• Paediatrics
• Surgery
• Traumatology
• Child health

War-time data have been pivotal in informing the evidence-based management of trauma in modern medicine.1 The established military-industrial complex that Dwight Eisenhower cautioned of in 1961 has now developed into a vast and established global war economy resulting in over 250 conflicts since World War II.2 The war industry relies on rafts of military spending, requiring frequent and large-scale conflict to sustain it. A further frequently unspoken aspect of war is the wealth of trauma data generated from combat and war victims, whether they be: soldiers, war prisoners and civilians either injured during armed operations or for unclear or unknown reasons.3 4 Civilian casualties have tended to proportionally increase over time: 5% in World War I, 50% in World War II, over 80% in the Vietnam war and around 90% in recent conflicts in the developing world.5 Kendrew Lascelles poem ‘The Box’ encapsulates the unfortunate circumstances of children that are entrenched in a war that is not their own. The current commentary calls into question the ethics of war-time trauma data, with particular reference to children. The example study below helps frame subsequent discussions:

• Study title: ‘Clearly defining paediatric massive transfusion-cutting through the fog and friction with combat data’6

• Journal (Year): Journal of Trauma and Acute Care Surgery (2015)6

• Study population: all injured patients younger than 18 years admitted to US combat support hospitals in Iraq and Afghanistan from 2001 to 2013. This included 3649 children, 1113 that required a blood transfusion within 24 hours of their injury and 173 children that ultimately died. The age range of the children could not be ascertained from the publication but the IQR was 6–13 years for those that required massive transfusion.

• Mechanism of injury: the circumstances surrounding why these children were injured or died is not clarified in the study. However, the most common mechanism of injury reported among children requiring transfusion was explosive (56%), followed by penetrating trauma (32%), and then blunt trauma (12%).

• Ethics statement: the following statement is included in the methods: ‘This study was initiated under a protocol reviewed and approved by the San Antonio Military Medical Center Institutional Review Board’. This institutional review board governs a military hospital, and has no known jurisdiction over the research subjects (civilian children in Iraq and Afghanistan). No further discussion of ethical dimensions or considerations were stated.

• Impact of publication: this study has been central to the paediatric trauma and massive transfusion literature.7 It largely justifies the threshold for more invasive intervention after a resuscitative threshold is met in injured children (over 40 mL/kg within the first 24 hours was associated with excess in-hospital mortality). It has been referenced by the ATOMAC (Arizona, Texas, Oklahoma, Memphis, Arkansas Consortium) trauma consortium,8 and other consensus guidelines.9 In total, it has been cited 149 times to date.

• Contextual aspects:

  Human rights law declares 18 as a minimum legal age for recruitment of children in hostilities. Recruitment or use of children under the age of 15 is defined as a war crime by the International Criminal Court. Therefore, given the median age in this study, the great majority of these children were either civilian casualties, or involved in a war through inhumane or criminal channels.10

Medicine has had a compromised moral record when it comes to human experimentation, with the most glaringly obvious and well-known example being Nazi experimentation on concentration camp victims.11 12 For the purpose of medical research, any research population deprived of ‘basic rights’ should be recognised as a vulnerable population. In undertaking medical research involving such vulnerable groups, the most recent iteration of the WMA Declaration of Helsinki Ethical Principles for Medical Research (successor to the Nuremberg Code) sets out particular conditions and recommendations. It states that the research is only justified if it is responsive to the health needs or priorities of the vulnerable population, and this population should stand to benefit from the knowledge, practices or interventions that result from the research.13 Issues relating to this type of research are seldom black and white, but it is recommended that research conducted on vulnerable populations should always be accompanied by a discussion of relevant ethical issues.14

The concept of virtue ethics places virtues (eg, justice, integrity) as central and autonomous, but virtue ethics may not allow benefit to be gained from data already collected. It is natural to turn to utilitarian considerations to overlook the glaring issues, and allow some good to come from human suffering and sacrifice. However, this does not in any way mitigate the horrors of innocent child suffering as a consequence of contemporary warfare. A core principle of using study data, regardless of ethical constraints, is to use its’ lifesaving potential. It would be harmful to future patients to ignore data that has already been generated.

There is an ethical problem when invaded populations are studied to the benefit of the colonisers or invaders. The arguments for not using such data include concepts of ‘tainted data’ which refers to the process by which end-users become corrupted by the morally questionable nature through which the data were generated, and the ‘legitimising evil’ argument which states that by using such data we confer legitimacy to the researchers and process with which it was obtained. It is difficult (if not impossible) to separate the academic advantages accruing to the researchers, a form of exploitation of human suffering, from the beneficial aspects of such research. Similarly, the ‘deterrence’ argument maintains that in refusing data that is ethically corrupt we discourage future researchers utilising similar methodologies.12

To use data without the consent of research subjects is to violate the violated anew.11 In this way, the reprehensible violation and disregard for their human ‘being’ precludes generation of any value. Consent in the context of conflict is highly problematic from multiple angles, and consent by proxy even more so. Nevertheless, the fact that the research subjects (or at least survivors or a representative group retrospectively) were not involved in providing approval for the use of this data in any capacity is insoluble.

War imposes catastrophic consequences on human life (figure 1). This includes combatants, and also the tremendous harms suffered by civilians despite their protection by international law. For children, the wider and less well documented impacts of war include: displacement, destitution and exploitation.15 War and organised violence necessitates families and communities to cope with loss of food and livelihood—furthermore, the breakdown of both educational and health systems.5 Women and children are disproportionately affected, as has been the case in Afghanistan. Rates of malnutrition, disease and death among children in Afghanistan are among the highest in the world after decades of war. Over and above the physical injuries from artillery and landmines (that may continue long after the war is ‘done’), over 80% of children in Afghanistan suffered psychological trauma from the war.16 Environmental contamination from depleted uranium weapons used by the US military in Iraq continues to cause congenital anomalies in newborns.17 The effects of war on civilian populations are immense and transgenerational.

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Figure 1

The Frame. ‘The world is my field of vision. From war to peace, my images are intended as a testimony of humanity as we follow the world's different paths’. Quote and image used with permission by photojournalist Reza Deghati © REZA/WEBISTAN.

Morality, humanity and professional integrity should place decisive barriers between ethical experimentation for the common good, and observed atrocities.12 We require critical engagement with war-time data, not just bearing in mind the required scientific rigour (particularly relating to information bias in emergency settings), but maintaining an understanding of the evolving sociopolitical context, agendas and power structures involved. One can conclude that the example study does not stand to impact positively on the study population, but rather maintains existing colonial power structures that exist in health globally.

This emerging frontier of bioethics remains unclear and is evolving. Understanding structural violence and leveraging from learnt experiences in related fields, beyond frameworks and simple actions, will be important in resolving this conundrum. A practical first step is understanding the motivations, incentives, concerns, sociopolitical context and responsibilities of key stakeholders in conflict-affected research, namely: funding bodies, humanitarian organisations, researchers, ethics committees, participants, publishers, editors and readers.

The responsibility of researchers for ethical practice is heightened in times of conflict, but mechanisms for oversight are poorly constructed and researchers face their own risks in such unstable environments. Existing organisational structures may corrupt or erode host country human research ethics committees and representative bodies, and individual participants may be rendered vulnerable, disempowered and silenced. What is required is the development of shared interests and trust between stakeholders. Decision-making should be redirected from the primary researcher and remote ethics committee towards a ‘research community’ where participants, groups and communities exercise agency and influence through engagement with the research process.18 Involvement of local researchers with the right power dynamics in the research team will enhance this process. Critical appraisal should not undermine or paralyse opportunities to conduct valuable research. A postresearch ethics audit may provide valuable insights rather than vexing retrospection.19 Ultimately an iterative ethical approval process may serve researchers, participants, and more broadly the research process, best.

When approaching wartime literature, the ethical imperative is to protect human rights (the right to life, to physical and mental integrity, and to privacy) and human dignity.20 Affirming the primacy of the human being over science (as well as society), we see that science is not an end in itself, and that humans are not mere instruments to benefit the scientific process. It is ethically unacceptable for invaders to extract data from invaded populations without consent (or at least proxy consent), then export the data to profit their home populations. Research rules that we hold to honour and protect children’s rights and welfare during peace and conflict should be applied rigorously and without borders.21 22