An Ethics of Care Perspective on Care to Battlefield Casualties

ABSTRACT

Soldiers hold special ethical obligations to prioritise care for those closest to them when dealing with combat casualties. This obligation draws on the unique, personal relationships already established, which soldiers have with their comrades. These relationships arguably overrule the need for impartiality barring only a significant difference in the severity of injuries. The bonds of fraternity deserve moral recognition that is not reflected in current conceptions of battlefield medical care. However, an ethics of care (or care ethics) approach does not reject care for enemies but suggests that extension to them occurs when there is no significant difference in severity to comrades first. It also calls on a different form of care called ethical caring, which as opposed to natural caring requires introspection on behalf of the caregiver. Ethics of care distinguishes treatment of the enemy from emotionally detached positions. Emotional detachment rejects the call to care and denies the development of a relationship, which is a foundational principle of care ethics.

KEYWORDS:

• Military ethics
• military medicine
• ethics of care
• bioethics
• combat ethics

Introduction

War can be seen as the antithesis of care; a time when care has failed, and when violence disregards its victims and their needs. War can be regarded as the ultimate example of a failure to understand the needs of others, where the common bonds of humanity have fractured beyond repair. Despite this, war may also be considered just or justified when guided by principles of discrimination of targets and proportionality of violence (jus in bello). To act outside those principles is arguably more unjust than to be a participant in war alone.

Yet, even in times of war, opportunities for care exist. For example, the treatment of victims of war offers opportunities to develop new relationships, foster understanding, and in turn prevent future hostilities.

Military environments are often considered to be inherently masculine domains. Despite the appearance of unregulated, male-perpetrated violence, however, there are considerable limitations placed on the conduct of soldiers at war, and many conventions and treaties govern their behaviour (Ben-Naftali 2011; Fleck and Bothe 2021; International Committee of the Red Cross 1949a). These legal frameworks have been developed to maintain a sense of common humanity, prevent unnecessary destruction, and limit the impacts of war on civilians. Special attention has been made to ensure adequate treatment and medical care for those injured in hostilities, particularly prisoners of war and civilians. The ethical foundations of this care can be scrutinised through a variety of perspectives, one of which is an ethics of care (or “care ethics”) approach.

Ethics of care as a normative moral theory arose in the mid-1980s as a response to seemingly male-oriented ethical views that devalued emotions and relationships in favour of more masculine conceptions of reason and autonomy (Jaggar 1995). Whilst the traditional position of care ethics is as a feminist ethical theory, concerned with the value and moral consideration of women, we will explore the application of such a theory to what has been historically described as an “authoritarian, hegemonic masculine institution”, namely, the military and its conduct in warfare (Wadham 2013).

We will examine the concept of ethics of care or care ethics as a moral theory concerned with the value of relationships. In so doing, we contend that care ethics is uniquely positioned to explore the ethical dimensions of the comradery of wartime combatants and, in particular, comradery as concerns medical personnel. We hope to demonstrate that there is an innate moral reason to prioritise one’s own forces, although not to the exclusion of all others.

Thesis statement

The primary aim of this article is to underscore that when examining battlefield casualties from an ethics of care perspective, we apply limitations to the concept of impartiality.

This examination from an ethics of care perspective will highlight reasons to extend treatment to civilians and other casualties that are absent from international humanitarian law.

Finally, we focus on the moral concerns of “emotional detachment” in the treatment of patients as a means of denying ethical care.

Ethics of care

Ethics of care (care ethics) is a normative moral theory grounded in the importance of relationships, respect, and being heard. It is strongly associated with feminist ethics and has developed in response to the traditional, justice-oriented perception of moral development, which, according to care ethics, does not take into account moral experiences and therefore has considered an interpersonal moral stage as being morally deficient (Koggel and Orme 2010). Care ethicists hold that we hold moral obligations to those with whom we have or hold relationships and with whom there exists potential for future growth in the relationship. That is to say, humans owe duties of care to those closest to them first and to others secondly (Noddings 2013).

Ethics of care implies there is moral significance to be found in relationships and interdependencies that are ubiquitous to human life. This moral significance is argued to be neglected in other moral theories and is seen as an alternative to traditionally male-oriented justice perspectives (Noddings 2013, 89–92). Care ethics holds that care is a fundamental value, perhaps even more fundamental than justice (Jaggar 1995). As all humans are dependent on care, particularly as infants, it is implied that care is a prerequisite to personal existence (Chadwick, Callahan, and Singer 2011). Care ethics builds on a motivation to care for those who are vulnerable and require assistance, inspired by an individual’s own memories of receiving care, past experiences of providing care to others, and a desire to reach an idealised form of self. Care ethics views human beings as primarily interrelated and dependent on one another, rather than as essentially autonomous individuals.

Care ethics is often compared to deontological and consequentialist moral theories, which can be seen as having a pre-occupation with duties and instrumentality without consideration of the relationships involved. Care ethics considers moral judgements to be contextual and moral standpoints as positioned, whereas principle-based or justice-based ethical theories are characterised by concepts of universality, objectivity, and impartiality (Jaggar 1995).

Moral reasoning from an ethics of care perspective values emotion in the consideration of moral conflicts as opposed to conceptions such as reason and objectivity more central to other ethical theories (Chadwick, Callahan, and Singer 2011). An ethics of care calls for “personal concern, loyalty, interest, passion and responsiveness to the uniqueness of loved ones, to their specific needs, interests and history” (Friedman 1993, 66); therefore, the tools used to examine and solve moral conflicts consist of empathetic reconstruction of the perspective of the other, and conscious balancing of responsibilities towards them and self, whereas justice-based positions consider the generalised other and logical deductive reasoning, recognising, and rule-application to solve moral conflicts.

The principles considered in moral conflicts when analysed with an ethics of care perspective are typically responses to human needs and avoidance of pain and suffering, whilst attempting to build and foster relationships. Within justice frameworks, the ethical principles of equality, reciprocity, and respect for autonomy are more frequently considered. An ethics of care transcends the usual relational ties of mutual aid and assistance that enable communities to function and invokes unconditional obligations that people will hold to one another by virtue of the status of their special, unique relationships (Sherwin 2006). This is frequently associated with concepts such as motherhood and the special relationship between a mother and child but can be broadened to further include other family members, friends, and colleagues with whom the carer holds a special relationship.

Care ethicists see care as a value, an attitude, and a practice, each of which has been seen as undervalued within Western society. Whilst there is extensive literature that examines the undervaluing of those who provide care in Western society and their social status, such discussions are not the focus of this article given its concentration on the application of care ethics to the military and warfare.

Nel Noddings (2013) posits two types of caring: natural caring and ethical caring. Where natural caring deals with caring for another because one wants to, and so happens naturally, ethical caring is the idea that there is a “right” way to care. Ethical caring is described as care that flows from seeing someone in distress or requiring care, acknowledging this, and deciding to act, even in the face of resistance (Noddings 2013). This form of caring is judged in the moment of recognising the call for care, the internal emotion of “I must do something”, and the choice to accept it or reject it. When faced with this decision, ethical caring as a practice requires one to consider what one’s ethical ideal would be, what previous care one has received and provided to others, and whether care at this moment would enhance that ideal or diminish it. In this way, ethical caring is a virtue that is developed over time and through the building of one’s ethical ideal. Through the building of ethical caring, accepting that care is requested, recognising the resistance to care, and deciding to act, it can develop into natural caring. Natural caring, as opposed to ethical caring, is care that follows naturally in recognition of the call to care, and the desire to act on it, where the desire and obligation are in alignment. When applied to the military context this extends to the care provided to comrades, the medic’s own ethical ideal as a healer, and how one has previously cared for others or has oneself been cared for. Care for one’s immediate team or section would flow most easily, as natural care, where treatment of enemy combatants would require overcoming a certain internal resistance, possibly over time approaching the ease with which one approaches natural caring.

This recognition of the resistance to care stands in contrast to justice-based approaches, which fail to recognise the inherent difficulty of answering the call to care where there is not just an absence of relationship, but even hostility towards the other.

Ethics of comradery?

To demonstrate that the principles of justice cannot be as easily applied to battlefield casualties as international law suggests, consider the following scenario. Two brothers walking down a street are attacked by a stranger for no apparent reason and one brother is stabbed in the process. Following the attack, the perpetrator attempts to flee by crossing the road but is struck by a car whilst doing so. This now creates two victims, one who has been hit by a car, and the other who has been stabbed. Towards whom should the remaining (uninjured) brother direct their aid?

In evaluating this kind of scenario there are several factors to consider. For one, we are not aware of any motive or intention of the attacker, only that they attacked. There are two victims, one is a man who has a stab wound and another has been hit by a car. We do not know the full extent of the injuries to either party, but we know the brother can only aid one of them at this specific moment in time. Where care ethics now diverges from objective conceptions of ethics is that ethics of care considers the issue of relationships. The man who has been stabbed is the brother of the person who is assessing the situation. They have lived their whole lives together and have a deep, personal relationship with one another. The man who was hit by the car is a stranger. His motivation for committing the initial assault is unknown, yet he was the perpetrator of the harm suffered by the other and has only harmed himself in the process of extrication from the situation.

This example is akin to many combat scenarios that occur in modern state vs. non-state hostilities. Modern conflicts have been marked by the rise of attacks by various non-state actors, from religious extremists to paramilitary criminal organisations (Watkin 2016). In the moment of attack by these combatants, there is ambiguity behind the perpetrator’s allegiance and their motivations. Just as it would not be unreasonable for a parent to tend to their own child first were they injured, so too is it not unreasonable for combatants to direct care to their closest comrades initially. This would be the claim of an ethics of care.

Noddings (2013) suggests two criteria for obligation in accordance with care ethics: the existence of or potential for present relation, and the dynamic potential for growth in relation. In considering this scenario, the existence of a present relation obligates categorically the uninjured man to provide aid initially to his brother. This obligation extends beyond the simple understanding of mutual aid for the betterment of the group or reciprocity into the realm of ethical and natural caring. As Gross (2013) argues in his exploration of the topic, priority to friends, family, and teammates on the one hand violates the principles of impartiality, non-discrimination and opportunity central to medical ethics, but on the other is fundamental to our understanding of moral behaviour. This does not negate the need to care for the attacker-now-victim entirely, but simply that the moral obligation first rests on caring for the one they already share a bond with.

In military units where small groups of individuals are dependent on the virtues of trust and loyalty, there is a third virtue not often considered: that they care for one another. Concepts of “Brotherhood” and “Fraternity” are often brought up when discussing the bonds formed between soldiers (Connor et al. 2021; Ingham 1996; Martin 2018; Maxwell 2018). Men and women who provide and protect each other in high-stress combat scenarios will often develop relationships as tightly connected as blood relatives (Connor et al. 2021). These soldiers fulfil both criteria as laid out by Noddings and as such satisfy both an absolute obligation of care and a priority over others (2013). International conventions do not reflect this dynamic in the immediacy of combat. When considering the treatment of a moderately injured comrade and a more severely wounded enemy, however, this distinction becomes blurred. In hypothetical scenarios it has been argued that soldiers would direct aid to their comrade first, then the more severely wounded, and only if the difference in scale of severity were extreme, tend to the enemy first (Gross 2013). This does not align with international principles such as the Geneva Conventions that maintain that the only reason to discriminate between casualties can be on the basis of injury severity (1989a).

Waning consideration

This relationship we refer to when considering the obligation of military forces to care for those closest to them regarding combat casualties is small in proximity and wanes precipitously by association (Noddings 2013). One could not argue that the obligation to care for family is the same as for a member of the same sporting team, and so this obligation is rapidly reduced by similar associations in wartime. A member of the same team or section, one who has a deeply rooted, personal connection with the other, is obligated, categorically, to care for this other. The same cannot be said of a distantly associated individual, such as by simply being the same nationality or even the same military force. This care is natural and occurs with only minor resistance even in the face of great danger to the soldier themselves.

Noddings (2013) suggests that our obligations to care are expansive, until care for those with less of a relationship impacts on individuals with whom they share a relationship and reduces or destroys the ability to care for those closest to them. In the combat environment, the medic or frontline soldier has an absolute obligation to treat their comrade, and should it be possible, they are to provide further care to others, to bystanders and enemy combatants for example, provided that the initial care is not impeded or restricted. Individual caregivers can only provide so much care before it detrimentally impacts on their current patients.

There is currently very little consideration of the harm conducted to civilians and little incentive to provide such care, even in events where civilians are involved in the immediate area (Rothbart, Korostelina, and Cherkaoui 2012). The 4th Geneva Conventions, articles 55 and 56, state that an occupying power merely has a duty to supply food and medical supplies, ensure access to hospital services and maintain public hygiene “to the fullest extent possible”, but no mention is made for the provision of direct medical assistance (International Committee of the Red Cross 1949b). An ethics of care would consider these civilians when they call for assistance and recognise their distress whilst keeping in mind the need not to overstretch the obligations of the ones providing that care to those closest to them. This care may not arise naturally as in natural care, but through ethical caring as will be described in detail later in this article. Whilst recognising the limitations of our care as it wanes in proportion to our ability to offer it and as one moves further away from those with whom one has or may perhaps develop and foster relationships, it does not mean that one can abandon one’s adversaries should it be possible to render aid.

Ethical caring for the enemy

As has been suggested so far, an ethics of care would find that one still cannot reject the enemy regardless of their attitudes towards their carer. An ethics of care would guide us to recognise that all combatants are inherent victims of war and violence, irrespective of their designation of friend or foe. In doing so, ethics of care fosters empathy for hostile forces and motivates carers to instil in enemy combatants, through the provision of care to them, a disincentive to commit further acts of violence (Held 2010). Care for the enemy may not come naturally or exist through what one considers natural caring, but the ethics of care calls on the carer to rise above their hostilities, to recognise their own moments’ previous experiences of care and obey the “I must”, even when it may bring them pain knowing what distress the enemy’s actions have inflicted on the carer and their comrades (Noddings 2013). This position suggests that where the carer has no immediate closer relation or that their ability to care is not impeded by reaching out to a lower position of obligation, then they must overcome their resistance and provide such aid. The test of caring in these moments comes not in the action of providing medical care but in the thoughts of the moment. Historically, healthcare professionals successfully treating their enemies have done so through practices such as emotional detachment, or through appeal to uphold the principles of beneficence or justice (Rubinstein and Bentwich 2017). These emotionally detached positions, despite leading to medical attention, ultimately reject the call to care.

Inherent to the creation of the Geneva Conventions was an unwritten understanding that soldiers who fought in wars were as much victims as they were perpetrators (Koch 2006). A belief that soldiers of all nations, religions, and creeds were fundamentally the same: a brotherhood of people who despite engaging in violent acts of conflict harboured no direct ill will towards their combatants. In this concept, combatants do not truly harbour hostility to their foes, or at least do so reluctantly. This idea of “Tutti Fratelli”, that soldiers are a brotherhood irrespective of their allegiance, provided a moral reason to care and to treat every victim of war, compatriots and enemies alike (Koch 2006). This history requires constant reflection to re-invigorate the sense of compassion inherent to humanity and it can be found using an ethics of care.

In the modern context of terrorism and state vs non-state actors, finding the will to care can be trying. Previous studies on physicians involved in the treatment of terrorists or civilians from enemy territories show a stark issue: they treat but do not care (Rubinstein and Bentwich 2017). Physicians in these situations find in themselves the ability to provide clinical treatment as required using emotional detachment and impartiality but rarely find in themselves the ability to empathise with these patients.

Emotional detachment in the treatment of patients is a rejection of the ethics of care. The denial of the potential for a relationship can be seen as an explicit denial of the call of “I must” and denies the possibility of relation and genuine reciprocal care. Treatment alone is not the same as care. Whilst others have written about their experiences in treating terrorists and enemies, they often rely on arguments from a principles approach (Gesundheit et al. 2009). It is rare to consider the treatment of enemies from an ethics of care approach (Jotkowitz and Sofer 2009). Ethical care of patients with whom the physician does not feel any kinship and with whom there are deep differences involves the shedding of the premoral work-up. The physician must remove these emotional barriers and accept the patient as a unique individual, with unique concerns and most importantly, a unique potential for relation. Whilst one may not ultimately agree with the actions of the individual in question or the cause they support, the physician must not be denied the opportunity for developing a relationship with them. Engaging with a patient from an emotionally detached state places a barrier to genuine relations that is antithetical to the ethics of care.

Consider the patient who is brought to the hospital after injuring themselves committing an act of terrorism. An expected initial reaction towards this individual may be one of abhorrence knowing the acts they have committed, to whom they were targeted and the relations with whom that patient keeps. At this moment, we have already judged the patient on their actions and have established barriers to care. From this position, our options are as follows: (i) to treat the patient as one would any other patient, emotionally and physically; (ii) to treat the patient begrudgingly from a duty to beneficence or impartiality; or (iii) to reject the treatment of the patient entirely from an ethic of retributive justice. As the actions of a patient prior to presenting for care are not a warrant to refuse treatment (Pellegrino 2003), the two remaining options are to treat only in the physical sense or to treat as one would any other patient. It is arguably far easier emotionally for the clinician to treat this patient in an emotionally detached manner, under the guise of a duty to the principle of justice, and much harder to treat them as a unique individual. But an ethic of care would see that we understand that we “must” care for the patient. This patient has led an entire life that has culminated in their actions of the moment. Medical practitioners are tasked with the care of patients and are not afforded the moral ethic to cast judgements on the recipients of their medical care. In treating enemies, and opening ourselves emotionally, reversing the thoughts from “something must be done” to “I must do something” and finally to a clear “I must”, we further build our own ethical ideal and our own potential for further relations. Once this relationship has been built, empathy can follow.

Treatment of a patient, from an emotionally detached position, diminishes in us our ethical ideal. Emotional detachment is an explicit rejection of a relationship; it is also a rejection of the call to care. Whilst the medical aims of treatment may be achieved, no relationship is fostered, barriers to further understanding are established, and genuine empathy cannot occur. As empathy cannot grow from this position, the physician has denied themselves the opportunity to learn and develop their practice of care and understanding of their patient. Simultaneously, failure to care for the patient withholds an opportunity for the patient themselves to develop their own sense of care, which could have reduced their potential for future violence. As Held contends, the most important factor in dealing with terrorism is finding ways to draw potential recruits away from the path of violence (Held 2010). We posit that the ethical care of patients can be that path. Genuine care for those who have sought to bring harm to others offers an alternative away from future violence. Listening to these patients and gaining an understanding of the circumstances that have led them to hold the views they do is perhaps the strongest weapon that exists against the perpetuation of a cycle of hatred and violence.

As Noddings (2013) argues, though our obligations are limited and delimited by relation, we are never free to abandon a preparedness to care. This is most strikingly demonstrated in the ability to care for the ones we harbour resentment or even hatred towards. Even in moments of great personal crisis, when we detest those presented in front of us who request our care, we must draw on our ability for ethical caring to find in ourselves the resolve to provide help and care. Noddings suggest that we are all permanently in a state of potential relation with another, by virtue of our mutual humanity, and as such a rejection of care diminishes in us our own ability to care, indeed, it diminishes in us our ethical ideal.

Our ethical ideal, borne from our self-reflection of the times in which we have been cared for and the times when we have been cared for, requires us to seek out and improve our relations with others, even when this may feel impossible. Thus, care for the enemy may break down our personal barriers to further relations, fostering an ability to form new and stronger relations, and in turn move us from a reliance on ethical caring into the realm of natural caring, even for the most hated of enemies (Held 2010).

Conclusion

Examining the issue of medical treatment of military casualties through the prism of an ethics of care allows exploration of previously overlooked perspectives. The ethics of care recognises the obligations soldiers have to each other through valuable bonds of fraternity, and such obligations deserve moral consideration in the treatment of casualties. In these situations, the principles of impartial treatment for casualties are overruled by the obligation to treat those closest to them. This, contrary to a perception that impartial care is immoral, recognises the uniqueness and importance of personal relationships. Nevertheless, it cannot be used as an excuse to refuse care to those outside our immediate relations when resources permit and doing so would not impede the care of one’s comrades. We are not free to reject the enemy, as a potential relation, and neither are we free to reject our allies. Each patient is a unique individual with whom a relationship can be fostered. The act of treatment alone does not imply care. An ethics of care recognises the importance of relationships and permits a level of partiality that justice-focused conceptions of ethics neglect. This recognition given by an ethics of care helps establish growth in practitioners and fosters their ability to care and to promote their growth from ethical caring into natural caring.

Disclosure statement

The views expressed are the authors' own and do not reflect endorsement by the Australian Defence Force.

Additional information

Notes on contributors

Joshua Armstrong

Joshua Armstrong is a current Australian Army medical officer with an interest in military ethics, in particular military medical ethics. He holds an MD degree and also a Master’s degree in Bioethics. He is an Associate Lecturer at Griffith University.

Lachlan Hegarty

Lachlan Hegarty is a Psychiatry Registrar with the Northern Sydney Local Health District undergoing training in psychiatry. He is the author of publications in Australasian Psychiatry and Emergency Medicine Australasia and has presented research across the fields of psychiatry, emergency medicine and general practice at medical conferences in Australia and New Zealand.