Care to the Wounded: A Core Duty of Humanity
A fundamental but neglected issue
In times of war and armed conflict, all parties have an obligation to provide care to the wounded and sick persons, be they from one’s own troops or from enemy groups who are hors de combat, without any distinction. This duty is a core obligation of International Humanitarian Law (IHL).
In recent years, considerable attention has been devoted in philosophy, law, and political science to the treatment provided to enemies, notably in relation to global issues and terror. While interest focused on the prohibition of torture and on formulating a response to terrorism, little attention has been given to the duty to provide care for wounded or sick enemies, as if this was considered a secondary matter. It may be that this duty was considered as too obvious and widely accepted to deserve any particular attention; or, that it was hoped that the respect of this duty would naturally follow on from respecting the prohibition of extreme violence and torture. Such arguments, however, could be misleading. The duty to rescue and provide care to the wounded and sick is not a secondary, but a core component of IHL. Secondly, its scope has recently been questioned in publications on medical ethics in conflict situations. Thirdly, impartial care to wounded enemies might well be an essential step toward respecting dignity and preventing extreme violence and abuse.
This short article1 explores some ethical aspects of this duty. Starting with the ethics of providing succor to a person in danger, it encompasses care for a wounded combatant and care to a wounded enemy, and suggests ways to address ethical challenges in this domain.
The duty to succor a person in danger
Do we have a moral duty at all to succor a person in danger? Or is providing succor just a nice thing to do on the part of people who like helping others? For Mencius in ancient times in China (372–289 BC), or Rousseau in modern Europe (1762), the answer was clear: to provide succor to someone in danger is simply to be human. For these writers, to feel pity to someone in distress and to act with humanity is completely natural; it is universal, and it is the source of all morality. For Rousseau, as for Mencius, this is the first moral duty, from which other duties are derived.
Other philosophers, however, came up against difficulties. Firstly, because this duty is born of pity and emotions. Immanuel Kant (1785) thought that moral philosophy should be founded on reason, and that a duty should become a universal moral law. However, if ethics segues into a radicalism of duty, the altruistic act becomes impossible unless it can be generalized and turned into a universal law.
A second difficulty is that providing succor exposes people to dangers, effort, and expenses, which might be considered as going beyond the call of duty. This has been the position of Beauchamp and Childress in “Principles of biomedical ethics” (1979), in which they developed an approach based on four principles: autonomy, beneficence, non-maleficence, and justice. As emphasis was placed on respecting the autonomy of the patient and the professional, little room was left for providing succor to a person in danger. For these authors, a doctor has a moral responsibility to stop at the scene of an accident “as long as the risk involved is minimal and to do so will only have a minor impact on his way of life. A doctor is not obliged to be a ‘Good Samaritan’, only a ‘minimally decent Samaritan’.”
Similar conclusions were reached by the liberal moral philosopher Ruwen Ogien (2007), who employed a graded concept of “Samaritanism” according to the level of risk for the rescuer. This “minimal ethics” only recognizes a restricted duty to provide assistance: the duty is limited, first by the risks run by the passerby or the relief worker; second, by the request or opinion of the person to be assisted. One has a duty to provide succor, and also a duty to safeguard one’s own security and health as well as a duty to respect the autonomy of the individual in danger, and not to rescue him against his own will.
The utility of saving lives
Utilitarian approaches point out other difficulties. Rescuing persons in danger is expensive, and it may divert limited resources from other activities where the benefits would be greater. McKee and Richardson (2003) defined the “rule of rescue” as the ethical imperative “people feel to rescue identifiable individuals facing avoidable death.” They note that rescue can conflict with a cost-effectiveness analysis, and may be criticized on the grounds of social injustice and public health. However, rescue has a social value: it responds to a reaction of “shock and horror”, and people value the fact of living in a society based on relations of mutual respect. Therefore, cost-effectiveness analyses should integrate attempts to help people in danger.
The question of proximity is posed by Peter Singer (1993). He recognizes a moral duty to rescue a child drowning before oneself; but, he argues, we have a similarly great responsibility to help distant persons in need, by contributing to humanitarian action. There is, however, a difference between those situations, replies Scott James (2007), which lies in your relationship to potential beneficiaries. In the case of a drowning child, there is a specific individual who relies on you and only you for survival; you have a strong duty to act when you are in such a relationship of “unique dependence”.
In short, the duty to rescue someone in danger is deeply rooted in human cultures, traditions, societies, and religions around the world. It applies, a priori, without limit or distinction; and it is circumscribed by other considerations: to preserve one’s own security and life; to respect the dignity and autonomy of the person in danger; to make good use of limited resources, taking into consideration other people in need; to act efficiently and with competence. In this respect, people who have a particular role, skill set and means to act, such as rescuers, healthcare or humanitarian professionals, have a more compelling duty to take action. They also have a responsibility to maintain their competence and skills. Ultimately, as a human being I have a responsibility to act personally when I am in a situation in which the dignity or life of a person in danger depends on my own action, and in which I have the ability to act.
Care for wounded combatants
Ever since antiquity, medical practitioners have been present among armies, but their role was often left unclear, and forces were essentially devoted to combat. Wounded soldiers were abandoned on the battlefield, and transporting a wounded comrade to the rear was viewed as a way of escaping enemy fire. When Napoleon’s surgeons Larrey and Percy invented a kind of “flying ambulance” (around 1797), surgeons started to provide care in the middle of the battlefield. Following their medical ethics, they provided care impartially to wounded people, enemies, and compatriots alike. They established rules of impartial triage for war casualties, and also defended the independence of medical services. This impartial and effective care for combatants earned them widespread recognition and admiration, to the extent that at Waterloo the Duke of Wellington directed cannon fire away from ambulances in order to give Larrey time to collect the wounded. From their practice on the battlefield, these surgeons established the bases of ethics in military medicine and in humanitarian action in war: humanity, impartiality, neutrality (inviolability), and functional independence of medical personnel and healthcare facilities.
After the battle of Solferino on 24 June 1859, Henry Dunant organized succors for wounded soldiers. He later made a pressing call to create relief societies that should be organized in times of peace. This resulted in the founding the International Committee of the Red Cross in 1863 and led to the adoption of the first Convention for the Amelioration of the Condition of the Wounded in Armies in the Field in 1864, which imposed on belligerent armies the duty to provide impartial care for all wounded combatants. Hospitals, ambulances, and personnel in charge of transporting and providing care for the wounded should be recognized as neutral, protected, and respected. For more than 150 years, the duty to rescue and to care for the wounded and sick who are hors de combat, is a primary duty set out in IHL.
Care for wounded combatants called in question
Some authors have questioned this duty, reaching conclusions which seem to weaken its scope or applicability. We briefly review issues raised by Michel Gross in a book on bioethics in war (2006) and in various articles. As a starting point, this author asserts that “the goal of military medicine is salvaging the wounded who can return to duty.” This affirmation leads him to challenge some essential ethical and humanitarian principles. Firstly, he questions the duty of care of the state toward war veterans and wounded combatants: badly wounded soldiers, he writes, only enjoy the same right to medical care as any similarly ill or injured individual; a military organization must only provide palliative care as the minimum medical care for severely wounded soldiers. Regarding impartiality, he suggests that particular medical efforts and specialized medical care should be dispensed only to wounded soldiers who might go back to duty. Severely wounded or sick soldiers would only receive a lower quality of medical care, or only palliative care. Likewise, wounded enemies, once captured and hors de combat, would receive a lower standard of care or palliative care.
Regarding medical neutrality, this author asserts that physicians are not neutral, they owe allegiance to the side they are fighting with. These views open the way to major ethical drifts, namely participation of medical professionals in abusive interrogation. Physicians and healthcare professionals owe their full medical loyalty to their patient, always and in any circumstances2. They also have separate duties as collaborators to the organization in which they work; but these duties do not interfere with medical decisions and the care provided to the patient. Any breach in the commitment to the patient, in particular any breach in medical confidentiality, has disastrous consequences in the practice of medicine: it destroys trust and the doctor-patient relationship, and opens the way to exploitation of the patient and to abuse. Medical confidentiality must be fully respected, in any circumstances.
Functional independence from authorities and institutions is therefore an essential condition for the exercise of military medicine and healthcare in detention facilities. Military physicians and health services depend on military authorities specifically for security, logistics, and their deployment; in the practice of care their independence must be fully respected.
As regards care to a wounded enemy, Gross quotes surveys of medics and physicians, in which some express a preference to give priority to comrades, before providing care to a wounded enemy. He suggests that “preferential care for family and friends is a fundamental moral obligation,” and accepts that at the platoon level, medics could give priority “based on friendship and intragroup commitment.” He admits that at hospital level, at a distance of the battlefield, physicians must give impartial care.
These analyses mix different relations, roles, and duties. An ethics of care does not imply favoring family or friends: on the contrary, it implies establishing a “just distance” between the professional and the patient3. For instance, medical ethics expect doctors to refer family members to the care of other clinicians, precisely because their strong feeling can interfere with clinical judgment.
Strong emotions occur at all levels during crises and in armed conflicts. High emotional tensions do occur as well in health services, in providing care to a person suspected of a crime or a terrorist act. These emotions and perceptions must be managed; they do not, however, offer any justification for preferential care to compatriots rather than to wounded enemies. The ethical response does not lie in suspending impartial care, but rather in strengthening the organization of military medicine, in order to ensure functional independence, and in promoting education in medical ethics.
Many conclusions of this author derive from the idea that military medicine follows strategic aims. This conception opens the way to attacks on fundamental principles of medical ethics and international humanitarian law. This author eventually accepts the possibility that doctors may breach medical secrecy, and may take part in interrogations or in torture if this is considered to be in the nation’s interests. As extreme as they appear, these positions derive from the idea that military medicine contributes to strategic aims. Healthcare and rescue are not subordinate to strategic or political interests, in any instance.
Towards an ethical response
Exploring the ethics of care for a wounded or sick enemy leads us to recognize strong ethical duties, and at the same time to contradictory emotions, ethical tensions, and challenges, both on the battlefield and in the provision of care. In order to address these tensions we propose the following ethical landmarks:
Providing succor and care for a person in danger is an ethical imperative. This duty is not dependent on strategic or political considerations.
Rescue of and care for persons in danger must be provided according to medical criteria, without consideration of nationality, side in the conflict, or any other distinction.
Respect for and protection of dignity, health, and life
Persons falling into the power of an enemy are in a situation of extreme vulnerability and dependence. Authorities, rescuers, and health-care providers have a duty to ensure that relief and care activities do not become opportunities for abuse.
Rescue activities and medical care are not contingent on strategic aims; under this condition they are able to provide non-discriminatory care for wounded and sick persons, and their mission can be respected and protected by all powers and sides in a conflict.
Commitment to the patient
The pact of care between a healthcare professional and a patient is a core element of medical ethics. It is based on trust and confidentiality, and involves the professional commitment to provide a patient with competent and effective care.
In order to be impartial and fully committed to the patient’s health and dignity, medical staff must have functional independence from political and military powers in the practice of medical care and related decisions. No strategic, political, or intelligence objectives should have any influence on the practice of healthcare. This autonomy must be reflected in the organization of care and in hierarchical relationships, with a clear separation between the military medical services and the operational command.
A trusting and personal relationship is an element of care, but traps arising from affective and emotional proximity or distance must be avoided. A “just distance” must be maintained, as in any care relationship. This may pose difficult challenges in contexts in which enemies have been perceived as inhuman or dehumanized. Humanization is part of care.
Respect for the life and safety of professionals
Rescue and emergency care may involve security risks and physical danger, notably in armed conflicts. The risks involved in these operations must be recognized, carefully evaluated, and mitigated. Ethics does not require sacrifice; it requires solicitude, generosity, and accepting some risks as part of rescue and care activities, in the spirit of responsibility.
Equivalence of care
Wounded or sick persons who are under the power of another force in a conflict, including detainees, are entitled to at least the same level of care as the general public in the country or territory, in relation to their needs.
Independent role of justice
Providing impartial care, maintaining medical neutrality, independence, and an appropriate therapeutic distance to the patient, is made possible in situations of extreme violence by the fact that justice is a separate task, with an independent role. This allows rescuers and health-care professionals to devote their efforts fully to their patients.
Establishing a proper carer–patient relationship can be extremely challenging in contexts marked by extreme violence and dehumanization; ensuring the security of professionals can conflict with the duty to provide succor and care in conflict areas; the provision of good-quality care can conflict with limited resources; and healthcare professionals encounter complex dilemmas as regards justice, ensuring medical confidentiality, or denunciation if they are informed of crimes committed or planned.
An approach of practical ethics is required in order to address such situations. These ethical challenges cannot be solved by ignoring one horn of the dilemma, or by following a procedure. The purpose of this work of “practical wisdom”, is to invent the conducts that, in the given situation, best meet the ethical aim of humanity4. Decision-taking in difficult ethical situations requires a process of deliberation and discussion within a multidisciplinary group.
Care for the enemy is a core element of ethics
Succoring a person in danger appeals to a basic sentiment of humanity, involving feelings and emotions of compassion and pity. Witnessing a situation of extreme danger or violence causes a reaction of shock and horror; failure to act and provide succor leads to feelings of shame, indignity, humiliation, and a sense of failing one’s own humanity. People feel ashamed when they feel guilty of passivity, powerlessness, or consenting to violence. They feel dehumanized. People who provide succor and impartial care, despite all obstacles, feel humanized. In his book “Humanity”, Glover explores the circumstances leading to inhuman behaviors of men toward other men, and the processes of dehumanization. He cites one example of humanity, the action of a doctor who was working in very difficult conditions in Srebrenica. After the war, he said that the thing he was most proud of was that “when captured Serbian soldiers entered the hospital, they lay side by side with Bosnian soldiers.”5
In their humanitarian activities in situations of war and armed conflict, ICRC (International Committee of the Red Cross) delegates witness such examples of humanity, and they devote much effort to promoting such human behaviors. They also witness many examples of abuse or extreme violence, on the battlefield and in besieged cities, in refugee camps and detention facilities. From their experience, ICRC delegates know all too well the terrible consequences of any divergence from ethical duties. The consequences are devastating, spread rapidly, and last for a long time. The prohibition of torture, inhuman and degrading treatment is absolute – for the sake of humanity and in recognition of the humanity of any human individual; yet this prohibition does not define humanity: it sets up absolute barriers beyond which the humanity of man is denied.
Providing succor and care for wounded and sick persons, whatever their side in the conflict, friends and enemies in war alike, is a paradigmatic situation of humanity.
1 This text is based on the article: Bouvier, P. (2013): The Duty to Provide Care to the Wounded or Sick Enemy, chap. in Baer, H./Messelken, D. (eds.): Proceedings of the 2nd ICMM Workshop on Military Medical Ethics, Bern/Zurich. The opinions expressed in this article are those of the author and not necessarily those of the ICRC.
2 Annas, G. (2008): Military Medical Ethics – Physician First, Last, Always, N Engl. J Med 359, pp. 1087–1090
R3 icœur, P. (2001): Autonomie et vulnérabilité, in Ricœur, P. (2007): Le Juste 2, Paris, p. 104. (Autonomy and vulnerability, in: Reflections on the Just, Chicago, p. 271).
4 Ricœur, P. (1990): Soi-même comme un autre (Oneself as Another), Paris, p. 312.
5 Glover, J. (2001): Humanity – a moral history of the twentieth century, London, p. 152.
Paul Bouvier works on health and ethical issues in humanitarian action with the International Committee of the Red Cross (ICRC) and with the University of Geneva, as lecturer in public health at the Institute of Global Health. He is a medical doctor specialized in paediatrics and public health and has been working in the field of mother and child health in Africa and in child public health and social paediatrics in Switzerland. He has worked as a medical delegate of the ICRC in assistance operations and in visits to detention facilities in various contexts of conflict. As Senior Medical Advisor of the ICRC since 2007, his responsibility encompasses health and ethical issues in humanitarian operations to assist and protect victims of armed conflicts. Since 2012, he has been the coordinator of the Health Emergencies in Large Populations (HELP) courses, organized in 12 countries, to train humanitarian professionals on public health and ethical approaches to responding to humanitarian emergencies.