Leonard Rubenstein, Perilous Medicine: The Struggle to Protect Health Care from the Violence of War (Columbia University Press, 2021)
Embracing humanity isn’t controversial — until it comes up against military necessity. The industrial warfare of the 19th century intensified the long-standing tension between humanitarian and military imperatives. The complexity of 21st-century warfare threatens to increase it to the breaking point.
As a U.S. Army medevac pilot, I read Leonard Rubenstein’s Perilous Medicine with considerable interest and sympathy. Rubenstein traces the journey of humanitarian principles from the Geneva conferences of the 1860s to their present pride of place in international law. He also demonstrates that, during the last quarter century, military necessity was often invoked to dismiss these principles and justify atrocities.
Perilous Medicine offers a depressing account of the depths of human violence. But it also sheds light on contemporary debates about health care in modern conflict. In recent years, some voices within the military have called for removing the red crosses from the sides of U.S. Army medical evacuation (medevac) aircraft in order to arm them, or even for abandoning the practice of having dedicated medevac aircraft altogether. By demonstrating the value of medevac and humanitarian law, Rubenstein reveals how dangerous these steps would be.
A History of Humanity
Which is more important: ending a war as soon as possible or fighting a war without dehumanizing the enemy? Perilous Medicine traces the history of this debate and makes the case for the latter.
Francis Lieber first codified the principle of military necessity. Lieber was a Prussian-American soldier and intellectual who, even after getting shot and left for dead fighting Napoleon, continued to believe war was a glorious national effort. Lieber connected jus ad bellum (the justification to fight) and jus in bello (fighting justly) through consequentialist ethics. He felt that bringing a just war to a swift end justified almost any act.
During the U.S. Civil War, Lieber led the drafting of “General Orders No. 100: Instructions for the Government of the Armies of the United States in the Field,” also known as the Lieber Code. The Lieber Code established rules of conduct for how Union soldiers should deal with Confederate guerillas. It remains the foundational code of conduct for U.S. armed forces, and Lieber’s philosophy of military necessity remains influential to this day. In fact, the foreword to the current Department of Defense Law of War Manual references the Lieber Code.
At roughly the same time, Swiss businessman Henry Dunant articulated the principle of humanity as an alternative to military necessity. Dunant witnessed the 1859 Battle of Solferino while on a business trip in Italy. After the battle, he saw thousands of wounded soldiers left unattended to suffer and die. This experience led him to found the International Committee for Relief to the Wounded. This committee soon transformed into the still functioning International Committee of the Red Cross. In 1863, the committee assembled a conference in Geneva to study military medical services. In 1864, the First Geneva Convention codified the conference’s recommendations. Dunant received the Nobel Peace Prize for his contributions to international humanitarianism.
The First Geneva Convention persists in an updated form today, having grown into the interconnected web of conventions and protocols that make up international humanitarian law. This body of law protects non-combatants and restricts combatants in armed conflicts. The underlying agreements only bind signatory states and groups. But this does not mean combatants can free themselves from humanitarian expectations by refusing to sign. Instead, customary international law holds every state and group to a generally accepted standard.
The Benefits of the Red Cross
What does this all mean for medevac aircraft? The two bodies of law disagree. Humanitarian law limits medical aircraft to predetermined routes, times, and altitudes. Customary law imposes a general duty to respect and protect any medical transport which does not commit actions harmful to the enemy. Indeed, combatants cannot take medical vehicles as war booty even if medical crew members act in self-defense.
However, neither body of international law criminalizes inadvertent damage to ambulances during active fighting. As a result, medevac aircraft sometimes come under fire and sustain damage. Military commanders usually address this threat by assigning armed escorts to accompany medevac aircraft. The logic is that overwhelming firepower from the air can create a lull in the fighting on the ground and allow medevac aircraft to evacuate the casualties. Advances in A.I. offer improvements in ambulance placement and armed escort coordination. Still, unarmed and unescorted ambulances remain the most vulnerable vehicles in any military fleet.
This vulnerability led concerned citizens to call for replacing the red crosses on U.S. medevac aircraft with machine guns. They argued that arming medevac aircraft will improve their ability to reach casualties in ongoing firefights and compensate for the loss of legal protection.
This would be a mistake. Adding machine guns would only provide a marginal improvement in firepower while reducing the resources needed to carry out effective evacuations. Worse, removing medevac’s red crosses would be a complete abdication of moral authority and destroy any chance of leveraging international law’s protections in a great-power war.
First, if a situation is so dangerous that a medevac cannot land, it will require more than helicopter-mounted medium machine guns. Instead, it calls for a full gunship escort. Gunship crews train for offensive operations, and their existing armament provides overwhelming firepower compared to a pair of medium machine guns.
More importantly, armed medevac aircraft would be less effective medevac aircraft. Door guns and door gunners consume three crucial resources: helping hands, weight, and space. Medevac units cross-train their crew chiefs to assist paramedics in flight. Making crew chiefs into door gunners would remove this extra set of hands. You can’t apply pressure to a gunshot wound if you’re manning a machine gun. Plus, while the Black Hawk has twice the lift capacity of its predecessor, the Huey, two machine guns, ammo, and a third crew member would reduce the weight available for medical equipment and patients. And on top of all this, the machine guns and their gunners take up precious space.
Additionally, many Black Hawk patient handling systems are incompatible with door gunner seats. Patient handling systems include sets of litter pans, hooks, shelves, and other storage areas. They enable en-route care by securing patients and equipment inside a helicopter cabin. In the Black Hawk’s HH-60 variant, the system accommodates up to six patients. Even without added armament, many medevac aircraft already fly without patient handling systems to conserve weight. In this case, the usual seating arrangements place the crew in one row, leaving room for four litter patients on the cabin floor. Flying with door gunners and a paramedic would occupy two rows of seats and reduce patient capacity by one litter. These capability reductions might not matter in routine evacuations, but mass casualty events are a different story. The U.S. Army thinks that great-power war will have casualty rates above 50 percent. This possibility calls for dedicating every available person, pound, and inch to evacuating casualties.
Last July, an article in Aviation Digest, the professional journal of the Army aviation branch, took aim at the combat medevac mission itself. It argued that the requirement to set aside aircraft for medevac duty constrains military commanders. This position assumes that this constraint hinders military effectiveness and costs lives by prolonging conflicts. In the author’s view, the U.S. Army should give its commanders maximum flexibility by removing dedicated medevac aircraft and officers from combat formations.
Abandoning medevac formations would be an even bigger mistake than simply arming them. Setting medevac aside does not hinder commanders. It enables them. Commanders do not have to ask how they will evacuate injured soldiers from the battlefield. Instead, a trusted agent fills this need. This frees commanders to focus on the thing only they can do: decide how to wage war.
Commanders need to provide the best leadership they can in great-power war. Information overload and operational tempo threaten to overwhelm many leaders. Eliminating medevac would turn evacuating injured soldiers into one of many competing priorities. It is inhumane to force commanders in this environment to decide between an evacuation mission and combat operations. Even worse, the threat environment in a great-power war may halt evacuation by multi-use aircraft. Air defenses could prevent multi-use aircraft from reaching casualties or, worse, destroy these aircraft completely.
A Better Way to Manage Medical Evacuation
Rubenstein provides a case study from the Levant that suggests a way to bypass air defenses and evacuate patients during a great-power war. In the early 2000s, the Israel Defense Forces, International Committee of the Red Cross, and Palestine Red Crescent Society developed a dispatch system to allow ambulances to reach casualties during fighting between Israeli and Palestinian forces: a life-or-death game of phone tag. It began with an evacuation request from the West Bank. The Palestine Red Crescent would receive the request and notify the International Red Cross. The Red Cross would forward the request to the Israel Defense Forces’ civil-military coordination unit. The civil-military unit would then contact the military commander on the ground, who would decide whether to clear the ambulance. The commander’s decision wound back up the phone chain to the Red Crescent.
The system’s initial implementation did not function well. In 2002, an Israeli sniper shot Iain Hook, a U.N. aid worker, and he died waiting for a Red Crescent ambulance. This and other failures led to calls for reform from Israeli, Palestinian, and international stakeholders. As a result, by 2004 the process had improved. Though the system eventually broke down as Israel’s attention shifted from the West Bank to Gaza, it nonetheless offered a short-lived example of Geneva Convention-compliant medical evacuation routing. The International Committee of the Red Cross could reprise this role by coordinating evacuation during a great-power war.
U.S. Army medevac crews currently seek medical and command approval before flying a mission. Crews could seek clearance and routing from the Red Cross in the same manner. The U.S. Army could even detail a senior medevac pilot to act as a liaison to the International Committee of the Red Cross and coordinate evacuation routing and clearance as troops submit medevac requests.
The goal of this system would be to allow medevac flights to function without risking hostile fire. But would it be reliable? Rubenstein discusses how Russia repeatedly bombed hospitals in Syria, even hospitals identified on a U.N. no-strike list. Similarly, a belligerent could abuse a coordinated routing system by attacking ambulances mid-transport. Were this to happen, however, not only would the attacker be guilty of a war crime, but the United States could simply return to using dedicated ambulances without international coordination and rely on customary international law. If the opponent continues targeting ambulances, the United States could do away with dedicated ambulances and evacuate casualties in some other way.
Rubenstein provides a clear-eyed recent history of violence against health care. Though the topic is pessimistic, he remains optimistic about the value of humanitarian efforts. For proponents of military necessity, Rubenstein articulates why humanity matters and how combatants suffer when it fails. For the aspiring humanitarian, he shows what it takes to make humanitarianism work. When weighing military necessity and humanity, Rubenstein puts his thumb on the scale for humanity. To maintain patient evacuation in future conflicts, the U.S. Army should follow his lead.
Capt. Robert Callahan is a medical recruiting company commander for the U.S. Army. He is a medevac pilot with operational experience in Central America and Afghanistan.
The views expressed in this article are those of the author and do not reflect the official policy or position of the U.S. Army, the Department of Defense, or the U.S. government.