surgeons operating in dark in Ukraine

Bioethics Forum Essay

Caring for Patients in Armed Conflict: Narratives from the Front Lines   

As wounded victims came pouring into the civilian hospital in Kharkov after the Ukraine war began in February 2022, Artem Riga initially was the only surgeon on duty. Some colleagues were fleeing the country and others were delayed because of the intense shelling. Doctors had to ration food and medical supplies, performing surgery in body armor, with sandbags on the windowsills of the operating room. A sudden attack significantly damaged his hospital and left patients covered in broken glass and other debris. Amid this chaos, Riga had to teach patients to care for their own wounds.

Riga’s essay is one of 16 accounts in the Narrative Inquiry in Bioethics symposium, “Healthcare Under Fire: Stories from Healthcare Workers During Armed Conflict.” They take place in war zones around the world, describing ethical dilemmas centered on uncertainty, scarcity, and injustice. The narratives also reveal the triumph of solidarity and courage, both in the delivery of health care and in the act of writing about the experience. The essays are intended to be a means of instruction and inspiration for other clinicians in similar circumstances.

“Some write as they listen for the next missile to land near them, while others reflect on conflicts they experienced decades earlier,” write symposium editors Dónal O’Mathúna, Thalia Arawi, and Abdul Rahman Fares in the introduction. Some of these conflicts are currently making headlines.

There were 2,562 reported incidents of violence against or obstruction of health care in 30 countries or territories in 2023, as reported by the Safeguarding Health in Conflict Coalition, a 25% increase over 2022. Four hundred and eighty-seven health care workers were killed, 445 were arrested, and 240 were kidnapped, and there were 625 incidents in which health care facilities were damaged or destroyed. Other humanitarian workers have also faced risk, exemplified by the seven workers from the World Central Kitchen charity who were killed and another gravely injured in separate Israeli air strikes in Gaza as this symposium went to press. This symposium highlights a few of the people behind the statistics.

Several stories raise questions about when it is appropriate for clinicians to perform tasks outside their scope of practice. Under “normal” circumstances doing so would be considered substandard care. But in a war zone, where specialists are lacking, this might be not only permissible but essential to care for patients who otherwise would have had no treatment. For example, Ryan C. Maves, a retired infectious disease specialist with the U.S. Navy, describes being hastily retained to be a “de facto cardiologist” alongside adult intensivists treating children and pediatricians caring for adults.

In the most extreme circumstances, care was provided by people with no medical training. To Riga, this care was not only medically essential, but also an uplifting demonstration of solidarity. “It was a miracle! Before my eyes, people turned into paramedics,” he writes. “I have never seen such a transformation and mutual assistance.”

Some authors struggle with whether to stay and care for patients during war while knowing that doing so would place themselves and their families in grave danger. Ghaiath Hussein, who conducts health research in South Darfur, asks whether the risk of violence against his staff and study participants outweighs the benefits. He continues to struggle with this difficult balance, but he has decided to continue his research there because he wants users of research reports coming from conflict zones to remember that people risk everything to generate important data that can help others.

Handreen Mohammed Saeed, writing from Iraqi Kurdistan, and Ryan Maves, the retired U.S. Navy medical officer, both discuss the ethical challenges of treating patients who are combatants against the health care team’s community. Saeed recounts a situation where injured militants arrived at his medical facility where many of the staff and other patients had been the victims of those militants’ violence. Some staff struggled intensely over caring for the militants. They held meetings to carefully and sensitively talk through their emotions and the ethical principles that guided them, and to listen to people’s painful experiences. They all concluded that their primary role was to care for everyone’s medical needs, not take the role of police or judges.

“I am a doctor from the Gaza Strip in Palestine,” writes Ola Ziara, who reluctantly asks whether it is worth saving a life only to subject the person to “this overstretched healthcare system, this unrelenting crisis.” Asking the question reminds her of her own pain and helplessness in the situation. There is no answer. “We must keep caring while walking through our pain,” she writes. But she adds that she’s no longer sure they can go on, such is the “unbearable grief” they carry.

Some say that bioethics has ignored war. Perhaps because there are specific subfields of military medical ethics and humanitarian ethics, many bioethicists assume health care ethics during war is adequately addressed. However, as these stories make clear, war creates ethical challenges not only for military and humanitarian health care workers, but also for civilian physicians like Riga.

Health care workers writing in the symposium rely on the principles and frameworks of bioethics to inform difficult decisions in times of uncertainty. For example, Oksana Sulaieva, head of a pathology laboratory in Kyiv, shares how her decision to stay in Ukraine and continue to provide laboratory services to hundreds of hospitals and thousands of patients was guided by her professional obligation of beneficence. Furthermore, she stated that “our professional duties were an anchor linking us to each other against fear and panic.”   

Some of the authors see their decision to write as an act of courage inspired by ethical values. “(The) value of this collection lies not only in its documentation of the harsh realities of providing health care in acute conflict but in the intimate and generous act of narration by health care providers operating in extraordinarily difficult circumstances,” writes Kim Thuy Seelinger, research associate professor and director of the Center for Human Rights, Gender and Migration at Washington University in St. Louis. “Their series of essays fosters a deeper understanding of the moral and ethical dimensions of their collective work and the risks they take to do it. The risks they take to write.”

To Esime Agbloyor, a physician from Ghana and a bioethics fellow at the Center for Bioethics at The Ohio State University, the symposium authors demonstrate courage, altruism, sacrifice, and truthfulness. “These authors chose to speak up and, by so doing, exude the virtuous traits that Aristotle describes,” she concludes. “They are worthy of praise and admiration.”

We agree, and we urge everyone to pay attention.

Emily E. Anderson, PhD, MPH, is a professor of bioethics at Loyola University Chicago, where she directs an NIH Fogarty-funded research bioethics training program for Ukrainian physicians and scientists in collaboration with Ukrainian Catholic University.

Dónal O’Mathúna, PhD, is a professor in the College of Nursing and associate director of research in the Center for Bioethics at The Ohio State University and an editor of the symposium. He collaborates with Dr. Anderson on an NIH Fogarty-funded project investigating research ethics during war.

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