The ethical arguments around pharmaceutical use in the military centres on concerns over the use of drugs by otherwise healthy individuals.
The Tarnak Farms incident described above illustrates the complex nature of decision-making in conflict. The US pilots involved had been airborne for more than 10 hours when they found themselves in the position of having only moments to make a life-and-death decision. The cognitive load experienced in the cockpit of an F-16 fighter aircraft is not to be underestimated, and pilots are required to be mentally alert at all times in order to process the large volume of critical detail necessary to make such split decisions. Many military tasks, particularly in combat, require personnel to remain vigilant for long periods of time in anticipation of an attack or a requirement to act. Furthermore, military activities often take place during hours when the circadian rhythm is at its trough: either early in the morning, or late at night. The cumulative effects of this over several months on operations – often in arduous conditions, with poor sleep – inevitably lead armed forces personnel to suffer from sleep deprivation, which can have significant effects on their cognitive performance. The long-term impact of such partial sleep deprivation has been shown to impair moral judgment and elevate the risk of human error, as well as reducing innovation and increasing pressure on individuals to conform with ‘group thinking’. Therefore, if bad decisions are made when tired in combat, is there even an ethical obligation to enhance soldiers in such circumstances?
The use of amphetamines, in the form of Dexedrine, by the pilots at Tarnak Farms had been sanctioned by the US Air Force as a part of its fatigue management programme, to overcome the negative effects of tiredness on long combat missions. The US is the only Western military to officially authorize the use of amphetamines in operations, and following the events at Tarnak Farms the US Air Force strongly defended its decision to prescribe the drug, calling it ‘the gold standard for anti-fatigue’. The dose taken by the pilots involved was low, equivalent to drinking several cups of coffee. Furthermore, pilots are required to undertake ground testing of the drug to check for potential adverse side effects before using it on operations. Following the events at Tarnak Farms, the US Air Force emphasized that the drug had been used in hundreds of missions without incident. This position has been verified by clinical trials, which proved that Dexedrine did not increase risk-taking behaviour during long periods of wakefulness.
The controversy surrounding the use of amphetamines in this instance has clouded debate over their use, preventing a more considered discussion of the broader ethical case for improving human performance in combat. The concerns over safety and negative side effects are one of the principal reasons why performance-enhancing drugs have not been more widely pursued by the military. But what if a drug were to achieve the operational benefits desired, without negative side effects or potential for abuse?
One such drug is Modafinil. Developed to treat narcolepsy and sleep apnoea, Modafinil promotes wakefulness and has been found to significantly improve vigilance, alertness and cognitive performance. In the US, it is available on prescription for the treatment of shift-work sleep disorder. No clinically significant side effects have been observed in the drug’s use. Modafinil also does not prohibit the ability to reinitiate sleep following treatment. It has been approved for use by the Republic of Singapore Air Force, and has been tested for military application in both the US and the UK. Furthermore, when compared with caffeine, which is widely used as a stimulant in the military, Modafinil was recommended as preferred by the US Committee on Military Nutrition Research, which described it as far superior, and with fewer side effects.
As pharmacological technology advances, there is likely to be further development of drugs such as Modafinil, which can be approved as safe when used appropriately. But the ethical argument for their use by the military goes beyond the specific properties of the pharmaceutical, and centres on concerns over the use of drugs by otherwise healthy individuals. The medical cost–benefit analysis for taking prescription drugs usually balances safety considerations against the benefits of overcoming disease or illness. But soldiers receiving pharmacological performance enhancements would not be unwell, and therefore a different cost–benefit framework needs to be applied. The salient ethical question here is whether it would be legitimate to administer drugs to healthy individuals in a military context. In answer to this, I propose three categories of scenario where this would be ethically permissible: 1) in ‘life vs death’ situations; 2) in cases of strategically exceptional mission requirement, and 3) within restorative limits.
During a military operation it is understood that life, limb and health are at greater risk than in a normal civilian environment. The perils and consequences of conflict situations present unique ethical scenarios in which extreme measures like pharmacological enhancement could sway the outcome between life and death. For example, would it be acceptable for a fatigued military surgeon who is suddenly inundated with conflict casualties to take a stimulant to deal with the situation? Or for a military pilot shot down over hostile territory to take an alertness-enhancing drug to facilitate their escape to safety? Or should the drug be kept as an ‘insurance policy’ by soldiers operating in isolated outposts, as a tool to be used in limited circumstances where the danger dictates?
In these life-and-death scenarios, which are not uncommon in conflict, it would seem ethical that the balance of risk would make the use of performance-enhancing drugs permissible. The key characteristics which define such acceptance are the grave consequences of potential outcome, and the lack of available alternatives. This would not be routine, but instead would regard pharmacological options as akin to other articles of specialist military equipment, deployed according to their specialism and role. In these scenarios, drugs could be utilized for specific purposes under particular circumstances where no alternatives are available – or when alternatives are deemed worse – and limited to the duration of the mission. If such an approach were adopted by the military, individuals would be required to test and train with the drug prior to deployment, as with any piece of military equipment, in order that its effects are understood by the soldier and the dosage is determined by a medical professional.
This is not to excuse poor prior planning. Military doctrine and procedures would need to be developed in order to ensure that drug-taking was not abused, and drugs were only issued as a last resort in these ‘life vs death’ circumstances, once alternative options had been exhausted. Such application would need to be unanticipated, and unplanned, rather than being a fall-back solution to address manageable variables such as manning shortfalls, or crew rest. It would be unethical for routine, planned missions to be reliant on the use of ‘life vs death’ drugs for their success.
If a planned mission required the use of pharmacological measures, this would only be ethical in cases of exceptional mission requirement, where not using drugs would result in a mission failure of strategic importance. An example of one such mission would be the deployment of Vulcan bombers by the RAF to destroy the runway at Port Stanley during the Falklands War in 1982. Operation Black Buck involved a series of long-range bombing missions, flown from Ascension Island in the South Atlantic to the Falklands, a return journey of nearly 8,000 miles that took a record-breaking 16 hours to fly. The aim of the mission was to deny the use of the airport to Argentine fighter jets, thus allowing British Royal Navy aircraft to operate from aircraft carriers in the area, in order to support troops on the ground. An in extremis mission such as this, where the gains to the overall operation are of strategic importance and are exceptional, could be planned to involve the use of pharmacological enhancement, where the aforementioned gains had been approved at the highest level, the drug had met safety approval and those taking it had trained to use it. Indeed, in the case of Operation Black Buck, the pilots were provided with the benzodiazepine Temazepam to aid sleep prior to the mission, to ensure they were fully rested before their departure.
The demands of combat operations are physically and mentally debilitating, particularly for troops deployed on the ground in arduous conditions.
The final category of scenario where drugs would be ethically permissible would be to restore degraded soldiers to previous performance levels. The demands of combat operations are physically and mentally debilitating, particularly for troops deployed on the ground in arduous conditions, such as those experienced in Afghanistan and Iraq, where daytime temperatures could exceed 50°C and the average weight of equipment carried by a soldier on patrol was 52 kg. Operating under these conditions for prolonged periods of time can result in a loss of performance below normal healthy levels, although the soldiers would not necessarily be classified as unwell. Synthetically facilitating the speed of the body’s recovery in such circumstances could bring a measurable advantage for operational effectiveness, without changing the predefined limits of a soldier’s natural physiology. This application of pharmacological enhancing technologies – to restore function to previous standards – would increase performance, but changes to the body would remain within the boundaries of what is anatomically normal.
For example, high-intensity exercise leads to a reduction in normal levels of testosterone, a key hormone required for the development of muscle and bone mass. Taking a synthetic testosterone, similar to anabolic steroids, could facilitate the replacement of lean muscle mass in soldiers after prolonged intensive military operations. A similar scenario would involve the use of melatonin to overcome jet lag, which occurs where soldiers travel across a number of time zones and are required to operate shortly following their arrival. Melatonin is a naturally produced hormone that regulates circadian rhythm, and, taken correctly, is an effective antidote to jet lag. In these circumstances, the drug administered must be taken in doses appropriate to restore the soldier to their previous level of function. Therefore, operating within this range of healthy physiology can be argued to not alter the essence of the individual, and could be considered ethically permissible.
The key ethical question that extends across all three of these categories is what it is we value in soldier performance, and to what extent we are willing to alter their physiology to achieve this, rather than developing equipment and procedures to augment and assist soldiers in their task.In order to respect the boundaries of what is human, any pharmacological performance-enhancing technology introduced to the military must be used under a risk–benefit analysis that balances the mission requirements against the use of alternative non-pharmacological options. Taking performance-enhancing drugs should not become routine in the military as a replacement for either poor planning or shortfalls in equipment and training.
