{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2025,8,15]],"date-time":"2025-08-15T02:44:11Z","timestamp":1755225851441,"version":"3.43.0"},"reference-count":30,"publisher":"BMJ","issue":"4","content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["J R Army Med Corps"],"accepted":{"date-parts":[[2018,9,27]]},"published-print":{"date-parts":[[2019,8]]},"abstract":"<jats:p>This paper reviews changes in the ethical challenges that have arisen in military medicine over the past four decades. This includes the degree, if any, to which providers during the Vietnam conflict have carried out what we now refer to as harsh interrogation measures in an attempt to extract information from captured enemy soldiers, the extent, if any, to which the USA used medicine as a means to try to win over the hearts and minds of civilians in occupied territory and how providers should treat service members who return from the front with combat fatigue. An issue that arose during the first Gulf War in 1991 is discussed, namely US service persons being required to take botulism vaccine without their consent. Finally, present challenges are discussed including interrogation measures such as waterboarding and the ethical issues posed in the recent past by the exclusion of gay service members and those posed presently by the inclusion of transgender members. Two ethical values are suggested that have remained constant, namely giving priority to the individual needs of service personnel over those of the unit when there are no urgent combat needs and the reliance on individual virtue when what they should do is morally unclear.<\/jats:p>","DOI":"10.1136\/jramc-2018-001036","type":"journal-article","created":{"date-parts":[[2018,12,7]],"date-time":"2018-12-07T11:37:26Z","timestamp":1544182646000},"page":"273-278","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":1,"title":["Ethical rationales for past and present military medical practices"],"prefix":"10.1136","volume":"165","author":[{"given":"Edmund","family":"Howe","sequence":"first","affiliation":[{"name":"Department of Psychiatry, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"239","published-online":{"date-parts":[[2018,12,7]]},"reference":[{"key":"2025081311275658000_165.4.273.1","doi-asserted-by":"crossref","first-page":"837","DOI":"10.1093\/milmed\/146.12.837","article-title":"Medical ethics - are they different for the military physician?","volume":"146","author":"Howe","year":"1981","journal-title":"Mil Med"},{"key":"2025081311275658000_165.4.273.2","doi-asserted-by":"crossref","first-page":"175","DOI":"10.1353\/ken.2003.0010","article-title":"Dilemmas in military medical ethics since 9\/11","volume":"13","author":"Howe","year":"2003","journal-title":"Kennedy Inst Ethics J"},{"key":"2025081311275658000_165.4.273.3","doi-asserted-by":"publisher","DOI":"10.1056\/NEJMlim044131"},{"key":"2025081311275658000_165.4.273.4","doi-asserted-by":"crossref","first-page":"3","DOI":"10.1056\/NEJMp048346","article-title":"When doctors go to war","volume":"352","author":"Bloche","year":"2005","journal-title":"N Engl J Med Overseas Ed"},{"key":"2025081311275658000_165.4.273.5","doi-asserted-by":"publisher","DOI":"10.1056\/NEJMp058145"},{"key":"2025081311275658000_165.4.273.6","first-page":"22","article-title":"Letter from a Vietnam Veteran","volume":"100","author":"Livingston","year":"1969","journal-title":"Saturday Review"},{"key":"2025081311275658000_165.4.273.7","unstructured":"Livingston G . Serving two masters: the ethical dilemmas that military medical students want to avoid\u2014but cannot, the washington post, 1996."},{"key":"2025081311275658000_165.4.273.8","doi-asserted-by":"publisher","DOI":"10.1016\/0277-9536(86)90279-0"},{"key":"2025081311275658000_165.4.273.9","unstructured":"Howe EG , Jones F . Chapter 8, ethical challenges for the psychiatrist during the Vietnam conflict. In: Jones F , ed. Textbook of military medicine. Washington, DC: Government Printing Office, 1995: 133\u201350."},{"key":"2025081311275658000_165.4.273.10","unstructured":"Vastyan E . Encyclopedia of bioethics. In: Reich W , ed. New York: Macmillan, 1978: 1695\u20139."},{"key":"2025081311275658000_165.4.273.11","doi-asserted-by":"crossref","first-page":"1328","DOI":"10.1176\/ajp.133.11.1328","article-title":"The why of fragging","volume":"133","author":"Bond","year":"1976","journal-title":"Am J Psychiatry"},{"key":"2025081311275658000_165.4.273.12","unstructured":"Veatch RM . The psychiatrist\u2019s role in war. In: Case studies in medical ethics. Cambridge, Mass: Harvard University Press, 1977: 245\u201351."},{"key":"2025081311275658000_165.4.273.13","unstructured":"Brody H . Ethical decisions in medicine. Boston: Little Brown & Co, 1976: 261\u20132."},{"key":"2025081311275658000_165.4.273.14","unstructured":"Howe EG . Chapter 11, point\/counterpoint - a response to Drs. Sidel and Levy. In: Beam T , ed. Textbook of ethical aspects of military medicine. Washington, DC: Borden Press, 2004: 312\u201320."},{"key":"2025081311275658000_165.4.273.15","unstructured":"Howe EG . Chapter 12, Mixed agency in military medicine: ethical roles in conflict. In: Beam T , ed. Textbook of Ethical Aspects of Military Medicine. Washington, DC: Borden Press, 2004: 331\u201360."},{"key":"2025081311275658000_165.4.273.16","doi-asserted-by":"crossref","first-page":"21","DOI":"10.2307\/3562332","article-title":"The use of investigational drugs without obtaining servicepersons\u2019 consent in the Persian Gulf","volume":"21","author":"Howe","year":"1991","journal-title":"The Hastings Center Report"},{"key":"2025081311275658000_165.4.273.17","first-page":"iv","article-title":"Guantanamo: ethics, interrogation, and forced feeding","volume":"174","author":"Howe","year":"2009","journal-title":"Mil Med"},{"key":"2025081311275658000_165.4.273.18","doi-asserted-by":"crossref","first-page":"317","DOI":"10.1002\/bsl.2370070304","article-title":"Confidentiality in the military","volume":"7","author":"Howe","year":"1989","journal-title":"Behav Sci Law"},{"key":"2025081311275658000_165.4.273.19","doi-asserted-by":"crossref","unstructured":"Howe EG . Ethical issues regarding LGBT and intersex service members. In: Ritchie C , ed. Gay mental healthcare providers and patients in the military. 2017. New York: Springer, 2017.","DOI":"10.1007\/978-3-319-66026-4_14"},{"key":"2025081311275658000_165.4.273.20","doi-asserted-by":"crossref","first-page":"193","DOI":"10.7205\/MILMED-D-15-00527","article-title":"Ethics and transgender service members, dependents, and retirees","volume":"181","author":"Howe","year":"2016","journal-title":"Mil Med"},{"key":"2025081311275658000_165.4.273.21","unstructured":"Howe EG . Further considerations regarding Interrogations and forced feeding. In: Goodman R , Roseman MJ , eds. Interrogations, forced feedings, and the role of health professionals. Cambridge: Harvard Law School, 2009: 75\u2013102."},{"key":"2025081311275658000_165.4.273.22","doi-asserted-by":"crossref","first-page":"1118","DOI":"10.7205\/MILMED-D-15-00131","article-title":"When, if ever, should military physicians violate a military order to give medical obligations higher priority?","volume":"180","author":"Howe","year":"2015","journal-title":"Mil Med"},{"key":"2025081311275658000_165.4.273.23","doi-asserted-by":"publisher","DOI":"10.1111\/jsm.12487"},{"key":"2025081311275658000_165.4.273.24","doi-asserted-by":"crossref","first-page":"74","DOI":"10.1177\/1457496916645964","article-title":"Chest-wall contouring surgery in female-to-male transgender patients: a one-center retrospective analysis of applied surgical techniques and results","volume":"106","author":"K\u00e4\u00e4ri\u00e4inen","year":"2017","journal-title":"Scand J Surg"},{"key":"2025081311275658000_165.4.273.25","doi-asserted-by":"crossref","first-page":"369","DOI":"10.1007\/s00266-017-0796-0","article-title":"Masculine chest-wall contouring in FtM transgender: a personal approach","volume":"41","author":"Lo Russo","year":"2017","journal-title":"Aesthetic Plast Surg"},{"key":"2025081311275658000_165.4.273.26","doi-asserted-by":"publisher","DOI":"10.1007\/s10508-012-0012-x"},{"key":"2025081311275658000_165.4.273.27","doi-asserted-by":"crossref","first-page":"146","DOI":"10.1016\/S1701-2163(15)30661-7","article-title":"Sexual and gender minority peoples' recommendations for assisted human reproduction services","volume":"36","author":"Ross","year":"2014","journal-title":"J Obstet Gynaecol Can"},{"key":"2025081311275658000_165.4.273.28","unstructured":"Beam TE , Howe EG . Chapter 26, look toward the future. In: Beam T , ed. Textbook of ethical aspects of military medicine. Washington, DC: Borden Press, 2004: 831\u201350."},{"key":"2025081311275658000_165.4.273.29","unstructured":"Beam TE , Howe EG . Chapter 27, a proposed ethic for military medicine. In: Beam T , ed. Textbook of ethical aspects of military medicine. 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