Research Magazine 2009

In Harm’s Way

The Wide-Ranging Repercussions of War

prisoners wearing white uniforms and flip-flops

Photo from Getty Images

In the past eight years, the wars in Afghanistan and Iraq and the larger “war on terror” have become such a persistent part of the national cognizance that, in some ways, these conflicts have also exhausted our attention and begun to fade from the public eye.

But at Boston University, faculty members in a range of disciplines—including medicine, public health, law, theology, social work, and international relations—are closely examining these conflicts to determine how military organizations, the U.S. government, and the public at large might be better equipped to address war’s ethical, legal, and psychological impact.

Medical Ethics—No Exceptions

George Annas

First, do no harm: medical ethics must come before the mission for military physicians, says George Annas, a professor of health law, bioethics, and human rights.

All’s not fair in love and war. From the Abu Ghraib prison in Iraq to the U.S. detention center in Guantanamo Bay, in recent years military physicians have been accused of ignoring medical ethics guidelines set forth in national and international codes such as the declarations on torture and hunger strikes of the World Medical Association.

“Accomplishing the mission is generally seen as the primary goal in the military, and at least some military commanders believe that military physicians should make exceptions to their medical ethics principles if the success of the military mission requires it,” says George Annas, a professor of health law, bioethics, and human rights in the School of Public Health and one of the University’s first two William Fairfield Warren Distinguished Professors. “This is neither good ethics nor good practice.”

According to Annas, current medical ethics problems in the military include physicians’ involvement in the interrogation of terrorist suspects and the force-feeding of prisoners on hunger strikes. Additionally, he questions the treatment and certification of U.S. soldiers with mental-health conditions prior to redeployment.

“Military physicians often debate whether they are physicians first and military officers second, or the other way around,” he says. Annas believes that doctors in the military “are and should be bound by universal medical ethics principles,” but at the moment there is no military doctrine on this question.

Further blurring legal boundaries are Justice Department lawyers, who concluded in the aftermath of September 11 that torture was not illegal in circumstances where subjects were monitored by doctors to ensure that military personnel avoided inflicting permanent injury.

“The lawyers needed the doctors to carry out the torture,” says Annas, whose forthcoming book, Worst Case Bioethics, explores the dangers of using worst-case scenarios to make policy. “And I think the doctors needed the lawyers to tell them they were immune from war crimes prosecution if they participated in them.”

His goal is to reverse this thinking and to make clear “that a physician does not escape from medical ethics obligations by putting on a uniform.” To do so, he proposes that doctors, lawyers, and military officers work together to protect human rights, strengthen democracy, and lift the threat of unethical behavior toward U.S. troops abroad.

“The lawyers needed the doctors to carry out the torture. And I think the doctors needed the lawyers to tell them they were immune from war crimes prosecution if they participated in them.”

To this end, Annas and a fellow professor of health law, bioethics, and human rights, physician Michael Grodin, organized a series of military medical ethics workshops to give government leaders and high-ranking military physicians the opportunity to discuss issues of medical ethics with human rights advocates, law professors, and medical ethics scholars, as well as retired military physicians.

After more than a year of workshops, the Assistant Secretary of Defense for Health Affairs joined these efforts, and the Department of Defense agreed to fund a workshop on military medical ethics at the Institute of Medicine in fall 2008. The workshops also earned Annas an invitation to speak at a conference of the Department of Defense’s Military Health System. His presentation focused on the problem of breaking hunger strikes at Guantanamo—a practice that he argues was used to punish, not medically treat, detainees—and was well received by military medical professionals, including Assistant Secretary of Defense for Health Affairs Dr. S. Ward Casscells, who said it prompted him to reconsider physicians’ participation in attempting to break hunger strikes.

In August 2009, Annas and another member of the medical ethics workshops addressed the new ethics subcommittee of the Defense Health Board, a body that advises the Secretary of Defense. Ultimately, he would like to see the Department of Defense adopt “a very clear policy on medical ethics” to avoid room for dangerous interpretation.

“I’m quite hopeful that when we get new leadership at the Department of Defense,” Annas says, “they will be studying everything that happened in the last eight years, and will issue a clear instruction that physicians never have to compromise medical ethics to serve their country.”

Triumph over Trauma

Looking at how religious groups responded to trauma experienced by Hurricane Katrina survivors, Shelly Rambo realized that faith communities aren’t always prepared to help set individuals who have experienced trauma on a path to healing.

“I started to think about the responsibility that I had as somebody who researched and studied and was deeply invested in the study of religion to deal with trauma,” says Rambo, an assistant professor of theology.

a soldier's hands holding a rosary

Photo from Getty Images

Focusing on the Christian tradition, she turned her attention to the narrative of resurrection, which is central to the Christian faith and offers insight into the way many believers interpret pain and healing. Most accounts of Jesus’s death and resurrection skip directly from his crucifixion on Good Friday to his rising again on Easter Sunday—a triumphant journey from death to life that Rambo suggests is inadequate for explaining the depth of suffering experienced by trauma victims.

Delving deeper into religious texts, Rambo says that it is Holy Saturday, the day after Jesus’s crucifixion and before the resurrection, that fully reflects the in-between nature of trauma, where one is still haunted by past events without yet seeing the hope of a new beginning. She stresses that a renewed reading of Holy Saturday—the event of Jesus’s descent into hell—could offer a way for trauma survivors to place their experience within the language of faith.

“Trauma, in my view, is not only an experience of encountering death. Trauma is really located in the crisis of surviving that death,” Rambo says. “There’s suffering in living beyond a death and not yet being able to see life.”

Interpreting Holy Saturday can help trauma survivors to both understand the experiences of survival and map a path to recovery, says Rambo, whose forthcoming book, Trauma and Redemption: Witnessing Spirit Between Death and Life, further explores the interweaving of life and death in the Christian tradition.

“Trauma is not only an experience of encountering death. Trauma is really located in the crisis of surviving that death. There’s suffering in living beyond a death and not yet being able to see life.”

In addition to her textual and theoretical work on trauma, Rambo has found ways to translate her conclusions into everyday practice. She is currently piloting a series of workshops for religious leaders looking for ways to enable their religious communities to assist returning veterans. In these workshops, Rambo turns leaders to “organic resources” within their traditions to assist in trauma healing. She also draws on developments in neuroscience—including findings that trauma survivors have trouble sorting through memories and talking about their experiences—to encourage a move from traditional talking therapies to an array of body-focused approaches, such as yoga, meditation, dance, and other physical activities associated with religious practices.

Though her work is rooted in the Christian perspective, Rambo says that all religious traditions offer trauma survivors ways to navigate through suffering.

“I want religious leaders to understand that trauma really lodges in people’s bodies,” Rambo says. “Often we are very word-oriented in religious communities and yet we have really deep practices, bodily practices” that can help relieve the weight of trauma.

Preventing PTSD Violence

Eight years ago, when Associate Professor of Psychiatry Casey Taft began researching the corrosive effects of post-traumatic stress disorder (PTSD) on soldiers’ relationships with their partners and spouses, he was filling a noticeable gap in the field.

Casey Taft

Casey Taft

“The problem of domestic violence in the military really didn’t receive a lot of attention,” he says, “until there were some high-profile incidents, such as Fort Bragg,” where four Army wives were killed within a six-week period in the summer of 2002. But even with increasing awareness, there continues to be a lack of treatment programs targeting PTSD-related partner abuse among the military population.

An anxiety condition that occurs after a person encounters the threat of injury or death, PTSD alters the body’s ability to handle stress. The disorder is characterized by a constant reliving of the traumatic event, a sense of emotional numbing, and symptoms of arousal and irritability—all of which can impede nonviolent conflict resolution among couples.

As a result, partners of service members and veterans with PTSD risk becoming victims of what Taft calls intimate partner violence, behaviors which involve physical, psychological, and sexual aggression. And because longer combat exposure is more likely to result in PTSD, the extended and repeated deployments common in the armed forces today pose an added danger to military families.

“PTSD is a strong predictor of relationship problems and difficulties in managing anger, which can lead to partner violence,” says Taft, who also serves as a psychologist at the Behavioral Science Division of the National Center for PTSD and the Veterans Affairs Boston Healthcare System.

Taft, along with co–principal investigator Candice Monson, associate professor of psychiatry at BU’s School of Medicine, and co-investigator Matthew Feldner, a psychologist at the University of Arkansas, is currently working to develop and evaluate interventions to prevent and treat partner violence. A large research team consisting of other experts in the areas of PTSD and partner violence, undergraduate and graduate research assistants, and postdoctoral fellows is also assisting in the project, which takes an empirical approach to creating and evaluating intervention programs.

With a $2 million grant from the Centers for Disease Control and Prevention, the team is conducting weekly group sessions for couples in non-abusive but distressed relationships where one partner has developed PTSD following deployment to Afghanistan or Iraq.

“We focus heavily on communication skills and helping the soldiers express their emotions, and doing things to try to establish more of a sense of intimacy,” Taft says, to help prevent partner violence from occurring in the future.

A second study, funded by a $1.5 million grant from the Department of Defense, seeks to develop and test an intervention focused on managing anger and ending ongoing partner violence. The project involves conducting weekly group sessions with individual male veterans who have engaged in physical aggression toward their partners upon returning from active duty.

In both studies, researchers are using data collected from veterans and their partners to prepare and evaluate these programs for possible future use by the military. “Given the scope of the domestic violence problem among those exposed to combat trauma who develop PTSD, and the number of returning veterans,” says Taft, “a lot of good can be done if we can develop something that works.”

Avoiding Collateral Damage

Stories about soldiers who “snapped” and harmed civilians are what capture the headlines, but political scientist Neta Crawford is investigating the unintended civilian deaths caused in Afghanistan, Iraq, and other fronts in the “war on terror.” When she found that the casualties caused by the United States far outnumber the deaths resulting from deliberate attacks on civilians in those war zones, she began to ask why there was so much collateral damage from conflicts that the Bush administration had said would be precise and avoid harm to civilians, and to question who is morally accountable for those deaths.

Neta Crawford

Neta Crawford

Part of the problem, says Crawford, a professor of political science and African American studies, is that the Department of Defense is ambivalent about protecting civilians. “Many people in the Pentagon, I think, subscribe to noncombatant immunity,” she says. “But on the other hand, they are willing to say that if it’s militarily necessary, we’ll accept a certain amount of civilian deaths.”

As a result, unintended noncombatant deaths have increased in recent years as the U.S. has employed more aggressive strategies to locate and capture terrorists or deal with “insurgents” in Afghanistan and Iraq. Unplanned air strikes, used in response to sudden enemy fire, for example, have become notorious for taking civilian lives.

“People say to you privately and publicly that they are doing their best, and I think they are,” Crawford says. “But on another level, they don’t get that the ways that they’re fighting are foreseeably causing lots of civilian injury and death.” Among the weapons used, for instance, are 2,000-pound bombs with an area of destruction roughly equivalent to the size of two football fields, which cannot discriminate between combatant and noncombatant when dropped in or near villages.

That’s why, Crawford argues, the moral responsibility for civilian casualties must be shared by military organizations, the state, and the public alike. “The vast majority of the harm that the U.S. has done to civilians is unintentional but foreseeable,” she says. “Therefore, we are obliged to reduce it.”

To raise awareness about what she describes as inadvertent but preventable civilian deaths, Crawford has spoken at conferences for military personnel and written extensively both in academic and non-academic publications. She is currently working on a book titled Ordinary Atrocity and Collateral Damage, which further examines how existing military rules of engagement and choice of weapons undermine civilian safety.

In strategizing its approach, the onus falls on the military to design and implement practices that will secure civilian immunity. But if the military fails to curb the use of particularly dangerous weapons or take other actions to ensure civilian safety, it becomes the state’s duty to step in and demand change, Crawford says.

The public, too, must evaluate information about military conduct and hold the military accountable by, for example, launching campaigns to gather momentum behind a given issue, voting out supporters of ineffective policy, or calling for taxpayer-funded reparations for victims.

“We cannot leave the business of making war to the military,” Crawford says. “We should know what our military is doing and what the consequences are.”

Chart: varied “collateral damage” estimate for Afghanistan, 2006-2008

Sources: North Atlantic Treaty Organization’s International Security Assistance Force (NATO ISAF); United Nations Assistance Mission to Afghanistan (UNAMA); Agency Coordinating Body for Afghanistan Relief (ACBAR); Marc Herold (HEROLD); Amnesty International (AI); Afghanistan NGO Safety Office (ANSO); and Human Rights Watch (HRW).

*Source indicates that their estimates are incomplete.

Chart courtesy of Neta Crawford