Fundamentals of understanding combatants in modern medical law

In COVID-2019 times, the sphere of medical law interests, as a branch of law, was enriched by the protection of patients’ rights suffering from the virus and its consequences. However, when the activity is connected with subjects participating in military conflicts, it opens the possibility to a scientific discussion concerning the protection of their rights, freedoms, and interests as combatants by modern medical law. The current focus of medical law includes differently directed issues.

Patients’ legal status, social support, protection of their legal possibilities, provide them the possibility to participate in a variety of programs generated by new technologies and scientific achievements, experimental types of treatment are just some of the mentioned examples. At the same time, there are issues of multidisciplinary nature that unite medicine, law, and even morality; for instance, positive and negative reproduction rights, euthanasia, and transplanting. Even more, national rehabilitation systems of combat veterans require a change of paradigm following the modern international approaches, standards, and practices (^{Pantielieieva et al., 2020}).

At the same time, due to the urgent need to discover the nature of combatants’ problems in pandemic times and the post-pandemic reality to suggest possible directions for their solution, modern medical law should investigate almost all the components of its subject of legal regulation regarding combatants as a specific kind of patient. Furthermore, in COVID-19 and post-COVID-19 times, the safety environment in this area must be supported by modern legislation concerning legal technologies as regulatory-protective instruments used by national governments and involve international organizations (^{Myronets et al., 2021}). Therefore, the core of the mentioned instruments used must be reflected in efficient medical law regulations concerning combatants.

In particular, armed conflict participants must be treated humanely and cared for by the Party to the conflict in whose power it may be, without any adverse distinction founded on sex, race, nationality, religion, political opinions, or any other similar criteria. Any attempts on their lives, or violence to their persons, shall be strictly prohibited. In particular, they shall not be murdered or exterminated, subjected to torture or biological experiments; they shall not willfully be left without medical assistance and care; nor shall conditions exposing them to contagion or infection be created (^{ICRC, 1949}). Even with their consent, it is particularly prohibited to carry out:

(a) physical mutilations;

(b) medical or scientific experiments;

(c) removal of tissue or organs for transplantation... (^{ICRC, 1977a}).

Also, all persons who do not take a direct part or who have ceased to take part in hostilities, whether or not their liberty has been restricted, are entitled to respect for their person, honor and convictions, and religious practices. They shall, in all circumstances, be treated humanely, without any adverse distinction (^{ICRC, 1977b}).

Taking into account the Geneva Conventions and its protocols, providing the wounded and sick access to health services during military operations is a requirement. This provision extends to the obligation to provide restorative care and rehabilitation, including mental health, including the requirements to maximize the fitness of the armed forces through garrison healthcare before deployment. Thus, the state’s obligations to provide healthcare to armed forces personnel and veterans are multidirectional. They include a legal regulative component, a supportive financial component, and an education component training doctors in the appropriate treatment for armed conflicts participants.

Theoretical thoughts concerning combatants’ status in modern medical law are based on the changing current reality of COVID-19. The entire world was unprepared to appropriately respond to such a challenge that became deadly in its consequences for many people, including military personnel. Combatants’ status is complicated because they combine three components simultaneously as specific subjects in the area of modern medical law. Firstly, they are in the status of ordinary patients, perhaps with specific needs. Secondly, their needs are based on specific requirements concerning the medical treatment of COVID-19 patients. Thirdly, being combatants, they combine the first and the second components and represent themselves as a specific category of people who need medical treatment during their military activity and even after that, when they are in reserve.

What is more, the combatants’ medical treatment may include their recovery after psychical and physical injury and even loss of body parts. However, even if there is neither mental nor bodily damage, the medical help may be concentrated on supporting combatants’ as COVID-19 patients. In this regard, the character of the medical support of nature must be different depending on the following three possible variants. In the first case, a combatant experience infection during military activity. Secondly, military personnel in reserve may fall ill to COVID-19 outside of military duties. Thirdly, a civilian may go through the mentioned infection and endure the consequences of its negative influence before the beginning of the military career.

All of the mentioned variants require a specific approach by the medical personnel. According to the current protocols, the first two variants are more traditional and focused on direct medical treatment. However, the third variant requires a specific form of health monitoring, given the largely unknown nature of negative consequences expression of the COVID-19. Regardless, even under current conditions, combatants must be understood as people with specific needs and requirements because they all have syndromes related to their military involvement.

Post-combat syndromes have arisen after all major wars over the last century, and we can predict that they will continue to appear after future conflicts. However, their form cannot be accurately forecasted, as they are molded by the changing health fears and the nature of warfare itself. They have proved notoriously challenging to treat mainly because veterans and their physicians were often in disagreement about causation (^{Jones, 2006}). As a result of the psychological rehabilitation program’s activities, not only are the military service person’s professional qualities being developed, so is a well-differentiated professional image of the world. In the future, it will be possible to predict the events of one’s own life, avoid unwanted situations for self-realization, develop the socio-psychological environment according to their own plan, and play a leading role in relations with others (^{Prykhodko, 2018}). Modern medical law must be involved in the mentioned processes by its regulatory-protective orientation on combatants. Indeed, the COVID-19 pandemic has shown a light on the abject failure of some government responses to the pandemic, from slow reaction to the crisis to inability to enforce rules (^{Ibrahim Shire, 2020}).

COVID-19

The modern pandemic reality created a new activity reality for combatants worldwide. In a way, it is possible to emphasize that COVID-19 became not just a common problem for humankind and a challenge for medicine in general; it became an additional burden for combatants and an additional constant threat to their lives. Thus, these non-ordinary conditions require an extraordinary response from the side of the law. This need may be appropriately formulated by medical law as one of its branches. If legislators truly understand the mentioned facts, it is possible to create an efficient legislative regulation in this sphere.

In pandemic times, we can use legal instruments to regulate and protect combatants’ rights, interests, and freedoms and simplify procedures to implement their legal possibilities. Therefore, the structure must be effective regarding this issue to protect combatants and people whose interests are protected by their military activity for the pandemic and even post-pandemic times. Thus, states can provide an effective general national policy to protect every member of their societies.

Every country should focus its combatants’ protection in the COVID-2019 reality in several directions. The first one is the financial-social support of combatants, including state funding, dwelling, and work-search programs for this group. The second one involves medical treatment according to so-called COVID-2019 protocols and the possibility of implementing positive and negative reproductive rights, requiring transplant needs of different nature. Also, modern states must offer appropriate provisions for euthanasia and decision-making policies concerning combatants’ body organs according to select programs. Finally, the third component involves specific programs for psychical traumas and post-traumatic stress disorder (PTSD).

Medical law, by its essence, develops untraditional themes and investigates the possibility of their legal regulation. COVID-19 generated once again the urgent need to discuss combatants’ legal status, juridical ordering of their possibility to satisfy traditional and non-traditional needs and protect the rights of military conflicts adequately. Modern science, including juridical, must accept the changing environment of humankind’s functioning. A specific “pandemic” type of regulation is required in these current pandemic times.

Even after collective immunity and vaccination, the environment will never be pre-pandemic; it will be post-pandemic and include the new requirements to regulate its participants’ relations. On the one hand, the previous creates a new state policy vision regarding medical treatment in general, on the other, and the recovery of combatants as COVID-patients. Therefore, the entire medical care and support system of active participants in military conflicts must be transformed due to the virus and its hazardous effect on people’s health and life. Moreover, it seems to be the biggest challenge because it consists of several differently directed components that are internally connected.

The current reality concerning armed conflicts participants requires reducing the chances of a COVID outbreak -social distancing and vaccination, the need to identify and treat COVID cases, and the need to provide support to cases of “extended COVID” effects. Every country must include legal and financial provisions that account for issues associated with recruits who have previously had COVID.

On the other hand, traumatic experiences in war zones are often widespread and affect many exposed individuals (^{Almoshmosh, 2016}). For example, in Operations Iraqi Freedom (OIF) and Enduring Freedom (OEF), approximately 11-20 out of every 100 Veterans (or between 11-20%) had PTSD in a given year. In the Gulf War (Desert Storm), about 12 out of every 100 veterans (or 12%) had PTSD in a given year. In the Vietnam War, close to 15 out of every 100 veterans (or 15%) were diagnosed with PTSD in the National Vietnam Veterans Readjustment Study in the late 80s. It is estimated that about 30 out of every 100 (or 30%) Vietnam veterans have had PTSD in their lifetime. Other factors in a combat situation can add more stress to an already stressful situation. This may contribute to PTSD and other mental health problems (^{US Department of Veterans Affairs, 2020}).

PTSD characteristics involve symptoms from four clusters: intrusiveness, avoidance, negative changes in cognition and mood, and changes in excitability and reactivity. In the context of the criminological problem, PTSD can be considered as (i) a criminogenic factor (this conclusion is explained by the statistical increase in the number of war veterans in the criminal justice system); (ii) a factor that increases the victimization of a person who has PTSD (the likelihood of becoming a victim of crime is increased by the other party to an armed conflict, and the possible development of “social outsider” in such persons; and (iii) a factor of suicidal behavior (^{Chernyshov, 2020}). Thus, the prospects for combatants in modern medical law may be represented as answers to the modern challenges that are still obstacles for active participants of military conflicts in many countries.

Furthermore, the psychological effects of war trauma are common and present in many ways at an individual level and affect communities as a whole (^{Almoshmosh, 2016}). PTSD is a spectrum disorder whose symptoms show psychological and neurobiological dysregulation and low functionality of a person on the social plane (^{Selimbasic, 2020}). For example, war veterans’ traumatic experiences can impact the psychopathology development in their children’s lives. The epidemiological studies so far indicate the link between the post-traumatic stress disorder of war veterans and their children’s mental problems (^{Selimbasic, 2020}).

Thus, rehabilitation as a health strategy, incorporating rehabilitation medicine, rehabilitation therapies, and assistive technology, is poised to become the key health strategy of the 21st century (^{Stucki et al., 2018}). Furthermore, constructing a relationship with the surrounding environment will allow the use of external resources in extreme situations and contribute to the continuous enrichment of the soldier’s personality (^{Prykhodko, 2018}). Thus, rehabilitation plays an essential role in constructing a combatants’ daily and professional reality and can even improve civilians’ comfortable and safe communication with them.

The legal and ethical questions should address how much of this is the responsibility of the military health system or a broader state health system. These questions should provide opportunities for dialogue and intergroup interaction to create an atmosphere of acceptance and enable reconciliation with members of society who reject former combatants based on their altered identity (^{Gluecker et al., 2021}).

PTSD

The modern reality dictates the challenges concerning combatants that must be overcome through standard state interaction and different instruments. Although the challenges are primarily financial, their origin and escalation are closely connected with each county’s internal and external policy. Given its compelling regulatory-protective nature at national and international levels, the role of jurisprudence in this process is significant. Modern medical law research and achievements could represent current law concerning the legal status of combatants and their efficient rehabilitation. Thus, this field of law should spare no effort to study and define guidelines and mechanisms to drive its performance concerning active participants of military conflicts. In our view, the challenges faced by combatants in pandemic and post-pandemic times can be divided into types.

One of these is a financial-social type that involves two interconnected elements. On the one hand, the proper state response to set additional financing for this military purpose in their budget expenditure. On the other, developing programs under systematic state control for social care for combatants to support them financially.

These programs should focus on housing for combatants, employment for military conflict participants, and socio-communicative projects for their rehabilitation. The last component must include state-supported mandatory psychical programs to help combatants readapt to civilian life. The social support may include job-finding assistance, occupational training, or microcredit provision, as well as various community-based activities (^{Wang et al., 2016}). This process may also involve non-governmental organizations.

The state links the granting of the status of a participant in hostilities to the emergence of several benefits aimed at making life easier for soldiers after returning to civilian life. For example, one of the declared rights is the possibility of obtaining housing by the state. However, this privilege sometimes becomes a problem because the demand for affordable housing far exceeds its supply (^{Cherneha et al., 2020}).

The success of the implementation of rehabilitation and readaptation programs for combat veterans depends on the perfection, timeliness of adoption of critical legal acts, proper financing and rational use of budgetary allocations, effective management on the principles of public-private partnership, and cooperation of state organs and non-governmental organizations (^{Pantielieieva et al., 2020}).

The medical type is focused on the medical potential represented, on the one hand, by its treatment and technological possibilities, and qualification of its medical personnel, on the one other. These two components depend on the state’s support to the medical industry, technological development, and proper modern training of future doctors and personnel to deal with combatants’ external and, more importantly, their internal issues. For example, PTSD affects not only the soldier but also their families.

Secondary traumatic stress (STS), for instance, has been strongly evidenced in partners of veterans seeking help. This topic’s importance and the lack of clarity afforded by the currently available evidence suggests a pressing need for further work to examine this subject in more detail (^{Diehle et al., 2017}). Post-traumatic stress disorder in war veterans has a strong impact on the mental status of their children and younger adolescents. There is a strong association with behavioral problems, emotional difficulties, distress and stress reactions, and neuroticism in children and younger adolescents. Post-traumatic stress disorder of war veterans who are parents is a strong predictor for developing psychopathological symptoms in children and young adolescents. Children and young adolescents are at increased risk of developing psychopathological symptoms in adulthood due to secondary traumatization (^{Selimbasic, 2020}).

This component is represented by the general state legislative system that is contained in each country’s medical law. What is more, besides traditional rights issues, this field of law must present answers to questions concerning, for example, the satisfaction of positive and negative reproductive rights, rights to euthanasia, and transplantology for the combatants in pandemic and post-pandemic times.

We believe that states must be fully responsible for the healthcare of armed conflicts participants and veterans in the form of pre-conflict, conflict, and post-conflict medical care and treatment, particularly those with physical or mental health issues. In times of COVID-19, the mentioned covers the legal implications of the post-COVID requirements of a military health service.

Prospects of combatants in modern medical law and their rehabilitation in pandemic and post-pandemic times

Conflict is not a positive event; however, the situations created by conflict could become a vehicle for women’s empowerment. According to ^{Yadav (2021)}, “conflict created the space for critical reflexivity, leading to significant transformations of gender relations and cultural practices.” The modern development of society, technology, and science determines the need for human rights; it becomes the basis for the emergence of new rights directly related to humankind’s progressive development (^{Titko et al., 2020}). In conditions of global changes and social transformations under modern challenges, the role of an educational function of law is quite significant (^{Myronets et al., 2020}).

Here, we present our vision of the prospects for active military conflict participants in medical law in modern-day conditions by distinguishing their specific features. For example, they could include the following characteristics:

All of the above-mentioned features characterize the types of challenges mentioned previously for the active participants of military conflicts. Thus, merely a proper response to these can ensure the implementation of combatants’ possibilities in their actual life, professional activity, and even as ordinary civilians after their military career. Similarly, we present our vision of the prospects of addressing the combatants’ challenges and their position in medical law in pandemic and post-pandemic conditions.

A financial-social prospect predicts the need to finance combatants’ health and social rehabilitation. The first one may be for combatants diseased with COVID-19 during military service, those contracting the virus while in reserve, and even those who acquired the infection before participating in military conflicts. Their medical treatment and health care must be provided according to specific procedures and protocols developed specifically for combatants. Negligence by the state concerning these groups can place other groups at risk. Especially if the disease occurs within acting military officers or reservists.

For example, one of the consequences for patients after COVID-19 is delayed reaction and thought process. For acting armed conflict participants, this situation can be dangerous, given that reacting slowly to outside threats may lead to physical traumas and even death. Other consequences could include communication difficulties, affecting the combatants’ perception of commands. Even personnel in reserve can also face personal and professional communication obstacles. This consequence and its legal regulation require further scientific research, and, undoubtedly, it must be addressed by modern medical law.

A similar approach is required in the case of combatants’ health rehabilitation involving transplantology. The modern states must develop and improve appropriate legal regulation regarding cases in which military personnel require organ transplants for life continuation. Rehabilitation must be integrated fully into a nation’s health system and be explicitly strengthened, specifically at the primary care level, to increase access and achieve its full potential (^{Heinemann et al., 2020}).

Ultrabilitation is a new and promising concept that promotes the notion of flourishing in rehabilitation settings. It focuses on moving beyond or around recovery and permitting novel forms of adjustment that complement the more standard outcomes relating to alleviating functional deficits (^{Kapur, 2020}). A significant number of traumatized combat veterans require creating a comprehensive system of effective physical rehabilitation. The primary task is developing a rehabilitation and reintegration system for combat veterans based on the state and society’s consolidation of efforts and comprehensive support. It should be adapted to the national historical, political, economic, legal, and socio-cultural contexts, focusing on implementing a better foreign experience (^{Pantielieieva et al., 2020}).

Military service members become more open to new experiences after undergoing psychological reinstatement training; it provides them with psychological security, new means of interaction, and security in addressing new tasks and tackling difficult life situations (^{Prykhodko, 2018}). At the same time, current medical law must provide a modern response to possible lethality for military conflicts participants regarding decision-making on their lives and body organs. We mean that theoretically, before the military service, every future combatant has a right to express concern regarding their right to euthanasia or its rejection based on their religious positions.

The same can be applied to combatants’ organs. Military members should take part in decisions regarding their organs and their transplant into other individuals according to their personal stance. Euthanasia and organ transplant issues are not properly regulated by modern medical law in every country; this requires rethinking and development. A similar situation is evident regarding positive and negative reproductive rights implementation. A causal connection between an individual’s involvement in a military conflict and the impossibility of having children after said participation requires specific programs to be developed and financially supported by states, especially in pandemic times, to provide, for example, in vitro fertilization.

Modern medical law must provide a legal response on these issues. Concurrently, this field of law must decide, for example, whose interests must be protected in case of pregnancies concerning abortion decisions. Statistics show that female combatants have a higher incidence of medical problems than their male counterparts. Many of these problems are unique to their gender, physical attributes, and physiology (^{Mathai & Kalra, 2018}). Moreover, ethical issues and challenges are part and parcel of the practice of medicine (^{Pingree et al., 2020}). Therefore, modern medical law must also pay attention to similar combatant-related issues in pandemic and post-pandemic times.

The second social part of the first prospect requires rethinking combatants’ dwelling, professional, and communication needs during their military activity and especially after it; this requires the participation of states and non-governmental organizations. Furthermore, the role of communication disorder rehabilitation is quite significant due to the possibility of psychical traumas for the participants of military conflicts and the acquisition of post-traumatic syndrome. We believe psyche rehabilitation programs should be compulsory for combatants, especially in developing countries that are ineffective concerning PTSD.

Psychological rehabilitation programs for military service members and combatants help restore an individual’s emotional self-regulation and neutralize aggressive manifestations, allowing higher tolerance of others, reducing the risk of maladaptation in extreme conditions, and increasing neuro-psychological stability to improve communication abilities and control consciousness over behavior (^{Prykhodko, 2018}). The previous defines the second medical prospect concerning combatants in medical law for the pandemic and post-pandemic times. Countries’ medical potentials may be implemented under appropriate state policy and financing this industry’s technological development.

Educational programs to prepare medical personnel to satisfy the modern needs of COVID-2019 and post-COVID-2019 conditions regarding combatants’ treatment and rehabilitation must be developed and supported by the states. Prevention of human rights violations is a key part of the protective policy of every country in the world (^{Myronets et al., 2019}). Thus, the third prospect, the legal component, requires painstaking and attentive work by each state and the entire international community to create and develop adequate legal regulations for the processes mentioned above and the effective protection of the participants’ rights and freedoms, given the needs of current pandemic and future post-pandemic conditions of combatants’ activity performing.