A psychiatrist goes to war: the physician's ethics in warfare
Gonzalo Herranz, department of Bioethics, University of Navarra
Session at workshop "The war in the former Yugoslavia".
European Documentation Center, University of Navarra
Pamplona, March 22, 1995
gradeThe text of this speech was drafted in a schematic way, but the storyline can be followed without special problems.
I. The complex history of the relationship between war and medicine.
II. The role of the psychiatrist in the creation and maintenance of combatant morale.
III. The ethical significance of the use of psychiatry as a weapon of war.
Things that happened in the Bosnian war
The use of Psychiatry as a war weapon
My interest: the ethics of the physician in war.
The military physician is bound by the same ethics. This is unique, in times of peace and in times of war.
But war creates a status of high ethical risk. War is a terrible crisis of humanity that can lead - as happened paradigmatically in Nazi Germany - to medicine or to unimaginable levels of cruelty.
To put our topic, the role of psychiatry in the war years of the former Yugoslavia, into perspective, we are interested in making a brief, schematic excursion into the
- complex history of the relationship between War and Medicine, to consider next
- the role of the psychiatrist in the creation and maintenance of the combatant's morale. Against this background, it will be easier to understand
- the ethical significance of the use of psychiatry as a weapon of war as applied by the psychiatrist Radovan Karadzic, President of the Bosnian Serbs, in the conflict in the former Yugoslavia.
Let's start with
I. The complex history of the relationship between war and medicine.
A mixture of heroic generosity and terrible crimes, of scientific advances and programmed brutality.
It is said that wars have been a great opportunity for the advancement of medicine. And that medicine has done much to humanize wars: to heal the wounded, to avoid cruelty.
Hippocrates already said: "Whoever wants to become a surgeon should enlist in an army and follow it to the battlefield".
The physician's function has been to cure,
in introducing a testimony of humanity,
in living the commitment to serve everyone equally.
It is said that wars have been a great opportunity for the advancement of medicine. And that medicine has done much to humanize wars: to heal the wounded, to avoid cruelty.
Some argue that international law began with the axiom "When enemies are wounded, they become brothers". Since ancient times, the physician has been respected as a non-belligerent, and privileges were granted to him so that he could carry out his work of healing.
Even when the Order of the Hospitaller Knights of St. John of Jerusalem, the Knights of Malta, arose in the 11th century, average, in the 11th century, they established the first military hospitals. They took up the sword to defend the hospital, and wounded enemies were treated as if they were comrades.
In 1747, on the eve of the battle of Fontenoy, Louis XV was asked how he wanted the wounded enemies to be treated. "Exactly the same as ours," he replied. "Once wounded, they are no longer our enemies."
This principle was codified in the First and Third Geneva Conventions. During armed conflicts, the physician's duties towards captured enemies derive from the rules of medical ethics and consist exclusively of medical obligations. International humanitarian norms define what these duties are, outline the responsibilities that authorities have towards physicians, namely that physicians have the right to approach to treat the sick and wounded and that they are immune from attack. Physicians and their assistants may not be taken prisoner, although they may be held to provide medical care to prisoners of war. In a prison camp, there may be three groups of physicians: those of the power that has taken them prisoner, neutral physicians (e.g., Red Cross), and retained (but not prisoner) physicians.
Documents on professional ethics. The WMA Declaration on the Practice of Medicine in Times of Armed Conflict. The Declaration is now almost 40 years old, having been adopted in 1956, although it was amended in 1983.
In its current version it says, among other things, these:
Medical ethics is the same in times of war as in times of peace. The physician's first obligation is to fulfill his professional duty. Guided by his conscience, he must preserve health and save life. It is therefore unethical to advise prophylactic, diagnostic or therapeutic interventions that are not for the benefit of his patient; or to weaken, without therapeutic justification, the physical or mental strength of a human being; or to use his scientific knowledge to destroy or damage life.
In time of war, experimentation on man is governed by the same code as in time of peace. Any experimentation on persons deprived of their liberty, whether civilian or military, or on the population of occupied territories is strictly forbidden.
In case of an emergency, the physician must administer the necessary care impartially, without discrimination on the basis of sex, race, nationality, religion, political party or any other status. And such medical care must be continued as long as necessary.
The medical secret must be kept by the physician in the internship of his profession.
Physicians should never use the privileges and exemptions granted to them for other than strictly professional purposes.
Under no circumstances may the exercise of professional duty be considered contrary to the law. A physician may never be prosecuted for maintaining professional secrecy.
development of humanitarian missions, decisive role of medical volunteer organizations on the development of the financial aid humanitarian . Attention to civilian victims, to particularly vulnerable populations: oasis of humanity. But also a field of rivalries, of vanities before the world, of profits in the multi-billion dollar business of humanitarian financial aid . Beware of NGOs.
Missions of Doctors for Human Rights: expert testimony of research of war crimes, human rights violations, with much more reliable and less fragile documentation than in previous times: violations of the neutrality of the doctor, medical services to refugees, use of prohibited weapons, torture, gratuitous damage to civilian population, mass rape, mass executions, genocides. Deliberate destruction of health infrastructure: attacks on hospitals, destruction and theft of materials, attacks on staff sanitary, ambulances, preventing access to medical treatment to civilians and soldiers, blocking of the submission or detour of sanitary material and humanitarian financial aid .
II. The role of the psychiatrist in the creation and maintenance of combatant morale.
To cure the wounded and care for the victims of epidemics are the main work of the physician in war, and the physician then makes his work according to his good clinical judgment. issue There are no major ethical conflicts, unless the number of wounded is so high that the decision has to be taken to abandon some to treat others, in contrast to the short and efficient care of many in the long term and with little chance of survival of a few: this is the selection process called triage.
Today, due to the new way of fighting (short and intense combats between not too numerous detachments) and with the advances of helicopter evacuation, the fighting morale has changed substantially. It has changed incredibly. Soldiers are much more afraid of being wounded than of dying: death is an inevitable fatality that ends soon. War wounds can mean years of suffering or permanent uselessness.
But one of the things that most concern the captains of war are not the physical dead and wounded in battles: but those injured in the soul. Little known are the data about the very high number of psychiatric casualties in the moments of hard battles. They have been revealed recently data of the II World War. In the II British Army, during the landing and battle of Normandy, 10% of the combatants had to be evacuated before the end of June 1944, at the end of August they reached 20% when the battle was over. In the rest of the French campaign it stabilized at 14%. Among the Americans the rate was always much higher: it reached a maximum of 54% in the 2nd Armored Division at the end of 44 days after the landing on the Italian Peninsula.
Maintaining combat morale is an occasion for conflict between medics and captains. There are epidemics of psychological breakdown among combatants. Ethical conflicts sometimes arise between the protection of the individual and the needs of war. The military commander demands that the individual be sacrificed to the needs of battle, while the physician proclaims that the individual human being must receive the best possible professional service, even if he fights on the opposing side.
The importance of psychological factors in combat readiness and in the conduct of a long and dangerous war is fundamental.
The ethos of the combatant has changed profoundly. The old morality of love of country to the point of immolation, the moral obligation not to feel fear and not to express it, the blind obedience to superiors, the infinite capacity for sacrifice, the sense of weakness, dishonor, guilt and lack of virility revealed by desertion or the betrayal of going over to the enemy created the idea that the death sentence in a summary trial, to punish infidelity and as an example to all, was an expression of justice.
One of the ways in which war has been humanized is in the recognition that the stress of combat, the physical exhaustion, the lack of sleep, the misunderstanding of the strategic plan, the terror for many of entering real combat for the first time, are all part of the behavior of normal people, loyal but human soldiers.
Thus, the recognition that the soldier is a human being, capable of heroism, but largely endowed also with psychological and moral weaknesses, has led to the humanization of the discipline and of the military code (although the application of the death penalty is foreseen in many nations for war situations, it is de facto abolished also in the military regional law ). But, at the same time, it has shown that psychology can play a decisive role in war.
There is not only a psychological and nervous war that tries to disconcert the enemy through fatigue, surprise, the creation of insecurity on the battle front and in the rear. We are now, at the age of fifty, asking ourselves about the morality of the bombing of Dresden. We will ask ourselves next year about the ethics of the atomic bomb attack on Hiroshima and Nagasaki. It was a brutal psychological punishment to ruin the fighting spirit.
Psychological manipulation as a weapon of war became a science during the cold war years. Many of the things that happened in Bosnia have to do with the application of techniques developed by psychiatrists and intended to make psychological manipulation a weapon of enormous war effectiveness.
Against this background, it will be easier to understand
III. The ethical significance of the use of psychiatry as a weapon of war.
Things that happened in the Bosnian war
In August 1993, JAMA devoted almost an entire issue to the war in the Balkans. It reported on the existence of a Center run by high school International Human Rights at De Paul University, where Cheriff Bassiouni is director . Bassiouni is collecting and analyzing data not only for academic examination, but for submission to the United Nations Commission of Experts studying human rights violations in the former Yugoslavia. Information obtained in situ by international Human Rights agencies (Amnesty International, Helsinki Watch), data (news, videos, photographs) provided by media correspondents, on incidents and crimes against human rights (BBC).
In the first year of work, information was collected on more than two thousand incidents (mutilations, rapes, murders, torture) affecting more than 25,000 innocent civilians. Among the purposes of high school is that this documentation, duly purged and validated, may one day serve as test before a war crimes tribunal.
It goes without saying that the parties in conflict in Bosnia-Herzegovina (Serbs, Croats and Muslims) share the same hatreds, attack each other with the same ferocity or fight for their own survival with the same fierceness. A high-ranking Spanish officer on the General Staff of the Blue Helmets told me, after spending many months in Bosnia, that there was no reasonable solution to the matter. In his opinion, there is no other alternative than for one of the groups to impose itself with blood and fire on the others and, clearly victorious, to show magnanimity towards the survivors.
All three groups without exception have committed war crimes. Two and a half years ago now, the Croatian Episcopal lecture made public a very strong condemnation of the inhuman and cruel actions carried out by Croatians (Catholics for the most part). But it went unheeded. But the most serious and degrading have been those committed by Serbs against Muslims.
It is a war of territorial conquest, with ethnic and religious hatreds, feelings of victimization and revenge, in which the perversion of Psychiatry is particularly manager. Radovan Karadzic psychiatrist and President of the Bosnian Serbs has instilled among his people and, especially among his soldiers, feelings to ignite the flame of aggressiveness and violence.
It does not seem necessary to make an anthology of savage attacks on dignity: the documentation accumulated in Chicago is terrifying. Here are some particularly eloquent samples.
Four concentration-burdel camps, where Muslim women from 12 to 60 years old were taken, and where soldiers lined up to rape them. Several women were held until they were 6 months pregnant, too late for an abortion, and thus forced to become mothers of children of Serbian fathers.
In the occupation of Vukovar, after a siege of almost 100 days, the Serbs evacuated 294 sick or wounded Croatian soldiers from the hospital, transferred them to a neighboring barracks, and killed them either by shooting them in the back of the head or by beating them. Forensic experts from the Physicians for Human Rights Organization have begun the exhumation and study of the mass grave in which they were buried.
Commander Arkan, a common criminal with more than 8 arrest warrants for crimes committed in Germany, Holland, Belgium and Sweden, twice escaped from prisons, has gained a sinister reputation in eastern Croatia. His ethnic cleansing techniques have been particularly sadistic. He has personally executed Croats in several villages, shot or hacked to death. Arkan had these scenes videotaped and gave them to the BBC for an interview, in which he said: "People may say I'm a murderer, but I don't give a damn. I'm proud that I did it, you know what I mean?
Hardening, or rather moral insensitivity, is a widespread phenomenon: in war anything goes. A Serbian soldier who was captured and tried convicted of raping 26 Bosnian Muslim women and murdering 19 of them, did not show the slightest sign of remorse. When Bassiouini asked him why he had killed them, why he had not let them go after raping them, the soldier looked at him indifferently and simply said: "Can I have a cigarette?
A special feature of the siege of Sarajevo has been the heavy attention on the hospitals. The main hospital was subjected to constant shelling. Surgical operations had to be performed without electric light, without anesthesia, without painkillers.
The use of Psychiatry as a war weapon
(And the role of psychiatrist Radovan Karadzic, President of the Bosnian Serbs, in the conflict in the former Yugoslavia).
The special violence of the Yugoslav war is largely due to the psychological manipulation of the combatants, especially the Serbian peasants, whose traditional hatred has been kindled by the propaganda and brainwashing authored by Radovan Karadzic.
The ideological genealogy of Karadzic has been brought to light by some researchers and journalists. "Psychiatry and genocide", "The Bosnian psychiatric conspiracy", "In Bosnia the same as in Lebanon: wars programmed by psychiatrists": these are titles of articles published in French, Italian or English journals.
Karadzic has been deeply influenced by his mentor Jovan Raskovic, the mad psychiatrist, director of an important asylum in Bosnia, where he dedicated himself to apply in a heterodox way the electroconvulsive therapy and collected materials for a book titled Crazy Peoples in which he traces a perverse profile of the ethnic groups of the ex-Yugoslavia. Karadzic massively spread Raskovic's theories among the Bosnian Serbs, in order to induce their people to acts of hatred against their rivals and to sublimate their inhuman acts in the service of Greater Serbia.
Raskovic's idea, exploited by Karadzic, is that since Muslims have an erotic-anal personality and are the subject of people who like to accumulate wealth, they are easy prey for deception and murder. Croats have a castrated mentality and are terrified of anything: they are incapable of exercising authority and must be guided by Serbs. The latter suffer from a collective Oedipus complex, they are capable of uncontainable outbursts of violence, whether their claims are justified or not: this trait is what particularly frightens the Croats. With this rudimentary outline , Radovan and Karaczic have imbued their people and led them to somehow rationalize their violent behavior.
In the Yugoslavian war, the rape of women has become a form of programmed aggression, formalized, subjected to a systematic administration, to logistics. It is known that rape is an almost inevitable part of the occupier of enemy territory, internship as old as war itself. But it has been elevated to the status of a strategy. Rape is not only an individual aggression, but also a terrible violation of the family and the community. It has as its purpose aim to dominate, humiliate and control behavior. In Bosnia, many rapes were carried out in the presence of the victims' husbands, children and siblings. The threat of systematic rape has a tremendous deterrent force, financial aid much more than weaponry to empty villages and towns: the threat of systematic use of public rape of women forces families to leave their villages and achieves a high rate of ethnic cleansing of the territory.
The administration of this punishment has been refined. It is preannounced, which in itself creates an intolerable status of alarm. If the male members of the family stay by their wives' side to protect them, they have to postpone or abandon the warlike actions they planned against the enemy and are immobilized. Many women who have been impregnated by their rapists have been held in special camps to prevent them from having abortions and thus become mothers of enemy children.
International law condemns rape as a war crime. It was first described as such in the trials of Japanese war criminals after World War II, when several military commanders were convicted for ordering such conduct by their soldiers. In January 1993, the UN sent a medical commission to investigate rape in the former Yugoslavia. It became clear that the crime had been committed on a large scale: data puts the number of women survivors of rape at around 60,000. Consequently, the UN Commission on Human Rights agreed to place rape among the war crimes and called for the creation of an international tribunal to specifically prosecute this crime, both those who perpetrated it and the immediate commanders who ordered it, as well as the higher authorities who encouraged or failed to prevent it. (In brackets, low figures: in peace and in war, the crime, if it has not been public, tends to be hidden, especially if it has not been followed, as usual, by gestation: humiliation staff, family and social incomprehension, moral stigma, emotional trauma).
The UN has set up a fund at research to develop techniques for identifying perpetrators. Difficult thing. The health staff can do a lot in the care of women who have been raped: incidence and evidence of violence.
Quantitative determination of the collective phenomenon: cases of pregnancy, pregnancy rate of 1% of rapes. Cases of multiple rape: the same woman by several soldiers. An estimated figure can be given.
Means of identification of the offending individual, thanks to identification technologies (DNA-polymerase chain reaction).
A serious problem: restoring dignity and health to battered people and their communities. Suicide rate, depression and psychotic episodes. Rejection of young women by their parents, or by their boyfriends, or the rest of the community. Just one hair is enough.
Where does this destructive mentality come from? The decisive role played by a good issue of Serbian psychiatrists in the Balkan tragedy has been highlighted. And interestingly by some of their patients. Jovan Raskovic was an internationally renowned psychiatrist, member of the Yugoslav Academy of Sciences and official psychiatrist of the Republic. Slobodan Milosevic, the strongman of Belgrade, was a patient of his, as was Milan Martic, chief of police in the so-called Republic of Karjna, the Serb-occupied Croatian territories. In Belgrade, another psychiatrist, Svetovar Stojanovic, returned from the USA to take charge of political propaganda.
Karadzic was at Columbia University to learn therapy techniques from group.
The role played, as early as the 1960s, by the Zagreb Mental Health high school in the training of this mentality and the connection of Yugoslav psychiatrists with the high school Tavistock, London, has been highlighted. Although listed as a conventional institution, dedicated to clinical and psychiatric research , the Tavistock has long been a laboratory of programs of study on psychological warfare of the British Army. Contacts and exchanges have been maintained between London and Zagreb since the late 1960s. Every summer they have held meetings on the Dalmatian coast, on an island off Korkula. The founder of these meetings was the Frankfurt School philosopher Max Horkheimer.
I end: pain to see how a doctor, called to heal, to alleviate pain, uses his knowledge of the weakness and vulnerability of man to harm him, to destabilize the community in which he lives, to sow death.