15.06.2017Report: 7th ICMM MME-Workshop "End-of-life care – ethical issues during missions"

The workshop was organized by the ICMM Center of Reference for Education of International Humanitarian Law and Ethics in close collaboration with the Medical Services Directorate of the Swiss Armed Forces and the Zurich Center for Military Medical Ethics. The Scientific program of the workshop was coordinated by Dr. D. MESSELKEN (Zurich Center for Military Medical Ethics) and Lt Col D. WINKLER (Chairman of the ICMM Center of Reference for Education on IHL and Ethics). The workshop was held under the patronage of Dr. R. BRUHIN, Prof. P. SCHABER, and MG (ret) R. VAN HOOF.

In total, 39 participants coming from 17 nations attended the workshop. They were almost equally from military or civilian backgrounds. The ICMM was represented by its Secretary General, MG (ret) R. VAN HOOF, MG (ret) M. MORILLON, Chairman of the Scientific Council, the legal advisors Col (ret) J. CROUSE and Col (ret) I. KHOLIKOV, BG (ret) L. KLEIN, Assistant to the Secretary General, as well as Major H. ESMEIRAN, Chairperson of the Nurses and Paramedics’ Technical Commission. Other major international organizations represented at the workshop were the ICRC and MSF.
The venue offered by the Forum Lilienberg proved again to be an ideal environment for the annual scientific workshop. In the relaxed atmosphere with a view on the Lake Constance, the discussions were intense but always respectful for differing opinions. The exchanges and debates continued on a more informal level late into the evenings.

The focus of the 2017 workshop – “End-of-life care. Ethical issues in military and humanitarian missions” – is currently of high interest. Ethical issues related to death and dying in clinical contexts have been increasingly debated in civilian environments in the last years. Furthermore, legal regulations dealing with physician assisted suicide have recently been amended in a number of (Western) countries. Deployed military medical personnel may face similar ethical issues in end-of-life situations to their civilian counterparts. They must however deal with additional layers of complexity: nowadays military missions are most of the time multinational and medical personnel thus routinely treat patients of different nationalities (and in foreign countries). Different attitudes and legal regulations regarding medical treatment options come into play and can collide. When they concern sensitive issues like end-of-life care, there is obviously potential for ethical and legal conflicts on several levels: they start from controversies among coalition partners but that may go so far as to provoke serious conflicts.

In the opening session, J. HENNING started the workshop by giving a general picture of issues in end-of-life care filled with experiences from intensive care both during military operations and in a European civilian environment. Whereas his presentation covered mostly a clinical setting in both the military and civilian context, the presentation of J. VIANT and G. LOARER introduced to a military situation during armed conflict. They presented the French approach (of doctrine and to training) and illustrated it with a practical case example. The latter reported on the challenges encountered by a first responder in the setting of a mass casualty event in the field with fatally wounded soldiers. Deployed medical personnel have to respect the legislation of their home country, and, at the same time, they must adapt to the particular situation which they encounter on a mission.

The second session comprised three presentations from philosophers on the topics of battlefield euthanasia or mercy killing on the one hand and on more general reflections about dying in war on the other hand. S. CHAMBERLIN and D. PERRY, in their respective presentations, tried to answer the ethical question, how seriously wounded wounded soldiers, who are grievously suffering, and facing little or no prospect of medical cure or pain relief should be treated and whether it can ever be ethically justified to intentionally hasten their dying. Referring to recent cases, the conclusion of both speakers was that these are extremely difficult questions to which no easy answer can be given. P. GILBERT then proposed some more general and thought-provoking philosophical reflections on the meaning of death (and life) in conflict contexts.

In the third session, that lasted the whole Friday, different perspectives on palliative care and assisted suicide added to a comprehensive picture. H. DRAPER presented some results from interviews with medical military staff who had been deployed in Ebola missions. The study aimed at capturing and exploring the ethical issues tackled by the medical personnel and in the context of curative and palliative care during the Ebola outbreak. It was thus about a military mission in a humanitarian context and linked the first day of the workshop with the second day that concentrated more on civilian contexts. With an overview of existing legal regulations concerning physician-assisted dying and assisted suicide J. COHEN presented different legal environments and ways to regulate these issues. He also outlined how the popular opinion in several countries has changed over time and will thus certainly evolve further.
E. NOUVET and M. HUNT, who work in a research project on palliative care in humanitarian action, both presented first insights from that ongoing research. One of the aims of their studies is to identify the key obstacles and sources of ethical challenges for palliative care approaches in humanitarian crises and to offer some ethical guidance. G. SCHOFIELD closed the second day of the workshop with a presentation that asked whether and how “our” models of e.g. palliative care can be exported and translated into practice in different cultural contexts without just imposing a Western approach.

The Saturday session of the workshop touched upon another aspect of provision of care to potentially dying persons, namely the treatment of detained persons on hunger strike. Even though hunger strikes are not necessarily an end-of-life situation, they can lead to it. In his presentation, M. GROSS illustrated ethical issues that arise in the context of hunger strikes and around the question of what means may be taken to prevent the dying of detainees in such situations. In the last presentation of the workshop, A. CHEBLY also talked about prison health and the management of hunger strikes. She presented the ICRC perspective on these topics and illustrated it with examples form her own huge field experience as an expert of health care in detention.

In a side presentation during the second day, D. MESSELKEN presented the ongoing project of a Database to collect, for teaching and research purposes, scenarios in military medical ethics. The project and the presentation can be found at https://scenarios.militarymedicalethics.ch/

The abstracts of all workshop presentations can be found in the program brochure that is available on the website of the ICMM Center of Reference for Education on IHL and Ethics (https://melac.ch/courses-workshops/ethics-workshop/2017-lilienberg). The publication of a comprehensive volume with the contributions from the workshop is envisaged.

Daniel Messelken | David Winkler