How can civilians support the military

Ethics and military

With regard to military medical ethics, the World Medical Association (WMA) declares:

Medical ethics in times of armed conflict or other emergencies are no different from medical ethics in peacetime.

What exactly is the statement that medical ethics does not change even in times of armed conflict? One possible answer could be the general validity of medical ethics principles. After that, norms are like that Do-no-harm-The imperative to avoid harm, to respect the duty of neutral and impartial care for the sick and injured and to respect the dignity, autonomy and privacy of the patients regardless of the respective situation. Whether in psychiatry, neonatology, pediatrics or geriatrics: the same ethical principles always apply. Circumstances may vary, and so may the condition of patients, but medical ethics do not change.

One may be tempted here - just like the World Medical Association - to subject the military medical ethics to the same logic and simply to regard military forces as a further patient group. This is also true in peacetime. For example, military personnel and their families in many countries receive the same medical care in military medical facilities as civilians do in the context of the respective national health system. In many cases there is even an overlap, especially when state hospitals treat both military and civilians. In such situations, the medical ethical principles apply without any distinction: every patient, whether military or civilian, is cared for according to the principle of medical necessity and receives treatment based on the respective national health plan, which includes life-saving measures on the one hand and the maintenance of quality of life on the other hand. Any other approach could result in allegations of bias and partisanship. The situation is quite different in times of war and especially on the battlefield. Here, the principle of military necessity can collide with the principle of medical necessity and sometimes take precedence. In the following, I will first explain the principle of military necessity and then explain how this affects the care and rights of patients in the event of war.

The difference between medical and military necessity

Military necessity is often defined as "the methods and means necessary to overwhelm an enemy that are not prohibited by international law" (Geneva Convention, Additional Protocol I, 1977, Article 35). There are two difficulties with this definition. First, it ignores the possible legitimate ends of a war that an enemy is overwhelmed to achieve. Sometimes it is necessary not to legally consider a country's war aims, since the question of legality is often difficult to assess in practice. Therefore, the law treats all fighters equally on the battlefield as long as they do not commit war crimes. Morally, on the other hand, there is absolutely good reason to limit the military necessity only to those war participants - whether states or non-state actors such as guerrilla organizations - who fight for a just cause. A just cause includes defending themselves or defending foreign nationals who are at risk of serious human rights violations by their own government (as was the case in Libya or Kosovo, for example). According to this logic, a repressive regime like Syria could not invoke military necessity to justify its military operations. In this case, there would be no need for military action from the outset. On the other hand, the limitation of military necessity to means and methods not prohibited under international law ignores the actual question. The critical question is actually: When can a participant in a war be allowed to override international law due to military necessity and to resort to apparently illegal or unethical means of war? In other words: can it be permissible under certain circumstances to violate international law or a medical ethical principle if this is militarily necessary? The answer is "sometimes". Sometimes, as I will show below, it may be permissible to treat soldiers according to their nationality rather than military necessity. To understand how this happens, it is first necessary to compare the military and medical necessities.

The following table compares military and medical necessities:


Military necessity

Medical need

Collective / national

Individually / collectively

What is good"?


Citizens' lives

Soldiers' lives

Securing the quality of life






Life of all patients

Securing the quality of life

Quality-Corrected Years of Life (QALY)


Normal functionality


The table makes two points clear. First, military necessity puts the collective interests of a state or people above the individual interests of most citizens. As a result, in wartime, citizens are typically drafted into military service and risk their lives in the process to protect national security. To achieve this goal, decision-makers, politicians and the military must defend the collective good. The medical necessity, on the other hand, is completely geared towards the individual. Doctors and nurses are based on the needs of each patient. To ensure this, the national health system must provide sufficient funds so that all citizens can be treated equally according to their medical needs. No citizen is expected to sacrifice his or her interests for a larger, good cause. However, there are collective constraints. The funds made available for medical care must meet some standard of equity that allows the state to make sufficient funds available for other basic services such as social security, education or security. Accordingly, medical care must be inherently limited. In addition, the individual must not be able to drive the entire system into bankruptcy. Therefore, the state cannot treat every disease. Nonetheless, he will try to give each individual the best possible treatment. That is why doctors and nurses are obliged to care for their patients as well and professionally as possible.

The second line of the table concerns the definition of the “good” to which the mentioned necessities are assigned. Both military and medical necessities are about saving as many lives as possible (of certain individuals) and ensuring the highest possible quality of life (of other individuals). The criteria for this, however, differ in each case. In war, the military necessity forces the state to sacrifice soldiers for the rescue of civilians, while the medical necessity usually makes no distinction as to whose life saving should be considered as a priority. The medical need applies to all patients. At the same time, the military and medical necessities should each ensure the highest possible quality of life. But here, too, a different kind of life is defended. In this way the state defends its collective, political life, whereas medical necessity seeks to save or improve the lives of individuals. Accordingly, the concept of quality of life also differs in terms of military and medical necessity. The quality of political life depends on many things such as freedom, national sovereignty, security and honor, the value of which in war is often placed higher than that of the individual human life: how many lives a country wants to risk for these goods is a decision that politics has to take when entering into a war. Quality of life in the medical sense is of course more concrete and includes the criteria of joy, pain, suffering, mobility, everyday functionality of the body and access to ongoing medical care. Here, too, a society may perhaps provide means to improve the general quality of life, but on the other hand it may forego the more expensive medical care that is only able to save a few lives. There are no binding rules for the weighting of life saving and quality of life. Rather, each society decides for itself - on the basis of universal human rights and their national priorities and values. Nonetheless, political life provides the framework for safeguarding individual life and will therefore often take precedence when these two interests conflict. This is often the case in war.

The relationship between military and medical necessity is complex, as different interests (collective and individual) as well as different goods (life and quality of life in the military / political / medical sense) collide. In order to better understand the relationship between the two types of necessity and their implications for international law, it is worth taking a look at the two principles in practice. Let us consider medical care for the wounded as an example. The question arises: Are medical professionals allowed to treat their compatriots first because of military necessity instead of following the principle of medical necessity, as stipulated in the principles of medical ethics?

Medical care for compatriots in the event of war

The iron rule for medical care in war is clear:

“Members of the armed forces [...] who are wounded or sick should [...] be treated and cared for with humanity, without any discrimination on grounds of sex, race, nationality, religion or any similar Reasons [...] Only urgent medical reasons justify a preference in the order of treatment. "(1st Geneva Convention 1949, Article 12)

To avoid misunderstandings, the commentary on Article 12 points out the following: Each warring party must treat wounded opponents as it would treat the wounded in its own army.

The military medical specialists know this requirement, but are also bound by a further rule: “The care of compatriots comes first.” The reasons for preferring compatriots over enemies lie in the military necessity as well as in the obligation to protect the lives of their own compatriots to keep in a dangerous situation.

All military medical organizations recognize that, due to the conditions in the battlefield, doctors may first have to give the scarce medical resources to the soldiers, who can quickly return to the battlefield, and only then can they treat other patients whose life and limb is in danger . A frequently cited case here is the "penicillin triage" in World War II: in 1942, military doctors used the scarce penicillin to treat soldiers suffering from gonorrhea so that they could be sent back into battle as quickly as possible. Only then did they treat the soldiers who were wounded in combat and who had become unfit to fight.1 Here the situation is clear. The military necessity demands that less seriously wounded soldiers are treated who can still make a significant contribution to the war - at the expense of the soldiers who need life-saving measures. This priority overturns the ethical principle of neutral treatment, which only follows medical needs.

The medical interventions carried out in Iraq and Afghanistan since 2001 also focus primarily on military necessities. Even if the military organizations use emergency triage plans to prioritize the treatments, moral hardship cases tend to be rare, in which a decision must be made as to whether the lives of seriously wounded soldiers are to be saved or the slightly wounded soldiers are made ready for action again. Questions about the care of local civilians injured in the crossfire or about the medical treatment of local forces fighting alongside US and NATO troops in Iraq and Afghanistan are far more common.

In order to support its soldiers, for example, the US Army offers medical care on several levels. So does the Battalion Aid Station (First aid station of the battalion) and takes over the ambulance transport, while the 20 people Forward Surgical Team (mobile operating unit) immediate treatment, surgery and evacuation into one Combat Support Hospital (Field Hospital) with 248 beds, which offers resuscitation, reconstructive surgery and intensive care and psychiatric treatment. If necessary, the wounded can also receive state-of-the-art treatment in Germany in the fully equipped Landstuhl trauma center or in the USA.

This system was designed to provide US soldiers with the best possible medical care. In addition, the medical facilities of the US armed forces also take care of local soldiers and civilians who were wounded in American military operations. But while seriously wounded Americans are flown to modern medical facilities, the seriously injured from the local military have to turn to a poorly functioning local health system for further medical help. This two-pronged system limits the access of local wounded to medical care and also, for example, to high-quality prostheses, so that they do not receive the same reparative operations as US soldiers on duty. The local civilians fare even worse. The coalition forces do not maintain on-site services for civilians and are sometimes forced to turn these patients away. Nonetheless, the coalition forces treat civilians caught in the crossfire to the extent that the "life, body and eyesight" of local wounded are saved. It is mainly about first aid. However, there are hardly any facilities for follow-up examinations or permanent care. However, there are two special situations. First, pediatric cases pose a particular challenge. Concerned about the negative headlines that could be expected if children were not given the best possible medical care, US medical facilities offer comprehensive and modern treatments for children. The second and no less problematic situation concerns the care of prisoners. As prisoners of war, prisoners are entitled to the same treatment as soldiers in the coalition forces and therefore even receive better care in the country of deployment than the allied forces. Accordingly, there are at least four or five different classes of patients: coalition soldiers, prisoners, native soldiers, native civilians, and sometimes children. These patient groups each receive different care for the same injuries.

The example shows that it is not always possible to treat the wounded strictly according to medical needs. The availability of resources for further and follow-up treatment - which clearly depends on the nationality of the patient - determines the further medical care of the wounded from the start. The same cases are not treated in the same way, and perhaps this is the right approach. However, this approach clearly violates the neutrality clause of the Geneva Conventions, according to which medical care should be strictly based on medical needs. And although some scientific opinions regard this duty to maintain neutrality and indiscriminate treatment as absolute,2 There are situations in war that call this point of view into question. First, when resources are scarce, the duty to treat soldiers who can best get involved in the war can override the duty to save lives.3 Second, the medical staff may cultivate an ethic of comradeship, also known as the welfare ethic, and initially treat their own soldiers regardless of the severity of their injuries, as they feel a special obligation towards their compatriots.

The sense of duty towards comrades shows at the same time how far the principle of military necessity extends. The following case is cited in this regard:

A U.S. soldier and an Iraqi army allied soldier both suffered gunshot wounds in the chest. Both have a low level of oxygen saturation in the blood. The lidocaine for local anesthesia is only enough for one patient and there is only one catheter for insertion into the chest. Usually one of the patients receives a thoracic catheter with local anesthesia, the other a needle decompression of the thorax in connection with care by a flight paramedic.4 

Which patient now receives the thoracic catheter and the local anesthetic and why?

When participants in an American workshop were asked how they would answer the question, the answer was unequivocal: "The wounded American." When I asked why, their answer sounded equally confident: "Because he's our brother!"(" Because he is our 'brother'! ")

So it seems that military medical personnel are divided on the Geneva Conventions. On the one hand, the principle of impartial medical aid is applied. On the other hand, a contradicting and often stronger duty is fulfilled to provide the best possible medical care for one's compatriots. The first principle does not need much justification. Ultimately, medical integrity and medical effectiveness are based on treating the most urgent cases first, regardless of rank, gender or nationality. But the second principle also seems convincing: armies go to war to win. It takes a healthy force to win, and a healthy force requires excellent medical care. It is therefore advantageous and correct to deal with your own compatriots first when resources are scarce. For this reason, many armed forces legitimately change the order of treatment when triage in the battlefield, when allocating penicillin during war, and when resources are scarce. Rather than dealing with the most urgent medical cases first, the medical professionals first deal with those who can get back to the battlefield the quickest. Accordingly, some patients die who could actually have been treated successfully, while others, whose treatment could also take place later, receive immediate care. The logic behind this is utilitarian and morally correct, because without a reversal of the order of treatment, the intactness of the troops and thus the military clout suffers. The result - defeat - is considered the worst case imaginable. With this argumentation, the wounded soldiers of the enemy also move to the end of the queue.

A similar but far more complex logic is behind the decision in the above case to treat one's own comrade first. In this scenario, the two patients are even allies and not enemies. The military benefits of saving one or the other would probably be the same. Nevertheless, the medical professionals speak out clearly for their compatriot.

One reason for this behavior is clearly utilitarian. Military sociologists have long known the importance of so-called primary ties (primary bondings) between soldiers and superiors, especially at platoon level (units with 40 to 50 soldiers). Primary ties begin with teamwork and interdependence and slowly develop into trust, loyalty, shared goals, mutual help, and sacrifice. Small military units are not simply a collection of well-coordinated, self-serving individuals, but rather a close community of comrades who are characterized by a new identity: They are comrades in arms. Given such solidarity, preferential treatment of comrades is militarily beneficial as it maintains the unit's moral integrity and combat effectiveness.

There is, however, another duty that binds some military medical professionals just as much as does medical ethics. This duty goes beyond utilitarian justice and the associated emphasis on the efficient and fair distribution of scarce resources. Rather, it underlines the special relationship that connects individuals with the people in their environment, to whom they feel a special obligation to provide assistance, regardless of the effort and other competing requirements.

It is easy to understand that preferential treatment of family and friends is perceived as a fundamental moral obligation. Nobody expects parents to look after other people in a special way before they have cared for their own children. Friends also have special obligations for one another that they do not have towards strangers. These are established intuitive perceptions that underscore what the philosopher Virginia Held calls caring ethics. The welfare ethic describes an unconditional mutual obligation between people who have a very special relationship with one another: One offers the life-sustaining treatment on which the other depends. The welfare ethic stands for an emotional rather than a contractual bond. It is about "personal concern, loyalty, interest, compassion and openness to the uniqueness, the special needs, interests [and] life stories of loved ones".

These particular preference-led obligations to friends, family members and compatriots inevitably raise questions of distributive justice: What happens when people outside this circle need care and attention more urgently? There is no doubt that this is a legitimate question, but the ethics of welfare is not about justice. Rather, friends and family members should help each other without expecting anything in return; often this is done with great personal effort and with the knowledge that the same help could be of more benefit to a stranger. If the life of one's own family or friends is in danger, then overly preoccupation with the possible rescue of a stranger is “one thought too many”, as Bernard Williams once put it so aptly. So is medical care for wounded enemies “one thought too many”? When military units are experienced like families, preferential treatment of compatriots can be just as morally imperative as preferential treatment of family members. The bonds among comrades-in-arms are no different from those among family members or friends and imply an unconditional one-sided duty to help one another in need.

When applied to the battlefield situation, the ethics of welfare has important implications. Three different scenarios are listed for this.

Same injuries

In the example given from Iraq, both soldiers have the same injuries and the same chance of survival. They are allies, and the preferred saving of a particular soldier's life does not translate into greater military benefit. If there is an emotional bond with both soldiers, one could toss a coin, but even if the lottery principle promises impartiality, the moral component of the duties that result from belonging to a primary group must not be misunderstood. These obligations are not incidental, but should only be used as a last resort aid after all other impartial criteria of distributive justice have already been queried. In this case, it is then morally permissible to treat the American first, as he is a comrade from the perspective of the treating health care professional.

Extremely unequal injuries

Medical soldiers insist, in some cases, that they treat a compatriot's smallest wound before dealing with the enemy. However, if you think about it more closely, it becomes clear what they mean by that: They will first stabilize the compatriot and then deal with the enemy when the wounded of the compatriot is only minor and the enemy has a serious or even life-threatening injury. In this case, the ethics of care is superseded by another rule, namely the Rule of Rescue, d. H. the obligation to help others if the effort is justifiable and the danger to a stranger is very great. On the other hand, on the battlefield, the relative severity of a soldier's injury may not be readily apparent to a field medic without extensive diagnostic tools or knowledge. This can lead to paramedics orienting themselves to the principles that apply to injuries of the same severity or injuries that differ only insignificantly. Both cases can justify preferential treatment to compatriots.

Moderately uneven injuries

These cases are the most difficult. To this end, consider the following two circumstances:

  • Sufficient medical resources are available to save the life of a compatriot or two (or more) enemies.
  • Compatriots are at risk of mutilation or limb loss, but the enemies are critically injured.

Usually the moral choice would be clear. Saving two lives is better than saving one life; Saving lives is more important than saving limbs. Nonetheless, caring ethics may permit a different judgment. In some cases it may be morally permissible to save the life of a compatriot rather than the life of two or more strangers (whether enemies or allies). Likewise, saving limbs may be considered more important than saving lives.

How is that possible? For one thing, following the compelling logic of caring ethics, a parent will place the life of their own child above saving many other lives. The principle of charity, the duty to help others, is greatly weakened when the price seems too high to the Savior. This will be the case if the rescuer is at risk of losing their child or another member of their primary group. When lives are in danger, our sense of obligation to friends and family becomes evident. The ability to save the lives of many strangers will not seem more important to us than our duty as parents (or soldiers) to save the lives of our own children (or compatriots).

Several scenarios are conceivable if limbs are threatened. For example, suppose that artificial limbs can restore most of the patient's physical function. Then, from the medical point of view, saving the limbs of one's own compatriot would not be valued higher than saving the life of the enemy. But a situation is also conceivable in which a loss of limbs would severely impair the prospect of a dignified life. In this case, the obligation resulting from primary ties may justify choosing limb saving rather than life.

Beware of the argument of the "inclined plane "

At this point, be warned against attaching too much weight to friends and family members. Even if primary ties are essential both for effective struggle and for the consolidation of particular, overarching moral obligations among group members, they neither justify the ruthless neglect of fundamental moral norms. The welfare ethic stipulates that doctors, nurses and paramedics, in addition to providing medical care for their compatriots, also look after strangers in emergencies and uphold basic human rights. Held describes this as the “moral minimum” of supply.

Paramedics acknowledge this when they report their readiness to stabilize or sedate seriously wounded enemy soldiers after dealing with the less severe injuries of their compatriots. This also explains why medical professionals may treat wounded compatriots first and then wounded enemy soldiers, but also refrain from caring for compatriots if they have already started treating the wounded soldiers of the enemy. This can be the case when surgeons have just started treating enemy soldiers and are suddenly faced with a large number of newly arrived injured people from within their own ranks. Individual reports suggest that doctors and nurses do not stop treating the enemy to take care of their own soldiers. Aside from the legitimate concern that stopping aid would be tantamount to murder, it is also clear that medical personnel develop a special relationship with the patient once they begin treating a wounded soldier. This new relationship in turn brings with it new, clearly perceived duties of care that cannot simply be neglected.

When resources are limited, military medicine faces difficult moral problems. Even with funding from a financially well-off country like the USA, wartime medical care is subject to resource scarcity. In such circumstances, doctors and nurses are often torn between legal norms and caring ethics. This dilemma is not easily resolved, but in cases like those described above, paramedics, nurses, and doctors should have no moral qualms about providing medical care to their own compatriots first.


The war poses particular challenges for medical ethics, as military necessities and special duties of care can undermine the principle of medical necessity and impartial treatment. The cases presented above are not the only ones in which military necessity influences the interpretation of medical ethical principles. Other cases are briefly mentioned here: the need to develop non-lethal weapons in order to conduct war more effectively; force-feeding prisoners on hunger strike who risk their lives for a political or military goal; or the development of efficiency-increasing technologies in which medical measures are used to improve military effectiveness.5 In each of these and in many other cases, military doctors have to reconcile their duties as officers on the one hand and medical assistants on the other.