Battlefield euthanasia — courageous compassion or war crime?

The term euthanasia derives from the Greek — “good death”. There are many caveats on the term, but it is most usefully defined as “a deliberate intervention undertaken with the express intention of ending a life, to relieve intractable suffering”.9

Euthanasia, particularly in a military setting, must be distinguished from “triage”, which provides an ethical framework for deciding on priorities of care in resource-limited (predominantly mass-casualty) environments. There is no doubt that in these situations, patients with overwhelming injuries may be triaged to “expectant care”. The overriding priority in all such cases is care, compassion and respect for human dignity and human life. The patient is provided with comfort until he or she either dies or the situation changes and resources become available to provide treatment.

Similarly, it is important to distinguish euthanasia from discontinuing life-prolonging measures (eg, removing ventilators) in situations where death is an inevitable consequence. These decisions are based on the futility of ongoing medical treatment and on the potential harm of continuing care. Although the outcome is the same — the death of the patient — the distinction lies in intent, method and responsibility.10,11

Although each of these raises its own ethical complexities, particularly in war, I will not discuss them further here.

The historical cases illustrate the complexity of a doctor’s position in considering euthanasia in war. No one would doubt the agony or overriding compassionate intent that lies behind a soldier taking such a decision on behalf of a comrade, but the involvement of doctors, as physicians and healers, in such acts is less morally clear.

Doctors have long considered themselves bound by the key tenet of the Hippocratic oath “primum non nocere” (first do no harm). Over time, some prohibitions within the oath have been removed, including those to surgery and abortion. Although morally offensive to many doctors, it is possible that, in the future, the profession may lift prohibitions to doctor-assisted suicide. Of note however, even in Hippocrates’ time, the Greeks permitted euthanasia or suicide as an alternative to a lingering and painful death.12,13 It is the specific involvement of physicians which was proscribed.

The underpinning ethical principles involved in battlefield euthanasia are primarily questions of patient autonomy, beneficence (doing good) and non-maleficence (not doing harm). This presupposes that there is a simple choice between preserving life and relief of suffering. However, the immediate needs of a suffering human cannot be ignored, and complex and difficult choices must be made.14

Autonomy (an individual’s right to determine his or her outcome) is inevitably compromised in times of war. Soldiers are obliged to follow orders, civilians live under conditions of martial law and/or occupation — all parties are subject to circumstances that deny freedom of action.

In the Netherlands, where voluntary euthanasia is legal, complex processes exist to ensure that patient consent is valid and appropriate.15 In war, such judicial process or peer review is seldom available. The confusion of war, the impact of fatigue, fear, hopelessness and fear of future suffering will inevitably influence the clarity of decision making. In a controlled elective situation, it is considered imperative to exclude patients who have depression from euthanasia. In a country at war, the effect of endured privations, occupation and atrocities could be argued to produce a kind of collective depression that extinguishes hope for the future.

In both the Napoleonic War and World War II examples provided above, euthanasia was justified, in part, by the desire to avoid a greater suffering — that promised by capture or torture by an encroaching enemy force. However, it is necessary to question the certainty of that future outcome and to discount the effects of rumour or flawed intelligence.

In none of the examples above was there clear consent from the patients. It could be argued that, even if they had requested otherwise, it may still be in their best interests to be killed painlessly and not abandoned to the enemy. This represents a slippery slope from non-voluntary euthanasia (where the patient is unable to request) into involuntary euthanasia (where the patient is able to request, but is not consulted and their views are not respected).12

Regardless of the moral arguments for and against euthanasia in a battlefield setting, the issue of medical involvement must be addressed separately. Doctors hold a unique position of trust in the community. Participation by doctors in euthanasia carries a grave risk of undermining public trust in the profession. Many would consider that:

A further concern is the potential for role confusion, applicable particularly to uniformed doctors; the distinction between a doctor acting in the interest of the patient or becoming an instrument of political or military purpose.1 Throughout history, states have sought medical legitimacy and complicity for corrupt purposes, the most notable being the Nazi regime.16 Equally, euthanasia involving potential witnesses against war crimes, or to avoid sensitive military information falling into enemy hands, constitutes politically motivated murder.

Some authors argue that, provided doctors are given a “moral distance”, physician complicity in euthanasia can be justified in some circumstances.14,17 This raises questions about whether there is a distinction between the doctor as the instrument of death and the arbitrator of death — is it possible to remove the doctor from the act, if not from the decision of death?

Another consideration is the method of death. Many modern modalities can alleviate pain and suffering, although, admittedly, not all are available or in ready supply on the battlefield. It could be argued (as was justified in Master’s case,7 above) that using a scarce resource (eg, morphine) in the face of expected large numbers of future patients may be inappropriate. It may be necessary to use a weapon instead.17

Two courts martial demonstrate the difficulties in distinguishing intent to relieve suffering, or mercy killing, from deliberate killing of wounded (enemy) combatants. In 2005, a United States army officer was convicted of “assault with intent to commit voluntary manslaughter” after shooting a wounded Iraqi insurgent.18 In 2010, a Canadian officer was found guilty of “disgraceful conduct” after allegedly shooting an unarmed Taliban soldier in Afghanistan.19 Neither incident involved doctors, although the defendant in the latter court martial “acted on advice of the medic”. Conversely, recently published memoirs of an Australian surgeon describe shooting a woman, mortally wounded in Kosovo in 1999, and again raise issues of the unique role and obligations of a doctor.20

As with civil society, war is governed by rules. Australia is a signatory to the Geneva Conventions, which are binding. The actions and responsibilities of doctors are covered in the special provisions of the Conventions, and form the basis of ethical military medical practice.2,21 In essence, there are three conditions:

• first, doctors may not partake in direct combat activities;

• second, doctors must treat all casualties of war on the basis of medical priority without regard for their status as enemy, coalition or civilian; and

• third, doctors have a moral responsibility to speak out against atrocities committed by any party.

The Geneva Conventions (First Geneva Convention, Articles 12 and 15; Second Geneva Convention, Articles 12 and 18; Protocol 1, Article 10 and Protocol 2, Article 7) prohibit euthanasia.

Doctors serving with the Australian Defence Force are governed by both Australian military regulations and Status of Forces Agreements, making them accountable for acts committed on overseas territory or involving foreign nationals.22 Australian nationals serving in overseas conflict may equally be accountable to that nation’s legislation. Australian legislation (Euthanasia Laws Act 1997 [Cwlth]), while allowing for palliative care and withdrawal of life-prolonging treatment, prohibits intentional killing of a patient.23

War is the ultimate failure of human relations. When participating in war, the moral principles enshrined in Australian law and in the Geneva Conventions apply regardless of the circumstances of the conflict. No doctor would wish to be placed in the invidious position represented in this article. For those who have made such choices, we can only have compassion.

When a society goes to war, it is to uphold and enforce its values over those of another society. Doctors hold an important role in society and in providing care for those harmed by the consequences of war. It is imperative that doctors’ professional values and ethical and legal responsibilities in these difficult circumstances are clear.