Virtual Mentor

Virtual Mentor. October 2007, Volume 9, Number 10: 681-687.

Clinical Cases

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Maintaining Medical Neutrality in Conflict Zones

The physician's duty to provide emergency treatment to combatants on both sides in an armed conflict persists, even in the context of today's asymmetrical warfare where not everyone plays by the rules.

Stephen N. Xenakis, MD, and Yishai Ofran, MD

Asher is a fourth-year medical student doing an international elective in northern Uganda. The clinic he's stationed in serves primarily the local community, and he's seen everything from routine ear infections to advanced AIDS, encephalitis, parasitic infections, and disseminated tuberculosis.

Learning Objective Understand the physician's ethical obligation to provide emergency care to combatants in armed conflict regardless of the combatants' political affiliation.

As one of the few Westerners the villagers have ever seen, Asher has created quite a stir. Although he's starting to feel more at home in the village, he knows that his actions are watched closely by the townspeople, and he's scrupulous about his interactions with them, always respectful and deferential to local customs and values.

The organization he's working with can only staff the clinic for eight months out of the year, so when an American medical team is there, news travels fast to neighboring communities, and occasionally people come from quite a distance to seek care. One evening, Asher heard a commotion outside the clinic. Several men and women had gathered, and there was shouting. Asher asked a nurse what was causing the upset, and she explained that men thought to be affiliated with a group of rebel fighters from the north were approaching town, and some had been wounded. Asher moved to send for the local physicians and ready the procedure suites, but the nurse stopped him. "We've worked for years to establish trust among the local people here-trust that's enabled us to dramatically improve the health in these communities. It would be a grave insult if we offered care to their violent enemies, and that would surely result in a huge setback for all our hard work. We should shut down the clinic before the rebels arrive because they're not welcome here."

Commentary 1

by Stephen N. Xenakis, MD

Candidates for the Supreme Court react to hypothetical questions as if they are radioactive and creatively dodge them at confirmation hearings. But physicians use them for teaching. This case study could fall under the teaching module entitled, "How Physicians Serving in a Hostile Environment Can Make Ethical and Practical Decisions."

Asher, the medical student in northern Uganda who is in charge of the clinic for the evening, must make an urgent decision about treating potentially hostile, even dangerous, patients and does not have time to consult with others.

Let's scan the thought bubbles bursting over his head:

 

  • First, do not harm;
  • There is a duty to treat all who come to me;
  • Ensure the safety of the patients and clinic staff;
  • Will these men attack us-is this a ruse?
  • Is there a political position that is ethical?
  • What is my credibility?
  • Can I explain the decision that I make to the staff and patients?
  • Will the clinic staff follow my guidance?

Clearly, questions about the nature of the medical care required are simple in comparison to figuring out the effective course of action. The student confronts a dilemma with no easy answers, one that draws on lessons in both leadership and ethics. In many ways, these perspectives are interdependent: good leadership is grounded in sound ethical principles, and sound ethical principles guide good leadership. As a retired Army general and physician who imagines assisting this fourth-year medical student with his urgent decision, I can see organizing his thought bubbles with these leadership and ethics perspectives in mind.

There are innumerable theories of effective leadership. It is axiomatic that good leaders succeed not only by making the right decisions, but also by how they implement those decisions. In this case, the young medical student must take the lead, act decisively, and secure the confidence of the clinic staff to follow him as the crisis unfolds.

The scenario implies that the landscape of political alliances, personal relationships, and cultural attitudes that influence daily life in the clinic have undermined the efforts to gain the trust and confidence of the entire local population. While the scenario may appear to be one of warring factions and tribal or clan warfare, experience tells us that civil conflicts of this nature are complex and nuanced beyond imagination. More than likely, the state of affairs is more tenuous and insecure than it appears. The nurse urges closing the clinic before the injured rebels appear at the front door. Clearly, she feels that the rebels are not welcome and that treating them would set back the progress of the past several months. But Asher is not a political expert and discerning the intricate politics of the community exceeds his understanding and sensitivity to the local political and social alliances and hatreds. He is not sufficiently expert to either unravel or act on a presumed ethical political position and close the clinic in the face of this emergency.

A Universal Ethical Principle

But the urgency of the situation, and the pressure on the young student to provide real leadership as well as medical expertise, calls for an ethical principle that is universal, consistent, and easily explained to all parties who come in contact with the clinic and doctor. The compelling proposition is "the healer cares for all who seek treatment." The principle is simple and anchors whatever actions, policies, and procedures follow. It stands up to challenges from disputing or aggressive authorities-as there is no partiality or possibility for prejudiced alliances or favors; it is unassailable. It is elegantly framed in the Geneva Conventions: "Recognizing neither friend nor foe, they care for the wounded and sick without distinction of nationality. For charity knows no frontiers" [1].

Imagine the heated conversations with members of either warring faction-murderers, rapists, plunderers. The physician cannot neutralize the intense emotions of the scene. But most cultures and ethnic groups recognize the special role of healing practitioners and their obligation to care for all who come to them for treatment and assistance. Societies establish a special covenant with healers and bestow privilege and authority on them. Universally, healers have social status with the understanding that they will extend their art and knowledge to everyone, regardless of political or social stripe, especially in times of emergency or crisis. In the interest of good leadership and sound ethics, the physician decides that the clinic will treat the injured and sick from the opposing faction.

But how? Now that the ethical principle has been established and reinforced, the intricacies of leadership must be put into action. Asher faces tremendously complex challenges in carrying out the decision-especially in protecting the clinic staff and other patients. The young medical student needs to organize the clinic quickly to receive the new patients and simultaneously assure the safety and protection of its staff and current patients. The decision to treat the opposition parties could backfire without adequate safeguards. He should emphasize that services are provided only under emergency conditions. In order to do that, all parties must be disarmed. Other villagers should be recruited to ensure sufficient security and crowd control. Within the clinic, treatment and waiting areas of opposing factions should be completely separated. Additional contingency plans should be made to protect patients and staff. With systematic and carefully considered triage, the treatment of the wounded will not jeopardize the safety of the others. More importantly, the troubles of the conflict would be kept separate from the work of the healers.

Often, a rational ethical decision is not judged by the logic of the underlying principles, but by the effectiveness of the leadership that executes it. The demeanor and confidence of the medical student and physicians as leaders assume overriding importance. A leader who speaks and acts with calm authority, even with some charisma, is more effective in carrying out tough decisions in complex scenarios like this one. The staff and patients who are frightened and anxious look to Asher for leadership in the crisis. For many, the final judgment about the wisdom of a decision is determined by the outcome. To say it another way, a seemingly ethical decision that contributes to large numbers of dead or critically injured staff and patients would be hard to judge favorably. Being right while causing more harm is hard to justify as ethical.

One does not have to venture into a hypothetical scenario in Uganda to see that the challenges faced by this medical student are a part of many doctors' lives. Every day, military physicians and clinics in Iraq triage and treat a host of local nationals not knowing whether they are friend or foe. They follow elaborate protocols to provide high quality care and maintain the safety and security of the patients and clinical staff as well.

In the end, the guiding principle of a physician's work is stunningly simple. The physician can only take action based on the fundamental ethical principle common to the healing profession-and that is to care for all who seek treatment. Whether detainees in Guantanamo, rebel factions in Sudan, or gang members in Los Angeles, the political situation is too complex to factor into an action plan. Ultimately, the exercise of good leadership may be the most important element in the final judgment. Sound ethical judgments and good leadership go hand in hand.



References

  1. Diplomatic Conference for the Establishment of International Conventions. Geneva Conventions. Convention (I) for the amelioration of the condition of the wounded and sick in armed forces in the field. Geneva, Switzerland. August 12, 1949. UN Office of the High Commissioner for Human Rights. http://www.unhchr.ch/html/menu3/b/q_genev1.htm. Accessed August 9, 2007.

Stephen N. Xenakis, MD, is an adjunct clinical professor at the Uniformed Services University of Health Sciences and has an active clinical and consulting practice. He is a brigadier general (retired) in the United States Army Medical Corps who served in various positions of responsibility over 28 years. He is actively engaged in developing applications of quantitative electroencephalography (qEEG) for primary care clinicians.

Commentary 2

by Yishai Ofran, MD

The first scene that comes to mind when we think of medical care in wartime is of doctors or paramedics operating on the wounded while bombshells and rockets explode all around. On the battlefield, where there is a shortage of medical staff, even moderate or mild injuries can lead to death when left untreated, so it is a fundamental moral imperative to help all people regardless of the uniforms they wear. The Geneva Convention is very strict in stating the obligation to provide medical care to all soldiers with no exceptions [1].

Asher probably pictured a scene such as this when the nurse in the case scenario above said they should close the clinic. Thinking she meant to deny care to the wounded, he would react strongly, unwilling to accept that instruction. Despite not having graduated from medical school, Asher would be committed to the Hippocratic oath and remember that the Geneva Conventions made no exceptions to medical neutrality in armed conflicts. Upon further discussion with the nurse, Asher would most likely hear something like the following: "Don't get me wrong, we won't let people bleed to death. We always give first aid and perform life saving procedures, but those people can get medical aid in their villages. They only come here when your team is here because we can give better treatment. If we let those people in, war will be back in our village and people like you won't stay here any more."

As the nurse points out, many of the moral dilemmas that medical staff encounter during armed conflicts do not occur under fire. Modern wars do not necessarily involve large masses of troops clashing on a well-defined battlefield. Acts of hostility and violence often erupt within civilian settings. Tension and fear undermine the normalcy of civil life during conflicts. The unresolved conflict impinges on people's simple daily decisions, even if not a single shot is fired.

The ethical dilemmas that stem from this situation are not only about treating war injuries but about treating simple diseases. Usually, throughout long-lasting conflicts people stay on their own sides. When they seek medical care they take into account the political and national affiliation of the medical facility. Yet, it may happen that they turn to a facility owned and operated by the "enemy" when the fear of disease outweighs the dread of the foe. People may actually cross the lines for what they believe is the best medical care they can get, particularly if their condition is grave and if the discrepancy in the quality of care offered on each side is substantial.

Recently, during the first days after Hamas took power in the Gaza strip, several dozen sick Palestinians who would usually have been treated at Palestinian hospitals in Gaza accumulated at the border with Israel, asking to be treated at Israeli hospitals. Those who required emergency or specific, sophisticated treatment were allowed to cross the border. When fighting subsided, patients no longer approached Israel 's border. Patients only applied for Israeli help when they were afraid that, due to the new political situation, they wouldn't be able to get any treatment in Gaza.

There is arguably no civil domain other than medicine in which such line-crossing during armed conflict is so frequent. Thus, medical staff stand in a rare interface between enemies. What may be obvious to Asher as a foreigner is much harder for local medical personnel to see. As natives, the staff and their fellow citizens often identify with, and support the goals of, one side of the conflict. Yet Asher has correctly identified the basic mission of a doctor. Medicine is not only the act of treating patients but also the values, goals, and efforts made to prolong life, prevent disabilities, and improve quality of life. Medicine is the exact opposite of violence.

The principle of medical neutrality is such that the more armed forces respect it the more tempting is to use medical staff and facilities for military purposes. In Martin Campbell's film Beyond Borders, an NGO's (nongovernmental organization's) medical delegation is allowed to operate within a civilian community only by agreeing to smuggle guns for the Khmer Rouge. This violation of the principle of medical neutrality leads in the end to the destruction of the medical camp clinic and the death of some medical staff members when their secret is discovered. As the movie illustrates, the responsibility for safeguarding the principle lies squarely on the shoulders of the medical staff. Even when identifying with one side of the conflict, no one should, in his or her capacity as medical staff, participate in acts of violence. Using access to medical aid as a tool in an armed conflict violates the values that are fundamental to good care. Preselection of people entitled to medical assistance on the basis of their political party should not be used as a tool to achieve political goals. Therefore, we have to make sure medical facilities remain accessible to all, regardless of political association.

According to a recent survey, when a patient requests a legal medical intervention which the physician opposes for religious or moral reasons, it is ethically permissible in the opinion of most American physicians to explain the reason for the objection, to disclose information about the intervention, and to refer the patient to someone who will provide it [2]. One should not, however, confuse moral opposition to a specific procedure with preselection of patients on the grounds of moral or political values.

Ethical rules should balance the well-being of specific patients with the needs of the system as a whole. No medical system can be blind to financial considerations. As a result, physicians may be unable to provide care due to lack of financial means or insurance coverage. The doctor's duty is always to verify that the patient is referred to another facility where he will be able to get reasonable treatment according to local medical standards of care. It is acceptable to refer a patient to a different facility in cases where best care for this patients clashes with the needs of the system. This should not be the case, however, if the reason for referral is external to patient-doctor interaction. The line between protecting the health system (the position taken by the nurse in our story) and using health system as a weapon in the conflict (Asher's initial interpretation of her position) is very fine.

We, as medical staff, should stand for the values of medicine, especially during wartime. Seeking the help of one's enemies at such times, reflects a patient's desperation or lack of other good options of care. We should remember that a patient's decision to ask our help is a statement of trust. Thus, we should be very careful when preferring the system's needs at the cost of the patient's health. Medicine should and can open a small path to peace, and it is up to us to show the way [3].

Once the patient enters the clinic, Asher should give him the best care he can. If the patient is responsible for terror or war crimes, giving the best medical care does not conflict with Asher's duty to call authorities, which will bring the criminal to justice. Shutting down the clinic to avoid providing care to a specific patient should be prohibited. Medical staff can and should lead and influence public values especially during wartime.


References

  1. Diplomatic Conference for the Establishment of International Conventions. Geneva Conventions. Part I, Article 4. Convention relative to the treatment of prisoners of war. http://www.unhchr.ch/html/menu3/b/91.htm. Adopted August 12, 1949. Accessed August 9, 2007.
  2. Curlin FA, Lawrence RE, Chin MH, Lantos JD. Religion, conscience, and controversial clinical practices. N Engl J Med. 2007;356(6):593-600.
  3. Ofran Y, Giryes SS. To be a doctor in Jerusalem: life under threat of terrorism. Ann Intern Med. 2004;140(4):307-308.

Yishai Ofran, MD, is a senior hematologist at Rambam Medical Center, a unit of the State of Israel's Ministry of Health in Haifa. He recently started a two-year research project at the Dana Farber Cancer Institute in Boston. Dr. Ofran did his residency in internal medicine at Hadassah Medical Center, Mount Scopus Hospital, Hebrew University in Jerusalem. He also serves as a military doctor in a reserve parachutist brigade in the Israel Defense Forces.

A Doctor's Duties in Terror-Struck Communities, May 2004

From Medical Neutrality to Medical Immunity, October 2007

The people and events in this case are fictional. Resemblance to real events or to names of people, living or dead, is entirely coincidental. The viewpoints expressed on this site are those of the authors and do not necessarily reflect the views and policies of the AMA.