Michael L. Gross: Bioethics and Armed Conflict: Moral Dilemmas of Medicine and War.

Stewart, Robert Scott

Michael L. Gross

Bioethics and Armed Conflict: Moral Dilemmas of Medicine and War.

Cambridge, MA: MIT Press 2006.

Pp. 400.

US$65.00 (cloth ISBN-13: 978-0-262-07269-4); US$26.00 (paper ISBN-13: 978-0-262-57226-2).

The issue of bioethics during armed conflict has received relatively little attention in the philosophical literature. This is odd in one sense since the acute need to develop an ethics of medical research on humans (and, derivatively, of the need to develop bioethics in general) was largely the result of the realization of the atrocities the Nazis committed during World War II in the name of medical research. In another sense, however, it is understandable that little attention has been paid to the application of bioethics to armed conflict because many assume, along with Pellegrino and Thomasma, that 'the physician has ethical obligations that transcend self-interest, exigency, and even social, political and ethical forces' (1). As a result, many think that the moral principles that we typically employ in analyzing medical ethics--e.g., autonomy, non-maleficence, beneficence, justice, and so on--must apply more or less in the same way no matter what the circumstances. This is in fact the official position of the World Medical Association, which claims that 'medical ethics is the same in times of armed conflict as it is in peace time' (1).

According to Gross, this position is fundamentally wrong: while it is an overstatement to say he believes that war changes everything, he does believe that war changes a great deal. The reason for this is embedded within the notion of 'military necessity'. Although Gross never provides a succinct and proper definition of it, he thinks of military necessity as part of the 'ends and means of war necessary to preserve the welfare of the state, its army, and its citizens' (59). Hence, while not everything is legitimated under the rubric of military necessity, nations do have the right, under just war theory, to protect themselves and their legitimate interests. In this sense, military necessity 'reflects a concern for the collective welfare of the political community that reaches beyond individual well-being' (59). As such, it will 'sometimes override the normative force of deontological moral principles central to bioethics' (59).

In light of this, consider, e.g., the right to life, and the concomitant obligation of the state to protect the lives of its citizens. In war, states send young men (and increasingly, young women) into situations where it is a given that many will die. This will, of course, have dramatic consequences for bioethics in times of war. 'Ordinarily,' Gross says, 'individuals enjoy the right to receive medical care as an extension of their right to life' (43). But if their right to life is attenuated, then so too is their right to medical care. This, in turn, raises a whole host of other issues. Do we owe all our citizens, combatants and non-combatants alike, the same level of medical care? Or ought combatants receive priority? If they should, is this the result of a sense of obligation for the risk soldiers have placed themselves in for our protection? Or do we do it rather out of the utilitarian consideration that we get them back to the front to fight again? If we do it for the latter reason, how will this affect medical triage? Ought we to treat those soldiers first whom we can return to the front, or should we treat the more seriously wounded first, even though they will in all likelihood never be fit for combat again? What about medical treatment for our enemies, whether they be civilians, combatants, or terrorists? Do we owe them anything? Do we owe them the same treatment as our own civilians and combatants? Given all these difficult questions, we can see why Gross subtitled his book, 'the moral dilemmas of medicine and war' and why he also maintains that '[m]ilitary necessity, therefore, joins the pantheon of other principles that guide medicine and war as first among equals, and forces the peculiar and noncaregiving dilemmas that characterize bioethics during armed conflict' (63).

In addition to these two dilemmas--the just distribution of medical resources in war (Chapter 3) and wartime triage (Chapter 5)--Gross deals with a number of others. In Chapter 4 he considers issues of patient autonomy for soldiers along with the derivative rights of informed consent, confidentiality and the right to die. He argues that considerations of utility and respect for individual autonomy flip-flop from peace to war. That is, in war respect for autonomy diminishes as 'patient rights pass from the hands of soldier patients to the hands of those charged with the collective welfare, with the expectation that costs to some individuals are offset by benefits to others' (136). In Chapter 6 he questions whether medical personnel can and/or ought to be considered as neutral in armed conflicts. He thinks, despite the belief of many that medical personnel are of course neutral, that such personnel actually face difficult dilemmas as they are pulled toward remaining neutral and toward 'civic responsibility' (210). That is, health care workers are citizens with obligations to their state as well as members of a particular profession with its own set of moral principles. The same sort of tension exists for health care workers when they consider whether torture or non-treatment (Chapter 7) or chemical and biological warfare (Chapter 8) are ever justified. Finally, in Chapter 9, Gross considers whether medicine is obligated to work actively towards peace.

Many readers will disagree with some or perhaps even all of Gross' conclusions, sometimes passionately so. I certainly would take issue with some of his claims regarding torture and chemical/biological warfare, and indeed also with his claim about the novelty of the threat posed by terrorism. Critics of his work, however, will have their work cut out for them because Gross displays considerable virtuosity with his subject matter as he navigates bioethics, ethical theory, the history of warfare, and contemporary geopolitics and presents incisive, penetrating and forceful arguments. As a result, I believe that this book is destined to become a classic in its field.

Robert Scott Stewart

Cape Breton University