Physicians Have a Duty to Treat the Enemy

Can doctors support the boycott of health supplies, including drugs and life-saving treatments, to the Russian citizens? Should they?

Recently, the issue was raised in chats and social media, especially here in Europe. The war is part of our daily life now. We are all engaged in helping Ukrainian refugees, providing basic healthcare, opening our homes to host them, and collecting goods and drugs to be sent at the borders of Ukraine where thousands of refugees are now piled up. We all recognize that there are victims and aggressors.

But when I have to answer such challenging questions, I am glad I chose to study and teach ethics and bioethics. Charts, guidelines, and ethical declarations work well as a “moral exoskeleton” that helps me to keep in mind the highest values of medicine, even when those values set very challenging moral thresholds and sometimes clash with my gut feelings.

The Geneva Conventions (four treaties signed in 1949, at the end of WWII, and three additional protocols signed in 1977) establish international legal standards for humanitarian treatment in times of war, including health assistance. They assure protection to the wounded and sick and to civilians in and around a war zone.

Of course, they are aimed primarily at protecting those who are attacked from the cruelty of the aggressor, and there is plenty of evidence that the Russian military campaign is breaking the rules of the Geneva Conventions by targeting hospitals and health facilities.

But does this allow the international medical community to cut ties with the Russian health system, preventing drug companies and the health industry from sending their goods to the country of the aggressor? In my view, the answer is no. The Geneva Conventions state that the rules of protection apply to civilians in any country involved in a war, and even to soldiers in need once they are wounded or leave the battlefield.

Even if we want to rely only on the classical bioethical theories of beneficence and nonmaleficence of the medical actions, we could be in trouble if we contribute to the crash of the Russian health system with the goal of pressuring the Russian government to stop the war. Russia is a very big country, already afflicted by huge inequalities in health. The economic boycott is already causing a shortage of lifesaving supplies, like drugs for chemotherapies and diagnostic technologies, as a Russian journalist described in an article on Univadis.it.We can easily predict that the number of avoidable deaths will grow fast. We already saw a significant rise in the mortality rate in Western developed countries during the pandemic, when access to preventive measures and treatments was affected. We expect that the sanctions will have a similar impact, and probably our policymakers expect that it will push Russian citizens to revolt against the war criminal that is governing the country. But policymakers have different roles and different ethical frameworks from physicians and health workers, according to modern bioethics.

The Interests of Humans Come Before the Interests of Science or Society

The Convention on Human Rights and Biomedicine (better known as the Oviedo Convention), signed by the Council of Europe in 1997, is the first legally binding international text designed to preserve human dignity, rights, and freedoms through a series of principles and prohibitions against the misuse of medical advances. The Convention’s starting point is that the interests of human beings must come before the interests of science or society.

It is grounded on the Universal Declaration of Human Rights by the United Nations, and especially on the articles from 22 to 27 that settle individuals’ economic, social, and cultural rights, including healthcare. They refer in particular to care given to those in motherhood or childhood.

The Oviedo Convention Iays down a series of principles and prohibitions concerning bioethics, medical research, consent, rights to private life and information, etc. But first of all, it sets the principle that everybody has the right to be treated, if sick, and that it is the duty of every physician to treat anyone in need, without asking and without expressing moral judgements.

This is an important, seminal principle of modern bioethics, enshrined also in other documents, like the World Medical Association’s Helsinki Declaration, adopted for the first time by the 18th WMA General Assembly in June 1964 and amended many times (the last one in 2013). Both the Oviedo Convention and the Helsinki Declaration are designed mainly to protect human beings in medical research.

This is also an issue that the medical community and the drug companies will have to face if they really want to stop any collaboration with the Russian scientific community, because modern bioethical charts state that those who start a clinical trial have the duty to bring it to its end, and also have the duty to keep on offering appropriate treatment to the patients recruited even in case of interruption of the trial, regardless of the underlying reasons.

This is not the first time that sanctions have had an impact on the health of a country. During the 1980s, the scientific boycott of South Africa affected the health of the South African citizens, even if drugs and medical supplies weren’t included in the commercial ban. Internal supporters of the sanctions, like the National Medical and Dental Association, one of the major medical anti-apartheid organizations, discussed ways to support the economic sanctions and, at the same time, protect the most vulnerable from the burden that resulted from these policies.

The “enemy as a patient” and what we can learn, from an ethical point of view, from the experience of physicians involved in treating their enemies was the subject of a very interesting recent study by Rubinstein and Bentwich. It’s a quantitative analysis of the implicit biases in Israeli physicians dealing both with wounded Syrian soldiers and Palestinian civilian terrorists

The results show that the Israeli doctors are more biased toward the Palestinian civilians, but the most interesting comment in my view is the one the authors added to the abstract: “This deficiency [of empathy toward certain types of enemies] undermines the principle of beneficence, thereby possibly influencing the fulfillment of the commitment to treat patients. Acknowledging and addressing the potential emotional and ethical deficiencies entailed in encounters with the so-called enemy-patients are of importance to the global medical community, since such encounters are increasingly an integral part of the current political realities faced by both the developed and developing worlds.”

In conclusion, is the medical community prevented from supporting any sanction or boycott? I think we can find a good answer in a statement on the moral status of scientific boycott at large published in Nature in 2003 by a group of scientists. According to the authors, which include Colin Blakemore and Richard Dawkins, a scientific boycott must fulfill precise conditions, including an explicit and widely shared judgement that it is worth abandoning the principle of universality of science for a particular, overwhelming gain.

We need to be sure that the boycott will actually help to change the “unacceptable behaviour of a regime” because it “is not merely a political gesture.” Last but not least, the boycott should be “part of an internationally agreed programme of measures that express collective horror against a regime and are necessary to avert some foreseeable disaster,” in order to avoid any decision driven by retaliation instead of beneficence.

In the case of the Russian commercial ban, those measures must be taken in support of Ukraine, in the first place, but also of the Russian civilians, perhaps through internationally supported programs to guarantee at least the life-saving supplies.

https://www.medscape.com/viewarticle/970550?src=soc_fb_220321_mscpedt_news_mdscp_ukraine&faf=1#vp_2

Créditos: Comité científico Covid