Editorials

Medicine and international humanitarian law

Law provides norms that must guide doctors in war and peace

August 1999 marks the 50th anniversary of the Geneva Conventions of 1949. This text, formed by combining the three previous conventions of 1864, 1906, 1929 and adding a fourth in 1949, imposes constraints on the conduct of war. It binds its signatorieswho are nation statesto a tight set of obligations regarding the care of the wounded, treatment of servicemen lost at sea, management of prisoners of war, and protection of civilians. 1999 also marks the 100th anniversary of the Hague Convention of 1899, a pivotal document in a long series seeking to limit methods of war and prohibit certain weapons. These two bodies of law, of Geneva and of the Hague, form the cornerstone of international humanitarian lawthe law relating to the conduct of individuals and nations in wartime.¹

This anniversary year follows by only one year the 50th anniversary of the Universal Declaration of Human Rights, the formative document in the modern field of human rights. The declaration establishes a set of principles regarding the state's relationship to individuals and communitiesfor example, that no one should be held in slavery and that everyone has a right to social security and education. It has served as the basis for the growing number of legally binding covenants, such as the Covenant on Civil and Political Rights, that contribute to that body of international law that is thought to apply to states in times of peace.² The occurrence of these anniversaries this year offers the BMJ the opportunity to explore in this special issue a number of ethical and policy dilemmas that face medicine and science when issues of moral choice arise in war and in peace.

The law's relevance to medicine

The discussions in this issue of the BMJ, whether through case example,³ historical analysis, ^{4 5} the careful analysis of clinical data,^6-10 or assessment of current and anticipated issues,^11-14 seek to illuminate the relevance of key points in international humanitarian law and human rights to those whose work in medicine is largely guided by the more familiar principles of medical and research ethics.

The importance of this inquiry will not escape those who have been reading the mainstream press as it reports from Somalia, Sudan, Afghanistan, Croatia, Bosnia, Rwanda, Congo, and Kosovo. International humanitarian law and human rights provide the normative context for those who try to deliver medical and emergency relief in war zones. What may be less apparent is the applicability of these principles to the peacetime preoccupations of many physicians and scientistswho work in genetics,¹⁵ molecular biology,¹⁶ or human research trials.¹⁷

On a daily basis physicians and medical scientists engage with the concepts of "do no harm," beneficence, autonomy, informed consent, and confidentiality. In their relationships with individual people as patients or as participants in research, medical professionals can rely on these principles of medical ethics as important starting points for a discussion on what ought to be done in a given instance of ambiguity or moral conflict.¹⁸

A feature of the late 20th century, however, is the intrusion of worlds other than those we are used to or have been given to expect. Wars in remote areas have drawn civilian medical personnel from Europe and North America to work with large numbers of ill or desperate people from unfamiliar cultures in settings of considerable danger.¹³ Epidemic disease ravages societies that cannot possibly pay for the cures available in the West.¹⁷ Advances in technology allow us the potential to manipulate the entire biological gene poolhuman, animal, and plant.¹⁵ Despite the fact that genocide can be, and is, committed with weapons as simple as machetes, much scientific effort and tremendous resources are being spent on designing new ways to wage war or combat terrorism on a massive scale. ^{6 16}

A crucial framework

The discourse of international humanitarian law does not furnish detailed road maps for negotiating this complex terrain of war and preparation for war. Nor does the discourse of human rights supply answers on how to proceed with scientific advances across large and disparate populations. But these two strands of thought, together with established principles of medical ethics, have since the end of the second world war provided the rules and standards by which the international community has determined that medicine, science, and government must all be held accountable.¹⁴

These rules and standards have been and will continue to be modified, as we learn more about our capacities and acquire more complex technology, as we try to improve our systems for assigning and imposing accountability, and as we struggle to close the considerable gaps in consensus regarding many of the principles. ^{19 20} Still, as we scan our recent past and near future, it is becoming increasingly clear that this framework is crucial in allowing us to understand, criticise, and moderate our actions in war and peace.

The key principles of international humanitarian law of relevance to physicians are neutrality, non-partisanship, independence, and humanitarianism. Physicians and other healthcare workers are protected from hostile action to the extent that they understand these principles and abide by the rules that flow from them.¹⁴

Familiar territory

An assumption behind these principles, barely made explicit in international law, is that physicians must practise both competently and according to the highest principles of medical ethics. In other words, to be protected in war a physician must first be deemed competent to practise in peace. Following on from that assumption, a physician must be impartial (treat everyone according to medical need); neutral (take no political sides in the conflict); independent (be separate from the conflict, unarmed, and directed by professional dictates); and humanitarian (committed to promoting the welfare of sick and injured people).

Major points of relevance in the law of the Hague relate to an appreciation of the concepts of superfluous injury and unneccessary suffering and how to assess the design or use of weapons from that perspective.⁶

The tenets of human rights, which emphasise individual dignity and freedom from state imposed harm, do not take thoughtful physicians far from familiar territory. These notions overlap considerably with those established in medical ethics but also modify them, specifically by expanding the notion of harm; restricting the ambit of beneficence; and giving increasing power to the implications of informed consent, autonomy, and confidentiality.

As war and peace merge

Issues of human rights impinge on medical decision making in many ways, particularly in cross cultural environments,¹⁷ with vulnerable populations, or across wide power differentials.²¹ Violations of human rights often have serious medical consequences and physicians can be particularly helpful. They can use their clinical skills or deploy the analytical frame of epidemiology and public health to document the nature and impact of injuries created by human rights abuses,^5-10 supply expert testimony,²² and advocate on behalf of those who have suffered.²³ Further, doctors should recognise the range of torture and repression in state systems²⁴ and be vigilant about policing their own guild lest some members use their medical skills in state sponsored violations of human rights.^25-27

The discourses of international humanitarian law and human rights, once thought to be entirely separateone for war and the other for peace are also now seen to overlap.²⁸ Current legal analyses of war and conflict allow for applying core human rights law as well as international humanitarian law, so that important human rights for refugees (such as the right not to be forced back across a border into a hostile country of origin) or for children (the right not to be forced into slave labour or into the army) are considered inviolate in settings of active hostilities.¹⁴

As readers deliberate on the questions of medicine, moral choice, and international law that are explored in this week's BMJ, we hope they will appreciate that in the sphere of international humanitarian law and human rights there is not only room for the moral voice of physiciansbut an outright imperative that it should be heard.

Jennifer Leaning, senior research fellow. 

Harvard Center for Population and Development Studies, Cambridge, MA 02138, USA

Footnotes

Jennifer Leaning, helped by Robin Coupland of the International Committee of the Red Cross, Geneva, and Vivienne Nathanson of the BMA's ethics and international division, is guest editor of this theme issue 

1.	Kalshoven F. Constraints on the waging of war. Geneva: International Committee of the Red Cross , 1991.
2.	Steiner HL, Alston P. International human rights in context: law, politics, morals. Oxford: Clarendon Press , 1996.
3.	Perrin P, Nolan H. Sharia punishment, treatment, and speaking out. BMJ 1999; 319: 445-447[Free Full Text].
4.	Kevles DJ. Eugenics and human rights. BMJ 1999; 319: 435-438[Free Full Text].
5.	Coupland RM, Meddings DR. Mortality associated with use of weapons in armed conflicts, wartime atrocities, and civilian mass shootings: literature review. BMJ 1999; 319: 407-410[Abstract/Free Full Text].
6.	Coupland R. Clinical and legal significance of fragmentation of bullets in relation to size of wounds: retrospective analysis. BMJ 1999; 319: 430-436[Free Full Text].
7.	Coupland RM, Samnegaard HO. Effect of type and transfer of conventional weapons on civilian injuries: retrospective analysis of prospective data from Red Cross hospitals. BMJ 1999; 319: 410-412[Abstract/Free Full Text].
8.	Meddings DR, O'Connor SM. Circumstances around weapon injury in Cambodia after departure of a peacekeeping force: prospective cohort study. BMJ 1999; 319: 412-415[Abstract/Free Full Text].
9.	Michael M, Meddings DR, Ramez S, Gutierrez-Fisac JL. Incidence of weapon injuries not related to interfactional combat in Afghanistan in 1996: prospective cohort study. BMJ 1999; 319: 415-417[Abstract/Free Full Text].
10.	Kruge EG. The incidence of mine and UXO injuries and deaths in Kosovo. BMJ 1999; 319: 450[Free Full Text].
11.	Smith C. Who gets hurt by all these weapons? BMJ 1999; 319: 395[Free Full Text].
12.	Woodhouse T. Preventive medicine: can conflicts be prevented? BMJ 1999; 319: 396-397[Free Full Text].
13.	Burkle Jr FM. Lessons learnt and future expectations of complex emergencies. BMJ 1999; 319: 422-426[Free Full Text].
14.	Bruderlein C, Leaning J. New challenges for humanitarian protection. BMJ 1999; 319: 430-435.
15.	Chadwick R. The Icelandic databasedo modern times need modern sagas? BMJ 1999; 319: 441-444[Free Full Text].
16.	Atiyah M. The scientist's dilemma. BMJ 1999; 319: 448-449[Free Full Text].
17.	Edejer TTT. North-South research partnerships: the ethics of carrying out research in developing countries. BMJ 1999; 319: 438-441[Free Full Text].
18.	British Medical Association. Medical ethics today: its practice and philosophy. London: BMJ Publishing Group , 1993.
19.	Advisory Committee on Human Radiation Experiments. The human radiation experiments. Final report. New York: Oxford University Press , 1996.
20.	Roberge MC. The new International Criminal Court: a preliminary assessment. International Review of the Red Cross 1998; 325: 671-677.
21.	Leaning J. Human rights and medical education. BMJ 1997; 315: 1390-1391[Free Full Text].
22.	Milroy CM. Forensic taphonomy: the postmortem fate of human remains [book review]. BMJ 1999; 319: 457.
23.	Geiger HJ, Cook-Deagan R. The role of physicians in conflicts and humanitarian crises. JAMA 1993; 270: 616-620[Abstract].
24.	Nathanson V. Doctors and torture. BMJ 1999; 319: 397-398[Free Full Text].
25.	Adshead G. Time flies.... BMJ 1999; 319: 458[Free Full Text].
26.	Leach JP. Lest we forgive. BMJ 1999; 319: 459[Free Full Text].
27.	Stover E, Nightingale EO, eds. The breaking of bodies and minds: torture, psychiatric abuse, and the health professions. New York: American Association for the Advancement of Science and WH Freeman, 1985.
28.	1948-1998: Human rights and international humanitarian law [special issue]. International Review of the Red Cross 1998; 324: 400-537.