Supersoldiers: Pharmacological performance enhancement in the military

What sort of performance enhancements are the military trying to achieve by using drugs?

Héloïse Goodley: Drugs would be useful where they would give you an additional advantage by addressing the human weaknesses in conflict or in combat. Firstly, there is overcoming fatigue – sleep deprivation – which is a very common problem in conflict. Secondly, there is strength as over the course of arduous exercise soldiers debilitate in strength and the ability to recover. Finally, there is mental trauma – PTSD – although in my paper I have dismissed this as an area where you would want to consider pharmacological enhancements.

We spend a lot of time protecting the human in war with equipment such as body armour and sensors, but we don’t necessarily think about other options that are available. That is largely because the idea of using drugs to enhance performance is quite taboo, and it is a taboo which comes mainly from sport – and that is the problem. In sport, it is seen as cheating and as unfair, unethical and illegal. But conflict is completely different, and you are not trying to achieve the same outcome. In sport, there is no social benefit in taking drugs – but in conflict there could be. It is an area that is still receiving a lot of resistance but I do think there are ethical and legal areas where it would make sense.

Has societal opinion always been opposed to soldiers taking performance-enhancing drugs? What has it been like throughout history?

Héloïse Goodley: No – and that is the interesting thing. One of the main conclusions of my paper is that society will decide what is acceptable, not the military. The Second World War is quite a good example. The German armed forces were initially using drugs – mainly to stay awake, and some anti-fear too – while in the Allied countries there was quite strong resistance to our armed forces doing that. But there was a debate about it and people did not like the fact that we were effectively disadvantaging ourselves. So it was actually society that encouraged the change.

By the end of the war, the Allied powers were pretty much all using pharmacological enhancement but, interestingly, the Germans had stopped. This was because they had experienced the negative side effects of it, the biggest one being a degree of paranoia that led to a breakdown of trust within teams, due to the particular drugs they were taking.

So there is definitely a historical precedent for it but is not at all common today. The only NATO member that uses any form of pharmacological enhancement is the United States, and they do it in a very controlled manner, they use a sleep management programme for pilots. There are some non-NATO members who do it, Singapore for example. As I said earlier, society decides what is acceptable for our soldiers to do and society has not yet had that debate and discussion, and right now, because we are not quite in the same conflict pressures and scenarios as Iraq and Afghanistan have wound down, it would be very difficult to try and have this debate. Although, ironically, this is exactly the right time to do it because you would want to be testing and seeing what it would do to soldiers in a peacetime context. But, at the moment, it is purely hypothetical.

In Afghanistan in 2002, two US air force pilots mistook Canadian soldiers taking part in a night-time training exercise for an attack and dropped a bomb which killed four Canadian soldiers and wounded a further eight. In their defence, the two pilots said their judgement had been impaired by amphetamines issued to them by the US Air Force. What are the implications of drug use for individual responsibility in conflict?

Héloïse Goodley: Known as the Tarnak Farms incident, this brings out some quite interesting principles on the moral responsibility that a soldier has in conflict. In this particular scenario they were pilots, but it could be a soldier on the ground as well. All soldiers have a moral duty under both international humanitarian law and human rights law, and there are two aspects to that moral responsibility.

Firstly, they must have the mental capacity to understand what they are doing and the consequences of their actions. And that is quite important, it’s a point in law called mens rea. It is basically criminal responsibility in that you had the intent, you knew what you were doing, and you knew what the consequences were likely to be.

Secondly is the requirement to control your behaviour. Interestingly, if you are involuntarily intoxicated, so if somebody spikes your drink or drugs you, you no longer have a criminal responsibility for your actions because you have lost the control of your behaviour. Obviously, if you deliberately get drunk, that was a deliberate act.

For a soldier to maintain moral responsibility, they must have both the mental capacity and the ability to control their behaviour. The ability to control behaviour is quite an interesting one. Although not pharmacological, one area where there is a bit more research is exoskeletons, this idea of a support robot around a soldier that would help them lift heavy things, for example. But what if that system could be hacked and the soldier would not be controlling it anymore? While this is beyond the realms of my paper, what scenario do you get into if soldiers are becoming more and more reliant on computers controlling their actions – but that computer is no longer controlled by them? There are similar ethical and legal principles here.

The interesting thing is that the moral responsibility under international humanitarian law underpins a state’s legitimacy to use armed force. As the United Kingdom or any other NATO member, our right to use our armed forces and go and prosecute violence is based on our ability to control that and guarantee it. If we can’t, our legitimacy to use armed force becomes undermined because we would be sending soldiers off to war not knowing what they could do. So it is not just the soldiers’ responsibility or the armed forces, it is actually governments too. You need to know that soldiers will stick to the laws of war in conflict.

Can a soldier be forced to take drugs? If drug use has been decided upon for a particular unit, can an individual soldier refuse?

Héloïse Goodley: A soldier cannot be forced to take drugs and can say no to inoculations, which creates moral and ethical problems within the army. Medical interventions must be delivered with free and informed consent – and therein lies the problem.

Firstly, the free consent is difficult to guarantee in a hierarchical organization. It is very difficult for a young soldier to say no to somebody who is much more senior. Thus, while a soldier has a right to say no, what that right actually feels like is a bit more ambiguous. There is also the responsibility to your peers. Because if you say no – and it is very similar to what is happening with the COVID-19 vaccination programme right now – you are basically relying on other people to say yes, to effectively accept the fact that you are not comfortable doing it. And that might be okay in society where you are not all part of a really strong team. But in the army, where you work together as a very close team, and you are expecting other members of the team to take a greater responsibility than you, it is going to lead to problems within that team.  

Secondly, the informed bit of consent is challenging because a lot of what we do is secret. How do you inform someone of something that you don’t want to be released into public knowledge? A good example of this is the first Gulf War. They thought Saddam Hussein was going to use biological warfare against British troops, so soldiers were vaccinated against biological weapons. The three they received were bubonic plague, whooping cough and anthrax but, obviously, you could not tell people what they were having because then Saddam Hussein would have found out what the British were prepared for and he could have used a different biological weapon. The army had a responsibility to protect its soldiers but, at the same time, could not reveal the extent of what was happening.

The military learnt some hard lessons as a result of that vaccination campaign and it has not been done since. When I was doing my research, I asked a military medic how often a soldier says no to a vaccination and she said she has never seen it but that they do ask a lot more questions now, they are more curious. But there is a very high level of trust within the military. For example, I deployed to the Democratic Republic of Congo, so I had to have a yellow fever vaccination. It is an entry requirement of the country, whether you are in the military or not – it never crossed my mind to say no.

Do you think that what is going on now in society in terms of people questioning the safety of vaccines and the impact of anti-vax propaganda is likely to be reflected in the army?

Héloïse Goodley: This links to the point about crossover from civilian acceptability. I think the vaccination uptake in the UK has been a lot higher than we expected. Yes, there seems to be quite a vocal anti-vax group, but it is nowhere near as high in the UK as it is in some other countries. Almost half of UK adults currently take prescription drugs, so drug taking in society is becoming more and more normalized. I think the COVID-19 vaccination programme will help normalize vaccinations.  

As I said, it is not common for soldiers to say no to a vaccine, mainly because they are pretty standard. But you are right, it has definitely brought in a really live debate now in the in the current climate. The army is a very young organization – the average age for a soldier is something like 26 – and under-18s are not currently being vaccinated so as they come through, it will be interesting to see how they have been informed by their experience and what their attitudes are. As far as I am aware, it has made them more curious for information, but not necessarily made them more resistant to the vaccines. Today, rather than the onus being on the soldier, it is probably more up to the army as an employer to articulate why it is important. I think that is a good thing.

The thing with the army is also the level of trust. Soldiers trust that what they are being asked to do has been thought through properly and with that comes a real responsibility for those who have decided on the course of action. With regards to pharmacological enhancement, it would be something that you would have to try and experiment with in controlled circumstances in the safety of the UK, properly administered by a doctor and monitored to see what the side effects are. However, I am not aware of any programmes in any of the NATO countries, including the US, where they are specifically designing a drug, it is all about using drugs that are already on the market that could also assist in the military, which means there is already a very large body of evidence about side effects.

In your paper, you say that although drugs can be useful in preventing PTSD, thus protecting soldiers’ mental health, there is also a risk in doing so. What is the danger in changing how soldiers experience war?

Héloïse Goodley: There is a piece of research from the United States looking at a drug called propranolol, it is a beta blocker that would block you from forming the emotions attached to an event, which is one of the big issues with PTSD. I think, to be fair, it is entirely hypothetical. The ability to administer that drug at exactly the right moment, I doubt in the first place. You would effectively have to take it in preparation for a traumatic event, which would itself create psychological distress.

But that aside, my bigger concern about changing the brain chemistry – neurological interventions – is how it would affect how we see and feel and conceptualize conflict. Particularly the existential elements of war – the fear, the trauma, the terror – those things are actually really important. The fact that soldiers have to go and experience them is very regretful but if a soldier does not come back with those experiences, society will not know what war is about. That sets a very dangerous precedent where you could effectively send soldiers off to war and the society that chooses to send them will have no proper knowledge or understanding of what war involves. You do not want to get into a scenario where a soldier can’t experience the emotional implications of what they are doing. War is a really emotive experience and to take that away would be huge.

It also affects the learning and feedback. If a soldier is not feeling doubtful about doing something, or just the high energy intensity of being in conflict, what will that do to their decision-making? There is also learning at the institutional level. The army learned an awful lot of lessons from Afghanistan. Not just lessons that involved kit and equipment and tactics on the ground, but also emotional lessons about how we do things, how we bond and how we develop and move forward. So there are a number of psychological consequences of interfering with brain chemistry.

Propranolol is a useful example of something that at first glance appears to solve one of our big problems – PTSD – but then you realize that PTSD actually has a role in society. And that is a horrible thing to say, but if we do not feel the emotions of war, we do not learn from war. Society does not actually experience war so if soldiers are not coming back with the memories of what they have been involved in, you basically desensitize conflict.

In your view, when would pharmacological interventions be ethically permissible?

Héloïse Goodley: In the paper, I set out three scenarios within what I think would be ethically and legally acceptable that also consider that the cost-benefit analysis framework and trade-offs in war are entirely different.

The first scenario is a life-or-death scenario, which sounds really obvious. The most plausible scenario is probably an anti-fatigue drug to keep soldiers awake. Soldiers might be out in a small outpost somewhere, surrounded and in a battle back and forth with the enemy, unable to get out. A situation like that can go on for days and the biggest threat in such a scenario is eventually losing your cognitive faculties because you are too exhausted. The ability to use a drug to keep someone alive until help arrives I think is both ethically and legally acceptable.

The second scenario is a bit more bespoke. It is where it would be of such strategic importance for a mission that if you did not do it, the outcome would be mission failure. The example I used here was a bombing mission during the Falklands war. The mission was to fly all the way to Port Stanley to destroy the runway so that the Argentinians could no longer use it to fly their fighter jets from, to stop them from bombing the British task force in the South Atlantic. It was a 16-hour flight, you would never normally ask a pilot to fly for that long. The soldiers took a drug called temazepam ­– a sleeping pill basically – to make sure they slept properly and were properly rested the night before, something that is perfectly within normal guidelines. This type of scenario only involves a tiny group of people, can be planned quite far in advance and can be signed off at the highest level – but is also of critical strategic importance.  

The third scenario is within restorative limits or within what is naturally physiological. I think people do not realize just how debilitating conflict can be, how tiring and exhausting, you often do not get a day off, sometimes you are awake for days on end, it might be extremely hot and you are carrying lots of kit. In the days of Afghanistan, soldiers used to go for six months and when they came back, while they were not unwell, they had probably lost quite a lot of muscle mass, a lot of weight, they were probably quite tired. It is a slow degradation because your body is not getting enough time to recover.

In this scenario, you are affecting someone within their restorative limits to bring them back up to a healthy level, and that would have to be done on a bespoke, person-by-person basis. The example I use is testosterone. When a male does prolonged physical activity, their testosterone levels decline if they do not have enough time to recover in between. Men need testosterone to restore muscle mass and for bone growth so if they are not having time to recover, slowly over time they will debilitate. You could give them an artificial testosterone – an anabolic steroid – but only a small amount to get them back to their normal level, not exceed it.

My caution with all of it is I personally do not think that drug use should become normalized in the armed forces. These are all examples of something that you would do in extreme situations and the key point of that is that drugs should not make up for other failures like poor equipment, poor planning or just mismanagement.