Bioethics Forum Essay

Bioethics Must Address War as a Public Health Crisis

For most of human history, war has been a major cause of injury and death worldwide, causing harms well beyond the battlefield. Today’s wars kill far more civilians than soldiers —the United Nations Secretary General conservatively estimates civilian deaths to be quadruple the number of direct battle-related deaths. Armed conflict not only takes innocent people’s lives, it also leaves misery in its wake. Civilian war zone populations face alarming rates of post-traumatic stress and other mental health disorders, often spanning generations. They are more prone to hunger and malnutrition, disease and disability, forced displacement from homes and communities, and lack of access to basic goods like health care, education, income, and opportunities. These social determinants of health impact the health of populations more than access to biomedical advances, accounting for 30%-to-55% of health outcomes.

Bioethics must address war not just as an individual tragedy but as a public health disaster. Bioethics’ earliest pioneers recognized this. They called for closer collaboration between bioethics and public health scholars, despite the challenge and clash of values –with bioethics emphasizing patient autonomy and individual rights, and public health highlighting the common good. Today, public health remains pressing for bioethics for many reasons: increased knowledge of the impact of the social determinants of health; heightened awareness of how structural injustice impedes health and drives violence and armed conflicts; and better appreciation of the need for bioethicists to cross borders to deal with global bioethics issues, such as emerging and reemerging infectious diseases, climate change, refugee and migrant health, global access to essential medicines, and generative AI.

Bioethics as a field is ill-equipped to meet these challenges because its primary tools were designed with a different purpose. The classic principles of biomedical ethics –respect for autonomy, beneficence, nonmaleficence and justice– helped societies correct unethical treatment of individual research subjects, and helped physicians and patients make difficult life-and-death decisions.

However, to speak to war as a public health crisis requires ethical principles targeting public health and focused on the common good. Our approach to war and public health sets forth six bioethics principles that aim to do this: health justice, accountability, dignified lives, public health sustainability, nonmaleficence, and public health maximization. These principles supplement the classic four, as well as previously proposed public health principles, bolstering the field’s ability to address war as a crisis for civilian populations. Below, we recount each principle, showing its ethical basis. We suggest how to deploy the principles in practice and hopefully, to enable wiser choices that lead to healthier, more flourishing human lives.

Bioethics Principles

Health Justice demands distributing health-related benefits and burdens fairly and stresses a special responsibility to populations most vulnerable to war’s health harms, such as women, and children. Health justice gains support from the right to health, which the U.N. has recognized as a fundamental right of all human beings.

Accountability holds warring parties responsible for war’s effects on civilian populations. It extends to international groups such as the U.N., International Criminal Court, and World Bank. Accountability’s basis is the dignity and worth of persons, which makes tactics like rape, torture, or using civilian populations as shields indefensible.

Dignified Lives mandates taking reasonable steps to safeguard people’s central human capabilities, such as their ability to be healthy; have bodily integrity; exercise senses, imagination, and thought; plan their lives; affiliate with others; relate to nature; play and recreate; and regulate their immediate environment.

Public Health Sustainability names the ethical requirement of military planners to maintain public health services for war zone populations. Its justification relates to the fact that being healthy directly impacts people’s access to a normal range of opportunities in life, such as their ability to make and carry out a life plan, access education, and earn a living.

Nonmaleficence and Public Health Maximization call for creating the best possible balance of public health benefits and harms. Applying these principles requires comparing the health benefits and harms of war to its alternatives, such as economic sanctions, arms embargoes, diplomacy, nonviolent resistance, positive incentives, or military assistance. All six public health principles take stock of short- and long-term health effects. Combined, they reframe the ethics of war, changing calculations of whether waging or continuing a war is ethically defensible.

Putting Principles into Practice

Putting these principles into practice requires bioethicists to engage more directly with war in their research, teaching, and service. Bioethics research should examine not just the ethical challenges associated with crisis response, but also war’s precipitating factors, such as poverty, food insecurity, displacement, and lack of equitable access to education, health care, and jobs. The preconditions that make war more likely are hardly inevitable. By addressing the social and economic conditions that trigger war, bioethicists can be a “bridge to peace.”

Bioethics teaching should raise awareness about war’s public health effects among trainees and the broader public. For example, education can take the form of hosting public lectures, developing courses, compiling cases, and designing other training materials. Curriculum should include a range of ethical approaches –e.g., those based on human rights, human capabilities, virtue ethics, communitarian ethics, Confucian political ethics and ubuntu ethics, to name a few. Enlisting the wisdom of many traditions not only lends itself to a richer, more sophisticated ethical analysis, it helps balance the field’s heavy focus on civil liberties and respect for individual autonomy, which reflects its Western, especially its American, roots. Since war is a global bioethics concern, ethical analysis must reflect the values and language of many societies.

Bioethics service might include deploying bioethicists as ethics facilitators to serve as advocates for war zone populations. To date, ethics facilitation has been applied mostly to clinical and research settings, yet it is highly relevant outside these settings where the health of populations is at stake. The core competencies for ethics facilitation include “clarifying the ethics concern(s) and question(s) that need to be addressed, gathering relevant information, clarifying relevant concepts and related normative issues, helping involved parties to identify a range of ethically acceptable options, and providing an ethical justification for each option.” These competencies can aid war planners and policymakers, as well as ordinary citizens, by focusing attention on war’s effects on human health.

To illustrate, consider what transpired during the civil conflict in El Salvador, when one-day truces were negotiated each year, from 1985 to 1991, between the government and guerrilla forces. This made it possible to immunize war zone populations on both sides against polio, diphtheria, whooping cough, tetanus, and measles. The truces came only after “a painstaking process that involved PAHO [the Pan American Health Organization], UNICEF, the Red Cross, and the Catholic Church.” Bioethicists can help with negotiations like these, serving as advocates for the health of civilian war zone populations. Emulating the World Medical Association, whose members express a commitment to giving medical care impartially to all, bioethicists should commit to advocate for the health of civilian populations on both sides of an armed conflict.

Wars are currently being fought around the globe, including 45 armed conflicts in the Middle East and North Africa, more than 35 conflicts in Africa, 21 in Asia, 7 in Europe, and 6 in Latin America. The U.N. documented over 33,000 civilian deaths from armed conflicts in 2023, a 72% increase over the prior year, marking a “resoundingly grim” reality. The U.N. has urged a global focus not just on international law, but on harms that civilians experience during armed conflict. Bioethics as a field must do its part, shining a light on war’s destructive effects on human health and the infrastructure required to support it.

Nancy Jecker, PhD, is a professor of bioethics and humanities at the University of Washington School of Medicine. @profjecker

Caesar Atuire, PhD, is a philosopher and health ethicist at the University of Oxford’s Nuffield Department of Medicine. @atuire

Vardit Ravitsky, PhD, is the President of The Hastings Center. @VarditRavitsky

Kevin Behrens, PhD, directs The Steve Biko Centre for Bioethics at the University of the Witwatersrand, South Africa. LinkedIn https://www.linkedin.com/in/kevin-behrens-622931159/?original_referer=https%3A%2F%2Fwww%2Egoogle%2Ecom%2F&originalSubdomain=za

Mohammed Ghaly, PhD, is a professor of Islam and biomedical ethics at the Research Center for Islamic Legislation and Ethics at Hamad Bin Khalifa University, Qatar. @IBioethics