Medical neutrality

Medical neutrality refers to a principle of noninterference with medical services in times of armed conflict and civil unrest: physicians must be allowed to care for the sick and wounded, and soldiers must receive care regardless of their political affiliations; all parties must refrain from attacking and misusing medical facilities, transport, and personnel. Concepts comprising the principles of medical neutrality derive from international human rights law, medical ethics and humanitarian law. Medical neutrality may be thought of as a kind of social contract that obligates societies to protect medical personnel in both times of war and peace, and obligates medical personnel to treat all individuals regardless of religion, race, ethnicity, or political affiliation. Violations of medical neutrality constitute crimes outlined in the Geneva Conventions.

Historical background

The principle of medical neutrality has roots in many social traditions.

  • The Hippocratic Oath, which requires physicians to practice medicine ethically, dates back to the fifth century.[1]
  • The idea of ‘do no harm’ has histories in “Jewish and Islamic, as well as Chinese and Indian medicine”[2]
  • Geneva Conventions (the core of international humanitarian law, supported and protected by the International Committee of the Red Cross):
    • The First Geneva Convention was written by Henri Dunant in response to seeing such the difficulty of treating wounded soldiers at the Battle of Solferino.[3]
    • The first and the following Geneva Conventions created the Red Cross, outline the protections of medical personnel in times of war, codify the protections of citizens, soldiers, medical personnel, etc.
    • The First Geneva Convention states that there should be no “obstacle to the humanitarian activities” and that wounded and sick “shall be respected and protected in all circumstances.”[4]
    • Article 19 demands that medical units, i.e. hospitals and mobile medical facilities, may in no circumstances be attacked.[5]
    • The Declaration of Geneva was created as an amendment to the Hippocratic Oath in 1948, a response to the human experimentation on Nazi prisoners.

Violations of medical neutrality

Medical neutrality is violated when health care professionals, facilities, or patients come under attack, or when medical professionals are not allowed to provide treatment.[6] Examples include:[4]

  • Attacks on hospitals
  • Attacks on patients
  • Attacks on medical personnel
  • Attacks on medical transport
  • Misuse of medical facilities
  • Breaches of medical ethics by medical personnel
  • Using the hospital/medical facilities in order to attack, fire/ fire rockets e.j., to civilians from the medical facilities
  • Using the medical facilities in order to house weapons or soldiers
  • Using the medical facilities for purposes other than medical assistance and/or aid to the public

Recorded violations of medical neutrality

Gaza (2021)

During the Israel bombing of Gaza in May 2021, parts of a Doctors Without Borders/Médecins Sans Frontières (MSF) trauma and burns care clinic were destroyed in the airstrikes. The strikes did not injure anyone inside the MSF's clinic, but it destroyed a sterilization room and damaged a waiting area. The strikes also destroyed the road that leads to the clinic, thereby blocking the access to it. The clinic was forced to close. [7] The airstrikes also lead to death of two prominent doctors in Gaza. Dr. Ayman Abu al-Ouf, head of internal medicine at Al-Shifa hospital, was killed along with 12 members of his extended family after an airstrike on his home on 16 May, 2021. Dr. Mooein Ahmad al-Aloul, a 66-year-old psychiatric neurologist, was also killed in his home during the al-Wehda attacks.[8]

Thailand (2021)

During the pro-democracy protest on February 13, 2021, there was footage showing Thai riot police beating a medical volunteer, while wearing a green vest identifying himself as part of medical volunteers offering services to both sides.[9]

Myanmar/Burma (2020 & 2021)

Ethnic and civil conflict has been a persistent part of modern Burmese/Myanmar society, and the Tatmadaw (Burmese Army) has used the pretext of a COVID-19 lockdown to secretly force local indigenous groups to work for them, continuing attacks on health care centres located in the conflict regions but serving the general community, and recently shelled a Red Cross boat carrying medical supplies causing International condemnation.[10] After the 2021 military coup d'état, during crackdowns on the peaceful protesters, the military has targeted the medics and ambulances attending to the emergency patients, leading to condemnation by World Medical Association.[11] United Nations Security Council has also expressed deep concern over restrictions on medical personnel.[12]

Chile (2019)

Since civil unrest broke out in October 2019, there has been backlash toward police and military forces for their disregard for medical volunteers who aid injured protestors. The best known and evidenced case thus far occurred Friday November 15, 2019. An ambulance was inhibited in its ability to transport a person suffering from cardiac arrest during a peaceful protest in Plaza de la Dignidad. The medical volunteers who were attending to him came under fire from carabineros’ rubber bullets, tear gas and water trucks. They were put at risk and hindered in their efforts to resuscitate the patient. One volunteer sustained a wound to the leg. The medical team's inability to safely attend to the patient and transport him to the hospital resulted in his loss of life.[13]

Afghanistan (2015)

On 3 October 2015, U.S. airstrikes killed 42 people and destroyed the MSF (Médecins Sans Frontières - Doctors Without Borders) trauma hospital in Kunduz, Afghanistan (See main article). Many patients in the hospital burned alive in their beds as a US AC-130 gunship made multiple passes firing upon the hospital from overhead. MSF's request for an independent inquiry was never honoured. The U.S. military investigated itself, eventually taking disciplinary action against a dozen service members. No criminal prosecutions followed.[14][15]

Bahrain (2011 & 2012)

The Bahraini government's crackdown on the Bahrain uprising in 2011 and 2012 included extensive violations of medical neutrality. An investigative report released by Physicians for Human Rights revealed that many doctors were attacked or incarcerated. Furthermore, Bahraini security forces have seized control of medical facilities, prevented patients from receiving treatment, misused ambulance services, and violently interrogated wounded patients.[16] In September 2011, 20 medical workers in Bahrain were sentenced to up to 15 years in prison for treating protesters.[17] These sentences were immediately condemned by United Nations secretary general Ban Ki-Moon and human rights groups such as Physicians for Human Rights.[18] Apparently in response to international pressure, the Bahrain government ordered that the doctors be retried in civilian court, but the verdict has yet to be decided.[19]

Egypt (2011)

In 2011, during political unrest, state security forces directly attacked protestors and field clinics, injuring and killing numerous people. A state security officer even dressed himself as a doctor and administered fatal shots to those injured in a field clinic outside of Tahrir Square.[20] Medical supplies were confiscated by “military officers and field hospital tents were burned down during a Tahrir raid.”[20]

Libya (2011)

During the 2011 Libyan Civil War, human rights groups documented violations of medical neutrality along with many other gross violations of human rights. Physicians for Human Rights conducted investigations within Libya in 2011, and found that the military had attacked and destroyed hospitals. Several eyewitnesses reported that Gaddafi forces attacked ambulances carrying injured combatants, despite the fact that the ambulances were marked with the emblematic Red Crescent. Medical personnel were kidnapped by Gaddafi's forces, and military forces used people as human shields.[21][22]

Syria (2011)

The Syrian civil war has been marked by widespread human rights abuses, including numerous violations of medical neutrality. Government forces have invaded, attacked, and misused hospitals and medical transports, preventing civilians from receiving health care. An estimated 250 doctors have been detained and tortured for treating wounded civilians.[23] An investigation by Physicians for Human Rights revealed that these circumstances have led to the rise of an underground health network.[24]

Iran (2008-2011)

In June 2008, Iranian authorities detained Dr. Arash Alaei and Dr. Kamiar Alaei, two well-known Iranian physicians and leaders in the fight against HIV/AIDS. The physicians, who are brothers, were held in Tehran's notorious Evin prison for over six months without being charged or tried. On December 31, 2008, a one-day, closed-door trial was held, in which the brothers were tried as conspirators working with an “enemy government” to overthrow the government of Iran. They were also tried at that time on unspecified other charges which neither they nor their lawyer were allowed to know, see the evidence of, or address.[25][26] They were charged with attempting to overthrow the Iranian government under article 508 of Iran's Islamic Penal Code. Kamiar was sentenced to three years in prison and Arash to six. The government of Iran used the brothers’ travels to international AIDS conferences as the basis for these claims.[27][28]

The international community decried the sentences of the doctors, and Physicians for Human Rights launched a campaign for their release.[29] In 2010, Dr. Kamiar Alaei was freed after serving two years in prison. Dr. Arash Alaei was released in August 2011 after more than three years of detention. Since their release, the doctors have reunited in the United States, where they continue their medical and advocacy work.[30]

Sri Lanka (2009)

Sri Lanka's lengthy civil war was marked by extensive human rights abuses. In 2009, the Sri Lankan air force violated the principle of medical neutrality when it destroyed the Ponnampalam Memorial Hospital in Puthukkudiyiruppu.[31]

Chechnya (1996)

During the Battle of Grozny in 1996 during the First Chechen War, several hospitals were attacked. Municipal Hospital No. 9 was invaded by Russian soldiers and approximately 500 civilians were taken hostage.[32] The ICRC Hospital of Novye Atagi, which was created to symbolize medical neutrality in the war-torn area, was attacked and six members of the ICRC staff were killed.[33]

Thailand (1992)

A year after a bloodless military coup in Bangkok in February 1991, the new government responded to the pro-democracy movement opening fire on a May opposition rally, resulting in 52 deaths, hundreds of injured, and many disappearances. Physicians for Human Rights reported that health professionals were prevented from reaching the wounded and the police shot at ambulances.[34]

El Salvador (1980-1992)

In the Salvadoran Civil War, many field clinics were attacked by guerillas. Patients were commonly abducted from hospitals, and government forces greatly limited the movements of health workers. Medical transports were also attacked, in some cases resulting in the deaths of medical workers.[35]

Mozambique (1977-1992)

During the Mozambican Civil War, the resistance group RENAMO was responsible for many violations of medical neutrality. Attacks on hospitals and health clinics were common. In one instance, RENAMO soldiers raided the town of Homoine, killing 442 civilians including hospitalized patients.[36]

Panama (1988)

Civil unrest and demonstrations began in Panama in June 1987. During the unrest, human rights groups such as Physicians for Human Rights documented a variety of human rights abuses and violations of medical neutrality. The military blocked access to hospitals and interfered with provision of medical care, took control of ambulance services for military purposes, and interrogated wounded patients. In addition, Panamanian physicians were kidnapped, beaten, and tortured for speaking out against government policies which prevented them from providing their patients with adequate care.[37]

Pakistan (1971)

In April 1971, Pakistan's military targeted ethnic Bengalis at the Lalmonirhat Railway Hospital, located in the northern tip of what was then called East Pakistan (now Bangladesh). Approximately thirty-seven Bengali civilians or non-combatants, including patients, doctors, nurses, and other health care professionals or medical personnel were summarily executed by the Pakistani military.

Organizations with a specific focus on medical neutrality

Medical Neutrality Protection Act of 2011 (H.R. 2643)

The Medical Neutrality Protection Act of 2011, (H.R. 2643), is a bipartisan bill introduced by Representatives Jim McDermott (D-WA), and Walter B. Jones, Jr. (R-NC) that intends to make the protection of medical professionals and access to medical services a global policy priority for the US government.[38]

  • The bill calls for the creation of the position of a United Nations Special Rapporteur on the Protection and Promotion of Medical Neutrality and calls for investigations of violations of medical neutrality. It also limits military aid from the US to countries that have engaged in violating medical neutrality, and as well bans their government officials from attaining visas to the United States.[39]
  • As codified in the Medical Neutrality Protection Act of 2011, violations of medical neutrality are:[39]
    • Militarized attacks on health care facilities, health care service providers, or individuals in the course of receiving medical treatment
    • Wanton destruction of medical supplies, facilities, records, or transportation services
    • Willful obstruction of medical ethics as specified in the World Medical Association's International Code of Medical Ethics, including preventing medical professionals from administering ethical medical care to individuals in need
    • Coercion of medical personnel to commit acts in violation of their ethical responsibilities
    • Deliberate misuse of health care facilities, transportation services, uniforms, or other insignia
    • Deliberate blocking of access to health care facilities and health care professionals
    • Arbitrary arrest or detention of health care service providers or individuals seeking medical care

References

  1. ↑ Ludwig Edelstein. The Hippocratic oath: text, translation and interpretation. Johns Hopkins University Press, 1996, p.56.
  2. ↑ Sheila McLean, First Do No Harm: Law, Ethics, and Healthcare, at 83 (Ashgate Publishing, 2006)
  3. ↑ Sperry, C.S. (1906), "The Revision of the Geneva Convention, 1906", Proceedings of the American Political Science Association, 3: 33–57, doi:10.2307/3038537, JSTOR 3038537
  4. 1 2 "Treaties, States parties, and Commentaries - Geneva Convention (I) on Wounded and Sick in Armed Forces in the Field,1949". ihl-databases.icrc.org. Retrieved July 18, 2019.
  5. ↑ "The Geneva Convention of 12 August 1949" (PDF). Loc.gov. Retrieved January 10, 2020.{{cite web}}: CS1 maint: url-status (link)
  6. ↑ "Physicians for Human Rights - The Principle of Medical Neutrality". Physicians for Human Rights. Retrieved July 18, 2019.
  7. ↑ "Israeli airstrikes kill civilians and damage MSF clinic in Gaza". May 17, 2021. Retrieved July 22, 2021.
  8. ↑ Stepansky, Joseph (May 17, 2021). "'Huge loss': Experienced Gaza doctors killed in Israeli attacks". Al Jazeera. Retrieved July 22, 2021.
  9. ↑
  10. ↑ "One Killed, Three Hurt as Myanmar Navy Sinks Boat Carrying ICRC Relief Goods in Rakhine State". irrawaddy.com. October 28, 2020.
  11. ↑ "WMA - The World Medical Association-Harassment and arrest of doctors in Myanmar condemned by physician leaders". Retrieved March 12, 2021.
  12. ↑ "Myanmar: UN Security Council strongly condemns violence against peaceful protesters". UN News. March 11, 2021. Retrieved March 12, 2021.
  13. ↑ "Colegio Médico denuncia agresión de Carabineros a ambulancia y funcionaria del SAMU que atendían a manifestante en Plaza Italia". 24 Horas (in Spanish). November 16, 2019. Retrieved November 17, 2019.
  14. ↑ "One year after Kunduz: Battlefields without doctors, in wars without limits". Médecins Sans Frontières (MSF) International. Retrieved July 18, 2019.
  15. ↑ Kabul, Spencer Ackerman Sune Engel Rasmussen in (April 29, 2016). "Kunduz hospital attack: MSF's questions remain as US military seeks no charges". The Guardian. ISSN 0261-3077. Retrieved July 18, 2019.
  16. ↑ "Persecution in Bahrain". Physicians for Human Rights. Retrieved July 18, 2019.
  17. ↑ Goodman, J. David (September 29, 2011). "Bahrain Hands Down Harsh Sentences to Doctors and Protesters". The New York Times. ISSN 0362-4331. Retrieved July 18, 2019.
  18. ↑ "Physicians for Human Rights - PHR Denounces Sentences Passed on Bahraini Medics and Protestors". Physicians for Human Rights. September 29, 2011. Retrieved July 18, 2019.
  19. ↑ "Bahrain Orders Retrials for Medical Workers", The New York Times, October 5, 2011,
  20. 1 2 "A brief history of field hospitals in Tahrir Square | Al-Masry Al-Youm: Today's News from Egypt". December 31, 2011. Archived from the original on December 31, 2011. Retrieved October 25, 2021.
  21. ↑ "MSN | Outlook, Office, Skype, Bing, Breaking News, and Latest Videos". Msn.com. Archived from the original on January 31, 2019. Retrieved July 18, 2019.
  22. ↑ "Witness to War Crimes: Evidence from Misrata, Libya" (PDF). S3.amazonamws.com. Retrieved January 10, 2020.{{cite web}}: CS1 maint: url-status (link)
  23. ↑
  24. ↑ "Syria: Attacks on Doctors, Patients and Hospitals" (PDF). S3.amazonamws.com. Retrieved January 10, 2020.{{cite web}}: CS1 maint: url-status (link)
  25. ↑ "Iran, Free Doctors Arash & Kamiar Alaei » Background". Retrieved July 18, 2019.
  26. ↑ "Physicians for Human Rights - PHR Criticizes Iran for Trying AIDS Doctors on Secret Charges". Physicians for Human Rights. December 31, 2008. Retrieved July 18, 2019.
  27. ↑ "Persecution of Health Professionals". Physicians for Human Rights. Retrieved July 18, 2019.
  28. ↑ PharmPro. “Iranian Physician Describes HIV/AIDS Work That Led to Imprisonment.” "Archived copy". Archived from the original on April 6, 2012. Retrieved October 27, 2011.{{cite web}}: CS1 maint: archived copy as title (link). Retrieved February 28, 2012.
  29. ↑ "Iran, Free Doctors Arash & Kamiar Alaei". Retrieved July 18, 2019.
  30. ↑ "Physicians for Human Rights - Released Iranian AIDS Doctors Share their Story". Physicians for Human Rights. Retrieved July 18, 2019.
  31. ↑ "The Sri Lankan doctors and the challenge for medical leadership". Ijme.in. Retrieved July 18, 2019.
  32. ↑ "Occupation of Municipal Hospital No. 9". old.memo.ru. Retrieved July 18, 2019.
  33. ↑ Bugnion, François (April 30, 1997). "17 December 1996 : Six ICRC delegates assassinated in Chechnya - ICRC". International Review of the Red Cross. Retrieved July 18, 2019.
  34. ↑ "Excessive Use of Lethal Force in Bangkok" (PDF). S3.amazonamws.com. Retrieved January 10, 2020.{{cite web}}: CS1 maint: url-status (link)
  35. ↑ "El Salvador: Health care under siege" (PDF). S3.amazonaws.com. Retrieved January 10, 2020.{{cite web}}: CS1 maint: url-status (link)
  36. ↑ "MHN: Homoine, 1987". March 7, 2012. Archived from the original on March 7, 2012. Retrieved October 25, 2021.
  37. ↑ "Panama 1987: Health Consequences of Police and Military Actions" (PDF). S3.amazonaws.com. Retrieved January 10, 2020.{{cite web}}: CS1 maint: url-status (link)
  38. ↑ "Physicians for Human Rights - Introducing Medical Neutrality Protection Act of 2011". Physicians for Human Rights. Retrieved January 10, 2020.
  39. 1 2 "H.R. 2643" (PDF). Govinfo.gov. Retrieved January 10, 2020.{{cite web}}: CS1 maint: url-status (link)

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