Journal of the Royal Army Medical Corps最新文献

Part I provides the historiographical context and examines the causes which led to the creation of the first independent research ethics committee (REC) at Porton Down, Britain's biological and chemical warfare establishment, in operation since the First World War. The papers in part I and part II argue that the introduction of RECs in the UK stemmed from concerns about legal liability and research ethics among scientists responsible for human experiments, and from the desire of the UK military medical establishment to create an external organisation which would function both as an ' internal space ' for ethical debate and as an ' external body ' to share moral and legal responsibility. The paper asks: What factors were responsible for causing military scientists and government officials to contemplate the introduction of formalised structures for ethical review within the UK military? It argues that Porton may have been exempt from public scrutiny, but it was not above the law of the land. By the mid-1960s evidence of serious ill effects among staff members and service personnel involved in tests could no longer be ignored. Whereas the security of the British realm had previously trumped almost any other argument in contentious debates about chemical warfare, the role of medical ethics suddenly moved to the forefront of Porton's deliberations, so much so that tests with incapacitants were temporarily suspended in 1965. It was this crisis, examined in detail in part II, which functioned as a catalyst for the creation of the Applied Biology Committee as the responsible body, and first point of call, for authorising human experiments at Porton Down.

This paper reviews changes in the ethical challenges that have arisen in military medicine over the past four decades. This includes the degree, if any, to which providers during the Vietnam conflict have carried out what we now refer to as harsh interrogation measures in an attempt to extract information from captured enemy soldiers, the extent, if any, to which the USA used medicine as a means to try to win over the hearts and minds of civilians in occupied territory and how providers should treat service members who return from the front with combat fatigue. An issue that arose during the first Gulf War in 1991 is discussed, namely US service persons being required to take botulism vaccine without their consent. Finally, present challenges are discussed including interrogation measures such as waterboarding and the ethical issues posed in the recent past by the exclusion of gay service members and those posed presently by the inclusion of transgender members. Two ethical values are suggested that have remained constant, namely giving priority to the individual needs of service personnel over those of the unit when there are no urgent combat needs and the reliance on individual virtue when what they should do is morally unclear.

Military medical research requires informed consent from test subjects, which is difficult to obtain for deployed (in-theatre) or prehospital studies where patients are incapacitated and legal representatives are not available. Although US and UK regulations make provisions for exceptions to informed consent, these are rarely used, thereby hindering trauma research and prospective experimental studies of new devices, surgeries or drugs. In their place, a survey of research articles published in the Journal of the Royal Army Medical Corps and Military Medicine between 2004 and 2018 shows how researchers turned to clinical surveys and retrospective, case or animal studies instead. The reluctance to enrol military personnel in interventional studies stems from past instances of abuse and current misperceptions of soldiers as a particularly vulnerable class of research subjects. Increasing the pool of research subjects to facilitate interventional studies to improve combat casualty care requires honing military medical ethics in two ways. First, it is important to implement existing informed consent regulations without special regard for the status of service personnel. This will expedite approval of waivers of informed consent. Second, aggressively recruiting civilians for military-related medical research increases the number of subjects available for trauma research. Community consultation and public discourse are the proper venues to deliberate on each recommendation.

Within military operations, military physicians and nurses experience a dual loyalty to their professional identities. The moral frameworks of the medical and military professions are not similar, and require different kinds of choices and action from its members. But above all, the legal framework in which the healthcare personnel has to operate while deployed is different from the medical moral standards. Military necessity is prioritised over medical necessity. In debates on dual loyalty, legal frameworks should be considered as a more decisive factor in ethical decision-making processes. Legal frameworks, both general and mission-specific, support this prioritisation of military necessity, complicating the work of military physicians and nurses. During the post-Cold War era, in which neutrality and moral supremacy have served as legitimising factors for military peacekeeping or humanitarian missions, this misalignment between the moral and the legal framework is problematic. What is legally correct or justifiable may not be morally acceptable to either the medical professional standards or to the general public. The legal framework should be given more prominence within the debates on dual loyalty and military medical ethics. This paper argues that the misalignment between the legal and moral framework in which deployed healthcare personnel has had to operate complicated ethical decision-making processes, impeded their agency, and created problems ranging from military operational issues to personal trauma and moral injury for the people involved, and ultimately decreasing the legitimacy of the armed forces within society.

Under customary international law, the First Geneva Convention and Additional Protocol I, medical personnel are protected against intentional attack. In § 1 of this paper, we survey these legal norms and situate them within the broader international humanitarian law framework. In § 2, we explore the historical and philosophical basis of medical immunity, both of which have been underexplored in the academic literature. In § 3, we analyse these norms as applied to an attack in Afghanistan (2015) by the United States; the United States was attempting to target a Taliban command-and-control centre but inadvertently destroyed a Médecins Sans Frontières hospital instead, killing 42 people. In § 4, we consider forfeiture of medical immunity and, more sceptically, whether supreme emergency could justify infringement of non-forfeited protected status.

Introduction: The long-standing debate on medical complicity in torture has overlooked the complicity of cognitive scientists-psychologists, psychiatrists and neuroscientists-in the practice of torture as a distinct phenomenon. In this paper, we identify the risk of the re-emergence of torture as a practice in the USA, and the complicity of cognitive scientists in these practices.

Methods: We review arguments for physician complicity in torture. We argue that these defences fail to defend the complicity of cognitive scientists. We address objections to our account, and then provide recommendations for professional associations in resisting complicity in torture.

Results: Arguments for cognitive scientist complicity in torture fail when those actions stem from the same reasons as physician complicity. Cognitive scientist involvement in the torture programme has, from the outset, been focused on the outcomes of interrogation rather than supportive care. Any possibility of a therapeutic relationship between cognitive therapists and detainees is fatally undermined by therapists' complicity with torture.

Conclusion: Professional associations ought to strengthen their commitment to refraining from engaging in any aspect of torture. They should also move to protect whistle-blowers against torture programmes who are members of their association. If the political institutions that are supposed to prevent the practice of torture are not strengthened, cognitive scientists should take collective action to compel intelligence agencies to refrain from torture.

When militaries mention loyalty as a value they mean loyalty to colleagues and the organisation. Loyalty to principle, the type of loyalty that has a wider scope, plays hardly a role in the ethics of most armed forces. Where military codes, oaths and values are about the organisation and colleagues, medical ethics is about providing patient care impartially. Being subject to two diverging professional ethics can leave military medical personnel torn between the wish to act loyally towards colleagues, and the demands of a more outward looking ethic. This tension constitutes a test of integrity, not a moral dilemma.