Health Care in Contexts of Risk, Uncertainty, and Hybridity

278 Pages·2021·3.3 MB·English

by  Daniel Messelken, David Winkler

Military and Humanitarian Health Ethics
Series Editors: Daniel Messelken · David Winkler
Daniel Messelken
David Winkler   Editors
Health Care in
Contexts of Risk,
Uncertainty, and
Hybridity
Military and Humanitarian Health Ethics
Series Editors
Daniel Messelken, Zurich Center for Military Medical Ethics, Center for Ethics,
University of Zürich, Zürich, Switzerland
David Winkler, Center of Reference for Education on IHL & Ethics,
International Committee of Military Medicine, Bern, Switzerland
The interdisciplinary book series Military and Humanitarian Health Ethics fosters
an academic dialogue between the well-established disciplines of military ethics on
the one hand and medical ethics, humanitarian ethics and public health ethics on the
other hand. Military and Humanitarian Health Ethics have emerged as a distinct
research area in the last years, triggered among other things by the unfortunate
realities of armed conflicts and other situations of humanitarian disasters - man-
made or natural. The book series focuses on the increasing amount of ethical
challenges while providing medical care before, during, and after armed conflicts
and other emergencies. By combining practical first-hand experiences from health
care providers in the field with the theoretical analysis of academic experts, such as
philosophers and legal scholars, the book series provides a unique insight into an
emerging field of research of high topical interest. It is the first series in its field and
aims at publishing state-of-the-art research, illustrated and enriched by field reports
and ground experiences from health care providers working in armed forces or
humanitarian organizations.
We welcome proposals for volumes within the broad scope of this interdisciplin-
ary and international book series, especially proposals for books that cover topics of
interest for both the military and the humanitarian community, and which try to
foster an exchange between the two often separate communities of military and
humanitarian health care providers.
Editorial Board
Sheena Eagan, East Carolina University, Greenville, NC, USA
Dirk Fischer, Bundeswehr Medical Academy, Munich, Germany
Michael Gross, The University of Haifa, Israel
Matthew Hunt, McGill University, Montréal, Canada
Bernhard Koch, The Institute for Theology and Peace (ithf), Hamburg, Germany
Leonard Rubenstein, Johns Hopkins Bloomberg School of Public Health, Baltimore,
MD, USA
Andreas Stettbacher, Surgeon General Swiss Armed Forces and Chairman of the
International Committee of Military Medicine
Stephen Xenakis, Uniformed Services University of Health Sciences, Bethesda,
VA, USA
More information about this series at https://link.springer.com/bookseries/16133
Daniel Messelken • David Winkler
Editors
Health Care in Contexts
of Risk, Uncertainty,
and Hybridity
Editors
Daniel Messelken David Winkler
Zurich Center for Military Medical Center of Reference for Education
Ethics, Center for Ethics on IHL & Ethics
University of Zürich International Committee of Military
Zürich, Switzerland Medicine
Bern, Switzerland
ISSN 2524-5465 ISSN 2524-5473 (electronic)
Military and Humanitarian Health Ethics
ISBN 978-3-030-80442-8 ISBN 978-3-030-80443-5 (eBook)
https://doi.org/10.1007/978-3-030-80443-5
© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature
Switzerland AG 2022
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Contents
1 Health Care in Contexts of Risk, Uncertainty,
and Hybridity – Introduction to the Volume . . . . . . . . . . . . . . . . . . . . 1
Daniel Messelken and David T. Winkler
Part I Doctrinal and Legal Aspects
2 Military Medical Ethics & the United States: An Overview
of Recent Developments in the Operationalized Landscape . . . . . . . . 19
Sheena Eagan
3 Attacks on Hospitals: An Alarming Problem
for Military Medicine as Well as for Humanitarian Medicine . . . . . . 37
Philippe Calain
4 Impact of US Anti-Terrorism Legislation on the Obligation
of Non-state Armed Groups to Provide Medical Care
to the Wounded and Sick Under IHL . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Audrey Palama
5 Military Medical Staff in Hybrid Wars . . . . . . . . . . . . . . . . . . . . . . . . . 77
Paul Gilbert
Part II T reating Soldiers
6 Morituri Soldiers on Operation Theatres:
The French Approach and a Case Analysis . . . . . . . . . . . . . . . . . . . . . 89
Gwion Loarer and Julien Viant
7 Patient Preference Predictors and Paternalism
in Military Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101
Nathaniel Sharadin
8 Battlefield Euthanasia: Ethics and the Law . . . . . . . . . . . . . . . . . . . . . 115
David L. Perry
v
vi Contents
Part III Treating Civilians and Humanitarian Missions
9 The Ethical Challenges of Providing Medical Care
to Civilians During Armed Conflict . . . . . . . . . . . . . . . . . . . . . . . . . . . 131
Michael L. Gross
10 Bridging the Gap Between Intentions
and Outcomes in Military Humanitarian Assistance
and Disaster Relief Missions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145
Joanne Clifford
11 Rescuing Relief in Remote Management and Programming:
Using a Duty of Care Transfer Review to Assess
the Accountability of Humanitarian Interventions . . . . . . . . . . . . . . . 167
Ali Okhowat and Caroline Clarinval
12 Unpacking the “Oughtness” of Palliative Care
in Humanitarian Crises: Moral Logics and What Is at Stake? . . . . . 179
Elysée Nouvet, Matthew Hunt, Gautham Krishnaraj,
Corinne Schuster- Wallace, Carrie Bernard, Laurie Elit,
Sonya DeLaat, and Lisa Schwartz
13 Risk and Infectious Disease Outbreaks:
Should Military Medical Personnel Be Willing
to Accept Greater Risks Than Civilian Medical Workers? . . . . . . . . . 201
Heather Draper
Part IV D oing Research
14 When to Suspend Bioethical Principles in Military Medicine
for Operational Purposes: A Framework Approach . . . . . . . . . . . . . . 221
Nikki Coleman
15 The Ethics of Biomedical Military Research:
Therapy, Prevention, Enhancement, and Risk . . . . . . . . . . . . . . . . . . . 235
Alexandre Erler and Vincent C. Müller
16 Military Medicine Research: Incorporation of High Risk
of Irreversible Harms into a Stratified Risk Framework
for Clinical Trials . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 253
Alexander R. Harris and Frederic Gilbert
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 275
About the Editors
Daniel Messelken is a research associate at the Center for Ethics at Zurich

University and leader of the Zurich Center for Military Medical Ethics (www.
cmme.uzh.ch). He also serves as Head Ethics Teacher for the Center of Reference
for Education on IHL and Ethics of the International Committee of Military
Medicine and is member of the Board of Directors of the International Society for
Military Ethics in Europe (EuroISME). Dr Messelken studied Philosophy and
Political Science in Leipzig and Paris (1998–2004) and received his PhD in philoso-
phy from the University of Leipzig in 2010. Besides Military Medical Ethics, his
main research fields include Just War Theory, the Morality of Violence, Military
Ethics, and Applied Ethics more generally.
David Winkler is director of the Center of Reference for Education on International

Humanitarian Law and Ethics of the International Committee of Military Medicine
(www.cimm-icmm.com, https://melac.ch). He is a medical doctor specializing in
neurology and holds a PhD in neurobiology. Lieutenant Colonel Winkler is a staff
officer in the Swiss Armed Forces Medical Services Directorate. He conducts clini-
cal and academic work at the Cantonal Hospital Baselland, and the University
Hospital Basel, Switzerland.
vii
Chapter 1
Health Care in Contexts of Risk,
Uncertainty, and Hybridity – Introduction
to the Volume
Daniel Messelken and David T. Winkler
Abstract This chapter introduces to the main topic of the volume, namely the
influence of the changing nature of warfare on the provision of medical care and the
ethical challenges that occur. It presents the main ideas of relevant concepts such as
asymmetrical warfare, hybrid warfare, and complex emergencies before illustrating
the ethical challenges that new forms of warfare create for military and humanitar-
ian health care providers. Examples of ethical challenges include embedding medi-
cal personnel in combating forces, questions regarding the treatment of detainees,
the need to uphold medical neutrality, and pitfalls of using medicine to non-medical
ends. The chapter concludes with a synopsis of the volume.
Keywords Hybrid warfare · Asymmetrical warfare · Complex emergencies ·
Military medicine · Military medical ethics
This book sheds light at different ethical challenges faced by health care personnel
(HCP) working in contexts of risk, uncertainty, and hybridity. The link between the
ethical challenges lies in the difficulties imposed upon HCP by the adverse condi-
tions of the environment they are working in. Contexts of armed conflict, hybrid
wars,1 or other forms of violence short of war, but also natural disasters all have in
common that what is normal under ordinary circumstances no longer can be taken
for granted. Hence, the provision of health care has to adapt to a different level of
1 The term “hybrid war” is notoriously under-defined. See our discussion in Sect. 1.1.2 below.
D. Messelken (*)
Zurich Center for Military Medical Ethics, Center for Ethics, University of Zürich,
Zürich, Switzerland
e-mail: [email protected]
D. T. Winkler
Center of Reference for Education on IHL & Ethics, International Committee
of Military Medicine, Bern, Switzerland
e-mail: [email protected]
© The Author(s), under exclusive license to Springer Nature 1
Switzerland AG 2022
D. Messelken, D. Winkler (eds.), Health Care in Contexts of Risk, Uncertainty,
and Hybridity, Military and Humanitarian Health Ethics,
https://doi.org/10.1007/978-3-030-80443-5_1
2 D. Messelken and D. T. Winkler
risk, to scarce resources, or uncommon approaches due to external incentives or
requirements. This affects the practice of health care as well as what can be seen to
be ethically acceptable in such contexts.
The contributions to this volume discuss which of the developments and changes
in recent conflicts are the most problematic ones with regard to the continued provi-
sion of health care. This analysis can provide some ground to adapt the organization
of military health care in order to meet the new challenges. It can also initiate a
reflection on how military and civilian health care providers may better cooperate in
these new conflicts where clear boundaries between battlefield/ military and the
civilian environment tend to disappear. In this opening chapter, we will introduce
the volume’s topic by elaborating on some of the key concepts that are recently used
to describe the different contexts in which military and humanitarian health care is
delivered. We will introduce different concepts to grasp with the changing nature of
warfare (Sect. 1.1) before showing how these changes have an impact on the work
of health care personnel (Sect. 1.2). We will close the introductory chapter by out-
lining the scope of the volume and giving a synopsis of the contributions (Sect. 1.3).
1.1 The Changing Nature of Warfare – Where Are
We and What Are We Talking About?
In its Strategy 2015–2018 report, the International Committee of the Red Cross
(ICRC) denounces an “increasingly complex operational environment”. If such a
statement is issued by an independent actor with broad insight into contemporary
conflicts due to its presence in almost all countries around the world, it certainly
describes the reality to an important extent. One of the aspects of the complex envi-
ronment is caused by changes in the modes of warfare. According to the ICRC,
contemporary conflicts tend to develop into “protracted and complex armed con-
flicts” that take place in a “multitude of locations with a multitude of evolving actors
and alliances, and without a clear end in sight” (International Committee of the Red
Cross (ICRC) 2014: 4 f). Hence, conflicts are seldom fought on a single and clearly
demarcated battlefield, they emerge out of a mixture of motives, and they involve
non-state actors and armed groups as well as official states’ armed forces. Ten years
ago, Hoffman has noted this development and noted its potential to “blur the dis-
tinction between war and peace, and combatants and non-combatants” (Hoffman
2007: 7).
Of course, war has always changed its nature and appearance like a chameleon
as Clausewitz famously described it. So, there is nothing new in the pure fact that
there are changes in the modes and nature of war. The interesting aspect of how
warfare evolves could therefore be better described as the question which color war
is taking nowadays and how this color blends with the provision of health care dur-
ing armed conflict. The names and labels given to the conflicts and new modes of
warfare after the end of the so-called “Cold War” range from simply “New wars”