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The moral rules of war, developed over two millennia, are referred to as just war theory. There rules may be divided into two groups, those that govern when a war may be initiated (rules of jus ad bellum) and those that govern how a war should and should not be fought (rules of jus in bello). These rules may be interpreted in different ways, for example, by distinguishing between a standard and a revisionist account of just war theory. Moral matters of war are also matters of bioethics when medical practice and medical research concerns apply to the practice of war. In such cases, the moral rules of war usually coincide with the rules of bioethics.
The ethics of war and bioethics are areas of applied ethics that are distinct areas of ethical investigation with some overlap. In this entry, the ethics of war (known as just war theory) is examined ﬁrst, and then the discussion shifts to a consideration of the area of overlap between the ethics of war and bioethics.
History And Development
Discussion about the ethics of war has been alive for over 2000 years. This intellectual conversation was for much of the time carried on primarily in a religious context, but more recently has also been pursued in secular terms. The main question has been: When and how is it morally permissible to wage war? What are the moral rules that apply to/in war? Traditionally this question has been put: When is a war (and war ﬁghting) just? This usually means, when is war and war ﬁghting justiﬁed? The result of this ancient discussion, the intellectual efforts to answer this question, is referred to as just war theory. An examination of the relation between the ethics of war and medical ethics is of more recent vintage.
As long as there have been human societies, there has been conﬂict among them, and this conﬂict has sometimes been violent. Warfare is the form such violent conﬂict has taken at least since human groups achieved a level of political organization characteristic of states. War may be deﬁned as organized large-scale armed conﬂict between states or state-like groups. War is an instrument, undertaken for a purpose. This is recognized in the famous adage of Carl von Clausewitz that war is the continuation of politics by other means. But in understanding war from a moral perspective, it is important to recognize that war is a purposive activity, and so it is inherently rule governed. It is not random or mindless violence. As there are moral rules that apply to war, there are moral rules that apply to the practice of medicine or bioethics, and these two sets of rules relate to each other in a number of ways.
Just war theory concerns the ethics of war, and many issues of bioethics arise in war as well. War is, in many cases, the ultimate public health catastrophe. Individuals in vast numbers are slaughtered, often in horrible ways, and many others endure great, long-lasting suffering. Medical resources are called upon to save lives and ameliorate the suffering, but they are inevitably inadequate to the task. The technology of saving lives advances, but the methods of military destruction develop more quickly, and in war, methods of destruction get the lion’s share of the resources. The issues of bioethics arising in war overlap some of the general moral issues of war. The discussion below will ﬁrst outline just war theory before turning to the moral issues where just war theory and bioethics join.
War is not only vastly destructive, but also often futile, leaving societies and individuals worse off than they were before the war. Given its destructiveness and futility, the most natural moral position to assume regarding it is one of complete prohibition, some form of paciﬁsm. But it seems that such an unconditional stance is too quick. To begin to understand war and its justiﬁability, it helps to think of it in terms of its opposite, peace. Peace is the absence of large-scale violent conﬂict, and, like war, is subject to moral assessment. If a particular condition of peace involves extensive social injustice, it is an unjust peace. If a state of peace is sufﬁciently unjust, it may be morally preferable to use violence to put an end to it. An unjust peace may exist within a state, as when there is slavery or extreme social oppression, possibility justifying a rebellion or civil war. Or an attack from without may threaten to replace a state’s just peace with the unjust peace of conquest, and this may justify a defensive war by that state. The claim that war can be just is the claim that peace can be sufﬁciently unjust that violence directed at putting an end to the injustice might itself be just. (Note that “war” here refers to the violent efforts of one side or the other in an overall armed conﬂict. In an overall conﬂict, which is sometimes referred to as a war, one side may be just and the other side unjust.)
Just War Theory
Just war theory encompasses an array of views that lie on a spectrum between paciﬁsm and realism. Roughly speaking, realism is the view that morality does not apply to war. According to the realist, military actions cannot be judged in moral terms; war is a realm beyond morality. According to the paciﬁst, there is no justiﬁcation for military violence. In contrast, according to the just war theorist, it is a mistake to claim that war is always permitted (as the realist does) or to say that it is never permitted (as the paciﬁst does). Just war theory contends that war is sometimes justiﬁed and sometimes not. Different versions of just war theory put greater or lesser constraints on war, resulting in positions closer to either paciﬁsm or realism.
Just war theory is a moral position, but note here that there are not only moral constraints on war, but legal constraints as well. In the past three centuries, international law has developed an elaborate set of rules governing war, known as international humanitarian law or the law of armed conﬂict. This body of law overlaps extensively with just war theory, but the two are not identical. Often the moral rules serve as a guide to the development of the legal rules, indicating what the legal rules should be or how they should be interpreted (Dinstein 2005).
Just war theory is divided into two parts, traditionally known as jus ad bellum, which concerns the morality of war, when it is justiﬁed to go to war, and jus in bello, concerning morality in war, or how war should be fought, the moral limits of conduct within war. In the standard account of just war theory, the two are largely independent, meaning that a just war (one that satisﬁes jus ad bellum) can be fought unjustly (failing to satisfy jus in bello) and vice versa (Walzer 2006). According to a more contemporary view of just war theory, which may be called the revisionist account, jus ad bellum and jus in bello are more closely related, in that, for example, no military conduct in war can be justiﬁed, if the war in question is unjust in ad bellum terms (McMahan 2009). The difference between the two accounts is explored as in the remainder of this entry.
Jus Ad Bellum
The justice of war at the ad bellum level is determined by whether the war satisﬁes certain criteria. The most important of these is just cause; a war has a just cause when there are reasons for the war that morally justify it. The most common just cause is defense against unjust aggression. If one state unjustly attacks another state, the second state would have a just cause for engaging in a defensive war in response. For example, Poland had a just cause to go to war with Germany in 1939 in response to the unjust German attack. But whether a state has a just cause for war is often not as straightforward as in this example. The realworld complexity often makes just cause (and other just war criteria) difﬁcult to determine. For example, wars often result from a reciprocal series of increasingly hostile interactions between two states, and it may be unclear which side ﬁrst initiates an action that would count as a military attack.
Consider one special sort of case where the application of the criterion is less than clear-cut: what is called anticipatory defense. If an unjust attack is underway, clearly the state under attack has a just cause for a defensive military response. But what if the attack has not yet occurred, but is anticipated? Does a military effort in anticipation of an unjust attack have a just cause? For example, consider the 2003 United States war against Iraq. The main reason offered for this war was to stop Iraq from using weapons of mass destruction it was allegedly developing. Was this a just cause (leaving aside the charge that this reason was based on a claim known by the decision makers to be false)? The case would be difﬁcult to make. It would depend on such factors as the likelihood that the anticipated attack would occur, the expected time until the anticipated attack, and whether alternative measures of avoiding the attack were available. Speaking generally, there may be justiﬁable cases of anticipatory defense, but the case for it is difﬁcult to make. Justiﬁed cases of anticipatory attacks are usually referred to as preemptive wars, while those that are not are usually referred to as preventive wars.
But having a just cause, while necessary, is not sufﬁcient as an overall justiﬁcation for going to war; other ad bellum criteria must be satisﬁed as well. In addition to (1) just cause, there is the criterion of (2) legitimate authority, which requires that war be declared by the political leadership of a state or state-like group. Another criterion is (3) rightful intention: a state must go to war for a morally acceptable reason: the war’s just cause must be the reason for which the war is actually waged, rather than being offered as a mere excuse. Of course, reasons for war are often multiple, but the main reason must be morally acceptable.
The criterion of (4) proportionality prescribes that a war must be reasonably expected to bring about more good than harm. This is a difﬁcult criterion to apply, both empirically and conceptually. One issue is what counts as harm: Is the relevant harm only the destruction of lives and property (and does it include or exclude lives of the opponent’s combatants), or does it comprise also the preservation of forms of government and cultural values (and how are these different factors compared)? Proportionality is tied to the criterion of just cause because a war lacking a just cause is unlikely to do any good at all. In addition, a war must have a (5) reasonable chance of success. It is morally unjustiﬁed to launch a war that is a hopeless cause. Finally, war must be a (6) last resort. A war should not be undertaken unless all alternatives (such as forms of diplomacy) with a reasonable chance of success have been tried. The satisfaction of all of these necessary conditions is sufﬁcient to show a war to be just or justiﬁed. But each of them carries with it considerable uncertainty in its interpretation and application, often more uncertainty than just cause itself does. As a result, since just cause is the most important of the ad bellum criteria, when it applies, it is often mistakenly treated as determinative by itself of the moral status of the war.
Perhaps the most important question of jus ad bellum is the moral foundation of just cause. Because war is a practice of states (or state-like groups), the moral foundation is traditionally said to be state sovereignty, the right of states to be free of external aggression. This is the way that jus ad bellum is understood under the standard account. But the sovereignty of a state is often at odds with the rights of its citizens. The sovereignty of a state may be used to protect the individual rights of its citizens, but it may not. A state may hide behind its sovereignty to avoid outside interference in its policies of domestic oppression. For example, respecting the sovereignty of a state that holds a portion of its population in slavery or is engaged in genocide against a minority is obviously working against the protection of individual rights. This observation gives rise the revisionist account of jus ad bellum, under which the protection of individual human rights rather than respect for sovereignty is the moral foundation of the theory. Thus, there are two approaches to the moral foundation of just cause, and of jus ad bellum in general: the sovereignty paradigm of the standard account and the human-rights paradigm of the revisionist account (Lee 2012). To understand just cause, it must ﬁrst be determined whether it is state sovereignty or the rights of individuals that lies at the moral heart of jus ad bellum.
Consider examples where these paradigms speak differently to the question whether a war has a just cause. What if Nazi Germany had not attacked its neighbors but had carried out the Final Solution on its own territory? In that case, the sovereignty paradigm would have denied a just cause and ruled out an attack on Germany by those concerned to end the genocide. Ending the genocide would not count as a just cause for war because the sovereignty of the German state would have trumped concern for the lives of those being slaughtered within its borders. In contrast, the human rights paradigm would have found in the purpose of putting an end to the genocide a just cause for war. This contrast existed in fact in the case of the Rwandan genocide of 1994. Ending that genocide would have been a just cause under the human-rights paradigm, but not under the sovereignty paradigm. The conﬂict between these two paradigms is evident in the current state of international law. Much of the law of war is based on the traditional sovereignty paradigm, and it denies legal justiﬁcation to a war that violates sovereignty, while at the same time other aspects of international law, such as human rights law, provide legal support for a war launched against another state to end an internal genocide.
A humanitarian intervention is a war undertaken as justiﬁed under the human-rights paradigm, such as an invasion of Rwanda in 1994 to end the genocide would have been. The question is whether a humanitarian intervention can satisfy the just cause criterion, given that it violates the sovereignty of the state in which the intervention occurs. In fact, the idea of humanitarian intervention turns upside down the traditional model that a paradigm just cause is defense against attack by another state. A humanitarian intervention is an attack on a sovereign state, and if it is justiﬁed, then the state’s defense against that attack, despite the violation of its sovereignty, lacks a just cause and is unjustiﬁed (A war cannot be just on both sides.) (May 2008). If a 1994 military intervention in Rwanda would have been justiﬁed, the Rwandan military would not have had a just cause to resist the attack, as the sovereignty paradigm permits. If individual human rights are thought to provide the ultimate moral foundation for and constraint on state action, then sovereignty can be, at best, only of instrumental value. If the protection of individual human rights is what justiﬁes military intervention, then it is the human rights paradigm rather than the sovereignty paradigm that is the moral foundation for just cause in particular and jus ad bellum in general. The advent of the human rights paradigm as a contender for the proper understanding of just cause points to a world beyond sovereign states, morally if not legally. To put this view in other words, the human rights paradigm is sometimes expressed by a redeﬁnition of the idea of sovereignty: the sovereignty that is in fact a moral protection against military intervention is sovereignty understood as conditioned on a state’s respect for the human rights of its citizens. In this sense, Rwanda in 1994 was no longer a sovereign state and had lost its moral barrier against intervention. Under this view, sovereignty becomes instrumental, its purpose being to protect individual rights. But it is an imperfect instrument at best.
Jus In Bello
Consider now the second branch of just war theory, jus in bello, the morality of conduct in war. Jus in bello is also understood in terms of a set of criteria, each necessary and jointly sufﬁcient for conduct in war to be morally justiﬁed. The moral conditions of conduct in war may be grouped under three criteria: discrimination, proportionality, and due care. Jus in bello, like jus ad bellum under the human rights paradigm, treats respect for individual rights as central, but how the individual rights are understood under jus in bello depends on whether one considers the standard account or the revisionist account.
Under the standard account, the criterion of discrimination (sometimes called distinction) requires that combatants discriminate between enemy combatants and noncombatants (or civilians), permitting them to attack only the former. Noncombatants are said to be innocent, in a functional or causal sense, in that they are not involved in the ﬁght and so pose no direct threat. Because they are not involved, they are not liable to attack; they are morally immune to attack.
Attacking noncombatants is the most serious breach of jus in bello.
This criterion raises a number of questions. First, how precisely are combatants and noncombatants to be distinguished in functional or causal terms? The line between those who are uniformed and those who are not does not do the trick, for some in uniform are not causally responsible for the ﬁghting (such as medics and chaplains), and, more importantly, some not in uniform have direct causal responsibility for the ﬁghting (such as guerrilla ﬁghters and, more generally, anyone who “picks up the gun”). Those liable to attack are all those who engage in the ﬁghting, whether they wear a uniform or not. This explains, for example, the generally accepted view that munitions workers, those who make armaments, are sometimes liable to attack; when at work on the munitions, they have a fairly direct role in the ﬁghting. In addition, combatants are not subject to attack if they are hors de combat, that is, unable to ﬁght due to injury, or if they have chosen to surrender; such combatants are immune from attack because they not causally involved in the ﬁghting.
A second question follows from the fact that the standard account casts the criterion of discrimination in terms of a functional (or causal) account of liability to attack. It seems, from a moral perspective, that the line between those liable and those not liable to attack should instead be drawn in terms of the moral responsibility of individuals for the ﬁghting, not their causal responsibility for it. This is the way that individual human rights are usually understood. Consider that many combatants, while causally responsible for the ﬁghting, are not morally responsible for it because their actions are not voluntary (due, for example, to coercion or ignorance). In contrast, many civilians would be morally responsible for the ﬁghting even without picking up the gun, given, say, their avid political support for the war effort. In general, the functional view of liability to attack seems at odds with everyday morality, which regards such liability in terms of moral, not causal responsibility. This is one of the reasons why advocates of the revisionist account of just war theory reject the standard account.
A third question with discrimination arises because civilian deaths in war are unavoidable. If discrimination prohibited all civilian deaths, war would become morally impossible, and just war theory would be effectively identical to paciﬁsm. This conclusion is avoided by specifying that discrimination precludes only intentional attacks on civilians. In war, modern war especially, most attacks put civilians at risk, even when the intention of the attacker is not to harm them. Such actions are not ruled out by discrimination. The criterion requires only that any harm or risk of harm to civilians not be intentional. The harm or risk of harm to civilians may be foreseen, but it cannot be intended.
But there are limits to the amount of harm an attack can impose on civilians. It would be morally wrong for combatants to bomb a large civilian crowd seeking to kill an enemy leader in its midst, even though the attacker might argue that the resulting civilian deaths were not intended. This brings in the second in bello criterion, proportionality, which is similar to its ad bellum namesake, but applies not to the entire course of a war, as ad bellum proportionality does, but rather to individual military actions. In the case of individual military actions, proportionality requires that it be a reasonable expectation that the military action would bring about more good than harm, with “good” being understood as the contribution the action is likely to make to winning the war. So proportionality puts some limits on the extent of the unintentional harm to civilians: that harm cannot exceed the military value of the intended target of the action. (The revisionist account sees proportionality differently).
The criteria of discrimination and proportionality are brought together under the doctrine of double effect. This doctrine is centered on the distinction between harm that is intended and harm that is not (the two types of effect), and holds that while the former is restricted under the criterion of discrimination, the latter is restricted only under the criterion of proportionality.
The third in bello criterion is due care, which requires that combatants take precautions, beyond those imposed by discrimination and proportionality, to insure that military actions do as little harm as possible, consistent with promoting the success of the war effort. For example, in virtue of due care, jus in bello does not permit the killing of enemy combatants, if it is possible to achieve the military objective without killing them. The killing of enemy combatants is permitted in general only because the achievement of a military objective usually requires this. To take another example of the application of due care, if there is a choice between attacking a military target during a weekday, when many civilians would be about, and on a weekend, when many fewer would be, and the military value of the two attacks is not signiﬁcantly different, due care prohibits the weekday attack, even if proportionality would be satisﬁed in either case. But what if the weekend attack were, for some reason, more risky for the combatants undertaking it? Even so, given that the risk were not too much greater, due care still requires the weekend attack. Combatants should assume some additional risk in order to lower the risk of harm to civilians.
The Revisionist Account Of Jus In Bello
Consider now the revisionist account of jus in bello and how it differs from the standard account. One important difference between the two accounts turns on the question whether jus ad bellum and jus in bello are logically independent. On the standard account, as mentioned previously, they are, in that the moral requirements on conduct in war do not depend on whether one is ﬁghting a just or an unjust war. In World War II, for example, American and German combatants were understood as subject to the same in bello restrictions on how they fought. In other words, under the standard account, there is a moral equality of combatants, meaning that the same in bello rules apply to the combatants on each side (Walzer 2006). This seems counterintuitive to many, given that one side’s war is just, and the other’s is not. Why should those ﬁghting an unjust war have the same moral leeway as their opponents ﬁghting a just war?
The revisionist account rejects the morally equality of combatants, seeing it as a consequence of the stipulation that jus ad bellum and jus in bello are logically independent, which the revisionist account rejects. Revisionists point out that the moral equality of combatants is not in accord with everyday morality. Consider how everyday cases of self-defense are understood morally. If one gang A attacks gang B without justiﬁcation, members of A are in the wrong, and members of B are justiﬁed in ﬁghting back. At the ad bellum level, so to speak, gang B is justiﬁed in ﬁghting, and gang A is not. Moreover, B’s justiﬁed counterattack does not justify a response from A. But according to everyday morality, what applies to the gangs, applies to their members as well. So, at the in bello level, so to speak, members of A and B are not moral equals. Members of A started out in the wrong and continue in the wrong. This everyday view of the morality of self-defense applies to war morality as well. Thus, combatants ﬁghting a just war are not liable to attack at all. This is a major difference from the standard account. Jus ad bellum and jus in bello are logically dependent, as the moral judgment at the ad bellum level determines moral judgments at the in bello level: it is unjust of combatants ﬁghting an unjust war to ﬁght at all. Combatants ﬁghting a just war are not liable to attack (so long as they are otherwise acting justly).
The contrast between the two accounts is also clear in the earlier discussion of causal and moral responsibility. On the standard account, the distinction between combatants and noncombatants under the in bello criterion of discrimination is in terms of functional or causal responsibility. Revisionists reject this view, holding instead that liability to attack is determined by an individual’s moral responsibility for an unjust conﬂict. This implies, as in the case just considered, that combatants ﬁghting a just war are not liable to attack at all. But it also implies a difference in who is liable to attack on the unjust side: it is only those morally responsible for ﬁghting the unjust war. Among combatants, this excludes those who, for whatever reason, do not ﬁght voluntarily, and among civilians, this may include, for example, those politically agitating for the war. In all these ways, the revisionist account brings the morality of war closer to everyday morality.
Also different for the revisionist account is in bello proportionality. In bello proportionality requires that a military action do more good than harm, but good cannot be deﬁned simply in terms of contribution to winning the war, as in the standard account, because there is no good in a victory by the unjust side. In bello proportionality can be satisﬁed only by the just side, since those on the unjust side are not allowed to ﬁght at all.
It should be noted, however, that revisionists generally recognize that the law of war cannot in practice be cast in terms of individual responsibility, but must largely follow the moral judgments of the standard account. In the heat of battle, one can seldom determine the moral responsibility of individual combatants ﬁghting an unjust war. In addition, the question which side (if either) is ﬁghting a just war is often a difﬁcult and controversial matter, even among those who are unbiased and have all the facts. It is also a matter of complete impracticality after a war to punish all of those who fought for the unjust side. For these and other reasons, the law must treat those involved in a war largely on the moral ﬁction of the moral equality of combatants.
Intrastate War And Terrorism
In recent decades, the dominant form of warfare has been wars not between states, but within states. While many of these wars involve intervention by outside parties (as with the American and French interventions in the Vietnamese civil war), the primary belligerents are from within a state. Intrastate wars include insurgencies seeking to overthrow an established government (civil wars proper) and insurgencies seeking to secede from a state, to establish an independent state on part of the territory controlled by a larger state (secession). They also include struggles for power by opposing groups when there is no one group effectively controlling a state (a so-called failed state). A variation of civil war is where insurgents challenge a central government that is, or is perceived by them to be, a puppet of an outside power. In many cases, these insurgents would be referred to as guerrillas, and their insurgencies as guerrilla wars.
In recent times, intrastate wars have often been insurgencies fueled by ethnic strife, as in the case of the current struggles in the Middle East between groups representing Sunni and Shia Islam. The tribalism of recent intrastate conﬂicts seems to challenge the very idea of the state system, imposed by Europe on the rest of the world.
For a condition of war or belligerency to exist within a state, the lawless activity that constitutes the insurgency must be centrally organized. There must be a military hierarchy, that of a “state-like group” that effectively controls the insurgency, in the absence of which there can be no possibility of holding the insurgents to the rules of war. When there is a state of belligerency, the rules of war apply to all parties, and these rules require that insurgents be treated differently from normal lawbreakers. For example, combatants, unlike criminals, cannot be put on trial or punished for using violence against the state (unless they themselves have violated the laws of war). When lawlessness becomes war, it is the in bello rules that apply, not the rules of policing and criminal justice.
The main ethical question about intrastate wars is whether just war theory provides adequate account of them. Given the prevalence of intrastate wars, if just war theory could account only for traditional interstate wars, this would be a major defect. There are some differences between the two types of war that might require some minor revisions in just war theory, for example, the fact that guerrilla ﬁghters often blur the sharp line between combatants and civilians. But the main problem of applying just war theory to intrastate wars lies, not surprisingly, in the inadequacy of the sovereignty paradigm. This traditional paradigm cannot justify the taking up of arms against one’s own state, which is an intervention in its sovereignty, nor can it justify outsiders coming to the assistance of an insurgency, since that as well is a violation of sovereignty. But the human rights paradigm can justify such activities, which is a strong argument for a revisionist account, at least of jus ad bellum. If a sufﬁciently unjust peace can justify violence directed at its correction, this must be a remedy available morally to any group, whether within a state or without.
Consider brieﬂy terrorism, which may be deﬁned as a practice of deliberately killing civilians to create fear or terror in a population at large in order to achieve political change. While the tendency today is to think of terrorists as individual, nonstate agents, the greatest and the original terrorists have been states. Most major wars contain some element of terrorism on the part of one or more of the belligerents. For centuries there have been sieges and blockades seeking to force military surrender by starving a civilian population. The technique of terror was reﬁned in World War II with the terror bombings of Germany and Japan. It is, of course, categorically morally ruled out by the in bello criterion of discrimination. It is a war crime, not a legitimate act of war.
War And Bioethics
Bioethics includes a study of the moral principles governing medical practice and research. These principles can create moral conﬂicts in the context of war, conﬂicts which can be illuminated and ameliorated, but not eliminated, by an appeal to the principles of just war theory. But before examining these conﬂicts, consider how the medical consequences of war should affect the application of the principles of just war theory itself. The medical consequences of war are, of course, severe.
A proper consideration of the medical consequences of war is probably most relevant for applying the criterion of proportionality, whether at the ad bellum or the in bello levels. Consider ad bellum proportionality, which requires that war be undertaken only if there is reasonable expectation that the overall harm the war would do is less than the beneﬁts it would achieve. In making this calculation, the expected medical consequences of war play a major, but often unappreciated, role. One way in which these consequences are relevant concerns the time frame in which harms must be considered in the proportionality calculations. The medical consequences of war often continue long after the war is over. Suffering of course continues, but so do deaths. So proportionality must be thought of in terms of a longer time frame than that of the war itself. For example, states at war often attack the civilian infrastructure of their opponent, whether accidently or because it is considered an acceptable “dual use target” (a target with both military and civilian uses). Such attacks can result in high level of civilian death and suffering, especially among children, and these consequences occur not only during war, but long after war is over. This same line of thought applies at the in bello level, for example, in the atomic bombing of Japan. For decades after the attacks, cancer deaths continued to occur among those exposed to the bombs’ radiation.
Now consider moral issues arising in war from the perspective of bioethics. Many of these occur for medical personnel due to conﬂicts between their obligations in war and their obligations as medical professionals (Sidel and Levy 2003; Gross 2006; Mehring 2015). Physicians in war are often expected or required to act in ways that subordinate their patients’ best interests as, for example, when they are expected to provide treatment that quickly returns the wounded to battle at the expense of what is best for them medically. Or physicians might be expected to act paternalistically by applying certain treatments universally, such as vaccinations, which are thought generally to be in their patients’ interests, but which may be against the wishes of some of the patients. Another conﬂict concerns the medical treatment of civilians: medical personnel are committed by their professional ethics to treat anyone needing their assistance and to distribute this treatment based on the medical need (medical neutrality). But in the military they are often required to give preference to combatants (on their side) over civilians or enemy combatants. In another area, military physicians may be required to assist in interrogational torture being inﬂicted on enemy combatants.
Some of these conﬂicts, as mentioned earlier, are cases where both the rules of war and the principles of bioethics are being ignored, which means they may not be moral conﬂicts at all. This is so for participation in torture, which is inconsistent not only with the professional obligation “do no harm,” but also with recognized in bello rules about the proper treatment of prisoners of war. This may also be so with the demand that injured combatants be treated ahead of injured civilians. The in bello criterion of discrimination may reject this practice as well, since it emphasizes avoiding harm to civilians, even at some extra risk to combatants. One complicating factor in many of these cases is whether the medical personnel are or are not enlisted in the military, for if they are, there may be an additional professional obligation in play, namely, the obligation to follow military orders.
Another military issue of salience to bioethics concerns weapons that cause unnecessary suffering. An example of this is the hollow point (or dum-dum) bullet. One issue is whether medical personnel, as enlistees, should participate in a military effort where such weapons are deliberately used. Here, bioethics is largely in line with the in bello criterion of due care, and indeed with the law of war, under which such weapons are often prohibited. Another issue is whether medical professionals should participate in the development of such weapons, for example, in research concerning the medical effects of weapons such as poison gas, biological toxins, lasers, or sonic explosions on human subjects. Of special concern in this context are weapons that, by design or in practice, do more harm to civilians than combatants, weapons one might refer to as inherently indiscriminate. For example, combatants are often protected against potential chemical and biological toxins, but civilians are not. Other weapons in this category would include cluster munitions, depleted uranium munitions, and the defoliant Agent Orange. Here too, though, the prescriptive implications of bioethics would usually accord with those of the in bello criteria of discrimination and due care.
Morality puts major restrictions on war, both on its initiation and on the methods by which it is fought. Collectively, these restrictions or rules are referred to as just war theory. Just war theory is divided into two sets of such rules or criteria, labeled jus ad bellum, which concerns when it is just to ﬁght, and jus in bello, which concerns how it is just to ﬁght. Interpretations of just war theory include a standard account and a revisionist account. The moral rules of bioethics can also be applied to war, and when they do they largely overlap with the moral rules of just war theory. One of the most important points of overlap between just war theory and bioethics concerns whether military physicians should put ﬁrst their patients’ interests or their state’s military interests.
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