Résumés
Abstract
Despite the increase in and evolving nature of armed conflicts, the ethical issues faced by military physicians working in such contexts are still rarely examined in the bioethics literature. Military physicians are members of the military, even if they are non-combatants; and their role is one of healer but also sometimes humanitarian. Some scholars wonder about the moral compatibility of being both a physician and soldier. The ethical conflicts raised in the literature regarding military physicians can be organized into three main perspectives: 1) moral problems in military medicine are particular because of the difficulty of meeting the requirements of traditional bioethical principles; 2) medical codes of ethics and international laws are not well adapted to or are too restrictive for a military context; and 3) physicians are social actors who should either be pacifists, defenders of human rights, politically neutral or promoters of peace. A review of the diverse dilemmas faced by military physicians shows that these differ substantially by level (micro, meso, macro), context and the actors involved, and that they go beyond issues of patient interests. Like medicine in general, military medicine is complex and touches on potentially contested views of the roles and obligations of the physician. Greater conceptual clarity is thus needed in discussions about military medical ethics.
Keywords:
- military physicians,
- conflict of roles,
- medical ethics,
- professional ethics,
- codes of ethics,
- dilemmas
Résumé
Malgré l’augmentation des conflits armés et des changements qui les caractérisent, les enjeux éthiques auxquels font face les médecins militaires sont très peu traités dans la littérature en bioéthique. Les médecins militaires sont des membres du corps militaire, même s’ils sont non combattants, et ils jouent un rôle de soignant tout en pouvant être appelés à agir comme aide humanitaire. Certains auteurs se sont même interrogés sur la compatibilité morale d’être à la fois médecin et soldat. Les conflits éthiques soulevés dans la littérature sur les médecins militaires peuvent être organisés autour de trois perspectives : 1) les problèmes moraux en médecine militaire seraient particuliers compte tenu des difficultés à respecter les principes bioéthiques traditionnels; 2) les codes d’éthique médicaux et les lois internationales seraient trop restrictifs ou inadéquats pour le contexte militaire; et 3) les médecins sont des acteurs sociaux qui devraient être pacifistes, défenseurs des droits de la personne, politiquement neutres ou promoteurs de la paix. Une revue des divers dilemmes rencontrés par les médecins militaires identifiés dans la littérature nous montre que ces perspectives se situent à des niveaux d’analyse différents (micro, méso, macro), que les contextes et les acteurs impliqués sont souvent différents et que les dilemmes vont bien au-delà des enjeux liés strictement à l’intérêt du patient. Tout comme la profession médicale en général, la médecine militaire est complexe et soulève des points de vue divergeant quant au rôle et aux obligations du médecin. Une plus grande clarté des concepts employés dans les discussions autour de l’éthique médicale militaire apparaît donc nécessaire.
Mots-clés :
- médecins militaires,
- conflits des rôles,
- éthique médicale,
- éthique professionnelle,
- codes de déontologie,
- dilemmes
Veuillez télécharger l’article en PDF pour le lire.
Télécharger
Parties annexes
Acknowledgements
I am grateful to professors Bryn Williams-Jones and Matthew Hunt for their constructive comments and suggestions on various drafts of this article. An early version of this paper was presented at the Points of Intersection Ethics, Rights, Health Care & Public Health in Humanitarian Assistance conference in Hamilton, Ontario, in 2010, and benefited greatly from the audience feedback. Many of the ideas here benefited from discussions with members of the Ethics in Military Medicine Research Group. The research for this article was supported by a scholarship from the Quebec Fonds de recherche sur la société et la culture (FRQ-SC), and funding to Bryn Williams-Jones, Lisa Schwartz and Matthew Hunt from the Ethics Office of Canadian Institutes of Health Research (CIHR).
Bibliography
- 1. Miles SH. Abu Ghraib: its legacy for military medicine. The Lancet. 2004;364(9435):725-9.
- 2. Allhoff F, editor. Physicians at War: The Dual Loyalty Challenge. New York, NY: Springer; 2008.
- 3. Pellegrino ED. The moral foundations of the patient-physician relationship: the essence of medical ethics. In: Beam TE, Sparino LR, editors. Military Medical Ethics, Vol 1. Falls Church, VA: Office of the Surgeon General; 2003. p. 3-21.
- 4. Annas GJ. Military medical ethics – physician first, last, always. New England Journal of Medicine. 2008;359(11):1087-90.
- 5. Gross ML. Bioethics and Armed Conflict: Moral Dilemmas of Medicine and War. Cambridge, Mass: MIT Press; 2006.
- 6. Moreno JD. In the Wake of Terror: Medicine and Morality in Time of Crisis. Cambridge, Mass: MIT Press; 2004.
- 7. Bloche MG. Clinical loyalties and the social purposes of medicine. JAMA. 1999;281(3):268-74.
- 8. Benatar SR, Upshur REG. Dual loyalty of physicians in the military and in civilian life. American Journal of Public Health. 2008;98(12):2161-7.
- 9. London L, Rubenstein LS, Baldwin-Ragaven I, Van Es A. Dual loyalty among military health professionals: human rights and ethics in times of armed conflict. Cambridge Quarterly of Healthcare Ethics. 2006;15:381-91.
- 10. Singh JA. American physicians and dual loyalty obligations in the “war on terror”. BMC Med Ethics. 2003;4(4).
- 11. Sidel VW, Levy BS. Physician-soldier: a moral dilemma. In: Beam TE, Sparino LR, editors. Military Medical Ethics, Vol 1. Falls Church, VA: Office of the Surgeon General; 2003. p. 293-312.
- 12. Santa Barbara J. Working for peace through health – ethical values and principles. Croatian Medical Journal. 2005;46(6):1007-9.
- 13. Schmitt MN. Military necessity and humanity in international humanitarian law: preserving the delicate balance. Virginia Journal of International Law. 50(4):796-837.
- 14. Madden W, Carter B. Physician-soldier: a moral profession. In: Beam TE, Sparino LR, editors. Military Medical Ethics, Vol 1. Falls Church, VA: Office of the Surgeon General; 2003. p. 269-91.
- 15. Gibson BR, Suh R. Doctors with borders: the role of health professionals in war and human rights. Medscape Public Health. 2007.
- 16. Gross ML. Military medical ethics: a review of the literature and a call to arms. Cambridge Quarterly of Healthcare Ethics. 2013;22:92-109.
- 17. Canli T, Brandon S, Casebeer W, Crowley PJ, DuRousseau D, Greely HT, Pascual-Leone A. Neuroethics and national security. American Journal of Bioethics. 2007;7(5):3-13.
- 18. Durand G. Introduction générale à la bioéthique: histoire, concepts et outils. Les Editions Fides; 2005. 580 p.
- 19. Drane JF. What is bioethics? A history. In: Lolas FS, Agar LC, eds. Interfaces Between Bioethics and the Empirical Social Sciences [Regional program on bioethics OPS/OMS publication series 2002]. Third Meeting of the International Advisory Board on Bioethics. Buenos Aires: Pan American Health Organization and WHO; October 2001; 15-32.
- 20. Schapowal AG, Baer H-U. Medical ethics in peace and in the armed conflict. Military Medicine. 2002 Aug;167(8 Suppl):26-31.
- 21. Howe EG. Point/Counterpoint-A response to Drs Sidel and Levy. In: Beam TE, Sparino LR, editors. Military Medical Ethics, Vol 1. Falls Church, VA: Office of the Surgeon General; 2003. p. 312-20.
- 22. Moran P. A military exception to “informed consent”: Doe v. Sullivan. St John’s Law Review. 2012;66(3), article 15.
- 23. Wynia MK. Breaching confidentiality to protect the public: evolving standards of medical confidentiality for military detainees. American Journal of Bioethics. 2007;7:1-5.
- 24. Frisina ME. Guidelines to prevent the malevolent use of physicians in war. In: Allhoff F, editor. Physicians at War: The Dual Loyalty Challenge. New York, NY: Springer; 2008. p. 39-52.
- 25. Miles SH. Oath Betrayed: America’s Torture Doctors. 2nd ed. Los Angeles, CA: University of California Press; 2009.
- 26. Childress JF. Conclusions and Next Steps. In: Military Medical Ethics: Issues Regarding Dual Loyalties: Workshop Summary. Washington, DC: The National Academies Press; 2008. p. 33-36.
- 27. World Medical Association. WMA Regulations in Times of Armed Conflict and Other Situations of Violence. 2012 (1956).
- 28. The Geneva Hippocratic Oath. Journal of the National Medical Assocation. 1949;41(5):225-6.
- 29. Miles SH. The new military medical ethics: legacies of the gulf wars. Bioethics. 2011;27(3):117-23.
- 30. Hathout L. The right to practice medicine without repercussions: ethical issues in times of political strife. Philosophy, Ethics, and Humanitarian Medicine. 2012;7(11).
- 31. 1949 Geneva Convention (I) for the Amelioration of the Condition of the Wounded and Sick in Armed Forces in the Field. Centre for International Law.
- 32. Gross ML. Why treat the wounded? Warrior care, military salvage, and national health. American Journal of Bioethocs. 2008;8:3-12.
- 33. Swan KG, Swan KG jr. Triage: the past revisited. Military Medicine. 1996;161(8):448-52.
- 34. Repine TB, Lisagor P, Cohen DJ. The dynamics and ethics of triage: rationing care in hard times. Military Medicine. 2005;170(6):505-9.
- 35. Rawling B. La mort pour ennemi : La médecine militaire canadienne. Ottawa, Canada: Agmv; 2008.
- 36. Beckett A, Pelletier P, Mamczak C, Benfield R, Elster E. Multidisciplinary trauma team care in Kandahar, Afghanistan: Current injury patterns and care practices. Injury. 2012;43(12):2072-7.
- 37. Kondro W. Afghanistan: Outside the comfort zone in a war zone. CMAJ. 2007;177(2):131-4.
- 38. Gordon S. The military physician and contested medical humanitarianism: a dueling identity? Social Science and Medicine. 2014;120:421-9.
- 39. Sokol DK. The medical ethics of the battlefield. BMJ. 2011;343(3):d3877.
- 40. Tobin J. The challenges and ethical dilemmas of a military medical officer serving with a peacekeeping operation in regard to the medical care of the local population. Journal of Medical Ethics. 2005;31:571-4.
- 41. Okie S. Glimpses of Guantanamo — medical ethics and the war on terror. New England Journal of Medicine. 2005;353(24):2529-34.
- 42. Koch T. Weaponising medicine: “Tutti fratelli,” no more. Journal of Medical Ethics. 20061;32(5):249-55.
- 43. Wang T. Towards a military medical ethics framework for genetic human enhancement. Penn Bioethics Journal. 2010;6(1):8-12.
- 44. Bloche MG, Marks JH. When doctors go to war. New England Journal of Medicine. 20056;352(1):3-6.
- 45. United Nations. The Universal Declaration of Human Rights. New York; 1948.
- 46. United Nations. International Legal Protection of Human Rights in Armed Conflict. New York; 2011. 119 p.
- 47. Giannou C, Baldan M. War surgery: working with limited resources in armed conflict and other situations of violence. ICRC; 2009. 351 p.
- 48. Darre É. Droit international humanitaire : problèmes éthiques posés au médecin. Université Aix-Marseille II - Attestation d'éthique médicale. 2002.
- 49. Iacopino V, Waldman RJ. War and health: From Solferino to Kosovo – the evolving role of physicians. JAMA. 1999;282(5):479-81.
- 50. Sidel VW, Levy BS. War, terrorism, and public health. Journal of Law, Medicine & Ethics. 2003;31(4):516-23.
- 51. Gross ML. Is medicine a pacifist vocation or should doctors help build bombs. In: Allhoff F, editor. Physicians at War: The Dual Loyalty Challenge. New York, NY: Springer; 2008. p. 151-6.
- 52. American Medical Association. Principles of Medical Ethics. 2001 (1957).
- 53. Horton R. Public health: a neglected counterterrorist measure. The Lancet. 2001;358:1112-3.
- 54. Levy BS, Sidel VW, editors. War and Public Health. Oxford University Press; 1997. 444 p.
- 55. Murray CJL, King G, Lopez AD, Tomijima N, Krug EG. Armed conflict as a public health problem. BMJ. 2002;324(7333):346-9.
- 56. MacQueen G, Santa-Barbara J, Neufeld V, Yusuf S, Horton R. Health and peace: time for a new discipline. The Lancet. 2001;357(9267):1460-1.
- 57. Wass V. Doctors in society: medical professionalism in a changing world. Clinical Medicine. 2006;6(1):109-13.
- 58. Zwi AB. How should the health community respond to violent political conflict? PLoS Medicine. 2004;1(1):e14.
- 59. Pinto AD. Peace through health. University of Toronto Medical Journal. 2003;80(2):158–60.
- 60. List JM. Medical neutrality and political activism: physicians’ roles in conflict situations. In: Allhoff F, editor. Physicians at War: The Dual Loyalty Challenge. New York, NY: Springer; 2008. p. 237-53.
- 61. Rascona D. The moral obligation of United States Military Medical Service. In: Beam TE, Sparino LR, editors. Military Medical Ethics, Vol 1. Falls Church, VA: Office of the Surgeon General; 2003. p. 320-5.
- 62. Baril D. Les principes de la guerre juste peuvent-ils s’appliquer au terrorisme? Forum. 2008.
- 63. Howe EG. Dilemmas in military medical ethics since 9/11. Kennedy Institute of Ethics Journal. 2003;13(2):175-88.
- 64. Bush GW. Memorandum: Humane Treatment of Al Queda and Taliban Detainees. US Government: Washington, D.C.; 2002.
- 65. Elsea J. Treatment of “battlefield detainees” in the war on terrorism. Congressional Research Service; 2005.
- 66. Carswell A. Classifying the conflict: A soldier’s dilemma. International Review of the Red Cross. 2009;91(873):143-161.
- 67. Rubenstein L, Pross C, Davidoff F, Iacopino V. Coercive us interrogation policies: A challenge to medical ethics. JAMA. 2005 Sep 28;294(12):1544-9.
- 68. Schweizer B. Moral dilemmas for humanitarianism in the era of “humanitarian” military interventions. International Review of the Red Cross. 2004;86(855):547-64.
- 69. Lischer SK. Military intervention and the humanitarian “force multiplier”. Global Governance. 2007;13(1):99-118.
- 70. Désilets L-P. La contribution du Canada à la reconstruction de l’Afghanistan : une mise en application du concept de “sécurité humaine”. Points de mire. 2004;5(6):1-2.
- 71. Duffield M. Global Governance and the New Wars: The Merging of Development and Security. London: Zed Books; 2001.
- 72. Nossal KR. “The world we want”?: The purposeful confusion of values, goals, and interests in Canadian foreign policy. Ottawa, ON: Canadian Defence and Foreign Affairs Institute; 2003.
- 73. Pearce G, Saul P. Toward a framework for military health ethics. In: Allhoff F, editor. Physicians at War: The Dual Loyalty Challenge. New York, NY: Springer; 2008. p. 75-88.
- 74. Wendler D. Are physicians obligated always to act in the patient’s best interests? Journal of Medical Ethics. 2010 Feb 1;36(2):66-70.
Parties annexes
Remerciements
Je suis reconnaissante envers les professeurs Bryn Williams-Jones et Matthew Hunt pour leurs suggestions et commentaires constructifs sur plusieurs versions de cet article. Une version précédente a été présentée au Points of Intersection Ethics, Rights, Health Care & Public Health in Humanitarian Assistance conference à Hamilton, Ontario, en 2010, et l’article a bénéficié grandement des commentaires de l’audience de cet évènement. Plusieurs des idées présentées ont progressé grâce aux discussions avec les membres du Groupe de recherche sur l’éthique en médecine militaire. La recherche pour cet article a été rendue possible grâce à une bourse d’étude de la part des Fonds de recherche sur la société et la culture (FRQ-SC), et du financement de Bryn Williams-Jones, Lisa Schwartz et Matthew Hunt par le Bureau d’éthique des Instituts de la recherche en santé du Canada (IRSC).