United States military medical personnel have a duty to treat enemy soldiers, but what about a suicide bomber who lives – do they have a duty to honor his wish to die? This is one of several dilemmas in end of life care specific to wartime that were explored at the 2010 annual joint ethics conference of The Hastings Center and the United States Military Academy, held at The Hastings Center on April 7.  

For 31 years, The Hastings Center and the ethics faculty at West Point have had meetings to explore issues in military and medical ethics. Daniel Callahan, cofounder of the Center, gave an overview of the debates over end of life care, which date back to the rise of intensive care units and other life-prolonging medical technologies. “We thought living wills and improved palliative care would solve the problems, but they haven’t,” he said. “We were naïve.”

Nancy Berlinger, a Hastings Center scholar who is overseeing the revision of its landmark Guidelines on the Termination of Life-Sustaining Treatment and the Care of the Dying, discussed the challenges of writing guidelines that are realistic for a variety of patients, including soldiers and veterans. “They may have pain, but value stoicism, associating bravery with not giving up,” she said.  

Lieutenant Colonel Mark Pallis, an orthopedic surgeon at the U.S. Military Academy who has served in Iraq and Afghanistan, said that living wills are rarely discussed in the military, in part, for fear of the impact on morale. “It would be horrific for soldiers, commanders, and providers to see nothing being done for a patient” with life-threatening injuries who did not want to be on a ventilator, he said.

On the other hand, Dr. Pallis acknowledged the benefit to spouses and other family members to know what a solder would have wanted. “I’ve seen family members suffer with that decision, and knowing the soldier’s wishes would help,” he said. He noted that the expectation of military medical personnel is to keep patients alive, and that more than 90 percent of injured soldiers who make it to a combat hospital survive to be transported elsewhere.