Step 1 – IDENTIFY THE PROBLEM(S)

Briefly state the Scenario: Your local military commander asks for off-duty medical personnel to contribute to guarding the perimeter of the military compound.

How do you respond?

List the Issues that arise from the scenario

• This could lead to a shortage of staff available to treat patients, potentially compromising the quality and timeliness of care provided.

• Off-duty medical personnel may not be adequately trained or equipped to handle the physical demands or potential danger associated with guarding a military perimeter. This could expose them to unnecessary risks and put their safety in jeopardy.

• If medical personnel are pulled away from their primary duties, it could cause operational disruptions in the healthcare setting.

• Medical personnel may feel conflicted or uncomfortable with the request to perform duties outside their professional role.

Identify Critical Information required and Assumptions to be made

• Understand the exact prohibitions on the use of medical personnel for military tasks.

• Consider if the medical component of the force (within the perimeter) should be placed outside the military perimeter and have a separate boundary that could be guarded.

• Consider if ‘off-duty’ medical personnel could undertake other tasks that could release more combatants to guard the perimeter (e.g. feeding, cleaning, sanitation duties).

• Consider if the request is a reflection of other tensions regarding the volume of work across the military force.

• What are the differences under IHL between those ‘permanently’ assigned to a medical role and those ‘temporarily’ assigned to a medical role – is there flexibility for ‘medics’ rather than ‘regulated professionals’ (i.e. doctors, nurses, paramedics)?

• What is the ethical threshold for medical professionals undertaking ‘intelligence’ work?

• Can health professionals ‘denounce’ their profession to undertake combatant activities?

Step 2 – ANALYSE

Patient: Even if the medical personnel is off duty, they may need to be called in during certain situations, such as emergencies or mass casualties. Having HCPs guarding the perimeter would put patients at risk as they would not be treating patients putting them in harm's way (non-maleficence). If the off-duty medical personnel are required to guard the perimeter, this could also lead to burnout, fatigue, and reduced ability to provide quality care, which would ultimately harm the soldiers and others in need of medical attention.

Clinical: “Healthcare personnel shall at all times act in accordance with relevant international and national law, ethical principles of health care and their conscience. In providing the best available care, they shall take into consideration the equitable use of resources.”

“Healthcare personnel, as well as healthcare facilities and medical transports, whether military or civilian, must be respected by all. They are protected while performing their duties and the safest possible working environment shall be provided to them.”

“In fulfilling their duties and where they have the legal right, health-care personnel are identified by internationally recognized symbols such as the Red Cross, Red Crescent or Red Crystal as a visible manifestation of their protection under applicable international law.”

WMA. ‘Ethical principles of healthcare in times of armed conflict and other emergencies’. At: https://www.icrc.org/en/document/common-ethical-principles-health-care-conflict-and-other-emergencies

Legal: The provisions of the Geneva Convention and accepted humanitarian law are explicit: medical personnel may only be armed with light-individual weapons for the protection of themselves or their patients; they may not ‘commit acts harmful to the enemy’ including providing area protection or other military activities. Protected persons (healthcare professionals, chaplains, personnel temporarily assigned to medical duties - holders of a designated identity document) may NOT guard anything other than medical units. - Customary IHL: 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 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.” At: https://ihl-databases.icrc.org/en/customary-ihl/v1

See: Convention (I) for the Amelioration of the Condition of the Wounded and Sick in Armed Forces in the Field. 12 August 1949. Articles 7, 19, 22, 24, & 40. At: https://ihl-databases.icrc.org/en/ihl-treaties/gci-1949?activeTab=

Societal/Military: There is an operational need to ensure security and protect the compound, especially in a potentially volatile or conflict-prone environment. The commander is focused on the overall mission success and safeguarding personnel and resources. This request presents a potential conflict between professional responsibilities and military duties (dual loyalty).

While their primary duty is to provide medical care, in a military context, medical staff are still soldiers or service members and may be expected to take on other duties, particularly during heightened security situations or emergencies.

“[...] Ensure that commanding personnel do not unnecessarily or deliberately make decisions or issue orders, in their area of responsibility, that have the effect of delaying or denying the delivery of, or limiting or restricting access to, health care.” - ICRC. ‘Protecting Healthcare: Guidance For The Armed Forces’. 2021. At: https://healthcareindanger.org/wp-content/uploads/2021/03/4504_002-ebook.pdf

Society generally expects medical personnel to be focused on providing care and diverting them to security duties could harm public trust in both the military and healthcare systems.

Step 3 – FUSE

● Summarise conclusions

● Insert citations to key reference sources for your analysis

● Determine the exact Decision(s) to be made

This question tests understanding of the duties of medical personnel, protected under the Geneva Conventions, and the limitations on their employment outside their medical duties. This is a common issue, especially in small units where medical personnel are part of the team.

Military medical personnel are entitled to carry weapons, in spite of being non-combatants, for self-defence and defence of their patients. Their weapons are limited to light individual weapons. They are not allowed to be involved in the collective defence of non-medical military facilities and assets. - ICRC. Customary IHL: ‘Practice Relating to Rule 25. Medical Personnel: Section B’. At: https://ihl-databases.icrc.org/en/customary-ihl/v2/rule25#cd86ba99-eba5-4891-b7a2-41ec9a9ee6e9

Step 4 – DECIDE

• What is your Decision?

• Why (can you justify it)?

• Residual uncertainly, need for review?

You could emphasise that medical personnel, especially when off-duty, should focus on their primary role of providing medical care, which is essential for the mission's long-term success. Having medical professionals perform security tasks could detract from their ability to provide proper care when required.

If the situation allows, it could be suggested that medical personnel be on standby or available to assist in cases of injury during the security operation but should not be actively engaged in guarding duties unless absolutely necessary.

Propose that qualified security personnel or other soldiers who are trained for perimeter defence take on the task, leaving medical staff to remain available for urgent care needs.

Reviewed and formatted by:

Adriana Salas Yeguez, MBBS Year 3 King’s College London

December 2024

Further reading:

Section 2A Protection of medical capabilities. Chp 1 Page 15. Allied Joint Medical Support Doctrine. AJP 4-10 https://www.coemed.org/resources/stanag-search