1. 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.

2. 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.

3. 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.

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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 , Defense Acquisition Management Policies and Procedures
SECNAVINST B, 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

13. 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

14. 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

15. 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?

16. 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”

17. 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

18. 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

19. Medical/Religious Symbols

20. 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

21. 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

22. 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

23. 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.”

24. 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

25. 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

26. 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

27. 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.

28. 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

29. 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

30. 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

31. 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

32. 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

33. 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

34. 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

35. 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

36. 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

37. 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

38. 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

39. Questions?