War correspondents working in conflict zones have brought to the world’s attention graphic and confronting images of the unimaginable horrors of war and the vulnerability of healthcare facilities when attacked by enemy forces.
Their reports have highlighted the extreme vulnerabilities of health care workers and their patients, who are left in fear, distress and confusion as the facilities in which they ought to be safe disintegrate around them.
In the year 2023 alone, at the time of writing, the WHO Surveillance of Attacks on Health Care (SSA) reported over 840 confirmed attacks on healthcare facilities across 18 countries and territories, resulting in over 600 deaths and 740 injuries (https://extranet.who.int/ssa/Index.aspx). The countries in which such attacks have been confirmed include Ukraine, the occupied Palestinian Territory, Libya, the Syrian Arab Republic, Armenia, Afghanistan, Myanmar, Somalia, Sudan and South Sudan, to name some. The documented attacks have ranged from the use of heavy weapons (eg. aerial bombings, drone and missile attacks), removal of assets and personnel, violent searches, assaults, militarisation, criminalisation of health care, the use of chemicals, and the use of fire. The harmful impact of these attacks has affected not only healthcare faculties and the patients and personnel within them, but also the transport, supply, and warehousing of vital medical resources. Ambulances and other emergency evacuation vehicles have also been the subject of targeted attacks, leaving them and their needed services completely destroyed.
As nations war, nurses, alongside their co-workers and patients, find themselves caught in the crossfire between opposing sides. The terror, fear and distress they face is unimaginable and beyond words to describe. Yet, they stay on the frontline. As Mohammad Hawajreh, an MSF nurse working at the Al Shifa Hospital (the largest medical complex and central hospital in the Gaza Strip) responded when questioned about current staffing levels at the hospital following the bombardment of Gaza,
…there’s not enough there [there’s not enough doctors, not enough nurses […] the impulse is to leave Gaza. But we are taking responsibility and the risk to stay with our people and to help them. And we don’t care about taking rest. We’re just keeping on and providing medical care (Hawajreh 2023).
A question of nursing ethics
Graphic images of hospitals being bombed, ambulances being destroyed and the disintegration of health care services in the conflict zones of Ukraine and the occupied Palestinian Territory have dominated world news reports over the past year. Since the outbreak of the Gaza-Israeli war following the horrific terrorist attack by Hamas on 7 October 2023, we have learned about hundreds of patients (many of them children) suffering severe burns, broken limbs, and deep shrapnel wounds lying injured on the floors of hospitals waiting for treatment which cannot be delivered due to a lack of staff and critical medical supplies. We learn of patients with 70% burns to their bodies who cannot have their burned skin debrided and grafted because there are no drugs and dressings for the procedures. We learn of young children with severe injuries arriving alone at a healthcare facility and screaming for their (presumably dead) parents. We learn of the thousands of pregnant women facing the births of their babies in unsanitary conditions, some having to have emergency caesarean sections without anaesthetics or antiseptics because none is available. And we learn of the impossible choices and soul deadening quandaries faced by doctors and nurses who, upon surveying the rows of bloodied patients lying on stretchers and trolleys, reflect ‘We have no idea what to do…There are injured everywhere’ (Dr Suaib Idais, 2023; see also Horn 2023).
As nurses contemplate the multiple reports and images posted by news media outlets from the world’s conflict zones, how are they to think about the rightness and wrongness of the wars they are witnessing? What sense can they make – if at all – of the unspeakable horrors and miserable cruelty of those wars? How ought nurses who are far away from the wars being raged respond to the destruction, distress and devastation being experienced by their counterparts who are trapped in the midst and mist of war? How are we all to think about the staff and patients in war-damaged hospitals who spend their nights in darkness and dread, fearing what is to come next? Is it even possible to make sense of the madness, the cruelty and the ugliness of what is going on, when the context of the conflicts are so complex, complicated, and politically divisive?
There are no simple answers to these complex questions and it would be naïve to suggest otherwise. Nonetheless, there are some ethical principles that form an ethics framework to which nurses can appeal in order to aid their critical thinking about the issues raised and whether, when, and how they ought to respond. In the discussion to follow, brief attention will be given to identifying the ethical framework that has been developed and appealed to throughout history to justify the ethics of war (‘Just war theory’). The limits of this framework and its oxymoronic nature will also be briefly considered as will the role and responsibility of nursing organisations to take a stand on (un)justified wars.
‘Just war’ theory
Deciding and waging war requires justification. Just what is to count as a sufficient and necessary justification in the case of war, however, is open to question. A key albeit controversial response to this question has been the development over the centuries of the ‘Just war theory’ – a theory that is held to provide an ethical framework for determining when it is morally permissible to go to war (Lazar & Frowe 2018).
The history of ‘just war’ theory can be traced back to Greek and Roman antiquity, and arguably the first normative theorist of war, the ancient Greek historian and general, Thucydides (circa 460–395 BC). The idea of ‘just war’ is believed to have been originally coined by the Greek philosopher Aristotle (384BC-322BC) and, over the centuries, gradually developed by moral philosophers, early and late scholastic intellectuals (including those from China, Japan and the Middle East), and theologians (Reichberg 2018). More contemporary Western versions of just war theories have their origins in the works of Catholic theologians Augustine of Hippo (354-430AD) and Thomas Aquinas (1225-1274). Judaism also has a rich history of developing debate and documents on the justification and conduct of war, with texts on the subject dating back to ancient times. Contemporary Jewish views on the ethics of war have been further developed to include reference to and guidance on the ‘special problems’ faced by the modern State of Israel (Solomon 2005).
Following the rich history of debate on the ethics of war, just war theory today is divided into three philosophical categories, each of which are underpinned by specific ethical principles and values:
- Jus ad bellum (the just right to war): this principle requires decision-makers to show that their decision to go to war is made for a just cause (is in response to a serious wrong or in self-defence), is based on the right intention (political leaders must be motivated by the ethics of war, not belligerence, revenge, or an attempt to improve their chances of re-election to public office), is made by a legitimate leader (the leader is recognised by the political community as having authority to make the declaration), is a proportionate response (it has the probability of success and will achieve the peace desired), is a last resort (all diplomatic and political options have been truly exhausted).
- Jus in bello (correct/just conduct during war): this principle places an emphasis on the way in which war is conducted and to make every effort to reduce suffering; it requires combatants to use discrimination (i.e., attack only legitimate targets – not civilians, aid workers and healthcare services, noting however that non-combatants killed by an attack may be a permissible ‘side effect’ if deemed necessary and proportionate), be proportionate (the war must not exceed the strategic aims and ethical benefits of the conflict), refrain from using intrinsically unethical means (e.g., torture, biological and chemical weapons, sexual violence), be individually responsible and accountable for their own actions (noting that it is well-established in international conventions and law that following the orders of a superior is neither an excuse nor a defence in war – a principle established by the Nuremberg trials after the second world war).
- Jus post bello (correct/just action after the war): this is a relatively new principle that comes into play once a war has ended, and concerns the transition to peace, restoration of damaged property, and restitution for the countries and communities affected (Lazar & Frowe 2018).
Views on the tenableness of just war theory vary, the precariousness of which rests on how the rules are interpreted or indeed whether they are accepted at all. As conflicts throughout history have shown, the rules of war have been and continue to be ruthlessly disregarded and/or flagrantly ignored by notorious wartime leaders and their armed forces.
Confidence in the rules of war wane when war leaders adopt a very loose interpretation of the rules – for example, on what is to count as a justifiable act of ‘self-defence’, a proportionate response, a reasonable ‘side effect’ of civilian casualties (euphemistically referred to as ‘collateral damage’), and the ‘justified sacrifice’ of hostages to enable a country to avoid surrendering to an aggressor. These loose interpretations (some might call them blatant violations) of the rules of war raise pertinent questions not only about the integrity of just war theory (some suggest it is little more than a pretence and a fallacy), but whether the theory can ever truly justify war given its horrendous and inhumane nature (Tzenios 2023). As anti-war scholars contend, ‘no plausible moral theory could license the exceptional horror of war’ (Lazar 2020, pl1).
The miserable cruelty of war
War is not OK and is never the best course of action despite just war theory advocates arguing to the contrary. As Tzenios (2023) notes,
… war is terrible and inhumane, especially when trying to rationalize war in a way that merely makes it dirtier. People want to be comfortable and confident about their morality even though it is impossible to reconcile their actions in the realm of war with their ethics (p4).
There is a sense in which the idea of war being ‘ethically just’ is oxymoronic – a contradiction – since war is always terrible: it causes devastating casualties, the loss of innocent life, the destruction of property, the perpetual displacement of whole populations of people, the degradation of the natural environment, the maiming and killing of domestic and wild animals, and long-term trauma that can reverberate through descendant generations – none of which are morally ‘just’ or morally beneficial.
Taking a stand
Given the horrendous moral harms of war, we must all take a stand. We must not merely denounce war but demand its prevention and its end. We must demand peace. And we must act in whatever spheres of influence we can to help achieve just moral outcomes. In the case of nurses, midwives and other health care workers, the most obvious sphere of influence is healthcare.
The International Council of Nurses (ICN) has been at the forefront of condemning attacks on healthcare facilities and health workers. Examples include its response to the attack on a children’s and maternity hospital in the port of Mariupol, Ukraine in 2022 (ICN 2022), and the bombing of the Al-Ahli Baptist Hospital in Gaza in 2023 in which hundreds of people, including patients, health care workers and displaced persons were killed (ICN 2023). Following the Ukraine attack, the ICN joined the European Federation of Nurses Associations and European Forum of National Nursing and Midwifery Associations in creating a global petition calling for ‘an immediate ceasefire, protection of health care professionals and facilities and the provision of urgent medical supplies to those in need’ (ACN 2022). This petition was conjointly signed by the Australian College of Nursing (ACN) and the Australian Nursing and Midwifery Federation (ANMF).
In addition to its condemnation of the attacks on healthcare facilities and health care workers in Ukraine and Gaza, the ICN declared its ‘solidarity with nurses across the globe who are working on the frontlines during conflict situations’ and launched its #NursesforPeace campaign (https://www.icn.ch/how-we-do-it/campaigns/nursesforpeace). In its media release condemning the violence, the ICN also called on all governments and combatants ‘to uphold the international laws that protect health workers and encapsulated in the #NotATarget campaign (ICN 2023). Also active in this sphere is the non-for-profit organisation Nurses for Peace https://nursesforpeace.org/, which works with experienced international European, American and African registered nurses, nurse educators and nurse managers.
Other healthcare related organisations actively campaigning for the protection of health care facilities and workers in conflict zones and the cessation of war, include:
- The Safeguarding Health in Conflict Coalition, a group of international nongovernmental organizations working to protect health workers, services, and infrastructure (https://www.safeguardinghealth.org/about-coalition)
- The Health Care in Danger Initiative (HCiD), an initiative of the International Red Cross and Red Crescent Movement aimed at ‘addressing the issue of violence against patients, health workers, facilities and vehicles, and ensuring access to and delivery of health care in armed conflict and other emergencies’ (https://www.icrc.org/en/document/partnership-key-ending-violence-against-health-care)
- World Health Organization (WHO) Stopping attacks on health care, an initiative which aims to ensure that ‘health workers everywhere are able to provide health care in a safe and protected environment without disruption from acts of violence’ (https://www.who.int/activities/stopping-attacks-on-health-care).
Regrettably, there is a shameful lack of political will on the part of those invested in war to end it and secure peaceable outcomes. Tragically, so long as authoritarian leaders, driven by their own personal ideologies, psychology, and vested interests use war as a means to shape the world in their own image, there can never be peace. What war mongering fails to consider is that without peace, there can be no prosperity. And without prosperity there can be no progress. And without progress there can be no prospect of achieving an enduring habitable world in which we can all live and flourish.
It is often said that the first casualty of war is truth. A second casualty of war to emerge in the context of the current conflicts is freedom of speech as evident by the (sometime brutal) suppression by authorities of both partisan and bipartisan protests.
It is understandable that many may not know what to believe when viewing the unrelenting media reports and images flooding our television screens and mobile devices. It is, therefore, incumbent on us all to make every effort to find reliable and verifiable sources of information to guide our decisions on how best to respond. Once satisfied about the authenticity and truth of the information and reports accessed, we must speak out and not be induced to self-censure and silence out of fear of a possible backlash against our stated views. One way of speaking out – and calling out – the injustices of war, is to join with others committed to peace and the protection of healthcare facilities, personnel and patients, and to speak with a collective voice. To this end, nurses can begin by supporting the initiatives being led by the ICN, and the activities of other organisations such the Safeguarding Health in Conflict Coalition and the HCiD, referred to above. While engaging in such support might seem futile, we must continue to hope that our collective voices will succeed in influencing public opinion to pressure leaders to be humane and humanitarian in their governance.
Australian College of Nursing. 2022. Australian nurses support international campaign demanding peace in Ukraine. Media release: 7 March. Online. Available at: https://www.acn.edu.au/media-release/australian-nurses-support-international-campaign-demanding-peace-in-ukraine.
Hawajreh, M. 2023. Quoted in Contrera G, Intagliata C & Kelly, M L. Gaza medical staff say they’re missing critical resources to help hospitalized people. Transcript from All Things Considered, 25 October. Online. Available at: https://www.npr.org/2023/10/25/1208577476/gaza-medical-staff-say-theyre-missing-critical-resources-to-help-hospitalized-pe.
Horn, A. 2023. As Israel’s war in Gaza rages on, doctors at Al-Shifa Hospital are faced with impossible choices. ABC News Online 2 November. Available at: https://www.abc.net.au/news/2023-11-02/inside-gazas-al-shifa-hospital/103051772.
Idais, S. 2023. Quoted in ABC News Online 1 November ‘Israel-Gaza war: Israel says strikes on refugee camp killed senior Hamas leader, first foreign nationals leave Gaza’. Available at: https://www.abc.net.au/news/2023-11-01/israel-gaza-war-latest-updates/103046888.
International Council of Nurses (ICN). 2022. International Council of Nurses condemns attacks on healthcare facilities and health workers in Ukraine. Press release 10 March. Online. Available at: https://www.icn.ch/news/international-council-nurses-condemns-attacks-healthcare-facilities-and-health-workers-ukraine.
International Council of Nurses (ICN). 2023. ICN condemns Gaza hospital bombing and calls for protection of health workers. Press release 18 October. Online. Available at: https://www.icn.ch/news/icn-condemns-gaza-hospital-bombing-and-calls-protection-health-workers.
Lazar, S. 2020. Just war. In The Stanford Encyclopedia of Philosophy (Spring 2020 Edition). Online. Available at: https://plato.stanford.edu/entries/war/.
Lazar, S., & Frowe, H. (eds). 2018 Online edn; Oxford Academic, 5 Oct. 2015). The Oxford Handbook of Ethics of War, Oxford Handbooks, Oxford University Press. Accessed 3 Nov. 2023.
Reichberg, G. M. 2018. ‘Historiography of Just War Theory’, in S. Lazar & H. Frowe (eds). 2018 Online edn (Oxford Academic, 5 Oct. 2015). The Oxford Handbook of Ethics of War, Oxford Handbooks, Oxford University Press (pp. 59-79). Accessed 3 Nov. 2023.
Solomon, N. 2005. Judaism and the ethics of war. International Review of the Red Cross, 87(858): 295-309.
Tzenios, N. 2023 Case Study: Just War Doctrine. Open Journal of Political Science: 13(1), 1-17.
MEGAN-JANE JOHNSTONE AO, IS A RETIRED PROFESSOR OF NURSING WHO NOW WRITES AS AN INDEPENDENT SCHOLAR. INTERNATIONALLY RENOWNED FOR HER WORK, SHE HAS PUBLISHED EXTENSIVELY ON THE SUBJECT OF NURSING ETHICS AND IS THE AUTHOR OF THE WIDELY ACCLAIMED BOOK BIOETHICS: A NURSING PERSPECTIVE.