Heavy Burdens

Ethical Issues Faced by Military Nurses During a War

Deborah J. Kenny, PhD, RN, FAAN; Patricia Watts Kelley, PhD, FNP-BC, GNP-BC, FAANP, FAAN


Online J Issues Nurs. 2020;24(3) 

In This Article



The first theme of Resources/Allocation was multifactorial and related to numbers and types of casualties, severity of injury, and humanitarian efforts. This included resources used to care for severely wounded service members that were thought to have been futile; and resources used on injured enemies, prisoners, on the local civilian casualties, or even on locals seeking care because they knew their own care system was deficient.

Care for Injured Allied Service Members. Service members in the wars in Iraq and Afghanistan saw injuries that would have been non-survivable if not for advances in medicine and definitive care practices. The injured were cared for by highly trained combat medics and nurses right on the battlefield at the point of injury. Once service members reached combat support hospitals, they had already received, in many cases, lifesaving care, but they were still severely injured. Nurses expressed some frustration with differing opinions as to whether massive resources should be used at all cost. This was particularly true when many casualties were received at one time and heart-wrenching triage was necessary. One nurse expressed:

P1: Because out there the theory of triage is reversed: you save the greatest good, not the greatest injured. So if we had to, and there was days that we did, we left somebody in the shade with a corpsman to attend to them, with as much morphine as he needed and kept him comfortable until he died. And sometimes they were still there and we'd go back for them afterwards and we'd throw whatever we had left at them.

Resources for Enemies and Civilians. Many nurses related stories of having to use scarce resources on enemies who had been injured in the same firefight and brought in with WSMs, or civilian casualties who had been in the area. They struggled with the need to use resources that were supposed to be used for Americans. Though they dutifully did what was required, most could not reconcile their actions, particularly because they knew the subsequent care these people would get outside the American hospitals was quite poor. Often these patients were kept for extended periods of time whereas American casualties were stabilized and transported in a matter of a few hours or days.

P1: But the one big discussion that we got into that really became an ethical discussion frequently and even before we went in, but definitely once we started seeing them, was using our supplies on the Iraqis.
G1: Caring for everyone who gets injured, the Iraqi civilians, Iraqi police, Iraqi army, the Americans from all over - our beds were very valuable. So we constantly had to triage and move patients out. This ethical dilemma came up over and over and over again in transporting Iraqi patients, because we had to transport them from Ballad to Baghdad, where they were assessed by the combat support hospital there, and then arrangements were made for them to go into the Iraqi medical system. Well, everybody had an overwhelming feeling that we were sending them to their death by sending them to the Iraqi medical system. So it was an ethical dilemma constantly, when we had to make arrangements to transport these patients out. So we would stabilize them and keep them as long as we can, to give them the best shot at life.

Limited Resources of the Foreign Medical System. Many respondents talked at length about some of the frustrations they had with the local medical system of the country. They knew the Americans were capable of providing better care for local individuals than they would have in their own hospitals. Much of the angst felt by our nurses was related to the fact that we were treating and likely saving people who would eventually be sent back to a local hospital unable to provide resources to continue care. They believed they were sending many people out to their deaths by releasing them from the American hospital and the nurses could not reconcile that with their own value system, even though they knew it was acceptable by the local culture.

G1: They usually the University Center wouldn't take a ventilated patient 'cause they didn't have the means - most of the time - well, their nurses weren't really nurses, and the doctors usually worked only days, till like three o'clock in the afternoon, and then they had like a tech working at night, so they never received the care. But I know in Baghdad - we called up on a couple of patients that we sent over to university, and we found within days of sending them over there, they were dead.
G2: It's strange. You just don't understand why. A lot of times - the Iraqi patients - they're very fearful of going to - when you're gonna transfer them to the Iraqi hospital, because they know, if they're Sunni or Shia, that they can die in there, just because of the difference.

Military Nursing Core Values

Military nurses are trained to view themselves as "officers first, nurses second." From the time they receive initial training in the military, they are taught that mission and need of the military comes first. Nurses were very aware of both responsibilities of being in a war zone, but struggled to reconcile military needs with human suffering. Many had beliefs that they were deploying solely to care for American service members but found themselves spending most of their time caring for Iraqis and Afghanis. This was because American service members were transported to Germany, then back to the United States in a very short space of time, whereas local citizens truly had no place to go. Additionally, when word got out to the villages that the Americans could help them more than their own medical system, they began showing up for care of all types, even non-emergent. To portray American good will to these people, they received care.

G3: Well, we knew we were going to. They go through the whole - everybody gets equal care. And - and you go to war with yourself. Because as a professional, you're gonna give everybody equal care. But as a soldier, it's very tough to treat Iraqis that you know. What we got mostly, as far as Iraqis go, we had a prison.
P3: Geneva Conventions and rules of war that we have to provide that for them, even if they don't provide the same thing for us. But it's just - when you're hands-on, when you're actually taking care of the soldier and taking care of the assailant, then it's a little more - makes it a little more difficult 'cause emotions are involved.

One nurse in particular related a story regarding her welcome home and the angst it caused her because she had gone off to war and was speaking about it to her family, having to defend her actions and her beliefs. She felt like she, herself, was reliving the Vietnam war experience some forty years later.

P4: Okay, so one thing that was hard was my [relative deleted] is very liberal. She's always out there protesting against the war. She's the quintessential liberal person, lives out in [location deleted]. Our political views don't clash, but she always likes to play the devil's advocate. She's always saying, "You have to understand," blah, blah, blah. I remember telling her it was really hard taking care of those EPWs (Enemy Prisoners of War) because the moral and ethical issues I would have. Knowing what they have done was really, really hard for me……… I started crying, I'm like, I cannot believe, I was using a whole lot of profanity at that point. I remember telling her…… "Don't have that kind of opinion until you get there because you don't know what you would do in that instance." I thought I had a very valid point in that because I took care of EPWs. So I said, "Do not judge the Americans, or U.S. for what they did, because you don't know what you would've done in that situation.

Nursing Code of Ethics

Perhaps the most important and expected finding of this study and of the deep dive into ethical issues was that the nurses seemed to have no conflict whatsoever with their roles as nurses. This finding was almost universally relayed by the nurses interviewed. None seemed to have difficulty in reverting back to the reason they became a nurse in the first place and that was human compassion.

P5: And that was the hardest thing I think I've ever done. And - you know what you think you might want to do. But then, what you're supposed to do comes through, and I did take care of him. It was one of the hardest things that I had ever done.
P5: We did. We talked a lot about it because - from the looks on everyone's faces, everybody had the same feelings. And we talked about the importance of what we had to do, to take care of the patients. That that's our job, and it's not only our job, it's our obligation.

The most poignant story of nursing core ethics came from one Navy nurse, who related a story of caring for a teenaged Taliban who was injured as he set off an improvised explosive device (IED) targeted to Americans. He wound up killing and injuring several Americans. To demonstrate the compassion with which this nurse cared for this patient, we are including the entire story here.

G4: And my first experience with a Taliban soldier from – Taliban bad guy, as they call them – I was given a black eye and a broken bone in my face from an attack from him. And so that was not something I'd been familiar with as a nurse, for as many years as I've been. Quite alarming. Didn't hit him back. But I continued to take care of him for the whole ten days that he was there. And it was a good thing. It reminded me of the oath I took as a nurse, to take care of any patient, anywhere, any time that I was needed to, and it was a challenge, because this particular one was just a boy, and he actually killed two of our American soldiers, so it was – every single bit of strength that I had to take care of him. Being a pediatric nurse, though, I could do it because I focused on the fact that he was a young patient, a young boy, and that's all he knew. So I gave him 100 percent of care, and I feel very good about that. He taught me a valuable lesson about giving care to someone you didn't want to…….. And it did make me grow. And who says you can't still learn as an old nurse. (laughs).
He had a- unfortunately, because he was so young, he had set an IED to explode, and instead of – well, it did explode, and it killed two of our young soldiers, but it also injured himself because he didn't get away. And he lost a leg, an arm, and was trached, and one eye. So the joke downrange was that I had half of a young boy that attacked me and I couldn't defend myself. But you know, as I said, it did teach me a valuable lesson, and I think the junior officers that saw how I handled the situation, and that I was willing to take care of him, even though he broke a bone in my face, I was still going to give him the best care and I wasn't going to back down. I was going to show him that he didn't scare me, that I was still going to be a nurse and I was still going to be an American.
Yes, actually it did. When he left – whenever you take care of a Taliban, I don't' know if you ladies – anybody in here has, but if they're a detainee, you simply finish taking care of them till they can care for themselves the best way, and you have no one to leave them with. You have to take them to the outside skirts, where it's safe for you, and leave them, and they have to get where they can get to for safety. So we simply took this man to the outside quarters of the air field and of course he's blindfolded and has earmuffs on, has no idea where we have brought him from – and it's for our safety, of course – and we drop him. And so he has to manage to get to safety himself. But knowing that, and how young he was, I know he was probably very strong, but I left him with a sack of water, food, and his bracelet that is for good luck. It's a religious bracelet that was taken off of him when he first came to our hospital. I gave it back to him. And said goodbye. And he thanked me in English, he said, Thank you, Commander, and the only reason he knew my rank was because the gentleman that rescued me, the MP that rescued me from when he hit me, said Commander, are you okay? And he remembered that. Our name tags are covered. Otherwise he didn't know my name. But he did know some English and he did understand, so I said to him, Tašakor, which is Thank you. And he looked very puzzled at me. And I told him, You taught me a valuable lesson, even though I don't think he understood me, I think he did because he saw my eyes. And I did become attached to him, even though he hurt me, but I think that if he made it back, he might say, they're not as bad as you think. They gave me very good care.

Caring for the Enemy

One of the largest sources for conflict from the nurses we interviewed was caring for the enemy, or those that U.S. soldiers have gone overseas to fight. Nurses had ample opportunity to care for them as well as for prisoners of war. While they showed compassion at every step of the way, they still sometimes had difficulty for numerous reasons. Sometimes the enemy or prisoners mistreated them, sometimes they were caring for an enemy alongside those Americans they had just injured. Some of them parsed out pain medications, so they would have enough for the injured Americans. However, that was rare and the majority of the nurses, though tested in ways they never imagined, also felt a certain pride in the fact that they overcame their fears and disdain. They believed they were able to make a positive difference in the lives of fellow humans and to perhaps sway the enemy perception of American service members.

G5: I think what a lot of nurses don't realize is, you hear in the States that you get to take care of Americans. And that's great. You get to serve your own people, so to speak. And then you go over there, and you're like, okay, I'm here to serve my American soldiers, they're over here, they're fighting the war, so I'm here to take care of them. And then when you're faced with – you just shot my American soldier. And I'm American. So we got a lot of insurgents that we had to take care of, and it was a whole lot to have to face that patient and know that – I have to give him optimum care, I have to give him just like an American soldier.
P6: And – I turned to walk away, and he said, you know, some of the prisoners have changed their minds about Americans. Because of the compassionate care they received. And I turned around – I was like – really? And he said, yeah, they actually gave up information about – like – where booby traps were set, and stuff. So in the end, it ended up saving all lives, not just American lives but – children and Iraqis and – and I just thought that was the neatest thing in the world to hear, because it was so hard and so much work, and so – spiritually challenging at times and – then to hear that it actually made a difference to be kind and compassionate.
P7: …..as well, that was in our compound – which was also challenging for us, and some of our people didn't like the idea of having to take care of Iraqis that were terrorist and were utilizing all our supplies, and they had nowhere to go. My edict to my staff was: These people are injured. Humanity-wise, we need to take care of them. I don't care who they are, what they did or anything else. That is what we need to do.

Caring for Civilians

Nurses never balked at having to care for local civilians who were either injured as collateral damage or ill, but they wavered because most of the time it was a long-term commitment. Sometimes they cared for them for months, trying to get them to a point where they could possibly survive outside the American hospital walls. The medical system in those countries was not as sophisticated as it is in this country, nor did it have the resources to care for injured people for the long-term. Their facilities were as overtaxed as the American hospitals, but we welcomed these people. The people knew this and seemed to flock to the hospitals for whatever care they could get.

G6: I mean, their culture is so different than ours. But he was such a long-term patient and we did that for him, too. So the nurses got to where we were looking into, how could we continue to receive these air mattresses and stuff for these patients, because the Iraqi patients pretty much get stuck there. There's no where [sic] to send them. If you want 'em to survive. It becomes a real, real nursing issue. And an ethical issue.

However, the culture of the people sometimes also conflicted with their own sense of survival and the nurses began to wonder why they were spending so much time and resources on people who did not share American values.

G2: Knowing that it was futile care, a lot of it, because they don't care. About survival the way we do. (Arabic phrase), "As God wills." They won't do anything. God wills it, it'll happen, and that means if I don't have to do anything, I don't have any responsibility for the outcome.…….

Yet at the same time, nurses had difficulty with overuse of American resources on local civilians, especially when bed space was in short supply, or resources were not available for American casualties. The nurses knew that triaging locals out of the hospital could very well be a death sentence for them. They often spoke about the compassion they felt for these civilians or children who, through no fault of their own were suffering because of a war.

P8: ….yet when you see these starving people who are in such need, your heart goes out to them and you think, well, somebody's gotta help. What are you gonna do these people are starving, and it's not just because of the two years of war. And then when you have people who've never had calcium in their diets so their bones are osteoporotic at 40 – their wound healing is terrible, you have 90-pound men as an average. And the men walk down the hallway and you can see every bone. They look like they belong in a concentration camp and you – it breaks your heart to see human beings in such need, and struggle with how to take care of them, but that wasn't – our job is [sic] to provide long-term care, so it was real hard ethically. Where do you draw the line in saying, okay, we're gonna send you home now. We're gonna send you to an Iraqi hospital, after we did all this work to save your life, and now you may die in an Iraqi hospital, but we're not a long-term rehab center. You know. What do we do?

Need for Follow-up/Closing the Loop

One of the more difficult things for nurses was caring for injured service members, putting every ounce of their energy into saving them for transport out of the country, then not knowing the outcome of their work. They expressed the need for more follow-up for those who made it through transport, because they believed it would validate their work. However, this was not often the case and all they could do was wonder about the outcome. They believed that was one of the continuing questions they asked themselves when they remembered a certain patient. Sometimes they wondered if saving some of the individuals from horrific injuries was going to be seen by the patient and his/her family as "worth being saved from." These were not the typical patients who had received their care in the States prior to deployment, so they wondered about the long-term disability of patients, both physically and mentally.

G7: And I think – I just got the thing, too, that we saw some horribly wounded people. I know it's not for us to decide, but were we really doin' them any favors, with the massive injuries – maybe we should have let 'em – some of 'em go. I mean, I had one guy who had two drains in his head, an ICP monitor and half his skull was out. I don't know how he did but I'm just like – the long-term prognosis – like I say, we don't know how they end up doin'. Or they're missin' both their legs and one arm, long-term. Are we really doin' them any favors.
G8: I couldn't tell you – I mean, I couldn't recognize any of the Americans that I took care of over there 'cause you have 'em for such a short period of time, and everything is so rushed, and you don't see 'em lookin' their normal, I mean, you see him intubated, and they're sedated, and they're usually swollen and puffy and full of fluid that we've pumped in, and you don't remember anybody's names. There's so many that you just don't remember. And then you feel bad because you come over here and – like I'll see burn patients, I'm like – I wonder if I took care of him, or I wonder if I took care of this one. So it's kinda – and you feel like – I feel like I should remember – that I should remember their names, or that I should remember something.