Medical Ethics and the U.S. Military
U.S. MEDICAL STUDENTS’ KNOWLEDGE ABOUT
THE MILITARY DRAFT, THE GENEVA CONVENTIONS,
AND MILITARY MEDICAL ETHICS
J. Wesley Boyd, David U. Himmelstein, Karen Lasser,
Danny McCormick, David H. Bor, Sarah L. Cutrona,
and Steffie Woolhandler
The objective of this study was to ascertain how much U.S. medical students
are taught about and know about military medical ethics, the Geneva Con-
ventions, and the laws governing conscription of medical personnel. The
authors developed an Internet-based questionnaire on these matters, and
e-mail invitations to participate were sent to approximately 5,000 medical
students at eight U.S. medical schools. Thirty-five percent of e-mail recipients
participated in the survey. Of those, 94 percent had received less than one
hour of instruction about military medical ethics and only 3.5 percent were
aware of legislation already passed making a “doctor ’s draft” possible;
37 percent knew the conditions under which the Geneva Conventions apply;
33.8 percent did not know that the Geneva Conventions state that physi-
cians should “treat the sickest first, regardless of nationality;” 37 percent
did not know that the Geneva Conventions prohibit ever threatening or
demeaning prisoners or depriving them of food or water; and 33.9 percent
could not state when they would be required to disobey an unethical order.
Several reports have alleged physicians’ complicity in the mistreatment of
prisoners being held by the United States at Abu Ghraib in Iraq and at Guantanamo
Bay in Cuba. Physicians may have advised interrogators as to whether particular
prisoners were fit enough to survive physical maltreatment, informed interrogators
about prisoners’ phobias and other psychological vulnerabilities that could be
exploited during interrogation, failed to report torture, and altered the death
certificates of prisoners who died as a result of torture (1–4).
International Journal of Health Services, Volume 37, Number 4, Pages 643–650, 2007
© 2007, Baywood Publishing Co., Inc.
Although the Geneva Conventions ban threatening, coercing, humiliating,
degrading, injuring, or murdering prisoners of war for any reason, the Bush
administration has argued that the Geneva Conventions do not cover the prisoners
at Abu Ghraib or Guantanamo Bay because they are “detainees” or “enemy com
batants” rather than “prisoners of war” (5–7). Nonetheless, physicians who accept
these labels violate medical ethical edicts. The World Medical Association, for
example, has declared that physicians should never participate in torture under
any circumstances (8).
It is not known, though, whether most military personnel understand what
constitutes torture. Some former U.S. Army interrogators have complained that
only after leaving the Army did they learn that tactics they were ordered to employ
at Abu Ghraib and elsewhere constituted torture by most definitions (9). A
2002 U.S. Department of Justice memo (10) that redefined torture as pain that
is “difficult to endure,” equivalent to the pain that accompanies “serious physical
injury, such as organ failure, impairment of bodily functioning, or even death,”
likely contributed to the Army interrogators’ ignorance about what is expected
of them ethically.
Recently, the number of U.S. physicians volunteering for military service has
declined, as has the number of students accepting scholarships for medical school
tuition in return for future military service obligations (11). These facts, combined
with a war on terror that has no end in sight, raise the possibility of a physician
draft, regardless of whether a general draft is instituted (12–14).
A plan for drafting health care personnel in the United States already exists.
In 1987, Congress authorized the Health Care Personnel Delivery System
(HCPDS), which established a specific process for a doctor draft. Congress and
the president can activate this process and begin drafting civilian physicians in a
matter of weeks. The HCPDS allows few exemptions and assumes a priori that
physicians practicing in the civilian sector are physically fit for military service.
How prepared would young physicians be for the ethical challenges of military
medicine? For this study, we queried medical students on their knowledge about
the potential for a doctor draft and the mandates of the Geneva Conventions, as
well as the amount of training they have received on military medical ethics.
We developed a computer-based questionnaire to assess medical students’ knowl
edge about the HCPDS and their attitudes toward a military draft; demographic
information; how many hours of education they had received on military medical
ethics; whom they supported in the last presidential election (to assess whether
responses were based on political beliefs and motivations rather than actual
knowledge); whether they had current, past, or future military obligations; and
whether they believed themselves to be familiar with the Geneva Conventions.
We then assessed the students’ actual knowledge of the Geneva Conventions by
644 / Boyd et al.
posing several hypothetical scenarios. The survey was formatted for e-mail distri
bution (as a website link) and automated tabulation of responses. Differences
between groups were analyzed using chi-square tests. We considered differences
significant only if the probability that they arose by chance was less than .01.
All analyses were conducted with SAS-PC statistical software (15).
Individual medical students at eight U.S. medical schools sent e-mail invitations
to participate in the survey to all of their fellow students and included a link to the
survey itself. Any student who clicked on the link arrived at a brief letter from
the survey’s authors followed by the questionnaire. No opinions about the war
or the military draft were expressed in the invitation e-mails, letter, or survey.
The Cambridge Health Alliance Institutional Review Board approved our
E-mails inviting participation were sent to approximately 5,000 medical students
at eight U.S. medical schools. Response rates at individual schools varied from
a high of 60.5 percent to a low of 19.4 percent. Overall, 35 percent of those who
received the e-mail, or 1,756 students, participated in the survey.
Characteristics of respondents are shown in Table 1. Fifty-one percent of
respondents were male; and 5.4 percent were currently serving in the military,
had served in the past, or were obligated to serve in the future. Respondents
represented each class (i.e., year) of medical school, although students expecting
to graduate four or more years hence were slightly over-represented (30.1% of
the sample). The majority of medical students (69.6%) supported Sen. John
Kerry in the 2004 presidential election.
Only a small percentage of respondents had received any instruction in
military medical ethics. About 94 percent had received less than 1 hour of
instruction during medical school about the ethical obligations of physicians
serving in the military. Just over 4 percent had received between 1 and 5 hours
of instruction, and 1.5 percent reported receiving more than 5 hours of teaching
about these matters.
Knowledge of the potential for a military draft was scant (Table 2). While
23.8 percent of students thought that a medical draft was more likely than a
general draft, only 3.5 percent of students were aware of the HCPDS. When
asked what course of action they might take if a physician draft were proclaimed
next week, 8.7 percent said they would “volunteer for service,” just over one-third
would use legal means to avoid or defer service, and more than one-fifth would
emigrate or refuse military induction. Thus, fewer than 50 percent of respondents
would willingly serve.
Overall, 5.7 percent of respondents believed they were “very familiar” with the
Geneva Conventions, and 66.1 percent responded that they were “somewhat
familiar” with them. But despite this 71.8 percent of respondents stating that they
Geneva Conventions and Medical Ethics / 645
felt either somewhat or very familiar with the Geneva Conventions, only
37.4 percent of all respondents correctly answered that the Geneva Conventions
apply regardless of whether or not one’s country has formally declared war.
When asked which wounded individuals should be treated first, 66.2 percent
of our total sample answered correctly that physicians should “treat the sickest
first, regardless of nationality.” More than a quarter (26.5%) incorrectly answered
that they should “treat their own soldiers according to level of severity and then
attend to the wounded enemy.”
Our scenario on acceptable interrogation practices asked what treatment was
permissible according to the Geneva Conventions if a prisoner is refusing to
answer questions about a recent skirmish in which more than 50 U.S. soldiers
died. More than one-third (37%) of respondents did not know that the Geneva
Conventions stipulate that it is never acceptable to deprive prisoners of war
of food or water, expose them to physical stresses such as heat, cold, and
uncomfortable positions, or threaten them with physical violence even if these
threats are not carried out.
646 / Boyd et al.
Characteristics of medical student respondents, percent
Expected year of graduation
2009 or later
Present, past, or obligation for future military service
Hours of training in military medical ethics
Candidate supported in 2004 U.S. presidential election
We asked under what circumstances an officer is ethically required to disobey
a direct order from a superior, and offered the following options: “when ordered
to threaten a prisoner with injection of a psychoactive drug that will not actually
be administered,” “when ordered to inject a harmless bolus of saline into a
prisoner who fears he is receiving a lethal injection,” “when ordered to inject
a lethal drug into a prisoner,” “all of the above,” or “none of the above.” Just
over 27 percent of respondents thought that the only scenario in which they
were ethically required to disobey was when asked to inject a lethal drug into
a prisoner; over 6 percent felt that none of these scenarios required them to
disobey; and 66.1 percent correctly answered “all of the above.”
Responses did not vary significantly by gender, expected choice of medical
specialty, expected year of graduation, or medical school. When students were
Geneva Conventions and Medical Ethics / 647
Medical students’ knowledge about the Geneva Conventions and the
military draft, and likely responses to a medical draft, percent
Aware of HCPDS
Is a medical draft more likely than a general draft?
Likely response to a medical draft
Volunteer for service
Await draft notification
Use all legal means to avoid service
Refuse military induction as an act of civil disobedience
Self-reported familiarity with Geneva Conventions
Not at all familiar
Correctly identified physicians’ obligations under Geneva Conventions
Situations in which Geneva Conventions apply
Priorities for treatment of wounded individuals
Acceptable interrogation practices
Situations in which orders must be disobeyed
Health Care Personnel Delivery System, the congressionally mandated process for drafting
physicians and other medical personnel.
stratified by presidential preference, two differences were noted. First, Bush
supporters were more likely than others to say that they would volunteer (25.8%)
and less likely to say that they would actively avoid service (23.8%) by legal
means, emigration, or civil disobedience (p < .0001). Second, Bush supporters
were one-third less likely than Kerry supporters (p < .0001) to know that prisoner
interrogations that deprived prisoners of sleep, food, or water or included threats
were illegal under the Geneva Conventions, or that it was necessary to disobey
officers who ordered such mistreatment. On all other questions, Bush supporters
answered similarly (p > .01) to other students.
Those with past, current, or future military service obligations differed from
other students on several dimensions. They were more often male (78.1% vs.
49.1%, p < .0001), were more aware of the HCPDS (15.4% vs. 2.6%, p < .0001),
and were much less likely to say that they would actively avoid future service
(6.3% vs. 58.1%, p <.0001). More of those with military obligations thought that
they were very familiar with the Geneva Conventions (38.5% vs. 3.8%, p < .0001),
but when asked to apply the Geneva Conventions to specific scenarios, they were
no more likely to answer correctly than other students.
To explore how response rate affected our results, we compared our overall
results with those from the single school in which the response rate exceeded
60 percent. On every question the responses of these students did not differ
significantly (p > .01) from those of students at other schools.
U.S. medical students receive little instruction in military medical ethics in
medical school and are often unable to correctly identify the ethical requirements
for professional behavior of military physicians. The vast majority of students
were also unaware of the HCPDS, which could result in the drafting of physicians
with little advance warning. It is particularly worrisome that medical students
with military obligations had scarcely more knowledge than other students.
How can we explain medical students’ ignorance of military ethics? The
United States may be at war but, other than news outlets, American civilians
are remarkably insulated from the heat of war. The U.S. Defense Department
forbids the photographing of flag-draped coffins, and imprisons enemy soldiers
offshore, out of view of U.S. courts and television cameras. It paints prisoner
abuse as the work of a few underling misfits, not official policy handed down
from above. President Bush does not demand shared sacrifice by all Americans
but instead lobbies for permanent tax cuts for the affluent (16), and asks that
Americans go shopping (17). Given that the United States currently does not
have a general draft, something that would cause every American to consider these
military-related issues immediately and personally, it is little wonder that medical
students are not taught about these issues and are not more familiar with military
648 / Boyd et al.
Several limitations of this study should be noted. We sampled only eight
medical schools, and the students at these medical schools may not be repre
sentative of those at all medical schools. Also, we had an average response rate
of 35 percent, which raises the question of how representative our sample was
within each medical school. We cannot tell how many students never received the
e-mail containing the survey link (another study (18) reported that 27% of their
e-mail invitations to medical personnel were returned as undeliverable) or, among
those who did receive it, how many never opened the e-mail. Therefore, our
observed response rate likely underestimates the true response rate, perhaps
dramatically. Regardless, the responses to each survey item varied little among
all schools, and in no case did responses from the school that had a greater than
60 percent response rate differ significantly from those at other medical schools.
As Americans, we owe our military our deepest gratitude and respect. We also
owe them a firm grounding in proper professional behavior before they enter the
frightening and disorienting moral climate of armed combat. Waiting to educate
physicians about these matters until after they have been drafted into or otherwise
already begun military service might be too late. Thus, we believe that U.S.
medical school faculties should be teaching students about military medical ethics,
both because institution of a draft could place them in combat situations in a
matter of weeks and—just as important—because physicians should be advocates
for humane, ethical treatment of prisoners everywhere.
Note — Each of the authors participated in the original conceptualization of the
project and in formulating the online survey. Each author also had full access to all
of the survey results and participated in analyzing those results and in composing
and editing drafts of the manuscript, as well as approving the final draft. We had
no outside funding for this project and we have no conflicts of interest to declare.
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Direct reprint requests to:
Dr. J. Wesley Boyd
26 Central Street
Somerville, MA 02143
650 / Boyd et al.