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03/21/2016

Military Suicide Capsules and Medical Ethics

by Steven H. Miles, MD

In December 2013, a Hearing Panel for the Health Professions Council of South Africa found Wouter Basson MD culpable for unprofessional conduct because of his work to produce chemical weapons, to medically assist rendition by commandos (kidnappings), and to provide cyanide containing suicide capsules to Special Forces’ operatives leaving for clandestine meetings. I served as an expert witness for the prosecution in the Basson matter in the area of medical ethics and military medicine.

The French philosopher-sociologist Emile Durkheim (1858-1917) is partly responsible for the confusion about strategic military suicide. He defined suicide as “all cases of death resulting directly or indirectly from a positive or negative act of the victim himself, which he knows will produce this result.” He did not distinguish a soldier whose actions entail accepting the high probability (or even certainty) of death in order to accomplish some task from actions in which the soldier’s chooses to die during the course of a military operation. For example, a soldier who throws himself over a grenade to save compatriots is valorous but not primarily suicidal. Such a soldier would, if given the opportunity, equally bravely put himself at risk by throwing a blast suppression blanket over the bomb.

A second kind of military suicide is a soldier who serves as a smart bomb as with the Kamikaze pilots of World War II or the suicide bombers of today.

A third kind of soldier’s suicide is that which is the tragic end of combat-induced mental illnesses such as Post Traumatic Stress Disorder, depression, substance abuse disorders, or despair.

All of the preceding instances differ from the choice to use a military suicide device, for example, ingesting a cyanide pill. In these cases, soldiers choose to commit suicide for rational-personal or altruistic reasons. Some might choose such a device to avoid capture, the suffering of captivity or torture. Or, they might commit suicide to preclude the possibility that they might under torture yield valuable intelligence to an enemy or become a valuable hostage or propaganda prize to the disadvantage of their homeland.

Cyanide capsules are easy to make and reliably lethal. They have been used for murder, executions and suicides and as a trope in popular culture. Potassium cyanide is easy to obtain, store, transport, conceal and unobtrusively self-administer. Cyanide ends life by arresting cellular metabolism by preventing hemoglobin from transporting oxygen. Thus, it causes a form of chemical asphyxiation. The public imagination of military cyanide suicide capsules is informed by movies such as Skyfall (a James Bond movie that showed a malfunctioning tooth capsule) and Get Smart, (that used a suicide pill for a gag line).

The history of the use of suicide capsules by the armed forces or intelligence agencies is murky but suggestive. Heinrich Himmler, a senior Nazi commander, used a cyanide capsule to commit suicide upon his arrest. Hermann Göring, another Nazi official, took cyanide shortly before he was to be executed at Nuremberg. A Flight Surgeon gave the pilot of the Enola Gay cyanide capsules to distribute to the crew in the event they crash-landed in Japan after dropping the atomic bomb on Hiroshima. Washington DC’s spy museum displays CIA Cold War era eyeglasses containing a cyanide pellet. Concerns about cyanide gas accidentally escaping inside the cockpit or flightsuit of spy plane pilots led the CIA to develop a fish-based neurotoxin to be self-injected with a needle. Such a device was concealed in a coin given to CIA pilot Francis Gary Powers for his 1960 U2 spy flight over the Soviet Union. If captured, as he was, Powers had been instructed to cooperate while maintaining the dignity of his office. Although some criticized Powers for not taking his life, the turbulent high altitude destruction of his aircraft and prompt capture made it unlikely that he could have used the suicide device even if had chosen to do so. The government investigation of that incident contains the only description of a military policy on the use of such devices for suicide.

The nature of Powers’ obligation in respect to the poison needle that was in his possession through this flight is part of the consideration of his obligation under his contract and as an American citizen. Powers was not instructed to use this needle. On the contrary, he was offered it as an optional item of equipment. He accepted it in contemplation of the possibility that he would be tortured if he were captured and that he might then prefer the use of this needle to the destruction of his own power to resist. He was given to understand, quite clearly, that any use by him of the needle was entirely optional with him.(p. 10)

North Korean agents and Tamil Tigers have also been known to have and used cyanide capsules. The United States government denies that suicide pills are provided to soldiers faced with capture by ISIS.

The Basson Case
In late 1981, South Africa created a clandestine “Project Coast” and recruited Dr. Wouter Basson to lead it. Basson developed biological and chemical weapons and also supplied various drugs to be used for kidnappings and assassination by commandos until COAST was disbanded shortly before apartheid ended in 1993. After the Apartheid government fell, Basson faced various criminal charges that were dismissed and he was granted amnesty. Basson returned to civilian medical practice. After a lengthy process, The Health Professions Council of South Africa agreed to review complaints that Basson had committed “unprofessional conduct” as defined in the Health Professions Act (Charge sheet on copy with author). Among the charges, was that Basson provided cyanide capsules to Special Forces soldiers who were deployed on missions. Basson testified that he purchased the cyanide from a chemical supplier, prepared capsules, kept them in a cabinet with other “scheduled medicines” and, on request, provided about twenty-five capsules to a Commander or Assistant Commander who would then issue them to the individuals concerned. He testified that Special Forces facing capture would thus have “the right to decide whether to accept of consequences of such a capture or not.”(Health Professions Council, 2007)

The Health Profession’s Council prosecution did not challenge the morality of military suicide capsules. Rather, it focused on how Basson managed the storage and dispensing of the capsules.

  1. Basson simply gave commanders of Special Forces units a sufficient number of capsules to distribute to the soldiers in the units. He did not personally examine the individual soldiers who were to receive the cyanide capsules. Thus, he did not assess if they had mental illnesses that are common in such soldiers (e.g., Post Traumatic Stress Disorder) that predispose to suicide. It was argued that Basson in accepting the medical role of dispensing these capsules was still obliged to act as a physician to protect the welfare of these soldiers by identifying those predisposed to suicide. Basson’s attorneys argued that the fact that the commanders decided if the soldiers were fit for duty and that Basson as a soldier was obliged to act according to the directives given to him. (That directive was never introduced.)
  2. Basson failed to learn and thus could not accurately inform the soldiers who might consider using cyanide about the symptoms that would follow ingestion. Unlike the popular imagination as exemplified in Agatha Christie’s novel Remembered Death, death by cyanide is not mysteriously and asymptomatically instantaneous. Basson inaccurately testified about that death by cyanide was humane, “it is generally accepted that within seconds it is over.”(Health Professions Council, 2007) As with other forms of asphyxiation, cyanide poisoning includes several minutes of confusion, anxiety, dizziness, nausea, palpitations, tachypnea, combativeness, gasping and convulsions. Setting aside the core ethics of physician-assisted combat suicide, an accurately informed soldier might consider information about the nature of death by cyanide to be material to the choice of cyanide compared to a head shot with a combat rifle.
  3. Basson stored the cyanide in a medicine cabinet that contained other medications, an unprofessional and behavior that endangered persons as the contents of the medicine cabinet were accessed for health care.
  4. Basson’s claim that his actions were justified because of force-majeure of either orders or extraordinary circumstances could not be accepted given a South African legal case concluding that medically assisted death, however personally justified, did not thereby become legal.

The Hearing Panel did not discuss the specific merits of these arguments. It simply favorably alluded to the first three in including this charge with others as meeting the standard of “conduct which, when regard is had to [a licensed physician] is improper or disgraceful or dishonourable or unworthy.”(Health Professions Council, 2013) The Hearing Panel generally found that Basson improperly held that medical ethics in war was a separate system of medical ethics. It stated, “[M]edical ethics are especially important in times of war and conflict. Medical doctors have a unique position in society, a sacred position, which impels them to stay true to the ethical values of the profession: beneficence, non-maleficence, justice and autonomy. This is equally true in conflict situations.”(Health Professions Council, 2013, p. 18) Further, “Medical ethics require the independence of thinking of each medical doctor. A doctor cannot simply rely on a military order to escape the consequences of his actions.”(Health Professions Council, 2013, p. 19) The Hearing Panel also cited the World Medical Association, “Medical ethics in times of armed conflict is identical to medical ethics. . . . Privileges and facilities afforded to physicians and other health care professionals in times of armed conflict and other situations of violence must never be used other than for health care purposes.”

The Hearing Panel has yet to suggest a punishment. The findings will be subject to appeal.

Conclusion
The Basson hearing is another landmark on the emerging application medical of ethics to the specialized issues occasioned by military medicine during wartime. For fifty years (thus, excluding the Nazi Doctor’s trial at Nuremberg) this domain has largely focused on physician complicity with genocide or torture. As in the Basson matter, medical licensing boards, rather than international courts or domestic criminal courts, have judged most of the increasingly prevalent cases with regard to physicians and war crimes. Whether the Basson ruling will be a precedent for future cases regarding physician dispensing of suicide pills to military personnel remains to be seen.

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