Battlefield euthanasia — courageous compassion or war crime?

Susan J Neuhaus
Med J Aust 2011; 194 (6): 307-309. || doi: 10.5694/j.1326-5377.2011.tb02980.x
Published online: 21 March 2011

Throughout history, doctors within both military and humanitarian organisations have, often under the most difficult circumstances, endeavoured to treat the injuries and suffering of those affected by war. The modern battlefield is characterised by serious injuries, including critical and incapacitating wounds, multiple amputations and severe burns among not only soldiers but also civilians. Treatment may not be technically or physically available, medical support systems may be inadequate and there may be no options to transfer the injured to other facilities for care. Doctors in war are frequently required to make complex decisions about the limitations and appropriateness of medical treatment, and to deal with the seemingly contradictory demands of preserving life and relieving suffering.2

In this article, I seek to explore the unique roles and responsibilities of battlefield doctors, specifically in the ethical dilemma of battlefield euthanasia.

History of battlefield euthanasia

The first recorded case of battlefield euthanasia is biblical,3 but the first recorded case involving a physician (albeit indirectly) was that of Ambroise Paré in 1537, after the fall of Turin.4 On encountering mortally wounded enemy soldiers, a senior French soldier “cut their throates gently”. This act horrified Paré, but he was, in turn, reprimanded by the soldier:

In 1799, Napoleon’s physician René-Nicolas Desgenettes was similarly horrified by an order (which he refused) to give lethal doses of opium to soldiers dying from bubonic plague, rather than leave them to the mercy of the advancing Marmeluk Army.5 In contrast, during World War II, Jewish physicians decided to administer hydrogen cyanide to four patients unable to be moved from their hospital beds, in order to spare them the expected brutality and death at the hands of the Sonderkommando.6 Of note, in this case, although supervised by the doctors, it was left to a nurse to act as the direct agent of death.

Also during World War II, Lieutenant Colonel John Masters recounted an episode when he and his surgeon were confronted with severely wounded soldiers in the face of advancing Japanese:7

There are few examples of civilian situations in which issues like these are confronted, although it is conceivable that natural disasters or a terrorist attack could produce both the overwhelming casualties and the breakdown of medical support structures required to produce such a scenario. In the days following Hurricane Katrina in August 2005, a doctor and two nurses were arrested on charges of homicide involving patients in Memorial Medical Centre, Louisiana. The hospital’s capacity to provide standard medical care for its patients had been crippled. Patients and refugees were crowded together for days with no lighting, no elevators, no toilets, no running water, no refrigeration or air conditioning, and no telephones. Evacuation had been slow and hundreds remained, including the sickest patients who could not be moved. Some clinicians were said to have ended the lives of some patients before leaving the hospital themselves.8

Moral questions and medical accountability

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

Unique position of the doctor

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

  • Susan J Neuhaus

  • Department of Surgery, University of Adelaide, Adelaide, SA.


Competing interests:

None identified.

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