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The term medical duties (sometimes known as the “medical mission”) describes the entire set of medical activities aimed at the civilian population in general, as well as wounded and sick persons, in times of conflict. They come under a specific protection regime within the framework of humanitarian law. Actually, the protection and care that must be granted to sick and wounded persons are the first step to all other provisions for treating individuals humanely in times of war.
Historically, these are the most ancient activities foreseen by humanitarian law. Henri Dunant created the first Red Cross Committee and drafted the first Geneva Convention in 1864 to regulate the fate and care of the sick and dead left on the battlefields of war.
The first two 1949 Geneva Conventions concern the protection of the wounded, sick, and shipwrecked members of armed forces, in the field or at sea. This special protection, foreseen for those who are no longer participating in the fighting because of wounds or illness, is extended to sick and wounded civilians in the fourth 1949 Geneva Convention.
The two 1977 Additional Protocols consolidated the protection set forth by the Geneva Conventions for wounded and sick persons; medical personnel, units, and means of transportation; and civilian or military medical services. These provisions are generally known under the term medical duties (GCIV Arts. 56, 57; API Arts. 8–31; and APII Arts. 7–12). The provisions are applicable in international and non-international armed conflicts. They are now recognized as mandatory rules of customary humanitarian law, binding on all parties to international or non-international armed conflict, including on non-state armed groups and parties who have not signed the Conventions and Protocols.
The Basis of the International Protection for Wounded and Sick Persons
If a member of the armed forces is wounded or sick, he or she can no longer participate in the fighting and is exposed to acts of revenge and ill treatment. This individual is no longer a threat to the opponent and can no longer be considered an adversary. He or she therefore must benefit from the same protection as those who are not participating in the hostilities and must be treated humanely in all circumstances (GCI–IV Common Art. 3).
Civilians who are wounded or sick in a time of conflict are incapable of fleeing, protecting themselves, or providing for their own needs. They are vulnerable and threatened by their illness. They are entitled to reinforced protection against the effects of fighting and to the right to receive treatment.
The general principles regulating the protection of medical duties are described in the following sections.
Ensuring the Protection of Wounded and Sick Persons in All Circumstances
The protection of wounded and sick persons must be ensured in all situations. Humanitarian law establishes that such persons are a separate category of protected persons, within which any distinction between combatant and civilian is abolished and all must be treated alike (GCI–IV Common Art. 3, API Art. 10 and 11, and APII Art. 7).
This protection is established in Common Article 3 to the four Geneva Conventions. This article establishes the minimum standards of protection that must be applied at all times, whether in international or internal armed conflicts, or even internal disturbances or tensions. This article contains the minimum customary guarantees applicable at all times to any individual, without discrimination based on his or her status.
Persons taking no active part in the hostilities, including members of armed forces who have laid down their arms and those placed hors de combat by sickness, wounds, detention, or any other cause, shall in all circumstances be treated humanely, without any adverse distinction founded on race, colour, religion or faith, sex, birth or wealth, or any other similar criteria. . . .
The wounded and sick shall be collected and cared for. An impartial humanitarian body, such as the International Committee of the Red Cross, may offer its services to the Parties to the conflict. (GI-IV Common Art. 3)These minimal provisions are completed by the two Additional Protocols, which provide that
all the wounded, sick and shipwrecked, whether or not they have taken part in the armed conflict, shall be respected and protected. In all circumstances they shall be treated humanely and shall receive to the fullest extent practicable and with the least possible delay, the medical care and attention required by their condition. There shall be no distinction among them founded on any grounds other than medical ones. (APII Art. 7; API Art. 10)
Ensuring That the Medical Services Function
In practice, the wounded and sick are protected by the guarantees established by humanitarian law to ensure that medical services continue operating in times of conflict. The law grants special protection to medical units, personnel, and means of transportation and posits that medicine and medical relief must be guaranteed free passage. This means, specifically, that
- medical personnel and installations may not be the object of attacks,
- medical installations are authorized to carry the distinctive emblem of the Red Cross,
- medical personnel and material must be protected from requisition, and
- the delivery of medical supplies must always be ensured.
Searching and Caring for the Wounded and Sick
To ensure that the wounded and sick are searched for, transported, and cared for, humanitarian law establishes a special protection status for medical personnel and means of transportation. It authorizes them to wear a distinctive emblem and guarantees their freedom of movement:
- Medical personnel must always be respected and protected.
- Members of medical personnel may not be requisitioned.
- They can undertake activities to search for the wounded and sick members of the parties to the conflict and facilitate their transportation. Such activities can only be limited on a temporary basis and only because of imperious military necessity.
- They must always be granted access to the places where their services are needed.
- They may not be required to give priority to any one or group of persons.
- In providing care to the sick and wounded, no discrimination may be made on the basis of grounds other than medical ones.
- Medical personnel may not be compelled to carry out acts contrary to the rules of medical ethics.
- Members of medical personnel may not be punished for activities carried out, no matter what the circumstances may have been, as long as their actions were compatible with medical ethics.
In Occupied Territories, Detention, or Internment
In certain situations, such as occupied territories, detention, or internment, the guarantees granted to medical duties must be reinforced so as to avoid the specific risks incurred by both the sick person and the person providing the care. Humanitarian law decrees specific rules for the following:
- Wounded and sick prisoners of war (GCIII Arts. 29–33): in certain cases, the patients must be cared for or hospitalized in a neutral country (GCIII Art. 132).
- Detained or interned persons (GCIV Arts. 91, 92): the possibility of releasing certain categories of persons from the places of detention or arranging for their accommodation in a neutral country is also foreseen (GCIV Art. 132).
- Occupied territories: the occupying power must not hinder the functions of medical services and must ensure that they are carried out in sufficient amount. The protecting powers of other humanitarian organizations are entitled to verify the condition of food and medical supplies at all times (GCIV Arts. 55–57 and 59–63).
- Persons deprived of their liberty for reasons related to the armed conflict, whether they are interned or detained (APII Arts. 5.1.a, 7).
- Finally, humanitarian law establishes specific rules for medical personnel and medical installations belonging to armed forces and for the wounded and sick persons in their care (GCI Arts. 12–37).
Medical Ethics in Times of War
Humanitarian law seeks to reinforce the strength and resilience power of medical ethics in situations of conflict. It raises medical ethics to the position of an international rule of law that is mandatory for all States. Without defining and codifying the entire content of medical ethics, the Geneva Conventions establish the framework of constant and consistent minimum rules within which medical activities must take place.
The aim is to clarify the obligations and prohibitions that international law imposes on the practitioner to help him or her withstand the national context of pressure, constraint, and violence. Humanitarian law hence sets forth:
- the medical behavior that is prohibited: these include medical acts and omissions that are not justified by the state of health of the patient and in conformity with medical ethics;
- the medical behavior that authorities may not prohibit;
- the principle that no person may be punished for medical activities he or she carried out, no matter what the circumstances may have been, as long as his or her actions were compatible with medical ethics; and
- it protects medical secrecy in times of conflict.
Prohibition of Medical Acts Not Justified by the State of Health of the Patient
Humanitarian law endorses the obligation to care for the wounded and sick and to respect the medical ethics surrounding these acts. Any willful act or omission that seriously endangers the physical or mental health or integrity of any person is a grave breach of the Geneva Conventions and hence a war crime (GCI Art. 50, API Art. 11). The fact of subjecting persons who are in the power of another party to the conflict to physical mutilation or to medical or scientific experiments of any kind that are neither justified by the medical, dental, or hospital treatment of the person concerned nor carried out in his or her interest, and which cause death to or seriously endanger the health of such person or persons, constitutes a war crime under the Statute of the International Criminal Court (Art. 8.2.e.xi). This provision calls into question the ethical framework of medical activity in detention facilities in times of conflict. It also raises the issue of individual criminal responsibility of medical personnel in charge of detained patients in times of conflict in case they disregard this specific legal framework for medical practice.
Rules of Customary International Humanitarian Law
The study on the rules of customary international humanitarian law published by the International Committee of the Red Cross in 2005 enshrines the minimum guarantees of treatment for civilians, wounded, and sick in times of conflict provided for in the Geneva Conventions. They are applicable in international and non-international armed conflicts.
- Rule 6. Civilians are protected against attack, unless and for such time as they take a direct part in hostilities.
- Rule 25. Medical personnel exclusively assigned to medical duties must be respected and protected in all circumstances. They lose their protection if they commit, outside their humanitarian function, acts harmful to the enemy.
- Rule 27. Religious personnel exclusively assigned to religious duties must be respected and protected in all circumstances. They lose their protection if they commit, outside their humanitarian function, acts harmful to the enemy.
- Rule 28. Medical units exclusively assigned to medical purposes must be respected and protected in all circumstances. They lose their protection if they are being used, outside their humanitarian function, to commit acts harmful to the enemy.
- Rule 29. Medical transports assigned exclusively to medical transportation must be respected and protected in all circumstances. They lose their protection if they are being used, outside their humanitarian function, to commit acts harmful to the enemy.
- Rule 30. Attacks directed against medical and religious personnel and objects displaying the distinctive emblems of the Geneva Conventions in conformity with international law are prohibited.
- Rule 109. Whenever circumstances permit, and particularly after an engagement, each party to the conflict must, without delay, take all possible measures to search for, collect, and evacuate the wounded, sick, and shipwrecked without adverse distinction.
The Individual Medical Report
In situations where illness, injury, or death is the result of a felony or a crime (e.g., rape, torture, assault, ill treatment, mutilation), doctors are required to produce an individual medical report certifying the results of a medical examination. The report is for the benefit of the victim or his or her heirs. Doctors are also urged to try to ascertain whether crimes are isolated acts or part of a broader plan or pattern of human rights violations.
According to some laws, the appointment of an official forensic medical expert is mandatory. Doctors sometimes have a legal obligation to lift medical secrecy and notify judicial authorities. However, in situations of conflict or crisis, such notification may further endanger a victim’s life. Doctors may thus refer to the specific provisions of medical ethics to maintain medical secrecy in such situations. ➔ Medical ethics
Medical reports can only be given to the victim. Where anonymity of victims is protected, figures on violence or ill treatment may be transmitted to the International Committee of the Red Cross in the context of the protectional activities it carries out on behalf of victims of violations of humanitarian law, or to other relevant United Nations agencies such as the Office of the High Commissioner for Refugees.
Medical reports made by national or expatriate medical staff are valid tools to enable acknowledgment and identification of injuries and traumas suffered by victims. It is a key element for victims willing to claim their rights. Furthermore, the report may help a victim to obtain refugee status or to be recognized as a disabled person or war victim. It may also help victims to denounce torture, rape, or mutilation in international or national criminal fora, even years later. Time limits for the filing of a complaint are spread over several years, depending on the nature of the crimes. With such delay, the victim can reasonably expect that his or her security is guaranteed before deciding to complain.
- Rule 110 . The wounded, sick, and shipwrecked must receive, to the fullest extent practicable and with the least possible delay, the medical care and attention required by their condition. No distinction may be made among them founded on any grounds other than medical ones.
- Rule 111 . Each party to the conflict must take all possible measures to protect the wounded, sick, and shipwrecked against ill treatment and against pillage of their personal property.
For Additional Information: Baccino-Astrada, Alma. Manual on the Rights and Duties of Medical Personnel in Art Conflicts . Geneva: ICRC, 1982.
British Medical Association. The Medical Profession and Human Rights: Handbook for a Changing Agenda . London: Zed in association with BMA, 2001.
Green, L. C. “War Law and the Medical Profession.” In Canadian Yearbook of International Law 1979 , 159–205. Vancouver: University of British Columbia, 1979.
Reyes, Hernan, and Remi Russbach. “The Role of the Doctor in ICRC Visits to Prisoners.” International Review of the Red Cross 284 (September–October 1991): 469–82.