April 20, 2024

Is informed consent possible on the battlefield?

Bioethics is never far from the war in Iraq. This time, the centre of controversy is Colonel John Holcomb, the head of the US Army’s Institute of Surgical Research, based on the campus of the Brooke Army Medical Center, in San Antonio, Texas. Col Holcomb is a highly respected and innovative trauma surgeon who has reorganised the way that the Army treats casualties. But his enthusiastic acceptance of unproven treatments for severely wounded soldiers has raised eyebrows.

Under his supervision, Army surgeons are using a controversial drug called Factor VII, which promotes clotting in cases of severe bleeding. He also strongly backs the use of experimental treatments on severely injured patients who cannot give informed consent. He contends that ethical problems pale in comparison to the toll that traumatic injuries take on civilians and soldiers every day. "You have a drug that you know is safe from the prospective randomised controlled clinical trials," Colonel Holcomb told the New York Times. "And you have to make a decision. It’s not something you can decide to talk about. It’s really yes or no. You have a lot of people bleeding to death in Iraq."

Despite his energy and good will, Col Holcomb’s critics say that he is using drugs and treatments which other trials have already shown to be of dubious benefit. An experimental blood substitute called PolyHeme, which recently failed a clinical trial in trauma patients, is being used in Iraq on wounded soldiers who cannot give informed consent.However, points out one of his defenders, Dr John Hess, of the University of Maryland, civilian haematologists rarely see injuries as severe as those soldiers receive in battle, so they may not understand the circumstances. Colonel Holcomb would never encourage the use of Factor VII if he thought it was endangering soldiers. "He feels deeply concerned about the soldiers, he goes over there, he takes care of them," Dr Hess says. "If you were hurt, he’s the guy you’d want taking care of you."