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Ethics and Military Medicine: Core Contemporary Questions 

Chapter 46

Ethics and Military Medicine: 

Core Contemporary Questions 

EDMUND G. HOWE, MD, JD*; ROBERT C. McKENZIE, DO†; and CHAD BRADFORD, MD‡

INTRODUCTION

ISSUES ARISING PRIOR TO DEPLOYMENT

Recruitment Issues

Treatment Concerns

ISSUES ARISING DURING DEPLOYMENT

General Questions Regarding the Nonmedical Treatment of Detainees

How Should Military Medical Care Providers Be Involved With Detainees, If At 

All?

How Should Military Care Providers Respond When Detainees Refuse to Eat?

POSTDEPLOYMENT PROBLEMS

Posttraumatic Stress Disorder

Head Injuries

Decisions “Outside the Box”

SUMMARY

*Professor of Psychiatry, Associate Professor of Medicine, and Director, Programs in Medical Ethics, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, Maryland 20814; and Senior Scientist, Center for the Study of Traumatic Stress, Bethesda, Maryland; formerly, 

Major, Medical Corps, United States Army 

†

Lieutenant Colonel, Medical Corps, US Army; Department of Behavioral Health, US Army Health Clinic-Vicenza, Caserma Ederle, Italy, Unit 31401, 

Box 13, APO AE 09042

‡

Commander, Medical Corps, US Navy; Division Psychiatrist, 2nd Marine Division, Division Surgeon’s Office, Attn: Division Psychiatry, HQBN 2MAR 

DIV, Camp Lejeune, North Carolina 28547; formerly, Forensic Psychiatry Fellow, National Capital Consortium, Washington, DC
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INTRODUCTION

Numerous new ethical issues have arisen in the 

past few decades as a result of developments in biology and technology. Others have arisen as a result of 

different kinds of warfare, as manifested by the terrorist attacks of September 11, 2001.1

 These changes 

have resulted in a need for reevaluation of traditional 

military medical ethics and some unprecedented 

paradigm shifts.2–6

The need for military behavioral healthcare providers to have a sound, basic understanding of these 

issues has also increased and is much wider in scope. 

Military physicians must now, more than ever, be 

aware of ethical considerations that may affect their 

clinical practices. They must also be cognizant of how 

ethical considerations can bear on policies the military 

is developing, whether these are behavioral or medical 

in intent. Furthermore, because military behavioral 

healthcare providers may be involved as ethics consultants or on ethics committees, they must understand 

core ethical arguments that have to be taken into account in these relatively new practices.

Consequently, this chapter will seek to address those 

major issues in which it can reasonably be expected 

that military behavioral healthcare providers might 

be involved. When appropriate, this discussion will 

describe specifically how these military behavioral 

healthcare providers might become involved in the 

topic areas discussed. This chapter also will highlight 

areas in which the need for de novo analysis has been 

posed. It will do this in the same order as the sections 

presented in this book—prior to, during, and after 

deployment.

ISSUES ARISING PRIOR TO DEPLOYMENT

Recruitment Issues

During the initial years of the ongoing war on terror, 

with mounting casualties, sustaining the needed flow 

of volunteers to enter the military became problematic. 

The need to meet recruiting goals led to a relaxation 

of enlistment standards. Changes included increasing 

the number of waivers being given for individuals 

with legal difficulties, lowering the Armed Services 

Vocational Aptitude Battery (ASVAB) scores, and becoming more permissive concerning tattoos that have 

specific pejorative connotations for some target groups. 

It is unclear what the effects will be on individuals 

recruited under the new conditions and how these 

precedents will affect short-term and more long-term 

military standards. However, since the overall economy worsened in 2008 recruits have been plentiful, and 

standards for waivers have again tightened.

One ethical dilemma here involves the competing 

factors of individuals’ right or wish to serve their 

country, the mission’s requirements, and the military’s 

need to maintain standards among soldiers who enlist. 

A second dilemma concerns how much recruits should 

be screened prior to being accepted. Individuals with 

lower ASVAB scores or criminal histories may become 

more of a burden on units as limitations are reached 

or antisocial behaviors recur. These outcomes may 

lead to situations in which unit efficacy is compromised or atrocities are committed. However, it might 

be an ethical error to exclude 100 individuals with 

previous legal difficulties if only one would reoffend. 

Furthermore, recent data have shown that individuals 

who have waivers are actually less likely to commit 

violent crimes. They also have a higher retention and 

promotion rate than the majority of soldiers, perhaps 

because these cases are scrutinized much more closely.7

Individuals with prior misdemeanor convictions, a 

lower ASVAB score, or a previous gang or racist group 

affiliation may want to serve their country or better 

their own financial or educational standing through 

military service. Allowing these individuals to serve 

may be in their best interests, but they may encounter 

continued difficulties within the services, possibly 

ending up with a shortened enlistment or a less than 

favorable discharge.

In addition, a military unit’s morale and readiness 

can suffer directly when standards are lowered. Having an individual with extreme racist views or a gang 

affiliation can divide and undermine the cohesion in a 

military unit, in which every member must be willing 

to save or assist every other member. Individuals with 

racist views may only be willing to pull individuals 

they like out of harm’s way, while allowing those of a 

“different persuasion” to remain exposed. Anything 

short of a completely integrated team may not operate effectively in high-stress combat environments. 

The potential complications that may occur as these 

individuals rise in the ranks and take over positions 

of leadership could also increase. In these positions, 

their choices could be based on affiliations or ethnicities, rather than abilities, which would erode the principles of equality and fairness. One possible solution: 

an additional probationary period for these special 

populations. This is already done for recruits who are 

obese or do not fit fitness standards so that they can 

meet fitness standards prior to basic training.
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Ethics and Military Medicine: Core Contemporary Questions 

The questions of what level of screening needs to be 

implemented and whether there should be a special 

“probational” track to allow these individuals into full 

service may need to be addressed. As there is no current empirical data to use to assess these arguments, 

this may remain an ongoing dilemma.

Treatment Concerns

Suicidal Depression During Basic or Preliminary 

Combat Training 

An ethical problem of an entirely different sort, 

but which also may occur before deployment, is what 

military behavioral health providers should do when 

soldiers state that they feel suicidal during basic or 

early training. Providers may believe that sometimes 

this is because these soldiers don’t want to be in the 

military, and not because they are truly suicidal. Wellknown procedures are in place for soldiers to request 

discharge. Soldiers may, however, not elect to take 

these, for various reasons, such as to save face. Indeed, 

sometimes soldiers may try to get out of the military 

by presenting with suicidal ideation; however, this is 

less common in today’s all-volunteer Army.

Military psychiatrists or other mental health workers to whom these soldiers present may over time: 

(a) initiate measures to give them an administrative 

separation to release them from service, because they 

see their depression as a preexising condition not 

responsive to treatment, (b) judge them to have a personality disorder, or (c) discharge them back to duty. 

Customarily, providers respond by giving the soldier 

a trial of psychotherapy and/or antidepressants.

The ethical problem primarily posed to providers 

stems from the fact that soldiers presenting during basic 

or advanced indivitual training, and before deployment, 

may (as at any other time) be genuinely depressed and 

suicidal.8,9 Thus, if military care providers don’t take 

all the precautions they could, this may increase the 

likelihood that some, even if only a few, of these soldiers 

will commit suicide. To the degree that providers take 

all possible precautions, they are acting in support of 

military needs as well as those of the soldiers.

The possibility of other soldiers temporarily or 

permanently feeling they want out of the military, 

and thus pursuing this same psychiatric out, may lead 

to military physicians treating soldiers with combat 

fatigue as they now do; that is, they treat most such soldiers with the expectation that they will return to their 

units in combat. If providers instead released these 

soldiers from their units and from further combat duty, 

inordinate numbers of soldiers could follow suit. 

A reason often given as an ethical justification for 

treating soldiers with the expectation of return to duty 

is that if soldiers return to their unit, they will be less 

vulnerable to having permanent psychiatric symptoms 

later because of survivor guilt, should the unit eventually lose members in combat. Factually this may be 

true, but as an ethical argument, this reasoning is fallacious. Respecting soldiers’ autonomy would in other 

contexts prevail over the value of doing what is best 

for these soldiers’ later symptoms. Respecting their 

autonomy “normally,” or in civilian contexts, would 

require military physicians to give soldiers the choice 

of risking these symptoms or risking death. 

The justification for military physicians to treat 

soldiers with combat fatigue with the expectation 

that they will return to their unit is both for the sake 

of the mission and the individual soldier in one sense, 

though not in another. That is, soldiers may do better 

in both the short and longer run if they can return to 

their unit. They may, for example, feel better being 

back among those they have known and be less prone 

to later psychiatric symptoms that would be due, most 

likely, to their previously having left their unit and 

never having returned.

Soldiers who are evacuated out of the theater 

usually do not stay in the Army, and they often 

do not remain in contact with the “buddies” they 

left behind. The loss of their social networks, the 

structure of the military, and associated healthcare 

may lead to a downward spiral into joblessness and 

even homelessness. Still, their being treated with 

this return-to-duty expectation is to some extent coercive and, thus, differs from what civilians seeking 

psychiatric treatment after trauma will encounter; 

indeed, this expectation deprives them of a source 

of additional autonomy.

A similar rationale supports military care providers 

treating soldiers in basic training who present with 

suicidal depression. Treating them with psychotherapy 

and medications, when there is a possibility that they 

are genuinely depressed, has a good likelihood of 

keeping these soldiers from leaving the Army and/or 

possibly ending their lives, even if at the time this does 

not seem the best that providers could do for patients 

who say they feel suicidal. In civilian settings, providers might try more to eliminate or reduce the source 

of ongoing stress. Military physicians treating these 

patients as they do now, in any case, reduces the possibility that too many other soldiers in basic training 

or other predeployment settings will present with suicidal depression, again for unconscious or conscious 

reasons, as a means for seeking a way out.

A final, additional ethical dilemma here is whether 

military behavioral healthcare providers should inform soldiers presenting in this manner of the “ground 
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rules” of seeking discharge by this means. They could 

tell soldiers that to be discharged for depression, they 

must generally first undergo a trial of psychotherapy 

and medication for approximately 6 months. However, 

in the current climate of increasing suicides during 

the last 6 years, this option is unlikely to be politically 

palatable. Nonetheless, there is an ethical obligation to 

disclose such facts, as opposed to allowing outcomes 

to be determined or significantly affected by keeping some information unknown. The question then 

becomes: Should providers regard soldiers reporting 

suicidal depression in this same category and not inform them of the ground rules or should they inform 

them? 

The optimal compromise between military physicians meeting the needs of the mission and those of 

these soldiers may be somewhat contradictory and 

paradoxical. It may be that optimally they should insist 

on treating and even giving these patients medication 

for 6 or more months while at the same time giving 

them full information concerning how these ground 

rules work. Providing this information may, in addition, be the only way in which they can treat these 

patients most successfully by gaining their trust. If this 

practice stems the potential flood of soldiers gaining 

discharge by this means (as it appears it would), treatment with disclosure in this manner should suffice to 

support the mission needs.

Predeployment Distress

The policy of deploying soldiers who are not emotionally prepared, or who have certain home-front 

issues to resolve, may cause undue distress to these 

soldiers and their families. A more liberal deployment policy may be in the best interests of soldiers 

and their units. The ethical dilemma of weighing the 

readiness needs of military units against the individual needs of such soldiers and/or their families 

can be problematic. Certainly, military units need to 

be at maximal strength, but having several soldiers 

“whose heads aren’t in the game” will be counterproductive. Individual soldiers may themselves be 

at risk or, because of distraction, they may put their 

team members at risk, and they may ultimately compromise a mission.

During the current war on terror, enlisting soldiers, 

all voluntary, know the potential risks of pending deployments. In the current situation it is just a matter 

of time until a soldier deploys; whether a soldier will 

deploy is not in question. Despite this knowledge, 

some individuals are less prepared to deploy than 

others. These individuals may be struggling with 

short-term adjustment issues, or they may have a family circumstance that could be resolved if they were 

just given a short period of time. Perhaps as little as 

30 days would be required to get them emotionally 

prepared to deploy, or to get their family circumstances 

resolved. Examples of the latter would be moving a 

wife stateside from Germany or making sure all financial matters are in order.

The risk to military units from such a “lenient” 

approach is 2-fold. First, allowing exceptions to, or 

delaying, individual deployments may violate the 

fundamental premise of fairness, in that the rest of their 

team is expected to be ready to deploy and to deploy 

on orders. Presumably, many other members of their 

unit would also prefer to delay, or even avoid, the deployment. Second, a military unit is only as good as its 

members, and if they aren’t present, the unit suffers. 

If some members are allowed to delay their deployment, this may be critical to the mission, as when the 

soldier not deployed is a generator mechanic, or the 

most competent communications specialist.

It may be ethically optimal to develop a way to 

deal with each individual circumstance on a caseby-case basis, with the general presumption that all 

units would deploy in entirety, as much as possible. 

A multitracked system to evaluate and clear deploying soldiers, with one track for those who require a 

short period of reconstitution or to accomplish familyrelated issues, another track for those soldiers who 

should not be deployed, and a third track for those 

ready to deploy may be the best of all options. By 

keeping commands informed about the process and 

the status of their soldiers, the needs of individuals 

and the needs of military units may jointly be best met. 

Current policy is to only deploy service members who 

have been stable for at least 3 months; otherwise they 

must get a waiver from the combatant surgeon, who 

is usually the Central Command surgeon.

Further Treatment Issues

Military behavioral healthcare providers must 

consider how social and emotional distance from 

members of their unit may affect treatment of potential unit member patients. Both at work and outside 

of work, military behavioral healthcare providers are 

likely to interact with their future patients on a regular basis. Maintaining too much distance from their 

units may give the impression of their being aloof and 

unapproachable, decreasing the likelihood of future 

referrals. Maintaining too close a relationship may 

establish a friendly, rather than a therapeutic, relationship. Close relationships may also hinder military 

behavioral healthcare providers’ ability to make an 

accurate diagnosis.

Military behavioral healthcare providers and their 

future patients are likely to be stationed on the same 
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Ethics and Military Medicine: Core Contemporary Questions 

base, in the same unit, and may frequent common 

work areas. Military bases tend to be insular, with 

those on the base frequently coming into contact with 

each other. They may share similar collateral duties 

such as command committees or other work projects. 

They may frequently cross paths and interact with each 

other at military functions such as awards ceremonies, 

formations, and command education and training. 

Outside of work they may frequent the same stores 

or use the same daycare. 

Vignette 47-1: A military psychiatrist maintained a distinct 

social and emotional distance from those in his unit. It was not 

his practice to socialize with staff or interact at command functions. When not in session with a patient, he would remain 

in his office with the door shut. When approached about this 

behavior the psychiatrist explained that he was indeed not 

socially phobic, but was rather purposefully maintaining his 

social and emotional distance from others in the command in 

case one day they should become his patients. He explained 

that if he were to get too close, he might be expected to be 

a “friend” to his patients; they might expect him to do the 

things that a friend might, such as to socialize together and 

share personal details of his life. Both of these, he reasoned, 

could be harmful to treatment. He also reasoned that if he 

became too close to his unit, he may have more difficulty 

recommending that they go to combat should the need arise. 

He also reasoned that this might hinder his ability to make 

an accurate diagnosis; that his pretreatment conceptions of 

the person might cloud his ability to perceive mental illness; 

and that this might lead him to diagnose mental illness that 

is not there.

Is this psychiatrist’s social behavior ideal or does it 

go too far? Or is it altogether inappropriate and unnecessary? Why? 

Although it is important to maintain the appropriate social and emotional distance, it is also important 

for military behavioral healthcare providers to be approachable and to facilitate referrals. It is difficult for 

military behavioral healthcare providers to help if no 

one is willing to make appointments with them. Military behavioral healthcare providers interacting with 

the unit while maintaining their professional bearing 

may be ideal. Keeping a “finger on the pulse” of unit 

morale is important to maintaining the fighting ability of the unit, and often is one of the jobs of military 

behavioral healthcare providers. Military behavioral 

healthcare providers should be educated about how 

their relationship to their unit may affect their treatment should such soldiers become their patients. The 

goal for these providers should be to offer appropriate 

treatment to their patients while maintaining maximum unit combat effectiveness. In order to achieve 

these goals military behavioral healthcare providers 

must maintain objectivity despite their social and 

emotional relationships with their unit.

ISSUES ARISING DURING DEPLOYMENT

One of the most important medical considerations 

that has arisen is how military physicians should treat 

prisoners of war (POWs). Under the Geneva Conventions, it is clear that military physicians should treat 

POWs equally to allied soldiers, but it is unclear how 

this equal treatment should be carried out. Suppose, 

hypothetically, that US soldiers and POWs have identical injuries. Military physicians could treat each on 

an alternating or random basis, or they could treat all 

US soldiers with identical injuries first. Or, military 

physicians using this second approach could use broad 

categories of injuries so that they could treat more US 

soldiers first and still, in a technical sense, treat both 

US soldiers and POWs equally.2

An ethical question arising in regard to detainees is 

whether military physicians should also treat detainees 

equally, even though from a legal standpoint, detainees 

may not meet criteria to be POWs, and the Geneva 

Conventions may not apply. Leaving aside the practical difficulty of determining who is a POW and who 

is a detainee, a key question regarding the treatment 

of detainees is the extent to which military physicians’ 

obligations as medical professionals should take precedence over their duties as military officers.

At a seminar on military medical ethics, a group of 

military physicians who recently served in Iraq were 

asked what they thought they should do if an enemy 

were brought in injured, they knew that US soldiers 

with “identical injuries” were on the way, and their 

commanding officer ordered them to withhold treatment until their own soldiers arrived and then to treat 

them first. All the military physicians present felt that 

they should refuse the commanding officer’s order. 

They thought that they should treat first whoever was 

before them because this was what, as physicians, they 

should do.

Legally and ethically, the military holds that all 

service persons should disobey an illegal or unethical 

order. Difficulties may exist, however, in determining 

what constitutes “illegal” or “unethical.” The integrity 

of the military system would require that military physicians, like other service persons, defer to orders when 

ambiguity exists in urgent situations. Afterwards, they 

should have these decisions reviewed as widely and 

quickly as possible.

Ethically, however, it may be possible to establish in 

advance when an order would conflict with a priority 

that military physicians hold as medical profession-
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Combat and Operational Behavioral Health

als and to decide then which priority should prevail. 

This endeavor could favor two outcomes. First, the 

military’s mission might undergo less risk of being significantly compromised. Second, it might help ensure 

that the highest medical standards were upheld.

Since the disclosure of abuses of detainees at Abu 

Ghraib, numerous concerns regarding detainees have 

been raised.10,11 The US government has invited experts 

on human rights from the United Nations and others 

to visit the detainee facility at Guantanamo Bay, Cuba, 

to inspect the activities there and confirm that present 

policies meet appropriate ethical standards. The results 

of these visits can become more conclusive, of course, 

only if all aspects of all operations there can be fully 

examined.

One core concern that has received particular 

public scrutiny and attention is the way in which 

military health professionals, especially psychiatrists, 

psychologists, and other medical care providers, have 

interacted with, and should interact with, detainees. 

The underlying presupposition is that care providers, 

being devoted to healing, should set the highest ethical standards in this as in all military contexts.12 Some 

healthcare professionals, however, question even this 

presupposition. Michael Gross, who wrote a recent text 

on military medical ethics, believes that military care 

personnel owe a higher duty to their country than to 

their profession.4 The converse of this position is that 

if there is a moral value that care providers should 

hold, presumably this value is important enough that 

it should also be held by all.

This second section of this chapter will examine 

core ethical questions that military care providers’ 

involvements with detainees pose. It will do this in 

three parts. The first part will consider basic questions regarding detainees, such as what approaches 

should be permitted during interrogations, whether 

a mechanism should be provided to allow exceptions 

to practices proscribed during interrogations, whether 

the permissible approaches should be enumerated 

specifically beforehand, whether detainees’ conditions 

should be made better over time, and who should decide all of these issues. These basic questions must be 

considered first because those that follow and involve 

care providers are to some extent contingent on these 

initial answers. 

The second part of this section of the chapter will involve questions specifically related to military medical 

personnel. These will include healthcare provider involvement in interrogations, if they should be involved 

at all, and confidentiality when treating detainees 

as patients. The third part will concern what is now 

the most difficult ethical problem faced by military 

healthcare providers treating detainees: what to do 

when detainees refuse to eat. This section will include 

a brief discussion of whether military care providers 

should have more opportunity to express their views 

and the nature of any special duties as military physicians during combat.

The ethical issues military psychiatrists may face 

in regard to detainees’ care are numerous. Military 

psychiatrists may be asked to serve as consultants 

during interrogations under the present Department of 

Defense (DoD) regulations (though psychologists, usually, will take on this role); they must, however, treat 

detainees solely and exclusively as clinicians would. 

This discussion will not attempt to provide the 

“right” answers to these ethical questions. Rather, it 

will presume that ethical analysis can’t provide these 

answers, because the values that should warrant highest priority may reasonably differ. It will, however, 

attempt to provide useful frameworks for considering 

the more difficult questions these situations pose. It 

will also present key considerations that those making 

these determinations should consider. It will finally 

suggest values that the ethical solutions eventually 

reached should take into account, regardless of what 

these solutions will be. 

General Questions Regarding the Nonmedical 

Treatment of Detainees

The core question involving detainees is the extent 

to which they should be regarded and, accordingly, 

treated primarily as persons who could have information that could save many lives, or as persons 

who no longer pose an immediate threat, and thus, 

like POWs, should be warranted optimal respect and 

care as persons who are no longer combatants. When 

detainees are first incarcerated, the ethical justification 

for treating them primarily as persons who may have 

information that could save others’ lives is greatest. 

Over time, increasingly, the strength of this justification 

will probably decrease. 

Three more specific key questions raised by nonmedical treatment of detainees concern (1) what 

approaches should interrogators be permitted to use 

during interrogations, (2) should the conditions under 

which detainees are incarcerated change over time, and 

(3) who should decide both of these questions.

What Approaches Should Interrogators Be 

Permitted to Use?

Widespread agreement exists that, ethically and 

legally, the United States should be prohibited from 

engaging in cruel, inhumane, or degrading treatment 

of detainees. Specifically, the question involves the 
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Ethics and Military Medicine: Core Contemporary Questions 

concrete concern as to whether any harm—permanent 

or transient, physical or psychological—should be 

permitted at all. A starting point for addressing all 

these questions is to ask what approaches law enforcement personnel now take in the United States with US 

citizens when they suspect that these individuals have 

already committed or may commit heinous crimes. 

Some believe that what the general public currently 

permits in these situations goes too far. Still, assuming that what is now legally permitted is at least ethically acceptable, if not ideal, brings into focus the key 

questions that should now be asked regarding limits 

to interrogators’ actions: should interrogators be permitted to cause detainees greater harm than what is 

allowable with citizens, and, if so, how much greater, 

and why? 

The main argument in favor of allowing interrogators to inflict greater harm to detainees by using more 

harmful techniques is to further the possibility of saving more lives. As a starting point in this discussion, 

a suspected serial killer is a paradigmatic example of 

a US citizen wanting to kill others now or in the future. Such persons, if released, may continue to kill. A 

second paradigmatic example that can be used for the 

purpose of conducting this analysis is a person such 

as Timothy McVeigh, when it was suspected that he 

blew up the Murrah Federal Building in Oklahoma 

City in 1995.

In cases such as these, law enforcement personnel 

in the United States are limited in spite of the fact that 

if they used more harmful techniques, they might 

potentially save greater numbers of lives in future 

terrorism cases. Detainees may differ in several ways 

from “ordinary” criminals. Chief among these are 

three: First, they may have information that could 

save many more lives, even more than individuals like 

McVeigh. The number of lives saved could be in the 

tens, hundreds, thousands, or even more. If a terrorist 

planned to release a lethal biological agent in New York 

City and a detainee could identify a plot and potential 

perpetrators before this took place, it could save the 

lives of perhaps millions. 

The likelihood of this occurring may be remote. It 

may, also, be uncertain whether a detainee has this 

information and if so, whether duress during an interrogation will elicit the information in time for it to be 

of value. Research indicates that most information obtained by coercive measures is unreliable13; still, some 

of this information may be of value. The ethical conflict 

then is between respecting detainees optimally, such 

as treating them as one would US citizens suspected 

of being serial killers or mass murderers, like McVeigh, 

versus possibly gaining information through severe 

treatment that could save countless lives.

Second, the present threat is different from what it 

was during even World War II when the Nazis committed genocide. Now, terrorists can live alone, out of 

communication with each other for years or decades, 

only then to emerge and possibly endanger an entire 

city. The only means of finding these terrorists and 

preventing such harm may be to learn their identities 

from detainees. 

Third, many contemporary terrorists may be motivated to kill others for a variety of reasons, including religious ones. Terrorists motivated by religious 

reasons, however, may not care whether they live or 

die in the course of killing others. Indeed, they may 

actively seek to die as they carry out their attacks. This 

“new” motivation may escalate the means they are 

willing to take, such as killing themselves or even their 

children, thus adding another reason that interrogators 

might be more ethically justified in using interrogation 

techniques harsher than US civilian law enforcement 

personnel use.

The indignity and harm that using more “vigorous” techniques would cause detainees are the main 

ethical arguments against using these techniques. 

What should be further said regarding these arguments? First, even if tens of thousands of persons 

could be saved as a result of detainees having specific 

and valuable information, it doesn’t follow that any 

and all means possible to produce this outcome are 

ethically justifiable. Interrogation approaches, at the 

extreme, include torture, threats of torture, and torture 

or threats of torture to detainees’ families. At some 

point, especially in ancient times, these approaches 

were used, in large part for their deterrent effect. Now, 

these approaches are generally deemed unconscionable choices that might destroy the values initially 

worth fighting for.

Second, in other contexts in the United States, absolute priority is given to respecting all persons’ dignity 

regardless of the numbers of lives that could be saved 

by not doing this. The best example and paradigm 

here is the present practice in the conduct of research. 

Regardless of the possible gain, no participants can be 

used against their will.

Some, such as Michael Gross, the author of the previously mentioned military medical ethics text, question 

whether traditional value priorities should continue to 

prevail at this time.4

 Gross cites the question of what to 

do if terrorists infiltrate themselves among civilians so 

that they will not be caught. He argues that there are only 

two options: (1) doing nothing and becoming defenseless, or (2) departing from previous values and accepting 

a greater loss of “innocent” civilian lives in the effort to 

rout out the terrorists who have infiltrated them. 

Should limits be proscribed and, if so, should these 
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be explicitly and specifically publicized? The first question to be answered here is where the line should be 

drawn between permissible and impermissible interrogation approaches. The second question that must 

be answered is the extent to which this line should be 

established by enunciating and publishing concrete, 

specific limits. If these limits are too vague, interrogators may more easily stretch them. Interrogators may 

do this for a worthy reason—hoping to save the greatest number of lives. Thus, due to the merit underlying 

this aim, many interrogators may seek to do this to the 

extent that they legally can. 

Specific limits help prevent this stretching. An example is the abuses that occurred at the prison in Abu 

Ghraib, Iraq. All military service persons know that 

they are legally required to refuse unethical or illegal 

orders. If it is unclear whether an order is unethical 

or illegal, a service person given such an order may 

be less clear on what to do. The cost of disobeying 

is potentially a court-martial. Thus, this is a strong, 

prima facie argument for establishing prior, specific, 

and concrete limits.

Too much specificity, however, that is too well 

publicized also carries a price when persons such 

as detainees may have information that could save 

lives. If limits are spelled out in too much detail and 

detainees come to know what these specific limits are, 

they may find it easier to “steel themselves” during 

interrogations so that they do not give information 

before these limits are reached. Consequently, they 

may give out less information and as a result fewer 

lives may be saved.

Should Detainees’ Conditions Be Improved Over 

Time? 

A similar price potentially exists in regard to giving detainees greatly improved conditions over time, 

such as to be able to communicate again with their 

families. Knowing that they can look forward to such 

privileges also may help them “hold out.” On the 

other hand, it is most humane to improve detainees’ 

conditions and give them the fullest access to their 

families after they have been interrogated and after 

the predominant likelihood of their giving information has passed. 

Once interrogation efforts have most likely exhausted the degree to which interrogators can “succeed,” 

logically the argument for giving detainees greater 

privileges, such as regaining contact with their families, should be greater. From this perspective, detainees 

should be regarded more and more over time as persons warranting greater respect and care, as opposed 

to their continuing to be regarded more as potential 

sources of life-saving information. If detainees know 

that in time this opportunity will occur, it may likewise 

make it easier for them to steel themselves during 

interrogations so that they don’t give out information 

that they otherwise would. Some might suggest that 

seeing their families could be used as a “carrot,” or 

incentive to give information. This approach would 

more extensively exploit detainees’ vulnerability and 

may be more ethically problematic and, in the view of 

some, even unconscionable for this reason.

As a possible alternative and a moral compromise 

between these conflicting values, greater opportunities 

could be given to some detainees but not all. Then, all 

wouldn’t know with certainty that they would ever 

gain these opportunities. It may be that, empirically, 

detainees’ knowledge of better futures will have no 

effect on their capacity or decision to withhold information during interrogations. Their knowing that 

they could see their families could, on the other hand, 

possibly increase their positive regard for the United 

States, and thus their willingness to give out more 

information. 

In general, detainees who are treated humanely may 

become more willing to give information over time. 

Even this possibility is ethically problematic, however, because it involves viewing detainees primarily 

not as ends in themselves, because they are humans, 

but as means to an end. Alternatively, it may be that 

detainees should only be ultimately regarded as ends 

in themselves. In this case, their captors should treat 

them humanely even at the expense of other losses, 

even including loss of other lives.

Remaining questions to be answered are whether, 

in extreme cases, there should be exceptions and a 

mechanism to implement the exceptions. Exceptional 

interrogation techniques might be permissible, in rare 

circumstances, when extremely extenuating criteria 

exist. These criteria might include many lives being 

endangered, the danger being imminent, and it being highly likely that a detainee has information that 

could save lives. In these situations there could also 

be a mechanism for outside review before exceptional 

interrogation approaches are used, as well as observation during the interrogation. The major argument in 

favor of permitting such a mechanism for exceptions 

is that it could save more lives. 

There are two ethical questions involved in interrogating detainees and having mechanisms for making 

exceptions to limits. First, what is the highest moral 

road? And second, what, if any, criteria would justify 

the United States not taking this usual “highest” moral 

road? In making these decisions, it may that a high 

price would be paid to maintain moral standards that 

most people can accept. This price would involve al-
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Ethics and Military Medicine: Core Contemporary Questions 

lowing persons’ lives to be lost and accepting this loss 

in advance.

Who Should Decide These Questions?

Who should decide what the limits for interrogators 

should be, notwithstanding the potential loss of lives? 

If established, should these limits then be made public 

and explicit?14(pp89–90) International codes may be one 

source of answers. Yet, ethically, using international 

codes alone to determine policy is problematic for 

many reasons. First, if the codes were enacted before 

the terrorist attacks of September 11, 2001, they could 

not have taken into consideration newer circumstances 

and possibly greater risks terrorists now pose. Codes 

enacted since this time, on the other hand, could. Second, codes by their nature are limited. Likewise, the 

ethical soundness of the tenets in all codes may be less 

sound in exceptional circumstances, such as when a 

detainee has information that could save thousands 

of lives.

These limitations inherent in codes may justifiably 

result in supporting interrogations that are harsh, or in 

allowing military medical personnel to treat POWs in 

ways that are unequal, as delineated in the discussion 

above. Military medical personnel may, consistently 

with international requirements, categorize all service 

persons and all POWs with abdominal wounds in the 

same group, notwithstanding these wounds’ seriousness and urgency. The code says that care providers 

must treat service persons and POWs equally. However, because it doesn’t specify whether both groups 

of patients must be treated alternately or on a random 

basis, military care providers could treat all their own 

soldiers in the same category of medical illness first, 

followed by treatment of POWs.2

Analogously, if a code prohibits interrogators from 

using cruel or inhumane approaches, it could, by its obverse implication, condone interrogators using harsh 

approaches that don’t quite meet the standard of cruel 

or inhuman, but nonetheless go beyond those permitted to US law enforcement personnel interrogating US 

citizens. It may be that these standards should be the 

same or, perhaps, that even the present policies for US 

citizens go too far—or not far enough—in allowing the 

use of harsh interrogation techniques.

Third, the risk of codes not being specific enough 

and not going far enough is especially possible because codes often represent a compromise. They may 

reflect political pressures and may, like laws, express 

the least demanding, but still permissible ethical action that persons should take, rather than expressing 

the highest ethical standards to which they can and 

should adhere. Because international codes represent 

a compromise that requires finding areas in which all 

can agree, codes may represent a “bottom line” acceptable to all participants. 

This situation currently poses a problem for the 

United States. Codes may proscribe certain practices 

with detainees, such as forced-feeding if the detainee 

is on a hunger strike. What may be optimal for countries in general may not be optimal or even acceptable 

for specific countries, such as those most targeted by 

terrorists for attack. Thus, the losses to these latter 

countries—such as the United States—for following 

the code may be greater and the benefits less than for 

other countries. Ethical analysis often can’t provide the 

right answers to these questions, any more than it can 

give an answer that is self-evidently valid. 

Achieving the best ethical outcome may be attempted by submitting what is at question to the 

optimal process of consideration. In the United States, 

this may mean submitting ethical questions such as 

these to legislators, who are the persons the greater 

society chooses to decide these questions, checked and 

countered, from time to time, by the courts. The decisions made at any one time may be overturned. Still, 

allowing legislation to determine ethical codes may be 

the best process possible.15,16(pp37–40) The “best antidote 

to bounded rationality—as manifested by cognitive 

biases and resulting errors in judgment—may be to 

deploy the law as a debiasing tool.”16(p37)

How Should Military Medical Care Providers Be 

Involved With Detainees, If At All?

The military’s general policies in regard to detainees, as just considered, are critical to the contingent 

question of how military care providers should interact 

with detainees.17 A first, core ethical issue in regard 

to military medical care providers’ involvement with 

detainees is the extent, if any, to which military care 

providers should isolate themselves from other military endeavors on the basis that they, as care providers, 

have a medical, profession-based, patient-oriented 

ethical standard to uphold, as opposed to a missionoriented moral standard. Key subquestions include the 

following: (a) how much should providers be involved 

in nonmedical actions, such as interrogations, and (b) 

what should providers do when they give detainees 

medical care. Should they, for instance, participate in 

force-feeding them?

In What Ways, If Any, Should Care Providers Be 

Involved in Nonmedical Acts?

There are many ways in which military care providers could be nonmedically involved with detainees.18
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Combat and Operational Behavioral Health

Psychiatrists and psychologists could work with 

interrogators during interrogations to try to find and 

probe areas in which detainees are most vulnerable 

in the hope of obtaining more information that could 

ultimately save lives. During interrogations, military 

care providers could also serve an opposite function: 

they could watch interrogations through a one-way 

mirror to attempt to ensure that the techniques interrogators use stay within their permissible limits and 

thus better protect detainees from harm.

What some view as the most overriding ethical 

concern here is that care providers have separate duties as care providers to detainees that may interfere or 

conflict with their obligations as military personnel or 

clash with military goals. The classical example in principle here is physicians’ obligation as physicians to do 

no harm, as proscribed under their Hippocratic Oath. 

Some view such care providers as having a higher 

moral standard regarding detainees’ well-being than 

interrogators, who are expected to at least be coercive if 

not harmful to detainees in seeking information. Thus, 

questions have been raised as to whether physicians 

should provide a safeguarding function for detainees 

by viewing them during interrogations through oneway mirrors.

Ethically, the assumption that military care providers have, or should have, a higher standard, as 

characterized above, may be more problematic than 

some have assumed. Persons in the military knowingly 

and willingly risk and often give their lives for their 

country. This is especially true when there is no draft. 

If there is a highest road in terms of behavior, it may be 

soldiers’ being willing to give their lives and carrying 

out other behaviors that also further the highest moral 

standards possible. Military noncare providers, such as 

interrogators, may be viewed as within this group in 

that they, like those willing to die during combat, give 

ultimate priority to trying to save others’ lives. 

However, it is not self-evident that care providers 

should serve some oversight function of interrogators merely because they and many others believe 

that they uphold a higher moral standard. What this 

suggests is that there may be, and perhaps should be, 

ethical conduct that both care providers and noncare 

providers would support equally. The military could 

adopt practices for interrogating detainees that most 

physicians, military or not, and most soldiers and most 

citizens would agree with. The military could decide 

also what actions, if any, it would need to take to enforce these standards. It would make sense, were this 

to occur, to view military personnel and military care 

providers as having moral values of equal status and 

to not see care providers as being the right group to 

serve an oversight function, practically or theoretically, 

because they serve higher moral values.4 

A second, related area of current controversy is 

whether physicians and particularly psychiatrists 

should not participate in the same ways as other care 

providers, specifically psychologists. The American 

Psychiatric Association (APA) has passed guidelines 

that forbid psychiatrists from being directly involved 

in interrogations, whereas the American Psychological 

Association has allowed participation to a greater extent. Inasmuch as both psychiatrists and psychologists 

may have clinical training, some psychologists question the basis on which psychiatrists—or physicians—

should be excluded from participating in military 

actions carried out to further the needs of the greater 

society, when psychologists aren’t, and possibly should 

not be, excluded.19–21 Nurses have raised this same 

question; however, their situation remains theoretical 

because nurses haven’t been asked to assist in interrogations. The same concern also applies to other mental 

healthcare providers, such as social workers. A possible 

overarching ethical question underlying these debates 

is whether it is possible for all military personnel, including interrogators and various care providers, to 

see themselves as pursuing the same ethical standards 

in serving the needs of the greater society. 

A further source of values that warrant moral 

weight and may conflict with those of care providers 

or those of the military is the greater society. A primary 

ground for society’s views warranting moral weight in 

regard to what physicians should do is that the public 

makes certain sacrifices so that medical students can 

learn to be physicians. Society funds medical schools 

and, more importantly, allows these students special 

privileges, such as to “practice” on bodies, whether 

cadavers or live patients, so they can learn the skills 

they will need later to be able to “cure.” This is also 

true in regard to other professionals such as nurses, 

clinical psychologists, and social workers.

Physicians, in return, at least implicitly promise to 

use their skills for good. This “good” may include conducting practices that society by inaction has implicitly 

condoned. Thus, in that society has allowed exceptions 

on this basis, exceptions justifiably exist. Physicians 

serve in some roles that serve society’s needs more 

than patients’ needs. An example is forensic psychiatry. 

Society, presumably, wants and accepts this.

One core ethical question regarding military care 

providers being involved in interrogations and other 

nonmedical military actions is whether society expects 

and accepts this, because if not, care providers may 

be violating their implicit promise to society to not 

harm but to “cure.” This question may be uniquely 

complicated, because the greater society might want 

physicians—psychiatrists in particular—to participate 
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in interrogations so that society may have greater protection. What the greater society wants and expects is, 

in theory, an empirical question. Society’s view may be 

expressed over time in how persons vote. The question remains, regardless of legislative outcomes, what 

moral weight should society’s view of the appropriate 

roles of care providers in the military have? Society 

may, on one hand, not want care providers to violate 

their implicit promise to cure, but on the other hand, 

society may want psychiatrists and other care providers to help protect society as much as possible.

The above question is of added importance because 

professional organizations may believe they, too, have 

a stake that warrants significant or even overriding 

weight in deciding what those within their profession should do. They may believe that their view 

should be decisive. Physicians have been told by the 

American Medical Association that they should not 

take on certain roles during criminal executions and 

psychiatrists, by the APA, that they shouldn’t evaluate criminal offenders and deem them sane to meet 

legislative criteria for execution. Organizations may 

take this same view in regard to psychiatrists or other 

care providers participating directly or indirectly in 

interrogations.

Thus, care providers within the military may fear 

that if the military asks them to serve in certain roles 

that depart from what their professional organizations have proscribed, they may jeopardize their good 

standing within these organizations or even lose their 

licenses to practice. This is again an instance in which, 

if possible, the military and these organizations becoming united and working toward adopting a shared, 

highest ethical value would be ideal.

Both the military and the APA may have grounds 

on which they could agree. Psychiatrists could, for 

instance, participate in formulating policy. Their 

agreeing on the level of participation in interrogations 

might make sense to both groups because behavioral 

healthcare providers offering suggestions in this capacity may help both the military and detainees. They 

may be able to suggest interrogation approaches that 

(a) are as effective but pose less of a risk of potential 

harm and (b) pose no more risk of potential harm but 

are more effective in eliciting information. These two 

possibilities illustrate an important general consideration regarding ethics that should always apply in 

cases such as this. That is, it is generally not difficult to 

recognize negative ethical aspects of a situation. What 

is more difficult ethically is to go one step beyond this 

and then find a better solution.

An important question regarding whether psychiatrists and other care providers should participate either 

indirectly or directly in interrogations is, therefore, 

what the relative gains and losses of each approach 

would be. One core consideration here is what would 

occur if psychiatrists, and other care providers, were 

not included in interrogations. The focus of controversy in regard to interrogations is, however, on 

military care providers being involved directly. Many 

care providers wince in response to the idea that they, 

themselves, as well as others, could rightfully perceive 

them as caring for patients on one day and stopping 

just short of inhumane treatment when working with 

detainees on the next.

It is not ethically clear that the solution of having 

mixed roles from one day to the next, sometimes in 

a forensic setting, which is generally accepted by forensic psychiatrists and psychologists, is sufficiently 

analogous to the interrogation issue to allow the 

justifications for one to apply to the other. When care 

providers evaluate suspected criminal offenders for 

insanity, they inform them that anything they say 

may be used against them. This warning helps respect 

these interviewees’ autonomy and helps behavioral 

healthcare providers in this role avoid engaging in 

implicit deceit.

Some believe that if care providers do the same 

thing with detainees, this may suffice, or at least reduce 

the extent to which the role of care providers, such as 

psychiatrists, is objectionable, so that they can, from an 

ethical standpoint, be justifiably involved in interrogations. This argument, however, may miss this point. 

The ethical presupposition made when forensic psychiatrists give this warning is that their conducting the 

evaluation is ethically justifiable even if psychiatrists 

find the interviewees to be sane as opposed to insane—

though the judge or jury will ultimately make this 

determination. This is because if psychiatrists don’t 

interview defendants to try to discern whether or not 

they were severely emotionally impaired when they 

committed their crime, the judge or jury will then have 

to make this determination. Without the psychiatry 

opinion, the judge or jury may be much more likely 

to infer that the defendants were sane. This could in 

some instances result in execution. 

In the interrogation of detainees, these same presuppositions don’t exist. The detainee is being pressured, purposefully, in the hope of affecting him or 

her sufficiently adversely to give up information. If 

the psychiatrist adds to this pressure, the psychiatrist 

is also doing harm. The psychiatrist could, however, 

also serve only as an ally to the detainee. For example, 

US military physicians have helped detainees greatly, 

some military care providers report, by developing 

their trust. This will be discussed in greater detail 

in the next section, which deals with detainees who 

refuse to eat.
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A final question that should be asked is how could 

psychiatrists and other care providers help interrogators? It may be that the experience of interrogating 

detainees has no harmful effect on interrogators. Alternatively, however, it may. This especially may be 

the case if detainees are from a different ethnic group. 

This also may be truer if the approaches interrogators 

can use are harsher. Military care providers being 

present can help confirm for interrogators that while 

in the process of the interrogation, detainees remain 

persons not inherently different from the interrogators. 

Psychiatrists and others participating in this way could 

then be allies who might benefit interrogators as well 

as detainees.

How Should Military Care Providers Treat 

Detainees?

Ethical treatment of detainees by military care providers is complex. A potential scenario could involve 

a detainee with diabetes. Here, clinicians informing 

interrogators of this condition may be essential so 

that interrogators respond in ways that will maximally meet detainees’ medical need for drugs such 

as insulin. Interrogators with this knowledge may 

require medical providers to monitor food intake so 

that the detainee is unlikely to become hypoglycemic. 

Yet, at the same time, if clinicians provide clinical information, interrogators could misuse it. Interrogators 

could threaten to allow detainees’ blood sugar level to 

dangerously fluctuate (whether or not they could or 

would, in actuality, do this) to try to get detainees to 

provide the information they want.

It may be wholly implausible that this would 

happen. Rather, if clear specific limits are in place, 

interrogators are obligated to stay within the rules 

previously proscribed by the DoD, even if these rules 

are to some extent vague and thus allow “loopholes.”22

Furthermore, the military could develop mechanisms 

to ensure that if care providers give interrogators information like this to help detainees, interrogators don’t 

misuse it. Such mechanisms could include outside 

review, ensuring greater transparency, as indicated 

above. In other contexts, care providers couldn’t be 

reasonably expected to be able to treat detainees optimally unless they could wholly respect detainees’ 

confidentiality. If detainees were depressed, they might 

share their feelings, honestly, only if they felt that they 

had trustworthy care providers.

Military physicians, in innumerable cases, have 

reportedly shown extraordinary compassion to detainees and, as a result, gained their trust. In these 

cases compassion was shown not to gain trust in 

hopes of improved information gathering, but to treat 

detainees with respect, simply as persons, regardless 

of whether it would affect provision of information 

or not. To attain and maintain this confidentially may 

require additional resources. An example here is the 

need for sufficient numbers of interpreters. If the interpreters for clinicians and interrogators are different, it 

could be expected, both theoretically and practically, 

that detainees would have greater trust in their care 

providers. Otherwise, they might fear that information interpreters hear during the “clinical hour” could 

then be passed on to interrogators, who could use the 

information against them.

More money spent by the military, and by extension 

the greater society, to provide the necessary conditions 

for optimal medical care should be a high priority. 

Treating detainees with optimal respect should, perhaps, generally take priority over other, competing 

ethical values. Plausibly, the military’s doing this 

would serve to enhance detainees’ trust. The military 

at Guantanamo now may provide first-class medical 

care to detainees. For example, medical care previously offered to detainees of a certain age includes 

evaluation of elevated prostate-specific antigen blood 

levels to possibly detect early prostate cancer and endoscopic examinations of their lower bowels to assess 

for possible early colon cancer. Does the military do 

everything for detainees that care providers would for 

prisoners in the United States or civilians in the best 

US hospitals? Should it? 

The answers to these questions are analogous to 

many others considered above. Some of these decisions may rightfully be those for the greater society. 

However, the greater society may be unjust. What is 

clear is that what should be done can be known with 

greater certainty only as what is being done now 

becomes increasingly transparent. Then, wherever 

the lines are drawn now can be subjected to greater 

scrutiny, and society, through legislation or the courts, 

can decide whether or not what is done now is what 

should be done. 

The main reason for the military’s acting on behalf 

of the greater society to maximize detainees’ trust may 

not be to “win them over” in the hope that they would 

then give information that could save lives. Rather, the 

reason may be to regard detainees as primarily ends 

in and of themselves. The idea that humans should 

never be used unduly as means to others’ ends, as 

opposed to ends in themselves, is a common principle 

accepted in ethics and put forth by Kant. It is based on 

what respect for humans and human dignity requires. 

If, for example, interrogators pretend they are friends 

of detainees to get information, these interrogators 

are deceiving detainees and using them as primarily 

means to US ends. Ethically this is problematic, though 
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Ethics and Military Medicine: Core Contemporary Questions 

it may be justifiable if one can argue for other reasons, 

such as saving millions of lives. 

Optimal care may then be warranted merely because detainees should, as fellow humans, have care 

providers they can trust regardless of what they have 

done or may have done. As persons and captives, they 

still warrant utmost respect. This value, and this value 

alone, generally is presumed to be overriding unless a 

compelling case against it can be made. Similarly, this 

principle should be adhered to in all instances in which 

detainees are involved unless some other, convincing 

case can be made. Thus, providing detainees with the 

utmost respect can be a core, initial ethical position 

on which all persons—interrogators and physicians 

alike—could agree, at least initially. 

In regard to specific approaches permitted during 

interrogations, it may be that a resolution acceptable 

to most concerned parties is achievable. All parties 

should seek ethical unity, if possible. A next strategy 

to resolving the many potential conflicts between care 

providers and other military personnel is to seek out 

and find value priorities on which most parties, both 

military and civilian, can agree. 

The value in regard to which pursuing this stragey 

may be most plausible may occur after detainees have 

been incarcerated and later, during every moment 

of their interrogations. This value is that detainees 

should be respected as persons. This fundamental 

concept is paramount not only in this country’s ethics, 

but also internationally. Thus, it may be that greater 

ethical agreement both nationally and internationally 

may be possible. With this agreement it may be that 

applications shared to a greater extent by all can be 

brought about.

How Should Military Care Providers Respond 

When Detainees Refuse To Eat?

Substantial numbers of detainees may refuse to eat. 

The core ethical conflict this brings about is whether 

military care providers should force-feed detainees 

against their protests and thus maintain their lives, or 

if providers should respect detainees’ autonomy by going along with what they request.23,24 The key question 

here is what care providers should do and why.

Should Care Providers Force-Feed Detainees or 

Respect Their Autonomy?

In this situation, the context is most important ethically. Generally it is considered a first ethical priority 

to respect persons by allowing them autonomy. The 

one value that may most reasonably override this 

is another deontological value—that is, respecting 

detainees in another way by maintaining their lives. 

Detainees may have uncertain futures and be denied 

physical contact with their families. Thus, respecting 

their autonomy by allowing them to choose to die is 

especially problematic. This is because showing respect 

for detainees as persons may better be accomplished 

by improving the conditions under which they live. 

Respecting their autonomy warrants more moral 

weight if the context in which they live maximizes 

their welfare and if, as a result of this, their capacity 

to make choices is unfettered by pressing personal or 

emotional needs.

If the detainees’ situations are improved as much as 

possible, it may be that it is justifiable to still force-feed 

them against their will because this maintains their 

lives. Thus, it may be more effectively determined at a 

later time whether this same refusal to eat, if they still 

are refusing food, should be respected. This rationale 

may lose moral weight over time because it will be 

increasingly implausible to believe that detainees will 

decide they really want to live at some point if they 

have continued to refuse to eat.

This principle, attending to persons’ greater context 

as opposed to their most immediate needs, is exemplified most notoriously by an example involving 

research in Willowbrook, New York. Here, several 

thousand children who were “retarded” were institutionalized and lived in poor hygienic conditions. 

Many, if not most, of the children contracted hepatitis. 

Researchers wanted to study hepatitis by intentionally giving the disease to a group of these children. 

They justified this because the children participating 

in this research would be better off in two ways: (1) 

they would live under better conditions, and (2) the 

hepatitis they acquired would be less severe in the 

research setting than if naturally acquired from the 

general population at the institution. 

The study began in the 1950s and continued into the 

1960s. After the study was completed, it was criticized 

on the basis that it had exploited the children’s poor 

condition and in doing so treated them primarily as 

means to others’ ends. To treat them as ends in themselves would have meant to change their surroundings and make their surroundings better. Since then, 

this has been done. These children, now adults, were 

placed in small group homes; Willowbrook Institution 

no longer exists.

The analogy here is that respecting detainees’ 

autonomy by allowing them to die in their present 

context may be problematic because efforts could be 

taken to improve their situation. Respecting them more 

may require establishing rigorous criteria to determine 

when detainees are much more likely to give useful 

information, and once this “window” had passed, 
740

Combat and Operational Behavioral Health

creating for them better living conditions (according 

to their views of what these should be). Otherwise, 

care providers granting detainees autonomy under 

conditions that offer them little to no present source 

of meaningfulness in their lives would respect their 

autonomy literally and, in this one sense, also further 

the likelihood of their wanting to die.

Ethically, the practice of allowing detainees who 

wanted to starve to death to do so could risk military 

care providers meeting the requirement of international law but violating its spirit, just as they could 

when treating US soldiers and POWs “equally,” as 

described earlier in this chapter.2 Care providers could 

literally respect detainees’ autonomy while knowing 

that their environment is impoverished and intentionally leaving it that way. Thus, detainees could live and 

be allowed to remain in an environment unnecessarily 

conducive to increasing the likelihood that they would 

want to die.

In the case of care providers granting detainees 

autonomy to starve themselves to death, a similar 

question of intent may be involved. Suppose that detainees remain living under conditions in which they 

can find little or no meaning and that the likelihood 

of them providing useful information has become 

remote. If they are then allowed to die, allegedly to 

respect their autonomy, this could be done due to an 

underlying intent to further the likelihood that they 

would choose to die, as opposed to an overt intent 

to respect their autonomy. It would be unclear what 

the genuine underlying intent of those allowing the 

detainees to die really is. 

In like manner, care providers respecting detainees’ autonomy in a context that they find meaningless, when this context could be changed, may not be 

ethically justifiable. Care providers may be implicitly 

accepting and supporting the circumstances that 

may contribute to these detainees’ deaths. It may be, 

on the other hand, that improvements in detainees’ 

lives aren’t possible for reasons related to security. If 

so, significant harms that could result from making 

these changes might preclude these changes from 

being made.

Military care providers, even knowing all this, may 

have limited choices. Regardless, if they act in ways 

that accept and support a suboptimal environment, 

they may be ethically guilty of moral complicity. Still, 

if they do respect the prisoners’ autonomy by allowing 

them to not eat—whether this is the providers’ choice 

or that of others higher in their chain of command—

they may then have an ethical duty to offer detainees 

sedation so that as they starve to death, they don’t suffer. By giving this sedation, these care providers would 

be facilitating these detainees’ deaths, because sedation would most likely shorten their lives. Providing 

sedation might be viewed for this reason as ethically 

unjustifiable. Yet, the military care providers’ intent 

would be to relieve the suffering of the detainees. Giving sedation might ethically be not only justifiable but 

also mandatory because it is more humane.

A second choice of military care providers under 

these conditions would be to refuse to participate, 

even in giving sedation. Care providers are outside 

the combat setting and thus they should have greater 

opportunity to express and adhere to personal values 

that they hold within their moral conscience. Their 

refusing to participate could violate the principle of 

military necessity if detainees’ starving was viewed as 

likely to rally persons throughout the globe to carry 

on their fight. Then, and only then, might military care 

providers have a higher, overriding ethical military 

duty to do what they must to further the military mission of protecting society. 

The possibility of rallying other countries or organizations against the United States could be the 

ethical justifification to require physicians to forcefeed detainees. If important military needs are not at 

stake, however, military care providers should be able 

to adhere to their own moral values and views to the 

same extent as their civilian colleagues.

What this should require in practice is itself an 

ethical question. Assuming military necessity isn’t 

present, should a recruiter of physicians who will 

care for detainees on a hospital ward only ask them 

whether they have moral scruples or, if they say that 

they do have moral scruples, then ask them further 

what these are? Asking them only whether they have 

scruples most respects physicians as persons by not 

requiring them to come up with “valid” reasons. Asking them the specifics of their scruples, in comparison, 

in effect disrespects them, because their moral values 

are respected to a lesser extent. In other words, in the 

latter case, their values and moral conscience would be 

respected only if they give “acceptable” reasons.

Furthermore, recruiters’ asking military care 

providers for the reasons for their scruples presupposes that logical reasons underlie all valid emotional 

“qualms.” However, this isn’t the case. Many times, 

what persons experience as a violation of their moral 

conscience is a felt emotion, and persons may or may 

not be able to articulate why they feel this way. Likewise, in its effect, this question also would discriminate 

between those physicians who report “good reasons” 

and those who do not. This may violate a morally 

important aspect of care providers being treated with 

equality and, as an unwanted consequence, it might 

divide them as a group.

The highest road for physicians to take with most 
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Ethics and Military Medicine: Core Contemporary Questions 

patients who want to refuse treatment and die by this 

means may be for these care providers to take measures to try to ensure that dying is what these patients 

really most want. Then, if and when providers have 

taken these measures, their highest moral road may be 

to accept the detainees’ wishes. For example, if patients 

have just undergone trauma and acquired quadriplegia, hours later they may request that their respirator 

be shut off. These patients’ care providers might well 

ask them whether they might be willing to take a bit 

more time because there are many persons in this situation who respond like the late Christopher Reeve, who 

lived for 9 years after suffering a catastrophic cervical 

vertebrae fracture in 1995. They may in time also find 

meaning in this wholly altered state. Military physicians may see their optimal ethical task as to take an 

analogous route with detainees.

The ethical idea at stake here is to try to enable 

such patients to be more truly autonomous and not 

unduly driven by overriding needs when these needs 

can be better met. This is especially important when 

one choice patients can make, namely death by starvation, is irreversible. The longer these patients persist in 

making this same request, the stronger the argument 

becomes for granting it, despite the fact that these 

patients may seem, from an objective perspective, to 

have unchanged needs. Subjectively, of course, even 

though their external environment hasn’t changed, 

detainees may be quite different “inside.”

Applying these ethical guidelines to detainees 

would suggest that an optimal ethical course might be 

to maximize the immediate benefits detainees could 

enjoy once reasonable time had been given to attempt 

to obtain information from them. After giving them 

maximal possible benefits, time should be allowed to 

help ensure that not eating was what a detainee really 

wanted to do. Detainees might change their minds 

over time and subsequently want to live without being 

aware beforehand that this might occur. Many patients 

with terminal illness want to die at one time only to 

feel later that they want to live on as long as they can. 

For this reason, even in the two states in the United 

States in which patients can have assistance in dying, 

their request generally must be repeated and sustained 

over a significant intervening period of time before care 

providers can go along with their request.

It might be claimed that because detainees’ external conditions are in so many respects impoverished, 

such as their not being able to have physical contact 

with their families, it is likely that many are genuinely 

depressed and thus their depression could deprive 

them of sufficient mental capacity to be competent 

to then choose to die. This concern, though ethically 

reasonable, would in principle be inconsistent with 

the possibility in civilian contexts in the United States 

that persons depressed or significantly emotionally 

impaired can still determine their outcomes. Thus, in 

this country, even if patients are severely depressed, 

this generally does not preclude them from making 

even life-ending decisions regarding themselves.

A question implicit throughout the above discussion 

is, however, whether patients who are ill or even have 

a terminal illness are the most appropriate subjects to 

use as an ethical analogy. It may be that no group will 

suffice as an analogy. Other analogies, such as prisoners incarcerated with life sentences, may be as, or more, 

valid, although not sufficient. This prisoner analogy 

could be cut in different ways. It might suggest that 

detainees should have much greater rights, such as to 

be able to meet physically with their families. But it 

might also imply (unlike the use of the medical analogy) that they should not have the option of choosing 

to die by starvation. The present policy of not allowing 

detainees to refuse to eat and thus to die by this means 

is based on US law regarding prisoners. 

The prisoner analogy may be flawed, depending on 

whether allowing prisoners to refuse to eat, even when 

they will be executed, is or isn’t ethically justifiable. 

The underlying rationale for not allowing the refusal 

to eat may be one of punishment. If so, the rationale 

of punishing detainees by this same means wouldn’t 

suffice. A second possible rationale some might offer 

for not allowing persons on death row to refuse to eat 

is that persons on death row may be depressed and 

for this reason incompetent to choose whether they 

want to die by starvation. This, too, wouldn’t suffice 

because even if patients are depressed, they still may 

be deemed sufficiently competent to refuse life-saving 

treatment.

In this instance there may be no adequately analogous situations. Military care providers not participating directly in interrogations may not be sufficiently 

like forensic psychiatrists, nor like physicians giving 

lethal injections to effect criminals’ deaths, nor like 

psychiatrists determining that persons are incurable 

sociopaths such that death should or should not be 

imposed. Likewise, a detainee wanting to starve to 

death may not be sufficiently like a patient with terminal illness wanting to refuse a respirator (or food 

and water) so that death is hastened. 

None of these examples may be a close enough 

replica of the detainee situation to serve as an ethically 

adequate model. If these analogies are insufficient, 

the answers to the above questions may thus be more 

difficult. Ethics may at best only shed light on the key 

factors to be considered. This analysis has considered 

both the importance and the limitations of codes. 

These codes emphasize the importance of respecting 
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prisoners’ autonomy. Allowing detainees to die under 

suboptimal conditions may, however, be qualitatively 

different from what those enacting these codes, which 

require respect for autonomy, had in mind. Thus, this 

different context should be considered.

The sanctity of persons’ lives is an important deontological value, as is respecting persons’ dignity 

in other ways, such as respecting their autonomy. In 

some situations it is considered ethically justifiable 

for physicians to override patients’ autonomy and to 

exercise therapeutic privilege. This is allowed by law 

in all states and recently has been reaffirmed by the 

Council on Ethical and Judicial Affairs, a body within 

the AMA.25 Physicians can exercise this privilege only 

when not doing so would, in their view, harm patients 

unduly. Whether overriding detainees’ refusals to eat 

would meet these same criteria is open to challenge. 

However, furthering detainees’ interests, such as in 

the use of therapeutic privilege, may be the only basis 

on which overriding detainees’ autonomy could be 

justifiable.

Soldiers’ Opportunity to “Speak Up”

Military care providers may have markedly different, even heart-felt, views on whether or not detainees 

should be force-fed. This raises a question in regard 

to not only this situation, but to all areas concerning 

the extent to which soldiers should be free to express 

their views and more specifically whether or not 

they should have more freedom than they have now. 

During combat operations, it is imperative that every 

soldier follows orders and works together with other 

soldiers to accomplish the mission, as directed. There 

is little room to question commands, unless the orders 

are in violation of the Uniform Code of Military Justice 

or the rules of engagement. Soldiers having a dissenting opinion may be vulnerable to highly significant 

sanctions if they speak out. 

There are also clear guidelines that limit a soldier’s 

first amendment right to free speech. But are the present limitations ethically optimal, or could the creation 

of an environment with more free flow of communication serve both soldiers and their commands better? 

Might the military be stronger if soldiers are allowed 

to verbally dissent? 

If soldiers could do this, they would need to 

be aware of the appropriate method to make their 

disagreements known, and a more “liberal” process 

would need to be set in place. This change might create a better system by instilling a pressure valve to 

allow soldiers an outlet for expressing themselves. 

This might work to increase morale by allowing even 

the lowest ranking individual an avenue to be heard. 

Many improvements may even be identified by this 

same method. 

Three recently occurring postdeployment problems 

particularly warrant ethical discussion. These are (1) 

whether soldiers with posttraumatic stress disorder 

(PTSD) should be redeployed, (2) what should be done 

when soldiers have or may have head injuries due to 

blasts, and (3) when, if ever, military physicians should 

make decisions on behalf of their soldiers’ interests and 

“against” rules and regulations, and “outside the box.” 

The appropriate role for military behavioral healthcare 

providers in these ethical issues is particularly evident. 

PTSD is among the most important of the disorders 

they must treat.

Posttraumatic Stress Disorder

The first of these problems focuses on whether soldiers who have deployed, and then been diagnosed 

with an acute stress disorder or PTSD, should be deployed again into a combat environment. This ethical 

dilemma revolves around the competing needs of the 

individual and the needs of the military. The needs of 

the individual may be best served by allowing them 

to delay deployment to allow treatment and healing 

or by avoiding another deployment altogether. 

This could, however, have a negative effect on 

soldiers by decreasing their expectancy that they will 

improve and may lead to a fixation of their symptoms 

and subsequent disability. This may also cause soldiers 

to experience increased guilt over not being with their 

buddies and unit during future operations. Some 

soldiers, especially those suffering from more mild 

degrees of PTSD, might not only want to return to the 

theater, but may do better if they do. 

Allowing these individuals to avoid a deployment can also have a significant effect on their unit’s 

readiness. Many individuals may begin to mimic 

these illnesses intentionally to avoid deployment. This 

“copycat” scenario is seen throughout military units. 

This phenomenon isn’t exclusive to deployments. 

There have been many accounts of one individual in a 

unit being administratively separated, or avoiding an 

agreed-upon military service commitment, and then 

this being followed by several other unit members 

claiming the same level of distress. Suicidality is an 

example, as well as soldiers alleging that continued 

military service would keep them at risk. They may 

POSTDEPLOYMENT PROBLEMS
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Ethics and Military Medicine: Core Contemporary Questions 

then request to be administratively separated. This 

can affect a unit’s readiness and decrease the available 

number of trained troops. A competing concern is the 

potential negative consequences for units that may 

have these individuals with them in theater. These 

individuals, in addition, may be more vulnerable to 

recurrent or progressive impairments, can consume 

a disproportionate amount of human resources, and 

may compromise security.

Allowing this means of exclusion, especially for 

those more mildly affected, may also have effects on 

recruiting. Indicating to potential recruits that soldiers 

in distress will be taken care of, even to the extent that 

continued deployments may not be required, may 

facilitate recruiting. The extent of this effect, if any, is 

open to speculation. In the present state of uncertainty, 

three key variables should be weighed and considered. 

Two are in favor of deploying these soldiers, and one 

opposes deployment. Suppose that deploying the soldiers, overall, does help their healing process. This may 

benefit these individuals and their families. Military 

units may also benefit by allowing them to maintain 

their needed unit strengths, and therefore having the 

needed numbers of trained soldiers to complete their 

missions. 

Recruiting, which currently faces many challenges, 

may be enhanced by going the “other” way, namely, 

by allowing affected individuals to delay deployment 

to receive treatment, or to avoid another deployment 

altogether. Empirical data will indicate more clearly 

over time how soldiers with PTSD respond overall 

to being redeployed. Until this information is better 

known, the best ethical solution to this question may 

remain more open to debate. 

Head Injuries

The second postdeployment ethical issue involves 

soldiers who return with head injuries caused by blast 

injuries, primarily in Iraq. Here what has been found 

is that these soldiers’ impairment may differ from that 

caused by other head injuries, such as those sustained 

in a car accident.26,27 These soldiers may remain literally competent or able to acknowledge accurately the 

pluses and minuses of accepting or declining treatment 

or of participating in research, but, at the same time, 

they may still have extensive underlying difficulties. 

These difficulties may become apparent only through 

formal cognitive testing. Most importantly, these difficulties may profoundly affect their judgment. The 

question has arisen whether the usual methods of 

assessing competency prior to allowing these soldiers 

to consent to treatment or to participate in research 

should suffice, or whether a special new category 

should be established in both treatment and research 

contexts to better take into account the recently discovered, unique cognitive impairments and needs of 

soldiers with head injuries.

Respect for these persons might require that a 

higher, stricter standard for determining competency 

be established. This would be, however, the first time 

that a special category of this type has been developed 

for such a specific group. Establishing such a standard 

could have the adverse effect of stigmatizing these 

individuals. It could also result in some soldiers becoming fearful or angry by limiting their autonomy 

or by alerting them for the first time that they had 

deficiencies of which they were unaware. This abrupt 

overwhelming of their denial could do exceptional 

harm.

The best approach in both these instances—

treatment and research—might be to provide greater 

procedural safeguards, individualized according to the 

harms potentially at stake. Depending on these harms, 

review of each soldier’s competency could be evaluated in detail by a specially constituted board with 

varied and exceptional expertise. This board could apply a graded standard, which would require a higher 

threshold for competency only when the treatment or 

research proposed posed a significantly greater risk. 

This approach might be roughly analogous to the 

greater protections provided now in regard to both 

treatment and research involving children. Requirements are established concerning children in research 

that don’t exist for adults and that vary according to 

the extent of children’s personal risks. DoD research 

regulations provide exceptional requirements for doing research that involves children, especially when 

the research involves more than minimal risk.

These additional innovative measures might be 

required on the basis of compensatory justice. Because 

these soldiers have taken extra risks on behalf of their 

country, safeguards that would help ensure that they 

make the best choices, even when they don’t know 

that they can’t make them, may be not only ethically 

optimal, but from the perspective of compensatory 

justice, may be ethically mandatory.

Decisions “Outside the Box”

The third postdeployment ethical issue to be discussed here involves whether it is ever justifiable 

for military physicians to make treatment decisions 

that are inconsistent with official policy. Should the 

military behavioral healthcare provider, for instance, 

always make decisions that are consistent with official 

policy, even if that policy may have a negative impact 

on patients’ treatment?
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Combat and Operational Behavioral Health

Official policy dictates that those active duty service members not physically or mentally capable of 

deploying should be placed on limited duty. Limited 

duty status is temporary, often removes the member 

from the current job, and serves several purposes. It 

allows the service member’s parent command the opportunity to obtain a deployable replacement. It also 

allows the nondeployable service member’s condition to improve so that return to full duty can occur. 

Without this limited duty option, this return may not 

be possible. Limited duty can, however, negatively 

impact treatment by reinforcing the patient role and 

delaying recovery. 

There may be instances, however, when a patient 

who is not mentally capable of deployment should 

not be placed on limited duty. For example, patients 

recently returned from war and diagnosed with PTSD 

from trauma that occurred during the war may not 

be mentally fit just yet to return to the war. It is often 

possible to continue to treat such patients clinically 

but not to place them on a limited duty status because 

they would not be deployed for some time. This can 

be highly advantageous and desired by such soldiers 

because it may prevent unwanted consequences from 

being placed for any length of time on limited duty 

status.

Is it ethical for the military behavioral healthcare 

provider in such a case to not follow official policy 

and to not place the patient on limited duty in order 

to provide or facilitate additional treatment? What 

is the best ethical choice in these instances? All rules 

tend by their nature to create some “bad results.” 

Military physicians making off-the-record exceptions 

may prevent some bad results. If, on the other hand, 

all such physicians commonly use their individual 

discretion, this would undermine the rules and possibly cause greater harm. In this case, it may be that 

military physicians would be ethically justified in 

making exceptions if the cases in which they would 

do so occur but rarely. In such instances, they should 

also establish and specify criteria that should be met. 

One such criterion might be that both the spirit and 

purpose for which the rule was made in the first place 

are not fundamentally violated.

What the relevant criteria warranting moral weight 

should be may vary depending on the type of case. 

Military physicians may vary on the criteria they 

choose and the moral weight they place on each if 

they use their discretion. Still, using discretion, and the 

foreseeable harms this may bring about, may ethically 

outweigh the harms that will occur if they followed the 

rules so absolutely that no exceptions would occur.

This last example of military physicians making exceptions is, perhaps, paradigmatic of all the problems 

examined in this chapter and thus an ideal one with 

which to end this discussion. Most ethical questions 

involve a determination not so much of what the decision or decisions should be “across the board,” but 

rather where along the spectrum of real and imagined 

circumstances one should “draw the line,” why, and 

who should draw it.

In this chapter, the authors have attempted to highlight many of the existing ethical questions as well as 

new and emerging ones that have arisen. There generally are no self-evident answers to these questions that 

all reasonable persons will agree on. Still, the principles 

and most relevant facts should always be considered 

by those having the responsibility to make these decisions. This is what, more than anything else, ethics 

and ethical analysis has to offer. This analysis may 

enable decision makers to more maximally consider 

“both sides.” 

In some cases, “ethics” can clearly show something 

is wrong. The rationales for genocide used by the Nazis 

during World War II are an obvious and unequivocal 

example. In most, more difficult ethical problems, 

however, the questions that arise are and must remain 

open to debate. In these situations, the debate is not, 

however, so much over what is right and what is 

wrong, but as just discussed, what should be the general rule; when, if ever, one should make exceptions; 

and who should decide.

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