Abstract
In emergency situations and while medical resources are sufficient, doctors are expected to prioritize and treat patients according to medical criteria only. In MASSCAL situations and when medical resources become insufficient, patient selection and prioritization changes. Rules of triage are applied with the aim of getting the best result possible under the circumstances, e.g., saving the largest number; collective health outweighs individual health. Still, according to the standard ethical principles, non-medical criteria should never influence the doctors’ decision of who will be treated. In military contexts, so-called medical rules of eligibility (MROE) provide rules that include non-medical criteria. This chapter aims to analyze if, why, and under what circumstances it may be ethically acceptable to prioritize patients according to non-medical criteria.
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Notes
- 1.
https://ihl-in-action.icrc.org/case-study/united-statesunited-kingdom-medical-treatment-and-care-wounded-soldiers-during-persian [last accessed on September 14, 2022].
- 2.
All amendments are marked by the use of blue color. It is unclear, if the original figure was published by ISAF or whether it was created by von Uslar to illustrate an ISAF document.
- 3.
The date of this case is not mentioned in the article, but the mission during which it occurred lasted from 2006 to 2010 (https://en.wikipedia.org/wiki/Task_Force_Urozgan last accessed on 15 September 2022). It thus happened before the ISAF MROE referred to in this paper were enacted but may nevertheless serve to illustrate the ethical issue as similar cases certainly occurred after 2011.
- 4.
The ethical challenges of this role conflict are usually discussed under the heading “dual loyalty conflicts” but without a definitive answer to the problem. See for example Allhoff (2008).
- 5.
As a side note: In IHL, the term “military necessity” has a clearly restricting meaning: attacks etc. can only be allowed if they are necessary and no less harmful alternative exists. In philosophy, on the contrary, necessity is often invoked to justify exceptions that exceed what would be allowed under normal circumstances.
- 6.
Legal obligations however do persist even if reciprocity is not given. The fact that someone is stealing from me does not give me a right to steal from him in return. The same is true in IHL.
- 7.
This also may lead to perceiving neutral actors like MSF as belonging to one side: they treat those from the other side, but not ours. The reason that they do not treat military from all sides is however not their taking sides, but the still better care provided by the military medical services of one side.
- 8.
Even if one does not agree with the counterarguments, the RevJWT argument does not apply to MROE excluding “innocent” civilians from medical care. The exclusion from medical care of civilian victims who do not participate in the conflict cannot be made on the same ground than that of unjust combatants (if one accepts the unjust combatant argument at all).
- 9.
Remember: MROE are typically used during deployment and to distinguish different levels of access for local patients and deployed personnel.
- 10.
The recent discussions about potential triage situations in the context of the COVID-19 pandemic has however shown that the acceptance of rules for triage can be difficult within societies.
- 11.
In addition, the responsibility of having to decide when to admit additional patient groups may put an unfair burden on the medical personnel.
- 12.
For an overview of the Just War doctrine see for example (Lazar 2017).
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Acknowledgements
Financial support for the work on this chapter was granted by the Centre of Competence for Military and Disaster Medicine of the Swiss Armed Forces.
The author would like to thank his colleagues at the Center for Ethics of Zurich University and the participants of the 9th ICMM Workshop on Military Medical Ethics for their valuable feedback and criticism to earlier versions of this chapter. The opinions defended in this chapter are those of the author.
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Messelken, D. (2023). Medical Rules of Eligibility – Can Preferential Medical Treatment Provisions Be Ethically Justified?. In: Eagan, S.M., Messelken, D. (eds) Resource Scarcity in Austere Environments. Military and Humanitarian Health Ethics. Springer, Cham. https://doi.org/10.1007/978-3-031-29059-6_9
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