Superfluous InjuryCoupland - PDF document

Superfluous InjuryCoupland The twentieth century has seen enor-ICRCICRC- Towards a Determination of WhichWeapons Cause ÒSuperfluous [Editor픀s Note: In March of 1996, M&GS published an article by Dr. Coupland entitledÒThe Effects of Weapons: Defining Superfluous Injury and Unnecessary SufferingÓ[M&GS 1996;3:A1], which represented the author픀s preliminary attempt to apply theepidemiology of the effects of weapons to international law. That article became theject participants, is excerpted from a longer document edited by Dr. Coupland and  At the time of publication RMC wasDirector, Division of Health Operations, Medicine & Global Survival, January 1998; Vol. 5, No. 1Superfluous Injury grade 3 wounds as mea- Weapons, Law, Injury and Weapons: A Health Issue? Montreux Symposium in March 1996 [3] andby the General Assembly of the WorldMedical Association in October 1996. Thefact that the medical profession has respon-sibilities for this health issue was also recog-nized at both of these meetings. Theseresponsibilities extend from the gathering ofdata about the effects of weapons on health3thus making the subject objective and under-standable, to advocating limits on the meansof warfare by invoking international human- Use of Weapons wounding capacity is the foreseeable effectresulting from the design of the weapon.When such bullets are either fired indiscrim-inately into a crowd or aimed by a sniper atthe head of specific individuals, factors relat- 1. The data relating to Òpoint-detonatingÓantipersonnel mines shows how the measuredeffects represent their foreseeable effect result-ing from their design and these distinguishthem from other conventional weapons. In this 3. The World Health Organization definition ofhealth is Òa state of complete physical, mental Weapons, and theLaw tive. Determination ofessary. Using medical Superfluous InjuryCoupland By contrast, a Òpoint-detonatingÓburiedburiedby foot pressure causes traumatic amputa-tion of the foot or legÑa foreseeable effectresulting from the design; user-dependentfactors determine, for example, the numberand kind of people injured. Retinal haemor-rhage from a blinding laser weapon is obvi-ously a design-dependent effect. The distinc-tion between design-dependent effects anduser-dependent effects is central to this doc-ument which focuses exclusively on thedesign-dependent, foreseeable effects ofweapons. An examination of the design-depen-dent, foreseeable effects of weapons mustinclude the question of whether a weaponcan be inherently indiscriminate. A weaponwhich injures both combatants and non-combatants alike does so most commonly asa result of user-dependent factors. However,indiscriminate effect may be design-depen-; a topical example being antipersonnelmines [6,7,8,9]. This aspect of the design ofweapons is not examined further here. Thereare legal instruments to limit the indiscrimi- Weapon Design and International of Justice recognized the fundamental cus--recent treaty which repeats this rule is 1977Additional Protocol I to the GenevaConventions of 1949 [11]; 147 States are partyto this Protocol. These treaties and others incorporate theconcept that any weapon system should not beof a nature to inflict Òsuperfluous injury orunnecessary sufferingÓ beyond the militarypurposes of the user and should not renderdeath inevitable6. Whether the effects of aweapon might constitute Òsuperfluous injury orunnecessary sufferingÓ on the part of the victimhave, up to now, remained within the realms ofemotional or philosophical argument. The first international treaty relating tothe design of weapons was the St PetersburgDeclaration of 1868 when a proposal madeby the Russian Tsar banned bullets whichexplode on impact with the human body.Similar treaties were the Hague Declarationof 1899 which banned the use of dum-dumbullets, the Geneva Protocol of 1925 whichbanned the use of chemical and biologicalweapons and the Chemical WeaponsConvention of 1993. (The use of poison orpoisoned weapons has been banned by cus-tomary law for centuries.) Applying theprinciples of these treaties to existingweapons is difficult; applying them toweapons under development is much moredifficult. At present, there is little control ofresearch or development of weapons.Another pertinent element of existinglaw is the Martens clause. This originated inthe first Hague Peace conference in 1899, wasrepeated in the second peace conference in1907 and has been carried forward intoAdditional Protocol I of the 1949 GenevaConventions. It states that civilians and com- The SIrUS Project The principal element of the SIrUS is one which affects combatants and non-com-1899. In the English translation of these regula- potential to pro-wound classifica--which can be mod-elled in a laborato-ry [24], were usedas the basis of con-sidering bodilyharm, the interna- Medicine & Global Survival, January 1998; Vol. 5, No. 1Superfluous Injury Project is the consideration of the effect of aweapon before its technology; this is a rever-sal of current thinking. The project hasinvolved a group of experts in the domain ofweapons, medicine, law and communica-tions who, first, have collated data relatingto the effects of conventional weapons7; sec-ond, have used this data as a baseline for theconsideration of the effects of all weapons;third, have defined four criteria which makean objective distinction between what consti-tutes and what does not constitute the effectsof conventional weaponsthese criteria as a basis for determiningwhich effects of weapons constitute Òsuper-fluous injury or unnecessary sufferingÓ; andfifth, request endorsement of this proposalby professional bodies. States have an obligation to determinethe legality of any new means and method ofwarfare it is procuring or developing. Theobjective of the SIrUS Project is to facilitatesuch a determination without legal wran- Generating a Proposal for aeapons A Combination of Concepts The proposal for a determination ofwhich design-dependent, foreseeable effects the effect of a weapon resulting from its design rather than the the effects of all weapons aremeasurable both on individuals and the effects of conventionalweapons on health which are welldocumented provide a baseline ofreference or yardstick for the fore-seeable effects of all weapons whenused against human beings; the degree of sufferinginflicted by a weapon is increased if Examination of the Criteria Criterion 1: [the weapons causes a] specificdisease, specific abnormal physiological state,specific abnormal psychological state, specificand permanent disability or specific disfigure- weapons produce fear and stress, these reac--neuroendocrine response to physical traumafrom conventional weapons is part of theireffects [17,18]. The same neuroendocrineresponse produced by an agent or energyform without physical injury would repre-sent a specific and abnormal physiologicalresponse. Conventional weapons do not generatean absolute necessity for blood transfusionas shown in the study. Criterion 1 wouldapply to any weapon which, for example,foreseeably causes gastrointestinal haemor-rhage and for which a blood transfusionwould be needed to treat the effect. Theimplications for needing a blood transfusionare particularly important; without a reliableand safe blood bank, which is difficult toestablish in a war zone, there is a risk oftransfusing blood that has not been cross-matched or tested for transmittable diseasesuch as syphilis, hepatitis B and HIV (thevirus causing AIDS) [19]. The need for multiple operations com-pounds the suffering from the effects ofweapons; those wounded by conventionalweapons do not require, on average, morethan 3 operations in a non-specialized surgi-cal facility. Thus a weapon which, for exam-ple, as a foreseeable effect causes facial dis- Criterion 2: [use of the weapon results in] afield mortality of more than 25% or a hospital The use of a weapon, the design ofwhich renders death inevitable, is alreadyprohibited in the same legal concept asÒsuperfluous injury or unnecessary suffer-ing.Ó The study shows, for different cate- 7. There is no formal definition of Òconvention- The Sirus The process whichtakes knowledge ofhuman form andfunction and thendesigns weapons tointerfere with thisform and functionseem to be consid- Superfluous InjuryCoupland gories of conventional weapons, how con- Criterion 3: [the weapon] inflicts grade 3wounds as measured by the Red Cross wound This criterion is needed to apply toweapons which although producingwounds without tar-geting a particular partof the body, simplyinflict large wounds.This would be the casewith exploding bulletsand dum-dum bullets.Table 1 of the studyshows that conven-tional weapons pro-duce less than 10%grade 3 wounds. Thisfigure would beexceeded by any mis-sile or wave formwhich carries muchmore energy andwhich foreseeablydeposits this energy inthe human body over ashort track. As a means tomove law from anapproach orientatedaround technologyÑas exemplified by prohibitions on explodingand dum-dum bulletsÑto an approachorientated aroundeffect, the Swiss gov-ernment has proposedto States a means to testmunitions for theirpotential to producelarge wounds; applica- Criterion 4: [theweapon] exerts effects forwhich there is no well recognized and proven into play the imbalance between the financeand technology that goes into the develop- Weapons inevitable linkbetween thenapalm and to Table 1 Proportion of the grades of first wound scored on the records of8,295 patients injured by fragments or bullets Grade 1Grade 2Grade 3Fragments(shell, 58.3%58.3%33.4%33.4%8.3%8.3%Bullets45.4%45.4%44.7%44.7%9.9%9.9% The proportion of the grades of the first wound scored by the Red Cross wound clas-sification in 8,295 patients injured by fragments and by bullets. The classification andthe significance of the grade of the wound is explained in the text.CICIfragments is 7.3% to 9.3%; and that for wounds from bullets is 9.1% to 10.7%. who were admitted within 24 hours of injury Number of patiients Number died 2,9264.0%4.0% 2,7064.6%4.6% 10218.6%18.6% 4.0%4.0% [Mine causingamputation 8906.2%6.2% ] Mortality in 8,762 patients admitted to independent ICRC hospitals within 24 hours ofinjury according to cause of injury. ÒMineÓ = all mine injured patients. ÒMine causingamputationÓ are those patients who arrived with a traumatic amputation or underwentsurgical amputation before dying; it is a subgroup of all mine injured.The percentages dying by cause of injury are different (Xp)cantly different from each other (as shown by partitioning of the chi-square statistic�.00;
. T;&#xhe p;rce;&#xntag;s d;&#xying;&#x fro;&#xm fr; gme;&#xnts,;&#x bul;&#xlets;&#x, an; mi;&#xnes ; re ;&#xnot ;&#xsign;&#xifi0;= 1.50 on 2 d.Ä., p0.05) confirming that the overall significance is due to the highproportion dying from burns. Medicine & Global Survival, January 1998; Vol. 5, No. 1Superfluous Injury of the law pertaining to them or stigmatiza-tion: criteria 1, 2 and 3 apply to Òpoint deto--must be examined carefully from the pointof view of the effects of such weapons. The purpose is to ÒdisableÓÑinflictingdisabilityÑbut the difficult question of howlong the person will be disabled for is notconsidered. If it is established what energyoutput, concentration or dose is Ònon lethalÓor temporary, one has also discovered whatis lethal or permanent. Thus for newweapons the dividing line between Ònon-lethalÓ and ÒlethalÓ may be fine or nonexis--Òsoftening the targetÓ may increase theÒlethalityÓ of conventional weapons. Inaddition, a doctor treating the wounded mayhave to treat people suffering from theeffects of both conventional and Ònon-lethalÓweapons. All new weapons can and shouldbe considered in terms of their effects andtherefore the four criteria. With regard to weapons that aredesigned to blind it has been argued that it isbetter to blind an enemy soldier than to killhim or her. This argument does not take intoaccount that conventional weapons are not100% lethal, the psychological impact of sud-den blindness [25,26], the extent of disabilityor the impact on a society of its soldiersreturning from battle having been irretriev-unconscious for a short period without last--ÒtargetÓ is still an important consideration;second, use of such an agent as a method ofwarfare is already prohibited under theChemical Weapons Convention; third, abasic principle of pharmacology is that theonly difference between a drug and a poisonis the dose and it is unclear how the correctdose can be administered in the battlefield. One cannot consider the effects ofweapons in general without referring tonuclear weapons. Criteria 1, 2 and 4 wouldburns and radiation sicknessburns and radiation sicknessnuclear debate, which is discussed extensive-concept of Òsuperfluous injury or unneces- Do Not All Weapons CauseWeapon Acceptable? represent total disarmament. munity to recog-nize the serious- Superfluous InjuryCoupland The medical profession is making nei- References 1. Coupland RM. The effects of weapons onhealth. Lancet 1996;347:450-451. 2. Sidel VW. impact on health. Br Med J 1995;311:1677-1680. 3. The International Committee of the RedCross. The Medical Profession and the Effects ofWeapons: the Symposium. Geneva: The 4. Coupland RM. The effect of weapons: definingsuperfluous injury and unnecessary suffering.Medicine and Global Survival 1996;3:A I . 5. Sellier KG, Kneubuehl BP. Wound ballistics.Amsterdam: Elsevier 1994. 6. Coupland RM, Korver A. Injuries fromantipersonnel mines: the experience of theInternational Committee of the Red Cross. BrMed J 1991;303:1509 1512 7. 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