The goal of military medicine is to conserve the fighting force necessary to prosecute just wars. Just wars are defensive or humanitarian. A defensive war protects one's people or nation. A humanitarian war rescues a foreign, persecuted people or nation from grave human rights abuse. To provide medical care during armed conflict, military medical ethics supplements civilian medical ethics with two principles: military-medical necessity and broad beneficence. Military-medical necessity designates the medical means required to pursue national self-defense or humanitarian intervention. (...) While clinical-medical necessity directs care to satisfy urgent medical needs, military-medical necessity utilizes medical care to satisfy the just aims of war. Military medicine may therefore attend the lightly wounded before the critically wounded or use medical care to win hearts and minds. The underlying principle is broad, not narrow, beneficence. The latter addresses private interests, while broad beneficence responds to the collective welfare of the political community. (shrink)

In 12 narratives, medical workers from Afghanistan, Darfur, Gaza, Iraq, Israel, Myanmar, and Ukraine describe the day-to-day challenges of providing quality medical care in austere conflict zones. Faced with severe shortages of supplies, overwhelmed by sick and injured civilians and soldiers, and subject to constant attacks on medical personnel and facilities, the contributors to this collection confront difficult dilemmas of justice, medical impartiality, neutrality, burnout, and moral injury as they struggle to fulfill their duties as medical professionals, military officers, and (...) conscientious citizens. (shrink)

Unlike most Western nations, Israel does not recognize full separation of church and state but seeks instead a gentle fusion of Jewish and democratic values. Inasmuch as important religious norms such as sanctity of life may clash with dignity, privacy, and self-determination, conflicts frequently arise as Israeli lawmakers, ethicists, and healthcare professionals attempt to give substance to the idea of a Jewish-democratic state. Emerging issues in Israeli bioethics—end-of-life treatment, fertility, genetic research, and medical ethics during armed conflict—highlight this conflict vividly.

Medical rules of eligibility permit severely injured Iraqi and Afghan nationals to receive care in Coalition medical facilities only if bed space is available and their injuries result directly from Coalition fire. The first rule favors Coalition soldiers over host-nation nationals and contradicts the principle of impartial, needs-based medical care. To justify preferential care for compatriots, wartime medicine invokes associative obligations of care that favor friends, family, and comrades-in-arms. Associative obligations have little place in peacetime medical care but significantly affect (...) wartime medicine. The second rule suggests liability for collateral harm that is unsupported by international law and military ethics. Absent liability, there are pragmatic reasons to offer medical care to injured local civilians if it quells resentment and cements support for Coalition forces. In contrast to peacetime medicine, military necessity and associative obligations outweigh distributive principles based on medical need during war. (shrink)

Because the goal of military medicine is salvaging the wounded who can return to duty, military medical ethics cannot easily defend devoting scarce resources to those so badly injured that they cannot return to duty. Instead, arguments turn to morale and political obligation to justify care for the seriously wounded. Neither argument is satisfactory. Care for the wounded is not necessary to maintain an army's morale. Nor is there any moral or logical connection between the right to health care (a (...) universal human right) and the duty to defend one's nation (a local political duty). Once badly wounded, soldiers enjoy the same right to medical care as any similarly ill or injured individual. National health care systems grasp this point and offer few additional health care benefits to veterans. In the United States, however, lack of universal health coverage skews the debate to focus on special entitlements for veterans without considering the health care rights that other citizens enjoy. (shrink)

Asymmetric conflict is changing the way that we practise and think about war. Torture, rendition, assassination, blackmail, extortion, direct attacks on civilians, and chemical weapons are all finding their way to the battlefield despite longstanding international prohibitions. This book offers a practical guide for policy makers, military officers, students, and others who ask such questions as: do guerillas deserve respect or long jail sentences? Are there grounds to torture guerillas for information or assassinate them on the battlefield? Is there room (...) for nonlethal weapons to subdue militants and safeguard the lives of noncombatants? Who are noncombatants in asymmetric war? What is the status of civilians who shelter and aid guerillas? And, do guerillas have any right to attack civilians, particularly those who aid and shelter members of the stronger army? If one side can expand the scope of civilian vulnerability, then why can't the other? (shrink)

Although the abortion debate continues to simmer in many places, the general issue of a woman's right to an abortion, at least in the Western democracies, is largely settled. In its place, the question of late-term abortion begins to assume a prominence only recently attributed to abortion itself. The advent of sophisticated fetal screening techniques makes possible detection of potentially severe fetal anomalies that in many cases are detected only late in the pregnancy, resulting in the need for late-term abortion.

The Israeli Patient Rights Act attempts to accommodate personal autonomy within an avowedly paternalist communitarian state. Although Israel is still groping toward a solution, the legislation begins to show the different form a communitarian version of autonomy must take.

Responsible citizens are expected to combine ethical judgement with judiciously exercised social activism to preserve the moral foundation of democratic society and prevent political injustice. But do they? Utilizing a research model integrating insights from rational choice theory and cognitive developmental psychology this book carefully explores three exemplary cases of morally inspired activism: Jewish rescue in wartime Europe, abortion politics in the United States, and peace and settler activism in Israel. From all three analyses a single conclusion emerges: the most (...) politically competent individuals are, most often, the least morally competent. This is the central paradox of political morality. These findings cast doubt on strong models of political morality characterized by enlightened moral reasoning and concerted political action while affirming alternative weak models that fuse activism with sectarian moral interests. They provide empirical support to further upend the liberal vision of democratic character, education, and society. (shrink)

Just war theory focuses primarily on bodily harm, such as killing, maiming, and torture, while other harms are often largely overlooked. At the same time, contemporary international conflicts increasingly involve the use of unarmed tactics, employing 'softer' alternatives or supplements to kinetic power that have not been sufficiently addressed by the ethics of war or international law. Soft war tactics include cyber-warfare and economic sanctions, media warfare, and propaganda, as well as non-violent resistance as it plays out in civil disobedience, (...) boycotts, and 'lawfare.' While the just war tradition has much to say about 'hard' war - bullets, bombs, and bayonets - it is virtually silent on the subject of 'soft' war. Soft War: The Ethics of Unarmed Conflict illuminates this neglected aspect of international conflict. (shrink)

Medical ethics in times of war are fundamentally different from those in times of peace. War brings military and medical values into conflict, often overwhelming other moral obligations, such as a doctor's charge to relieve suffering, in the face of military necessity.

From the first days of conscription, physicians have declared their opposition to unjust wars by using their good offices to aid draft evaders.

Communities are the chief source of philosophical sloppiness these days. Varying endlessly across the entire range of human experience, communities raise the specter of moral relativism that makes ethics sometimes seem a misguided and futile enterprise. Yet the language of communities and their multitude of norms, preferences, and principles present an opportunity, and challenge, to confront abiding moral problems in immeasurably richer and more novel ways. But neither the opportunities nor the challenges were always obvious. On the contrary, the origins (...) of the Enlightenment coincide with an assault on the disharmony posed by restless and unruly communities. (shrink)

Medical ethics in times of war are fundamentally different from those in times of peace. War brings military and medical values into conflict, often overwhelming other moral obligations, such as a doctor's charge to relieve suffering, in the face of military necessity.

“Medicalized” weapons—those that rely on advances in neuroscience, physiology, and pharmacology—offer the prospect of reducing casualties and protecting civilians. They could be especially useful in modern asymmetric wars in which conventional states are pitted against guerrilla or insurgent forces. But may physicians and other medical workers participate in their development?

ABSTRACT How should physicians act when faced with corporal punishment, such as amputation, or torture? In most cases, the answer is clear: international law, UN resolutions and universal codes of medical ethics absolutely forbid physicians from countenancing torture and corporal punishment in any form. An acute problem arises, however, in decent societies, but not necessarily liberal states, that are, nonetheless, welcome in the world community. The decent society is often governed, in whole or in part, by religious laws, and while (...) these states abridge various human rights they are peace loving, generally tolerant, and offer their citizens wide avenues for political participation. Under these circumstances the prohibition against corporal punishment and torture weakens, often compelling physicians to participate. This is true in two cases. In Rawls’ hypothetical nation of Kazanistan, Islamic law is the order of the day, and amputations and corporal punishment play an integral part in the execution of traditional Islamic justice. In Israel, torture is sometimes used to elicit the information needed to thwart impending terror attacks. In each case, a physician's participation is essential. In light of the near universal condemnation that accompanies torture and corporal punishment, physicians can only appeal to norms anchored in collective well‐being and concern for life that override respect for human dignity in these societies. Western societies have consistently rejected this reasoning, but it is part and parcel of life in the decent society. (shrink)

Military medical ethics is garnering growing attention today among medical personal in the American and other armies. Short courses or workshops in “battlefield ethics” for military physicians, nurses, medics, social workers, and psychologists address the nature of patient rights in the military, care for detainees, enemy soldiers and local civilians, problems posed by limited resources, ethical questions arising in humanitarian missions, as well as end-of-life issues, ethics consultations, care for veterans, advance directives, and assisted suicide. Although many of these issues (...) are the core subjects of any bioethics curriculum, military medical ethics presents unique challenges to bioethics educators. (shrink)

abstract During the current round of fighting in the Middle East, Israel has provoked considerable controversy as it turned to targeted killings or assassination to battle militants. While assassination has met with disfavour among traditional observers, commentators have, more recently, sought to justify targeted killings with an appeal to both self‐defence and law enforcement. While each paradigm allows the use of lethal force, they are fundamentally incompatible, the former stipulating moral innocence and the latter demanding the presumption of criminal guilt. (...) Putting aside the paradigm of law enforcement which demands due process and forbids extra‐judicial execution, the only possible avenue for justifying named killings lies in self‐defence. While named killings might be defensible on the grounds that there are no other ways to disable combatants when they fight without uniforms, the costs, including the cost of targeted killing emerging as an acceptable convention in its own right, should be sufficient to view the practice with a good deal of caution. (shrink)

Abortion, particularly late‐term abortion, and neonaticide, selective non‐treatment of newborns, are feasible management strategies for fetuses or newborns diagnosed with severe abnormalities. However, policy varies considerably among developed nations. This article examines abortion and neonatal policy in four nations: Israel, the US, the UK and Denmark. In Israel, late‐term abortion is permitted while non‐treatment of newborns is prohibited. In the US, on the other hand, late‐term abortion is severely restricted, while treatment to newborns may be withdrawn. Policy in the UK (...) and Denmark bridges some of these gaps with liberal abortion and neonatal policy. Disparate policy within and between nations creates practical and ethical difficulties. Practice diverges from policy as many practitioners find it difficult to adhere to official policy. Ethically, it is difficult to entirely justify perinatal policy in these nations. In each nation, there are elements of ethically sound policy, while other aspects cannot be defended. Ethical policy hinges on two underlying normative issues: the question of fetal/newborn status and the morality of killing and letting die. While each issue has been the subject of extensive debate, there are firm ethical norms that should serve as the basis for coherent and consistent perinatal policy. These include 1) a grant of full moral and legal status to the newborn but only partial moral and legal status to the late‐term fetus 2) a general prohibition against feticide unless to save the life of the mother or prevent the birth of a fetus facing certain death or severe pain and suffering and 3) a general endorsement of neonaticide subject to a parent's assessment of the newborn's interest broadly defined to consider physical harm as well as social, psychological and or financial harm to related third parties. Policies in each of the nations surveyed diverging from these norms should be the subject of public discourse and, where possible, legislative reform. (shrink)

Both trolleys and war leave innocent victims to suffer death and injury. Trolley problems accounting for the injured, and not only the dead, tease out intuitions about liability that enhance our understanding of the obligation to provide compensation and medical care to civilian victims of war. Like many trolley victims, civilians in war may suffer justifiable, excusable, or negligent harms that demand compensation. Chief among these is collateral harm befalling civilians. Collateral harm is endemic to war and comprises permissible but (...) unavoidable death or injury following necessary and proportionate military operations. Although state armies sometimes offer condolence payments for civilian death, injury, and property loss, they deny liability. Instead, they use compensation to enhance counterinsurgency efforts and assuage feelings of agent regret. As part of the medical rules of eligibility, Coalition forces in Iraq and Afghanistan also provided medical care to victims of collateral harm. However, they denied care to similarly sick or injured civilians. While compensation is often justified to cure the harm civilians suffer, the differential use of medical resources is not. Rather, medical care remains subject to the principle of beneficence and medical need. The duty to provide civilian healthcare in war, particularly in wars of humanitarian intervention, is far-reaching and imposes significant costs that military and medical ethics are yet to recognize. (shrink)

ABSTRACT How should physicians act when faced with corporal punishment, such as amputation, or torture? In most cases, the answer is clear: international law, UN resolutions and universal codes of medical ethics absolutely forbid physicians from countenancing torture and corporal punishment in any form. An acute problem arises, however, in decent societies, but not necessarily liberal states, that are, nonetheless, welcome in the world community. The decent society is often governed, in whole or in part, by religious laws, and while (...) these states abridge various human rights they are peace loving, generally tolerant, and offer their citizens wide avenues for political participation. Under these circumstances the prohibition against corporal punishment and torture weakens, often compelling physicians to participate. This is true in two cases. In Rawls’ hypothetical nation of Kazanistan, Islamic law is the order of the day, and amputations and corporal punishment play an integral part in the execution of traditional Islamic justice. In Israel, torture is sometimes used to elicit the information needed to thwart impending terror attacks. In each case, a physician's participation is essential. In light of the near universal condemnation that accompanies torture and corporal punishment, physicians can only appeal to norms anchored in collective well‐being and concern for life that override respect for human dignity in these societies. Western societies have consistently rejected this reasoning, but it is part and parcel of life in the decent society. (shrink)

Since 2022, the EU, US, and other nations have imposed medical sanctions on Russia to block the export of pharmaceuticals and medical devices and curtail clinical trials to degrade Russia’s military capabilities. While international law proscribes sanctions that cause a humanitarian crisis, an outcome averted in Russia, the military effects of medical sanctions have been lean. Strengthening medical sanctions risks violating noncombatant and combatant rights to healthcare. Each group’s claim is different. Noncombatants and severely injured soldiers who cannot return to (...) duty enjoy the right to adequate health care that sanctions cannot undermine. Combatants falling captive enjoy the same medical care that adversaries provide their own troops. Combatants yet to renounce hostilities, however, have no claim to medical attention and remain subject to sanctions. Nevertheless, medical sanctions prove unworkable in this complex environment of conflicting rights and command no place in a sustainable sanction regime. (shrink)

ABSTRACTAre all forms of guerilla warfare apprehensible? Or can there be such a thing as just guerilla warfare? If so, what would be the reasonable requirements we would make of guerillas in order to consider them just? The remarks below, based on my new book The Ethics of Insurgency; A Critical Guide to Just Guerilla Warfare, summarize my attempts to answer those questions, discussing such issues as legitimate authority, just cause, and compliance with the laws of armed conflict, including the (...) use of human shields and ‘soft-war’ tactics such as cyber warfare. Three commentators thereafter delve into some of the most central critical questions and objections, to which I subsequently reply. (shrink)

During asymmetric war, state armies must care for their local allies, detainees and the civilian population in two contexts: acute care for those wounded during military operations and medical care for the general population as required by the Geneva Conventions. Constrained by scarce resources, state armies face a number of moral dilemmas that affect care on the ground.Triage. As they deploy, state armies allocate in-theater medical resources to care for their soldiers. In-theater care does not provide for long-term treatment. Its (...) purpose is to return warfighters to active duty or to quickly evacuate them to the US or Europe for comprehensive medical care. Limited beds and personnel make it impossible to provide the local population with the level of care that Western soldiers receive. As a result, the US and other armies develop complex and often arbitrary rules to treat civilians. The inability to provide high-level care to all, creates tensions with local civilians and host country allies.Ensuring local medical care. The Geneva Conventions require occupying armies to “ensure the medical needs of the civilian population.” Specifying these needs is a medical and moral challenge. What level satisfies this requirement? How much aid should the occupying power provide? How best to distribute existing resources? How should state armies protect NGOs that provide significant medical care and often find themselves under attack by insurgents?Medical Diplomacy. While the purpose of medical care is to treat the sick and injured, medical care also serves security needs. Medical care is a long-established tool to win the hearts and minds of the local population. Since the Vietnam War, however, critics have charged that medical diplomacy subverts the purpose of medicine, places medical personnel in the service of war and provides poor medical care. (shrink)

Medical ethics prohibits caregivers from discriminating and providing preferential care to their compatriots and comrades. In military medicine, particularly during war and when resources may be scarce, ethical principles may dictate priority care for compatriot soldiers. The principle of nondiscrimination is central to utilitarian and deontological theories of justice, but communitarianism and the ethics of care and friendship stipulate a different set of duties for community members, friends, and family. Similar duties exist among the small cohesive groups that typify many (...) military units. When members of these groups require medical care, there are sometimes moral grounds to treat compatriot soldiers ahead of enemy or allied soldiers regardless of the severity of their respective wounds. (shrink)

Gaucher disease is a rare, chronic,ethnic-specific genetic disorder affecting Jewsof Eastern European descent. It is extremelyexpensive to treat and presents difficultdilemmas for officials and patients in Israelwhere many patients live. First, high-cost,high-benefit, but low volume treatment forGaucher creates severe allocation dilemmas forpolicy makers. Allocation policies driven bycost effectiveness, age, opportunity or needmake it difficult to justify funding. Processoriented decision making based on terms of faircooperation or decisions invoking the ``rule ofrescue'''' risk discriminating against minoritieswho may already suffer from inequitabledistribution of (...) heath care resources. Apartfrom cost, Gaucher disease prompts questionsabout abortion. Unlike severe geneticdisorders, Gaucher offers no grounds forabortion and, in many ways, is analogous togender based abortions that are prohibitedregardless of fetal age. Finally, Gaucherraises concerns about the disclosure of geneticinformation. These affect potential carriersasked to participate in population studies andcarriers and patients who must considerdisclosure to others. These concerns weigh theright to privacy against communal interests andbilateral commitments. (shrink)

Military Medical Ethics for the 21st Century is the first full length, broad-based treatment of this important subject. Written by an international team of practitioners and academics, this book provides interdisciplinary insights into the major issues facing military-medical decision makers and critically examines the tensions and dilemmas inherent in the military and medical professions. In this book the authors explore the practice of battlefield bioethics, medical neutrality and treatment of the wounded, enhancement technologies for war fighters, the potential risks of (...) dual-use biotechnologies, patient rights for active duty personnel, military medical research and military medical ethics education in the 21st Century. (shrink)

Because we are often nagged by the thought that we might not have behaved any differently than those good citizens whose respect for the law and fear of punishment led them to support the Nazi regime, we are fascinated with the behavior of ordinary Germans. Careful to first strip away the pathological explanations of German behavior, Pellegrino and Thomasma ask simply whether ordinary Germans could have reasoned and, by implication, acted differently. Although their affirmative answer is consistent with the activism (...) we have all come to demand of the Germans, it is not clear whether we, ourselves, can lay full claim to the moral high ground. (shrink)