A framework for Military Bioethics

Abstract

A widely accepted framework governs biomedical research and the practice of medicine in the civilian sector, but no such framework exists to guide the military in how it should treat its own personnel. Civilian bioethical principles are unsuitable because of fundamental differences between civilian and military core values. This paper proposes a framework for military bioethics. It begins by describing core military values, articulating how they differ from civilian goals and values, and explaining how these differences limit the ability of civilian bioethical principles to govern military biomedicine. The paper then puts forward a set of more appropriate principles for the military and discusses how these principles apply in three main areas of controversy within military bioethics: the use of military personnel as research subjects; the deployment use of biomedical agents; and the obligations of military physicians toward their own troops.

Key Words:

• Military bioethics
• human subjects research
• military physicians
• proportionality
• paternalism
• fairness

ACKNOWLEDGEMENTS

Research funding for this paper was provided by the National Human Genome Research Institute of the National Institutes of Health (1R03HG006730-01), the Dean Lindsey Cowan Research Fellowship, and the Greenwall Foundation. The authors would like to thank Shannon French, Jason Gatliff, Eric Juengst, Robert Latiff, George Lucas, Gary Marchant and Tom Murray, plus the referees for the Journal of Military Ethics, for their comments on an earlier draft.

Notes

1. The discussion in this paper focuses on the US military and therefore Western bioethics. Eastern bioethical principles have many similarities, including an emphasis on beneficence and humanitarianism (see Post 2004).

2. Some commentators hold that the welfare of research subjects can never be sacrificed for the greater good (see Shalala 2000; Williams 2008). The regulations governing human subjects research derived from the Belmont Report, known as the Common Rule, clearly disagree, although they impose greater protections for subjects in experiments that pose more than minimal risks (45 CFR §46.116(a)(6)), and prohibit research on children that poses more than a minor increase in minimal risk, unless the risk is justified by the prospect of direct benefit to the children (45 CFR §§ 46.405–406).

3. In fairness, some civilian bioethicists and healthcare commentators incline more closely to the military approach, believing that our society cannot afford for healthcare professionals to place the interests of individual patients above the welfare of other members of health insurance plans or the interests of society as a whole. Instead, they argue, we should adopt ‘bedside rationing’, a triage-like approach in which physicians withhold beneficial treatments from some patients whom they consider to be of insufficient value to society, or in order to make what are deemed to be more efficient use of the available resources. But this is a minority viewpoint among civilian bioethicists and therefore it is fair to say that the civilian principle of beneficence remains inconsistent with the military value of selflessness.

4. Gross's apparent distinction between bioethics in war versus peacetime is addressed below.

5. One study found that more than 20 per cent of all prescriptions written by doctors in their offices were for unapproved uses, with the percentage of off-label prescribing for cardiovascular ailments as high as 46 per cent. The study also found that 50–80 per cent of cancer patients receive chemotherapy on an off-label basis (Radley et al. 2006).

6. As explained in the Advisory Committee Report on Human Radiation Experiments (ACHRE 1995), Secretary of Defense Charles E. Wilson distributed a memorandum throughout the military in 1953 that permitted Armed Services personnel to serve as research subjects only if they gave their voluntary consent. Although the Wilson Memorandum was classified top secret until 1975 for reasons that are not entirely clear, the Army Chief of Staff issued a non-classified version of the memorandum in 1954 as Army Directive CS:35 and incorporated CS:35 into Army regulations as AR 70-25 in 1962. The Air Force issued the Wilson Memorandum as a regulation in 1965, and the Navy included a requirement of voluntary research consent in its Medical Department Manual in 1967. In addition, the Navy made it clear in 1969 that the requirement of voluntary consent applied to both patients and healthy subjects, and the Army followed suit in 1973 in AR 40-38.

7. The SSCVA (1994) recommended that the doctrine be deemed inapplicable if military personnel were injured in experiments in which they were forced to serve as subjects.

Additional information

Notes on contributors

Maxwell J. Mehlman

Maxwell J. Mehlman is Distinguished University Professor, Case Western Reserve University, Arthur E. Petersilge Professor of Law and Director, The Law-Medicine Center, Case Western Reserve University School of Law, and Professor of Biomedical Ethics, Case Western Reserve University School of Medicine. He holds a JD from Yale Law School and BAs from Reed College and Oxford University, which he attended as a Rhodes Scholar.

Stephanie Corley

Stephanie O. Corley is the Dean Lindsay Cowan Research Fellow, The Law-Medicine Center, Case Western Reserve University School of Law. She holds a JD from Case Western Reserve University School of Law.