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Medical Ethics in the Battlefield

By Michael Cook

War turns the ethics of doctors on its head.

Films are a rich source of hypotheticals for medical ethics classes. I recall a gut-wrenching scene in The Last of the Mohicans. From a great distance the hero, Hawkeye, shoots his best friend just as he is about to be burnt at the stake by vengeful Huron Indians.

Was this a “mercy killing”? Is it ethical to kill fellow soldiers in wartime to ward off worse suffering? If that’s not clear, how about wounded enemy soldiers?

This has happened in recent conflicts. Last year a Canadian Army officer was found guilty of “disgraceful conduct” after the “mercy killing” of a wounded Taliban insurgent. Apparently Captain Robert Semrau felt bound by a “soldier’s pact” to end his suffering. “He told us that he shot the Taliban; he put him out of his misery and, if anything came of it, he would wear it,” a corporal told the court-martial.

In 2004 American Staff Sgt Johnny Horne Jr killed a badly wounded Iraqi teenager in Baghdad. He also painted this as a “mercy killing”, although it emerged that the 16-year-old had been an unarmed and innocent non-combatant. Naturally he was found guilty. “Mercy killing” was an excuse to cover up his lethal error. Or his racism. Or his sadism.

If military law does not recognise mercy killing as an option for soldiers, it is even stricter for Army doctors.

Even for them, the golden rule is still the Hippocratic maxim, “primum non nocere” – first, do no harm. As A/Prof Susan J. Neuhaus, of the University of Adelaide’s Department of Surgery points out in a recent issue of the Medical Journal of Australia, the absolute nature of this principle has been weakened by abortion and various surgical procedures. But “mercy killing” is still beyond the pale.

Nonetheless, in times of stress and terror, it can be a professional temptation. After Hurricane Katrina in 2005, a doctor and two nurses were charged with murdering patients who could not be moved from a devastated hospital. No one was convicted – which scandalised prominent American bioethicist Arthur Caplan. “The deaths of the nine persons at Memorial Medical Center in New Orleans are all cases of active euthanasia,” Caplan wrote. “Each person died with massive doses of narcotic drugs in their bodies.”

Prof Neuhaus points out that, like public emergencies, war turns medical ethics on its head. The responsibility of a doctor is to save lives; the responsibility of a soldier is to take them. A doctor respects autonomy; a soldier surrenders his autonomy and follows orders.

The Geneva Conventions shine a light for doctors through a thicket of dual loyalties – as a citizen, to their comrades and, as a doctor, to the wounded. Doctors may not partake in direct combat activities; doctors must triage casualties whether they are enemy, ally or civilian; and doctors are obliged to denounce all atrocities, even those committed by their own soldiers. The Geneva Conventions specifically forbid euthanasia.

In the light of this, how should we assess the experiences of Adelaide cardiothoracic surgeon Craig Jurisevic? In 1999 he went to Albania to help refugees from Kosovo in a local hospital. To his immense dismay the hospital was controlled by the Albanian mafia. He denounced them and, as a result, he had to flee to a recruitment centre for the Kosovo Liberation Front. There he took up arms, trained young recruits, went on patrols, killed Serb militia. In his view these combat activities were “preventative medicine”. His experiences are chronicled in a memoir, Blood on My Hands. A film may be on the way.

Unsurprisingly, perhaps, Dr Jurisevic says that he suffered from post-traumatic stress disorder for years – “terrible dreams, flashbacks, all of that”. Combining the role of healer and killer must be a terrible strain.

Australian doctors will be participating in more and more wars in the coming years. As Neuhaus says: “It is imperative that doctors’ professional values and ethical and legal responsibilities in these difficult circumstances are clear”.

Jurisevic’s unsettling story shows that, despite mandatory medical ethics lectures, some doctors easily forget their first commandment, primum non nocere.

Michael Cook is editor of the online bioethics newsletter, BioEdge.