Medical ethics in time of armed conflict are identical to medical ethics in time of peace," declares the World Medical Association. (1) Were this the case, wartime and peacetime medicine would turn on the same principles and present similar dilemmas. But war fundamentally transforms the major principles and central issues that engage bioethics. A patient's rights to life and self-determination contract; human dignity strains under the barrage of military necessity; and the interests of the state and political community may outweigh considerations of patients' welfare. Also, actors and interests multiply. Combatants and noncombatants, enemies and allies, states and individuals, citizens and soldiers, prisoners of war, the wounded and the dying, those who can return to combat duty and those who cannot--all of these litter the battlefield.
Armed conflict augments the general principles of bioethics with those peculiar to the conduct of war. For instance, states are obliged to recognize noncombatant immunity, minimize collateral damage, and adhere to a principle of proportionality, when fighting threatens to take the lives of civilians and destroy their property, if difficult bioethical dilemmas arise when fundamental moral principles conflict, war adds novel dimensions of its own, as competing bioethical principles must contend not only with one another, but also with the overriding "reason of state" and military necessity that animate any issue of military ethics and may overwhelm other fundamental moral obligations.
Medical ethics in war are not identical to medical ethics in times of peace. Moreover, the nature of war is itself changing as conflicts between nation-states and sub-state actors--guerillas, insurgent ethnic groups, and international terrorist organizations--replace conventional war between sovereign nations. The changing modes of warfare create difficulties for the established conventions of war. They also create new dilemmas for medical personnel, who may be called upon to lend their expertise to the prosecution of war rather than simply to relieve the suffering it causes.
Medical and Military Ethics
In contrast to medical ethics, a wide range of agents, interests, and principles characterize military ethics. Whereas bioethics turns its attention to the patient, either as an individual or class of individuals, military ethics focuses on the rights and interests of three distinct actors: combatants, noncombatants, and the state. The 1949 Geneva Conventions define noncombatants as "persons taking no active part in the hostilities." These include civilians--"people who do not bear arms"--as well as prisoners of war and wounded soldiers. Combatants, on the other hand, bear arms and belong to military organizations that oversee compliance with international law; they include uniformed soldiers, irregulars, members of militia, and guerillas. This definition excludes terrorists who defy international law by intentionally targeting civilian populations.
Alongside individual actors stands the nation-state or political community with interests of its own. Nation-states are internationally recognized sovereign bodies, while political communities reflect the underlying linguistic, historical, ethnic, or religious groups that state or sub-state actors may represent. Representing a "collective way of life" or national ethos, states and political communities are "super-personalities" with a range of interests not necessarily identical to, and possibly in conflict with, the interests of their members.
In spite of divergent actors and interests, the ethics of medicine and armed conflict share norms anchored in the right to life, autonomy, dignity, and utility. The right to life, a central feature of contemporary political theory, grounds a state's obligation to safeguard the lives of its citizens, while liberty, interests secure political self-determination and its close cousin, medical autonomy. …