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The Warfighter’s Dilemma

by Wyatt Studniski

You were best friends in grade school and did everything together.  Joined the military together, went to boot camp together, deployed together.  It was fun at first and it felt just like the vacations of your childhood.  The ride there never seemed to end, but when you arrived it was like it never happened at all.  Then you haul around your packs, get settled into your new vacation home, and try to enjoy yourself.  But the good times are fleeting in war.  Grab the pack, grab the rifle, and march into the inferno.  Most of the time it goes right or as right it can go in war, but then.  The point man fell first in the ambush, then those immediately behind him.  The noise burst your eardrums, the explosions shook your bones, and the adrenaline pumped ever faster throughout your body.  Those still alive were able to manage a haphazard defense.  Even in the confusion you never left his side and he the same.  The screaming only got worse, never drowned out by the noise, nor ever forgotten.  Air support wasn’t enough and the artillery couldn’t deter.  The heat of it all burned deep in the unrelenting humidity.  Then his rifle exploded violently, throwing shrapnel into your arm and abdomen.  You stumbled, then crawled, wiping the blood from your face as you reach him.  No amount of pressure could stop the bleeding, replace the limbs, or stop the screams.  Helicopters sputtered overhead, but they never landed.  You could hear the bullets hit and pierce the steel as you pleaded for them to land, but they barely escaped themselves.  The medics couldn’t make it, maybe they too were dead or dying.  Your words could not seem to comfort him as he slowly died.  He whispered, and you leaned in to listen as he asked for his momma.  The tears and blood mixed together as they flowed down your face.  You couldn’t just leave him there, but you both knew he wasn’t going to leave that piece of ground alive.  As you drew out your pistol and inched it slowly near, his shaking hand pulled it close.  Not many made it out.  Nobody went home unscathed by the horror and pain.  Now the memory of what you did will haunt you, but the suffering needed to end.

Fig. 1. Marine holding a wounded comrade in Vietnam circa 1967 (Leroy).

The aim of this paper is to show when battlefield euthanasia can be a viable choice of action, but never be legalized.  Battlefield euthanasia is a reality in war, and to get a better understanding of battlefield euthanasia, regular euthanasia should first be covered.  The basic meaning of the word euthanasia “comes from two Greek words, eu and thantos, literally meaning ‘easy or gentle death’” (Olasunkanmi 31).  The Nazis also used the word as a “euphemism… to sanitize their early extermination of those they deemed defective” (Kipnis 79).  Also, the Greeks, “in Hippocrates time… permitted euthanasia or suicide as an alternative to a lingering and painful death” (Neuhaus 308).  Battlefield euthanasia is when someone is dying without hope to recover and is thus killed to relieve them of their agony.  This should be seen and performed as a merciful act when done with proper intent and the utmost empathy for the persons suffering.  Euthanasia can be differentiated between the two forms, “passive and active” (Olasunkanmi 31).  To mercifully kill someone in the passive form is to withhold care when they could otherwise be kept alive, but not without a great deal of suffering.  “Active euthanasia” is the use of some form of force, whether that be a firearm, pill, or syringe (31).  This is the more relevant form in relation to battlefield euthanasia, because typically some type of force will be used, but this is not to say passive might not also have a role.  Lastly, the three different types of consent, according to Olasunkanmi, must be discussed.  “Voluntary euthanasia” is quite obvious in that the receiver is asking for it voluntarily, expressing their autonomy.  Second, “involuntary euthanasia is conducted against the will of the patient”.  The suffering individual’s autonomy was not respected and was killed by someone who thought they were being merciful by euthanizing them.  Third, “non-voluntary euthanasia” happens when the act is performed because the patients consent is unavailable (31).  An example would be someone who could be unconscious, brain dead, in a coma, or any other way communication cannot be achieved to tell whether or not the person would like to die.  They could not exercise their autonomy.

There have been many cases of battlefield euthanasia throughout history.  Accounts range from biblical instances up into the present-day wars occurring in the middle east.  One case of an acceptable case of battlefield euthanasia comes from world war two; “Jewish physicians decided to administer hydrogen cyanide to four patients unable to be moved… to spare them [from] the expected brutality and death at the hands of the Sonderkommando” (Neuhaus 307).  Especially with hindsight, it can be seen that this was an acceptable case of battlefield euthanasia.  An example of an unacceptable case took place in 2008 when Canadian Capt. Robert Semrau shot an injured Taliban fighter who was not given any medical aid, and British helicopters were even available to provide medivac, but were not called (Perry 119).  By the end of this paper it should be surmised as to why the first example would be acceptable and the second as unacceptable based on my arguments.

The rules the Geneva Convention (circa 1949) has regarding the wounded should be provided and understood for those who don’t know because some points of the following passage will be brought up in later argument:

Members of the armed forces… who are wounded or sick, shall be respected and protected in all circumstances.  They shall be treated humanely and cared for by the Party to the conflict in whose care they may be… Any attempts upon their lives, or violence to their persons, shall be strictly prohibited…; they shall not willfully be left without medical assistance and care, nor shall conditions exposing them to contagion or infection be created.  Only urgent medical reasons will authorize priority in the order of treatment to be administered… The Party to the conflict which is compelled to abandon wounded or sick to the enemy shall, as far as military considerations permit, leave with them a part of its medical personnel and material to assist in their care.  (Cunningham)

Another part of understanding battlefield euthanasia is to talk about battlefield triage.  The word triage itself originates “from the French verb trier, meaning ‘to sort’” (Pelegrino 381).  Defined, the word triage is the “screening and classification of wounded, sick, or injured patients during war or another disaster to determine priority needs and thereby ensure the most efficient use of medical and surgical manpower, equipment, and facilities” (381).  It should seem redundant that those in the most need would receive the most care during a disaster situation given there are adequate resources available.  When sorting out the casualties there are five different classification that are assigned in “decreasing order of medical emergency” (381).  The first, or those in need of care immediately is “urgent… if death is to be prevented” (381).  Second is “immediate,” those who need life threatening wounds stabilized (381).  Third is “delayed,” and fourth is “minimal” (381).  Lastly, “expectant” are those individuals that are so severely wounded that “even if [the] patient were the sole causality, his survival is still unlikely” (381).  They are the unlucky person who is evaluated and left to die (and suffer) so others can be treated.

That last category, “expectant” leads me into my first set of arguments.  Those tagged to death don’t necessarily need to suffer until they die.  If medics are available and they still have supplies to spare, they can administer morphine to dull the pain.  If the medic has an ample amount of morphine, and feels it is appropriate, he may even give several doses to help with the pain.  But there is a problem with administering too much morphine: it can cause the patient to die.  In the civilian world, terminal sedation happens when a “doctor can render a patient unconscious while withholding nutrition and hydration: death ensues in a matter of days” (Kipnis 79).  The battlefield version of terminal sedation is the same principle; the use of force via a drug to cause death, but much faster rather than delayed over several days.

Now, I will illustrate how morphine can kill someone.  There are a couple of ways morphine can kill you, first is when an overdose occurs.  “Morphine is an opiate… [and] doses of morphine over 200mg are considered lethal to [the] average person… [but] in cases with hypersensitivity, even 60mg… can cause death” (“Morphine”).  However, that is less likely to be why the person died from terminal sedation via morphine.  “Morphine causes general central nervous system depression, the most common effects being slowed breathing and heart rate” (“Adverse”).  A lack of oxygen is what can be drawn from that statement.  For the severely wounded who are bleeding (internally or externally), possibly missing limbs, be in shock, and/or have punctured lungs this is a serious threat.  They are very likely going to have issues breathing which is reducing oxygen levels, along with losing the blood to carry the oxygenated cells, and then have the morphine now suppressing their breathing.  When oxygen levels get very low brain cells will start dying, and the heart will stop beating as well, resulting in death if immediate action is not taken.  Immediate action would be something like CPR, but in a combat situation the medic will not always going to have time to do it when there may be other causalities to attend to.

In most cases, terminal sedation is not being seen as a criminal act of battlefield euthanasia, as with the civilian use of it.  Before I give reasons as to why accidental terminal sedation may happen, I would like to assume that a modern combat medic’s training is sufficient enough to prevent it from happening.  But, terminal sedation could still happen for several reasons, first of which is like previously stated, a medic could have a hard time knowing when a patient’s breathing will slow enough to kill them in a chaotic situation.  Another reason could be when the medic is jumping from one wounded to the next while triaging, he could lose track, become stressed, fatigued, or another soldier may have already administered morphine, or the medic may have become incapacitated in some way.  All of those make it much easier to explain when it happens in the heat of combat because the wounded are being treated as the Geneva Convention demands.  These reasons also offer a good alibi when it is performed intentionally.  So, how does this relate to battlefield euthanasia?  Well, I believe that it is no different for several reasons, and yet it is mostly overlooked it seems.  The wounded individual is being killed in order to relieve them of their suffering through direct action of another.  It would be categorized as “voluntary active euthanasia” (or involuntary if unconscious) because of the use of force via the syringe used to inject it, and the soldier wanting the medical care.  To finish, I believe there is nothing wrong with terminal sedation on the battlefield when done with the proper intent and the utmost empathy for the persons suffering like I have previously mentioned.

Now for forced abandonment: when someone has to be left behind, most likely to die.  The forthcoming arguments are best analyzed by the use of a paraphrased version of the “Swann Scenario” (Pelegrino 384).  In this scenario, sometime during the Cold War, the Soviet Union invades and a vicious war erupts.  The Soviets are brutally advancing with unconfirmed reports that they are killing severely wounded POWs, and possibly torturing them as well.  As a physician in a field hospital you are swamped with casualties.  Supplies are becoming a growing concern as there has been no resupply, and a future resupply is uncertain.  With the Soviet advance threatening the field hospital, you are ordered to retreat immediately.  The problem is with very limited time and transportation, it will not be possible to bring all of the causalities, especially the severely wounded in order to retreat successfully.  This leads me to ask three questions: Do you stay with them and provide care as the Geneva Convention would want?  Do you leave them behind to suffer and possibly be killed, or tortured by the Soviets? Do you euthanize them?

The first argument concerning this scenario is a strait forward one, the Utilitarianism approach.  An incredibly basic understanding of what Utilitarianism is, would be through it’s “maxim, ‘the greatest good for the greatest number’” (Peligrino 392).  This is the Principle of Utility; the idea that the greatest amount of happiness must be achieved at the cost of the least amount of unhappiness at all times in all situations, for all individuals involved.  To decide what is morally right or wrong by using the principle of utility it can be looked at as a simple math equation.  When trying to decide, the happiness and unhappiness must be counted up among all the options by whatever standard dictates a unit (which is quite tricky).  Then with some basic arithmetic it will show which option is left with the most happiness left after subtracting the unhappiness.  Which makes that the correct option according to the principle.  So, when you add up the happiness of a few causalities getting their physician to stay, and compare it to the vast amount of potential happiness by the physician leaving the answer should be obvious.  My reasoning for using this principle though is to argue for the euthanasia of the causalities by the physician.  The unhappiness of dying would be great, but the unhappiness of having to wait for its release, possibly be tortured, and then die would be a greater amount of suffering.  Either way it is only unhappiness that is compared, but the least amount is enough to justify the action.  Sometimes we have to settle for the lesser of two evils so to speak.  By actively euthanizing, or letting the expectant and urgent causalities die by means of abandonment, it will allow the medical unit to provide care for future causalities.  This action would be better for the combat unit because it will continue to get medical care rather than be severely crippled by the loss of a physician, and their team/supplies.  The form of euthanasia should also be considered because if medical supplies are used to mercifully kill the wounded, it would be a waste.  The supplies would be better used on future casualties rather than euthanasia (392).  “The utilitarian analysis would seem to require euthanasia of (or simply abandoning) all patients and retreating with an intact unit and supplies” (392).

You may be asking, aren’t doctors supposed to care for their patients, and not kill them?  This is a normal train of thought in a world with seemingly unlimited supplies, and sophisticated medical equipment.  On the battlefield, that is not the case, especially in the “Swann Scenario” (384).  The “Hippocratic Oath states ‘I will prescribe regimen for the good of my patients according to my ability and my judgement and never do harm to anyone’” (384).  With that in mind it would seem that the physician should not mercifully kill the causalities.  That is the “dominant interpretation of the oath” accepted by most people, but the oath can be interpreted differently (391).  By not allowing “a comfortable death… it is ‘doing harm’ to the patient [by allowing] him to continue… suffering” (391).  Not to mention that he could be tortured by the Soviets, and this suffering would not only be physical, but mental as well.  Knowing that you have been left behind to die, not knowing when you’re going to die, or how you will die, and wondering what the Soviets may do to you would be unneeded suffering.  By not euthanizing, it “violates the… conflicting goal of acting ‘for the good of my patient’” (391).

Now you may be pondering, well the physician can still abandon and let the causalities die rather than kill them.  The physician could do that if they so choose, but abandonment of a patient is prohibited and punishable.  Although, it may be able to be overlooked in situations like the “Swann Scenario” I would still argue against leaving the causalities to suffer.  I am a first responder, and it was made quite clear that as a first responder I would get in a great deal of trouble if I ever abandoned a patient.  Whether it’s me at the bottom of the ladder or the physician at the top, abandonment is strictly prohibited.  Now that I have made that quite clear, what else can justify the euthanasia of the causalities in the “Swann Scenario” (384)?  To clarify, as an EMR I can only leave a patient when someone of an equal or greater level of training like an EMT takes over, or I can no longer provide care because I am not physically able, or the area becomes too dangerous for my safety.  Kipnis provides an argument regarding a civilian catastrophe that can be applied to this military scenario:

Once the patient is unattended, no further care can be on offer.  When the only other option is to abandon the patient (no care at all), it may be that the best treatment would be one that beneficently and painlessly ends life.  The euthanizing of black-tagged patients… may represent ‘appropriate care under the circumstances’: the least-worst option.  On this argument, forced abandonment would justify euthanasia rather than merely excuse it.  Not only would it be a reasonable choice: it would be the right choice. (79)

This argument would not allow me to justify killing one of my potential patients just because the scene became unsafe for me when firefighters, or other specially trained recovery teams could then go provide care.  This does however apply to the overall theme of chaotic, and disastrous military situations where there is the argument for the accepted use of battlefield euthanasia.

One last argument, but now from the perspective of an individual’s case rather than the previous ones focusing more on the physician.  This story comes from World War II when a Russian officer who collaborated with the Nazis was mortally wounded in France by an SAS, and French partisans ambush.  “Still lucid… [he] begged his SAS captors to kill him… ‘what would you do?’ he asked. ‘If I go back to Russia, I’ll be shot. If I go back to my German masters, I’ll be shot.  And now these Frenchmen want to shoot me too for what I’ve done here’” (Macintyre 30).  He was shot in the head by an SAS commando in response to his dire question.  There was no chance of living for the Russian, he would die from his wounds, or by his perceived notion of execution at the hands of the Germans or Russians.  He clearly gave voluntary consent to be euthanized, and the SAS/French partisans were in no position to provide any level of adequate care.  For those who think it is wrong to kill no matter what the case may be, and say it would be better to let him die rather than euthanize him, I will leave you with this:

A famous argument by James Rachels… there is no necessary difference between killing and letting-die, meaning that if someone’s motives and intentions are ethical, then either choice can be justified; moreover, active euthanasia can actually be more ethical than letting die, if euthanasia will result in less suffering to a mortally wounded or terminally ill patient. (Perry 119)

Even with all these arguments for the acceptable use of battlefield euthanasia, it should never be legalized.  By allowing it to be legalized there would be a presumably strong chance for it to become a slippery slope issue.  It would also be incredibly difficult to enforce.  Along with the possibility that it could get out of control further by soldiers performing it outside of acceptable parameters, which could prompt the enemy to so as well.  This would be even more of an issue with the countries that have signed and abide by the Geneva Convention than those who have not.  It would leave no guaranteed rights for the wounded if they chose to abuse the law.  An example of these lack of rights can be seen in the Vietnam war when I interviewed a two-tour vet; “They (the Vietnamese) were known to kill their own wounded… [and] if you (an American) couldn’t move when they found you, they wouldn’t bother moving you and just kill you, too” (Doe).  The vast possibilities of abuses presented by this slippery slope argument should be reason enough to keep battlefield euthanasia from being legalized.  But I feel that there is more to add:

Retired US Marine Corps lawyer Col. Stephen Shi argues that ‘hard cases make bad law,’ and concludes that it is better to keep the rule for soldiers very simple: do not kill anybody who is not a threat… it would be unfair to ask soldiers to bear the burden of making euthanasia decisions or carrying them out, given all of the other pressures and traumas weighing on them in combat. (Perry 119)

This could also apply to physicians, but they are highly trained and unlikely to be subjected to direct combat, and I stand by my earlier argument regarding them.

To conclude, there is a time and a place for battlefield euthanasia to happen and be acceptable.  Those instances are hopefully few and far between.  If and when they do happen however, I hope justifiable reasons can be seen and taken into consideration when a punishment is handed down by the military courts.  “It may seem justifiable to end unbearable suffering, but we need to be sure the unbearableness of the suffering is a verifiable fact, not merely a well-intentioned assumption” (Cunningham 133).  If I could not persuade you, I hope I have at least opened your eyes to a reality in our world that should be not be ignored, or wholly condemned.

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