissonance in the physician, requiring mindful attention to balancing loyalty to the state with loyalty to the patient.
Enemy combatants pose a direct and dangerous threat to the security and stability of the state. In war, active enemy combatants have no intrinsic right to life or medical care. Wounded enemies are no longer a significant threat and are reclassified as non-combatants, thereby regaining their rights to life, medical care and humane treatment. The Geneva Convention states, “All wounded, sick and shipwrecked, to whichever Party they belong, shall be respected and protected…shall be treated humanely and shall receive, to the fullest possible extent and with the least possible delay, the medical care and attention required by their condition. There shall be no distinction between them on any other grounds.”1
There is a theoretical and practical basis for treating wounded enemy non-combatants the same as wounded friendly soldiers. It is consistent with the training of physicians that all patients are equally deserving of treatment. Supporting this belief may
Table 47.1. Traditional wartime triage categories
Table 47.2. Factors influencing discrete categorization of the wounded
help protect (or at least not breach) the internal morality of military physicians, whose behavior by virtue of formal and informal authority influences others. Treating enemy non-combatants the same as wounded friendly soldiers emphasizes the enemy’s humanity and may prevent abuses rooted in the dehumanization of the enemy. Practically, physicians hope that following this agreement will incent their enemies to do the same.
Civilian non-combatants are those taking no active part in hostilities such as the local civilians, aid workers, displaced persons, and media. Similar to enemy non-combatants, civilian noncombatants are to be triaged akin to friendly soldiers. Noncombatants may have involuntarily diminished autonomy due to the hegemony of the armed conflict. Despite the humanitarian imperative and the public relations boon of treating civilian noncombatants, access to care may be hindered in a resource-poor environment.
Principled triaging is arduous. It would be easy for honorable physicians to be unconsciously influenced during triage. One can also imagine physicians consciously overcorrecting to inappropriately prioritize enemy noncombatants out of a fear of being unfair. On the other hand, it takes courageous physicians to choose appropriately to spend limited resources on enemy noncombatants instead of countrymen.
The case emphasizes the murkiness of triage. One could imagine prioritizing the friendly soldier given his more tenuous state and the realization that resources may diminish after the others receive care and other wounded arrive. On the other hand, repairing a vascular injury could be time and material consuming and more pressing demands eventually may require intraoperative abandonment and re-categorization of the soldier to expectant.
If all the wounded men were treated as equals, then one could imagine starting with the patients with internal bleeding (on the theory that an easily fixable problem now may turn into a more costly problem later), temporizing the femur fracture and delaying work on the patient with the vascular wound until the next wave of wounded and more resources arrive.
• During state-sponsored armed conflict, military physicians will be placed in situations where they need to triage honorably.
• Knowledge of some of the ethical underpinnings of the decision-making process would aid in making these difficult decisions in a tense situation.
• Close examination of the nature of the differences between bioethical principles in peacetime as well as wartime will ultimately lead to a better understanding of the difficulties faced by physicians during armed conflict.
a Rules relating to the conduct of combatants and the protection of prisoners of war, 1988 extract from “Basic Rules of the Geneva Conventions and their Additional Protocols”; Geneva: ICRC, 2nd edn.
b Rules relating to the conduct of combatants and the protection of prisoners of war, extract from “Basic rules of the Geneva Conventions and their Additional Protocols”; ICRC, Geneva, 1988; 2nd edn.
1* Beam, T. and Howe, E. (2003) A proposed ethic for military medicine. Military Medical Ethics: Volume 2. Peligrino, E.G., Hartle, A.E. Howe, E.G., eds. Department of Defense, Borden Institute, Washington, DC, USA.
2* The World Medical Association Regulations in Times of Armed Conflict. Originally adopted by the 10th World Medical Assembly, Havana, Cuba, October 1956, most recently amended by The WMA General Assembly, Tokyo 2004 and editorially revised at the 173rd Council Session, Divonne-les-Bains, France, May 2006.
3* Gross, M.L. (2004). Bioethics and Armed Conflict: Mapping the Moral Dimensions of Medicine and War. Hastings Cen Rep, 34(6), 22–30.
Emergency War Surgery (2004). 3rd United States Revision. Department of Defense, United States of America.
International Dual Loyalty Working Group (2003). Dual Loyalty & Human Rights in Health Professional Practice. Physicians for Human Rights 2003.
Repine, T.B., Lisagor, P., and Cohen, D.J. (2005). The dynamics and ethics of triage: rationing care in hard times. Mil Med, 170, 505–9.
Rubenstein, L.S. (2004). Medicine and War. Hastings Cen Rep, 34(6), 3.
Singh, J.A. (2003). American physicians and dual loyalty obligations in the “war on terror.” BMC Med Ethics, 4, E4.