To endure the anguish of wartime, look to medical ethics

The wars in Syria and Ukraine have provided fresh reminders of the challenges physicians face during armed conflicts. Supply shortages, the deaths of colleagues and having to practice outside of one’s specialty can all leave doctors feeling unmoored and unsupported.

An education session at the 2022 AMA Annual Meeting, “The Role of Medicine in Armed Conflict: Ethical and Professional Impacts,” highlighted the challenges physicians often face when delivering care during wartime and outlined ethical guidance that can alleviate some of the anguish involved.

The session was sponsored by the AMA Young Physicians Section (AMA-YPS), which gives voice to and advocates for issues that affect physicians under 40 or within the first eight years of professional practice after their training as residents and fellows. AMA-YPS has more than 26,000 members.

Zaher Sahloul, MD, advises physicians, “You have to be ready before the war.”

“As a physician, first of all, there's not time to think. So you have to be ready before the war," Zaher Sahloul, MD, a critical care specialist at Chicago’s Christ Advocate Medical Center, said at the session. “You want to make sure that your emergency room has policies and drills on these issues and that you are ready to step beyond your expertise in the war as a physician. You may be the only pediatrician in the place, but you are now going to be dealing with many other injuries.”

Dr. Sahloul is president and co-founder of MedGlobal, a humanitarian and health nongovernmental organization serving refugees, displaced persons and other marginalized communities around the world. Another practical thing physicians considering volunteering in conflict zones should know is that most of the deaths in war are because of noncommunicable diseases such “diabetes, heart attacks, COPD, pulmonary embolism and so forth because there's not enough resources to treat them and many of them do not have access to hospitals or routine health care.”

War may be the enemy of health, but it’s not as if medical ethics change completely, or even significantly, during armed conflict.

“The fundamental ethics still apply. You are there to treat people who need you,” said Elliott Crigger, PhD, director of ethics policy at the AMA and secretary to the AMA Council on Ethical and Judicial Affairs, which maintains and updates the AMA Code of Medical Ethics.

So while physicians might rarely need to consult crisis standards of care in peacetime—the COVID-19 pandemic is a notable exception—those standards are nonetheless always present at most health care organizations.

“How do I allocate the four people I have to the 700 patients we have?” Crigger said hypothetically. “One thing the Code is pretty clear on is that you do it on the basis of medical need, not on the basis of affiliation or social status or economic considerations. Once you've identified that cohort of patients who all have the same medical need and you've still got too many patients for your resources, then you begin to make more fine-grained distinctions.”

These include who is most likely to benefit and who is most likely to survive.

“In the end, you're going to have to recognize that you cannot provide all the care that's needed,” Crigger said. “There's no way around the fact that you cannot save everyone, and you have to live with that.”

Read about why COVID-19 has provided a timeless lesson in ethics.

Physicians tend to ask themselves, “What’s the best I can do?” Crigger noted. “In situations that are impossible to begin with, the more relevant question might be: What's the least bad thing I can do? Is there a worst outcome overall that I can ameliorate or prevent?”

In fact, “least bad” is an approach that has long been embraced in medical ethics.

“Can I explain why I made the decision I made in as compelling a way as possible?” he said. “It won't necessarily get you agreement from everybody, but being able to say ‘why’ is perhaps at the heart of ethics. And being present—being there, doing what you can, recognizing that you have a responsibility, even at risk to yourself, even when pestilence prevails” is what matters most.

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Treating just a single patient can reverberate through a community, Crigger noted.

“That's clearly the case in a public health emergency,” wherein one person can be a vector for many others. “If I can treat him or her, I can help preserve health for others,” he said.

Still, physicians practicing in wartime might easily feel they are failing to meet the need for care, especially when they talk to patients’ family members.

“Acknowledge what you can't do, but promise, ‘Here’s what I'm sure I can do, and here's what I will try to do,’” Crigger said. “Even if you are not the best specialist—if you're all that's available—you do what you can.”

Read the updated AMA Code of Medical Ethics opinion on providing urgent medical care during disasters.