Contributors.

Modern war poses hard ethical problems for the practice of medicine, making it difficult to identify medical ethics during times of armed conflict with medical ethics during times of peace. This sets up an enduring challenge for medicine, as doctors and other healthcare professionals weigh their responsibilities as caregivers against other responsibilities and obligations that citizens must shoulder during war.

The battlefield and wartime conditions often challenge physicians as to their understanding and commitment to the ethics of medicine. In Homer's Iliad we read of the first physicians on the battlefield before the walls of Troy, the sons of Asclepius, Machaon, and Podalirius. In his 16th century autobiography, Ambroise Paré recounts the first case of battlefield euthanasia of the wounded and of posttraumatic stress disorder and was renowned for his skill and humanity in the care of his soldiers. Dominique Larrey established the principles of triage of the wounded during the Napoleonic wars. It is out of warfare that the Geneva Convention and the Red Cross emerged. But what does history tell us about the ethical dilemmas of the military physician? Should prisoners receive care equal to that given to one's own troops? Can torture be used to extract information that may save lives? Is it ethical to enslave captured soldiers? Is the doctrine of the double effect valid as originally applied to war? Should a physician's ethics require him or her to speak out against perceived violations? This paper explores these issues from a historical perspective and I seek the voices of soldiers in the field wherever possible.

When Hippocrates (or perhaps a contemporary) wrote these words, some time after 430 BC, he and his colleagues could do little for either good or harm to sufferers from infectious disease. Indeed, they themselves were at particular risk. Thucydides, describing the so-called plague of Athens of 430 BC (probably not bubonic plague, but unidentified) in his History of the Peloponnesian War, writes that “mortality among the doctors was the highest of all, since they came more frequently in contact with the sick.”I am grateful to Prof. Malcolm Dando for helpful comments on an earlier draft of this article.

By the end of the Second World War the advancing allied forces discovered a new nerve gas in Germany. It was called Tabun. Codenamed GA, it was found to be extremely toxic. British experts were immediately dispatched to examine the agent. On arrival, they discovered that German scientists had also developed even more toxic nerve agents, including Sarin, known as GB. The first organized testing of Sarin on humans began in October 1951 at Porton Down in Wiltshire, Britain's biochemical warfare establishment since the First World War. In February 1953, volunteer number 562 experienced the first recorded serious adverse reaction. Testing continued. Two months later, on April 27, six subjects were given 300 milligrams of Sarin. One of the volunteers, a man named Kelly, suffered serious ill effects, fell into a coma, but then recovered. Although asked by their superiors to reduce the amount tested to the “lowest range of dosage”—which would have been somewhere in the region of 10–15 milligrams—Porton's scientists continued their tests with a “lower” dosage, reducing it from 300 to 200 milligrams.I thank the two referees for their helpful and constructive suggestions. The paper was written as part of a Wellcome Trust-funded project on “Cold War at Porton Down: Medical Ethics and the Legal Dimension of Britain's Biological and Chemical Warfare Programme, 1945–1989.” I thank the Wellcome Trust for its generous support.

Point:

Wars must be won if our country … is to be protected from unthinkable outcomes, as the events on September 11th most recently illustrated…. This best protection unequivocally requires armed forces having military physicians committed to doing what is required to secure victory…. As opposed to needing neutral physicians, we need military physicians who can and do identify as closely as possible with the military so that they, too, can carry out the vital part they play in meeting the needs of the mission.

Counterpoint:

We believe the role of the “physician–soldier” to be an inherent moral impossibility because the military physician, in an environment of military control, is faced with the difficult problems of mixed agency that include obligations to the “fighting strength” and … “national security.”This paper is based on the Dual Loyalty Project (1998–2000), which was funded by the Greenwall Foundation to develop guidelines that protect the human rights of patients in situations where health professionals face dual loyalty conflicts. The intellectual contributions of the International Dual Loyalty Working Group, as well as the assistance of Ms. Kathy Mallinson and Dr. Joanne Stevens in preparing this manuscript are gratefully acknowledged.

Military conflicts inevitably lead to the detention and interrogation of adversaries (or perceived adversaries), and American military action in Afghanistan and Iraq has resulted in the protracted and scrutinized detention and interrogation of varied personnel. Detention and interrogation, in turn, inevitably lead to moral and legal questions, and these questions have been especially poignant during and following the aforementioned campaigns. Controversially, the Bush administration did not afford Geneva Convention protections to so-called enemy combatants; these protections would have increased the standard of care (e.g., legally, medically) afforded to detainees and would have limited the interrogation options available to military personnel. Also controversially, reports have alleged that military interrogators have practiced “stress and duress” tactics that include “sleep management” (i.e., sleep deprivation), “dietary manipulation” (i.e., food withholding), “environmental manipulation” (e.g., exposure to extreme temperatures, presence of dogs), forced maintenance of uncomfortable positions for extended periods of time, isolation (sometimes for longer than 30 days), hooding, and so forth.I thank the following people for their helpful discussions and feedback on the ideas in this paper: Jean Maria Arrigo, William Casebeer, Michael Davis, Jan Goldman, Michael Gross, David Guinn, Kenneth Kipnis, Justin List, Jonathan Marks, Albert Pierce, Michael Pritchard, Len Rubenstein, Allen Weiner, Matthew Wynia, John Yoo, Daniel Zupan, and two anonymous reviewers. Their correspondences should obviously not be taken to imply that any of them agrees with my conclusions. This paper was presented at The Australian National University and at the 2005 meeting of the Australasian Association of Philosophy; I thank those present for their comments, especially Dirk Baltzly, Jeanette Kennett, and Thomas Pogge.

We are living in a time of war on multiple fronts. This is as true metaphorically as it is geographically. In particular, we live in an age in which war has been declared against disease, and war has been declared against terror. This essay considers in tandem the costs of those wars—more precisely, the costs of those metaphors of war.The author gratefully acknowledges contributions to this paper from conversations at a colloquium of the “town-gown” medical ethics discussion group at Indiana University's Poynter Center for the Study of Ethics and American Institutions, with special thanks to Richard Miller (Poynter Center director), Jennifer Girod, Caitlin Kelly, Gates Agnew, and Byron Bangert, and from conversations at Tokyo University's 21st Century COE Project for Death and Life Studies, with special thanks to Susumu Shimazono and Miyako Takahashi.

The terrorist attacks of 2001 were a reminder that individual and collective safety cannot be taken for granted. Since then, physicians, alongside public health professionals and other healthcare professionals as well as nonhealthcare personnel, have been developing plans to enhance the protection of public health and the provision of medical care in response to various threats, including acts of terrorism or bioterrorism. Included in those plans are strategies to attend to large numbers of victims and help prevent greater harm to even larger populations.The Council on Ethical and Judicial Affairs of the American Medical Association formulates ethical policies for the medical profession through its interpretations of the AMA's Principles of Medical Ethics. The Council at the time this report was adopted consisted of Michael S. Goldrich, M.D. (Chair); Priscilla Ray, M.D. (Vice-Chair); Regina M. Benjamin, M.D., M.B.A.; Daniel Higginson (student member); Mark A. Levine, M.D.; John M. O'Bannon, III, M.D.; Robert M. Sade, M.D.; Monique A. Spillman, M.D., Ph.D. (resident member); and Dudley M. Stewart, Jr., M.D. Staff to the Council at the time the report was adopted were Audiey Kao, M.D., Ph.D. (Vice President, Ethics Standards Group); Karine Morin, L.L.M. (Secretary); and Sara Taub, M.Be.

Physicians have special professional obligations to respond to medical emergencies. A bioterrorism attack would be a medical emergency. Thus, it seems that physicians would have an obligation to respond to a bioterrorist attack. However, the scope of those obligations, and their limits, are vexed topics. General rules may be comforting but the details and nuances of particular situations will always be relevant.This work was supported by the MacLean Center for Clinical Medical Ethics. The funding source had no role in the analysis or in the decision to submit the manuscript for publication.

Those who read only the introductory section of “Physician Obligation in Disaster Preparedness and Response,” the statement from the AMA's Council on Ethical and Judicial Affairs, apparently an elaboration on CEJA Opinion 3-I-04, E-9.067, will find an expression of laudable professional responsibility in the face of a disaster. There the AMA authors explicitly acknowledge “that unique responsibilities beyond planning rest on the shoulders of the medical profession” (emphasis added). They also declare that, “physicians are needed to care for victims. In some instances, this will require individual physicians to place their health or their lives at risk” (emphasis added). As the AMA authors note, these responsibilities have been accepted at least since the writing of Thomas Percival in 1803 and endorsed by the AMA in posting their 1847 code. The commitments are also asserted in the preamble of the AMA's most current Principles of Medical Ethics, which states that “a physician must recognize responsibility to patients, first and foremost,” and again in Principle VIII, which states that “[a] physician shall, when caring for a patient, regard responsibility to the patient as paramount” (emphasis added).

The AMA's Council on Ethical and Judicial Affairs' position statement on “Disaster Preparedness and Response” is a welcome discussion of an important issue: the extent to which physicians have a responsibility to treat people affected by disasters in which the nature, source, and cause of the harm is unclear and where the risk is largely unknown.All authors contributed fully to drafting and shaping this paper.

In February 1975, a group of leading scientists, physicians, and policymakers convened at Asilomar, California, to consider the safety of proceeding with recombinant DNA research. The excitement generated by the promise of this new technology was counterbalanced by concerns regarding dangers that might arise from it, including the potential for accidental release of genetically modified organisms into the environment. Guidelines developed at the conference to direct future research endeavors had several consequences. They permitted research to resume, bringing to an end the voluntary moratorium that the National Academy of Sciences (NAS) had instituted several months earlier. They also served to illustrate that the scientific community was capable of self-governance, thereby securing public trust and persuading Congress not to institute legislative restrictions. Finally, they underscored the importance of weighing unforeseen risks inherent in some research against potential benefits that may arise from these same endeavors.The Council on Ethical and Judicial Affairs of the American Medical Association (AMA) formulates ethical policies for the medical profession through its interpretations of the AMA's Principles of Medical Ethics. The Council at the time this report was adopted consisted of Michael S. Goldrich, M.D. (Chair); Priscilla Ray, M.D. (Vice-Chair); Regina M. Benjamin, M.D., M.B.A.; Daniel Higginson (student member); Mark A. Levine, M.D.; John M. O'Bannon III, M.D.; Robert M. Sade, M.D.; Monique A. Spillman, M.D., Ph.D. (resident member); and Dudley M. Stewart, Jr., M.D. Staff to the Council at the time the report was adopted were Audiey Kao, M.D., Ph.D. (Vice President, Ethics Standards Group); Karine Morin, L.L.M. (Secretary); and Sara Taub, M.Be. Shane K. Green, Ph.D., was a Fellow in the AMA's Institute for Ethics.

The question of how to prevent the malevolent use of biomedical research is not new. It has its genesis in how to prevent any new technology, invention, or scientific discovery created for the benefit and advancement of human welfare being used for the expressed purpose of harming the human community. There is the ethical component, the social responsibility component, and the intent to preserve the beneficent characteristic of biomedical research (that it not be used for malevolent purposes) at stake in this issue.The views presented are strictly those of the author and do not reflect any official policy of the United States Army or the Government of the United States.

The American Medical Association's (AMA's) Council on Ethical and Judicial Affairs' (CEJA's) new “Guidelines to Prevent the Malevolent Use of Biomedical Research” are both timely and appropriate. These guidelines are a product of the increasing realization of the “dual use” potential of life science discoveries. Although biomedical research usually aims at the development of new medicines, vaccines, diagnostics, and so on, the very same discoveries that could benefit humankind in these ways also often have implications for the development of biological weapons. The CEJA Guidelines draw attention to this fact and hold that physician–researchers have responsibilities regarding the uses to which their discoveries are put. Medical researchers should assess the likely social benefits and harms of their work and avoid projects where the latter outweigh the former. Knowledge and the advancement of science should not be the only aims of scientists; “commitment to public welfare and safety” are also essential. Toward the aim of preventing the malevolent use of research discoveries, the CEJA states that “regulatory oversight” of research (with an eye to potential harmful uses of potential discoveries), increased ethics education of physician researchers, and sometimes perhaps even censorship of research findings, are warranted.

Although research findings have always been subject to abuse, scientific advances and recent events have increased concern about the perils of some biomedical knowledge. The Council on Ethical and Judicial Affairs (CEJA) addresses this potential in its guidelines for physician–researchers (PRs). The guidelines do not advance many novel ideas or provide substantive guidance for PRs. Advocacy for professionalism, weighing costs and benefits, and balanced oversight are uncontroversial and have been proposed before. The difficult task is to define what they require, and here the guidelines are vague. We discuss critically two issues that deserve careful attention.Authors contributed equally to this work. The views expressed herein are the authors' own and do not necessarily reflect the views of the National Institutes of Health, U.S. Public Health Service, or the Department of Health and Human Services.

These CQ Sources were compiled by Bette Anton.

In their paper “Members First: The Ethics of Donating Organs and Tissues to Groups,” Timothy Murphy and Robert Veatch question the ethical underpinnings of LifeSharers, a grass-roots effort to increase the supply of organs by giving organ donors preferred access to organs.

“Dissecting Bioethics,” edited by Tuija Takala and Matti Häyry, welcomes contributions on the conceptual and theoretical dimensions of bioethics.

The section is dedicated to the idea that words defined by bioethicists and others should not be allowed to imprison people's actual concerns, emotions, and thoughts. Papers that expose the many meanings of a concept, describe the different readings of a moral doctrine, or provide an alternative angle to seemingly self-evident issues are therefore particularly appreciated.

The themes covered in the section so far include dignity, naturalness, public interest, community, disability, autonomy, parity of reasoning, symbolic appeals, and toleration.

All submitted papers are peer reviewed. To submit a paper or to discuss a suitable topic, contact Tuija Takala at tuija.takala@helsinki.fi.Many thanks to Professor Raanan Gillon and Professor Dariusz Galasiński for their helpful comments on my earlier ideas on deception, and to an anonymous reviewer for the useful suggestions on the first draft.

This section is meant to be a mutual effort. If you find an article you think should be abstracted in this section, do not be bashful—submit it for consideration to feature editor Kenneth V. Iserson care of CQ. If you do not like the editorial comments, this will give you an opportunity to respond in the letters section. Your input is desired and anticipated.