Medical Operations and The Law of Armed Conflict This class is intended for members of the medical community. It provides an overview of international law, the law of armed conflict, and special rules applicable to medical personnel, medical facilities, hospital ships, and medical transports. It is a one and a half hour to two hour class routinely taught to the Strategic Medical Readiness Course (SMRC), the Joint Medical Planners Course (JMPC), and the POMIC.

OVERVIEW Sources and Purpose of International Law The Law of Armed Conflict The 1949 Geneva Conventions The Distinctive Emblem Medical Personnel Medical Facilities Hospital Ships and Transports This course covers the following topics. It is not designed to make you an independent expert in the field. Please ask questions at any time.

Sources of International Law International Agreements Customary International Law - the practice of States General Principles of Law Teachings and writings of highly qualified jurists (professors, etc) Provide brief overview of the sources of International Law, as well as the practice of International Law - mention customary International Law, Treaty Law, International Agreements, etc.

Treaty Law Geneva Conventions (1949) Additional Protocols (1977) GC1 SICK AND WOUNDED GC2 SICK, WOUNDED AND SHIPWRECKED AT SEA GC3 PRISONERS OF WAR GC4 CIVILIANS Additional Protocols (1977) PROT 1: PROTECTION OF VICTIMS OF INTERNATIONAL ARMED CONFLICT PROT 2: NON-INTERNATIONAL CONFLICTS * outline and describe the purpose of the Law of Armed Conflict

The Law of Armed Conflict What is it? That part of international law that regulates the conduct of armed hostilities. Also called the Law of Armed Conflict (LOAC). JCS PUB 1-02 (12 Apr 01) DICTIONARY OF MILITARY AND ASSOCIATED TERMS * outline and describe the purpose of the Law of Armed Conflict

The Law of Armed Conflict Purpose? To ensure that the violence of hostilities is directed toward the enemy’s forces Complements the principles of warfare, particularly the concepts of mass and economy of force Taken together, the law of armed conflict and principles of war focus on the import of concentrating force against military targets while avoiding expenditure of personnel and resources against things that are not militarily important Provides stability in international relations- Reciprocity! * outline and describe the purpose of the Law of Armed Conflict

Basic Principles of the Law of Armed Conflict military necessity proportionality unnecessary suffering discrimination or distinction * as indicated in the most recent DoD Kosovo Report, we applied all of these principles during the conduct of Operation Allied Force

Military Necessity Targeting a certain object offers a definite military advantage May use that force not forbidden by international law which is necessary to secure the prompt submission of the enemy * as indicated in the most recent DoD Kosovo Report, we applied all of these principles during the conduct of Operation Allied Force

Proportionality May not cause suffering, injury or destruction to civilians or civilian objects disproportionate to the military advantage gained Collateral damage will happen Question is how much is acceptable Issues of weapons choice and tactics * as indicated in the most recent DoD Kosovo Report, we applied all of these principles during the conduct of Operation Allied Force

Unnecessary Suffering May not inflict suffering, injury or destruction not actually necessary to accomplish legitimate military purposes * as indicated in the most recent DoD Kosovo Report, we applied all of these principles during the conduct of Operation Allied Force

Distinction/Discrimination Must distinguish between military objectives and civilians and civilian objects Military objectives Combatant personnel Objects Contribute to the enemy’s warfighting/war-sustaining effort Destruction would constitute a definite military advantage Includes both military and economic targets * as indicated in the most recent DoD Kosovo Report, we applied all of these principles during the conduct of Operation Allied Force

MEANS OF WARFARE GENERAL PRINCIPLES APPLICATION RIGHT TO INJURE HAS LIMITS MILITARY NECESSITY VS. UNNECESSARY SUFFERING DISTINCTION (MUST NOT BE INDISCRIMINATE) AND PROPORTIONALITY APPLICATION INTERNATIONAL ARMED CONFLICTS IMPLEMENTATION THROUGH LEGAL REVIEW OF WEAPONS DOD Instruction 5000.2 , Defense Acquisition Management Policies and Procedures SECNAVINST 5000.2B, Review of Weapons under International Law * must weigh the military necessity of the target with the potential collateral damage; will the collateral damage be disproportionate in light of the anticipated military advantage to be gained by the military action * DoD reviews all weapons to ensure they comply with the principles of the Law of Armed Conflict; certain weapons, for example fragmentation weapons do not meet the standard nor comply with LOAC; weapons which could result in fragments, undetectable by medical means, may not be used

Lawful Targets Combatant personnel Military objectives Those objects which contribute to the enemy’s war-fighting/war-sustaining effort and whose destruction would constitute a definite military advantage. Can include both military and economic targets * in next slide, I will review in detail, who qualify as combatant personnel

Lawful Combatants Regular Armed Forces Uniformed Forces Except Medical Personnel And Chaplains Irregular Armed Forces Under Responsible Command Distinguishable From The Civilian Populace Carry Arms Openly Comply With The Law Of Armed Conflict Lawful Combatants get “Combatant Immunity” Unlawful Combatants do not could be tried for murder

Unlawful Targets Noncombatants and persons hors de combat (wounded, sick and SW) Civilians and Civilian Objects All civilian property and activities other than those used to support or sustain the enemy’s war-fighting capability. Would not include dual use facilities * when conducting targeting analysis, must determine if the target has a dual use, that is both military and civilian; what effect will elimination of the target have on the enemy’s warfighting effort? What effect would destruction have on the civilian population?

Incidental Injury/Collateral Damage Not unlawful if incident to attack on military objective/combatant personnel Must not be excessive in light of the military advantage anticipated by the attack Commander’s obligation to minimize Additional Protocol 1 which uses language “take all feasible precautions”

Deception In Armed Conflict Ruse And Stratagem (Lawful Deceptions) Decoys False Communications Camouflage Surprise Feigned Movement Perfidy (Unlawful Deceptions) - Misuse Of Protected Status Or Protective Signs And Symbols False SOS/Mayday Feigned Surrender Misuse Of Red Cross Symbol Misuse Of Protected Platform (I.E., Hospital Ship, Fishing Boat) * it is unlawful deception, and a violation of LOAC to misuse a protected platform such as a hospital ship or aircraft

The Distinctive Emblem 3 Recognized Emblems The Red Cross The Red Crescent The Red Lion and Sun Numerous Unrecognized Emblems Protection is not contingent upon using a protected emblem. Recognition of status is the key If status of medical personnel is recognized on the battle field, that is enough to bestow privilege

Medical/Religious Symbols

Medical Personnel Respected and Protected Personnel afforded status (GWS, Art. 24) Medical personnel “exclusively engaged in the search for, or the collection, transport or treatment of the wounded or sick, or in the prevention of disease.” Accidental killing or wounding of such personnel in the proximity to military objectives gives no cause for complaint Identification Armlet - left arm; distinctive emblem Special identity card (DD Form 1934) If exclusively engaged in the direct care of the wounded and sick, the following medical personnel are protected doctors, surgeons, nurses, chemists, stretcher-bearers, medics, corpsmen, orderlies, nurse practitioners, etc. administrative staffs of medical units also protected drivers, generator operators, cooks, etc. Identification requirements - Art 40, 1949 Geneva Convention No. I arm band in actual practice has not been worn with any regularity, and BUMED has no regulations regarding wearing the arm band studies have shown that a regular arm band is not recognizable beyond 60 meters

Armed Forces Medical Personnel If exclusively engaged in the direct care of the wounded and sick, the following medical personnel are protected doctors, surgeons, nurses, chemists, stretcher-bearers, medics, corpsmen, orderlies, nurse practitioners, etc. administrative staffs of medical units also protected drivers, generator operators, cooks, etc. Auxiliary Medical Personal personnel afforded status: - hospital orderlies, nurses, or auxiliary stretcher-bearers - used to search for, collect, transport, or treat the wounded or sick - during the execution of these duties Must identify themselves - armlet, identity disc, or military ID status Geneva Convention status GWS, Art 25 - these auxiliary medical personnel are entitled to “respect and protection if carrying out these duties at the time they come into contact with the enemy or fall into his hands.” GWS, Art 29 - shall be POW’s, but shall be employed on their medical duties in so far as the need arises

Medical Personnel Subject to capture (exception, hospital ships) Not POWs, “retained personnel” but shall receive benefits of POW as a minimum Retained for health of POWs Repatriated when military requirements permit * neither medical personnel nor crew of hospital ships may be captured

Medical Personnel Privileges shall continue their medical functions shall be granted facilities for medical care shall be permitted to visit all POWs SMO shall be responsible for duties & communications Subject to internal discipline, but shall not be compelled to do any work not medical may not be deprived of insignia, identity cards or armlet Art 28, GWS - “Within the framework of the military laws and regulations of the Detaining Power, and under the authority of its competent service, they shall continue to carry out, in accordance with their professional ethics, their medical and spiritual duties on behalf of prisoners of war, preferably those of the armed forces to which they themselves belong.”

Medical Personnel -Responsibilities Must refrain from acts harmful to the enemy Must refrain from direct participation hostilities Must render care to all sick and wounded Must screen EPW’s for repatriation

Medical Personnel Harmful acts include: using hospital as a shelter for combatants using hospital as arms depot or observation post placement of unit to impede enemy attack Harmful acts do not include small arms for self defense can return fire if enemy attacks a protected facility can not shoot at enemy lawfully capturing a field hospital IAW International Law may carry small arms as firewatch and to guard enemy patients without losing protected status * may carry small arms - pistols, sub-machine guns and rifles for self defense or defense of patients

Losing Protected Status Medical personnel must refrain from hostile action Medical personnel who use force, other than in self-defense, become combatants As combatants, lose retained status and could be subject to trial for a violation of the law of war for misusing the medical emblem and its protection Do not lose protection for carrying small arms to guard patients who are EPW

Performing Other Duties US Navy Regulations (1063) When assigned to a combat area, medical and chaplain personnel shall only be assigned duties commensurate with their protected status. When not in a combat zone, they can be assigned any duties.

Duty of Rendering Care Must render care to all sick and wounded, regardless of whether enemy or friendly No adverse distinction based on race, nationality, religion, or political opinion Sole basis for priority of treatment is triage, even if that means enemy wounded are treated first * no POW may be subjected to physical mutilation or to medical or scientific experiments of any kind

Code of Conduct - Exceptions for Medical Personnel Article II: never surrender; exception: medical personnel are subject to lawful capture and may only defend themselves when fired upon Article III: requires POWs to escape and aid others; medical personnel are “retained personnel,” and do not have a duty to escape or to aid others in escaping Article IV: requires senior military member to take command; service regulations prevent medical personnel from assuming command over non-medical personnel * these list medical personnel exceptions to the Code of Conduct

Medical Facilities Fixed Medical facilities may not be attacked protection not contingent on proper marking but on recognition must be situated so as not to imperil May not be used in a hostile manner May not be destroyed, but utilized for care of wounded and sick Hospitals identified by hoisting distinctive flag and by use of distinctive emblem Equipment marked with distinctive emblem

Hospital Ships & Medical Transports Hospital Ships - built or equipped specially and solely to assist, treat and transport the wounded, sick, and shipwrecked. Hospital ships may not be attacked or captured Hospital ships’ medical personnel and crew may not be attacked or captured, even if there are no sick or wounded on board - definition contained in Art 22, 1949 Geneva Convention No. II Privileges - hospital ships and medical transports can not be attacked or captured, Art 22 - privilege also applies to the hospital ship lifeboats and to coastal rescue craft - should fighting occur on the hospital ship, the sick-bays and their equipment should be respected and spared, as far as possible, Art 28, 1949 Geneva Convention No II - any hospital ship which falls into enemy hands, in port, shall be authorized to leave the port; Art 29 Obligations - names and descriptions of military hospital ships must be given to the Parties to the conflict ten days before they are employed - notice of particulars regarding the voyage of military transports shall be given to and approved by the adverse party; Art 38, 1949 Geneva Convention II - military hospital ships shall afford relief and assistance to the wounded, sick, and shipwrecked without distinction to nationality. Art 30

Hospital Ships & Medical Transports Hospital ships shall be distinctly marked all exterior surfaces shall be white one or more dark red crosses, as large as possible, displayed on side of hull and horizontal surfaces hoist distinctive and national flags lifeboats and small craft painted similar to ships may illuminate painting and emblem at night or during reduced visibility Medical transports shall be identified in accordance with notice and approval procedures Medical transports - chartered to transport equipment exclusively intended for treatment of wounded and sick or prevention of disease. may not be attacked or captured provided that notice of voyage has been given and approved

Departure from Role as Hospital Ship Failure to follow rules for exclusive medical use of the ship or transport could result in retaliation by the enemy Enemy may lawfully attack a medical facility or personnel if they are being used inconsistent with their protective status; notice may be given before such an attack may be made - may not be used for any military purpose - shall not hamper the movement of combatants; Art 30 - may arm the crews of ships for maintenance of order for their own defense or that of the sick and wounded - may temporarily store, while awaiting transfer, portable arms and ammo taken from the sick and wounded Art 31 adverse party may exercise five forms of control over a military hospital ship: (1) search (2) order to stand off or taken certain course for reasons of military security (3) control of visual and auditory means of communication (4) detain the ship for a period not to exceed seven days (5) place a neutral observer on board

Hospital Ships Belligerent Rights Belligerents may: search order to stand off or take a certain course for reasons of military security control visual and auditory means of communication detain the ship for a period not exceeding seven days to ensure secrecy of military operations place a neutral observer on board Ship must submit to identification and inspection procedures

Secure Communications Secure communications - “may not possess or use a secret code” for their communication Modern day comms issues position and location for receiving wounded need for Video-teleconferencing for medical procedures Protocol I acknowledges “times have changed” and San Remo Manual encourages international law to change to permit use of encrypted communication Code 10/N6 initiative - Secure Communications - may not possess or use a secret code for their wireless or other means of communication. Art 34; guarantees hospital ships won’t improperly use transmission equipment - Operational Problems/Issues: most fleet units use secure comms; without COMSEC, hospital ships have interoperability problems - medical aircraft can not be vectored in without giving away their location - warships carrying wounded to the ship will compromise their position (warships carrying wounded may be attacked even during transfer) - can’t order medical supplies without giving away tactical info - French and Spanish translation of Art 34 prohibit only encrypted transmissions,not the receipt of encrypted transmissions - whether or not use of limited or total COMSEC equipment is considered legal, the hospital ship might be targeted if the enemy perceives the use to be a threat

Hospital Ships Weapons Systems Crew-served now on board for AT/FP Not specifically addressed by the 1949 Geneva Convention Art 35, however, states that the crews of the ships may be armed for self-defense Small arms/Individual Weapons Crew-served now on board for AT/FP Code 10 initiative - Self-defense measures: the taking of limited self-defense measures against anti-ship missile attack such as equipping hospital ships with chaff, ECM and infra red decoy dispensers would not violate their protected status; however, equipping ships with CIWS would be inconsistent with their protected status; arming crews with light individual weapons does not deprive ship of protected status

Hospital Ships Notice of names and descriptions must be given ten days before they are employed Shall afford relief to all without distinction Shall not be used for any military purpose and shall not hamper the movement of combatants Permitted to arm crews for self defense and discipline utilize navigation and communication equipment temporary storage of arms taken from patients transport of medical equipment

Medical Aircraft May not be attacked if exclusively employed for removal & transport and flying at heights, times and on routes specifically agreed upon between belligerents Shall obey every summons to land and permit examination Involuntary landing wounded, sick, and aircrew are POW medical personnel are retained personnel Shall be clearly marked with distinctive emblem Prohibited to fly over enemy territory * In Vietnam, we were never able to complete an agreement and the enemy fired on medical evacuation helicopters, whether marked or not. Consequently, markings were removed and U.S. medical helicopters were armed. * medical aircraft shall be clearly marked with the distinctive emblem and their national colors on their lower, upper and lateral surfaces * all equipment must also be marked with a distinctive element

Questions?