AMA Journal of Ethics^®

Case

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.

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 2

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.