Bioethics challenges in times of war

According to data from the Uppsala Conflict Data Program (UCDP), the past 3 years have witnessed the highest number of deaths in armed conflicts since 1994, the year of the Rwandan genocide. Between 2021 and 2023, the UCDP recorded more than 700,000 deaths in armed conflicts, with over 320,000 in Ethiopia, more than 160,000 in Ukraine, over 44,000 in Mexico, more than 40,000 in Afghanistan, and over 32,000 in Syria.2 The United Nations High Commissioner for Refugees estimates that more than 120 million people worldwide have been forcibly displaced by the end of April 2024.3

This special issue seeks to provide a broad perspective on the ethical and human rights challenges faced by healthcare providers and policymakers in the context of, or as a consequence of, armed conflict. Since we launched the first call for contributions to this special issue in June 2022, sadly, more armed conflicts have started, including the Israel–Hamas and Israel–Hezbollah wars,4 a civil war in Sudan, and a new escalation of the Nagorno–Karabakh conflict between Armenia and Azerbaijan.

For this special issue, we have selected contributions that provide theoretical reflections on (bio-)ethical and human rights challenges in the context of war, as well as discussions of ethical and human rights issues in specific armed conflicts. We have aimed to achieve a collection of diverse voices and perspectives and to include contributions from various world regions and different academic and professional backgrounds. Our special issue does not aim to provide a definitive or comprehensive analysis of currently occurring armed conflicts, nor does it claim to cover all ethical and human rights issues in the context of armed conflicts. Such ambitious objectives would be beyond the scope of even a much more substantial publication. Rather, we view this special issue as an explorative work that intends to motivate a broader academic community to engage with the field of bioethics in armed conflict. Indeed, there is great need for a plurality of voices united in the endeavor of contributing to an inclusive global discourse on the ethical and human rights challenges of armed conflicts.

Ethics and human rights can fulfill various roles in the context of armed conflicts: analyst, arbiter, mediator, documenter, and a voice for those suffering from the consequences. In all these functions, empathy as well as evidence-based, transparent reasoning play a key role. Furthermore, ethical analysis contributes to the formulation of novel standards of international humanitarian law, which may be required in response to evolving practices in warfare. It is also pertinent to note that, according to the Geneva Conventions, medical personnel operating in the context of international armed conflicts are bound by the principles of medical ethics. Nevertheless, research on medical ethics in armed conflict remains a niche subject, with only a few specialized research centers around the world.5

The first section of this special issue is composed of five articles. Eva and Steven van Baarle present and discuss a value-based reflection tool to complement ethics support in military organizations. Michael Gross analyzes and discusses the ethical obligation to provide civilian healthcare in war. Nadja Wolf analyzes the concept of solidarity in the context of armed conflicts. Aleksandra Glos discusses the implications of children's right to play in times of war. Eva Regel discusses the factors contributing to moral distress and moral injury in healthcare workers supporting civilian populations.

The second section, composed of six articles, discusses ethical and human rights challenges in specific war and post-war settings. Favour Uroko discusses the ethics of healthcare worker responses to girl child abuse in camps for internally displaced persons in Nigeria. Maide Baris, Orhan Onder, and Gurkan Sert discuss ethical issues in the context of refugee healthcare in Turkey. Krzysztof Kędziora discusses the implications of the human right to health for refugee healthcare in Poland. Zohar and Shmuel Lederman discuss the responsibilities of bioethicists in times of war using the case study of Yemen. Zohar Lederman analyzes the concept of loneliness as a lack of solidarity in the context of the Israeli–Palestinian conflict. Lukasz Wiktor, Maria Damps, Grace Kansayisa, Szymon Pietrzak, and Bartłomiej Osadnik outline bioethical challenges in post-war development aid using the example of post-civil war Rwanda.

As outlined previously in this editorial, we are publishing this special issue to encourage more colleagues to contribute their expertise to this important research topic. As the number of fatalities from armed conflicts has peaked in recent years, so have attacks against healthcare facilities, providers, and patients. With the advent of new technologies, including artificial intelligence, in warfare, the need for ethics and human rights work in this area drastically increases. Without guidance from ethics and human rights, technological progress may become, in a wording chosen by Albert Einstein during the First World War, “comparable to an axe in the hand of a pathological criminal.”