Violence in Syria — A Report on Healthcare’s Ethical Challenges

Our Director of Conflict and Health, Len Rubenstein, published a report titled “Reality Makes Our Decisions: Ethical Challenges in Humanitarian Health in Situations of Extreme Violence.”

In collaboration with the International Rescue Committee and SAMS (Syrian American Medical Society), the report addresses some of the unique and difficult challenges humanitarian health organizations working in settings of extreme violence. The report, based on almost 100 interviews with organizational managers and front-line health workers, identifies these challenges and makes recommendations to humanitarian organizations to develop processes — now rarely in place — to address the questions in a structured and systematic way.

The report focused on Syria and explored the ethical dilemmas faced by healthcare workers in a 3-pronged manner. They conducted a systematic literature review to understand “the range of ethical challenges in humanitarian health practice in conflict settings and the approach taken to their resolution,” interviewed managers of supporting organizations and healthcare workers, and held workshops to review the findings. Furthermore, the workshops also facilitated discussions for future recommendations to address the ethical challenges faced by healthcare workers who may find themselves in politically turbulent areas strife with violence, not only Syria but also in places such as Afghanistan, Yemen, and the Democratic Republic of Congo.

For Syria in particular, the report noted that the current political crisis is characterized by an unconventional frequency of attacks (i.e. bombings and shellings) on hospitals and healthcare workers; the Geneva Conventions outlines the concept of medical neutrality wherein medical services in times of armed conflict must be allowed to continue without disruption. In principle, all parties must refrain from attacking medical facilities, personnel, and equipment regardless of political affiliations. Failure to do so constitutes a war crime; however, the Syrian regime, Russia, and ISIS have continued to attack medical facilities. Since the beginning of the Syrian War in 2011 to 2018, there have been 550 hospital bombings.

The bombings alone — the direct threat on their lives — are not the only fears felt and challenges faced by Syrian healthcare workers; they are plagued with heart-wrenching decisions daily; they must make daily decisions to ration out limited resources, often determining who lives and who dies. They must submit to the coercion of armed groups, work within the confines of limited support, and must deal with their own psychological trauma/distress from the strains of these conditions.

Furthermore, the study found that the most frequently reported ethical challenge faced by healthcare providers was providing the highest attainable quality of care, and the most frequently reported difficult humanitarian principle to uphold was neutrality. It makes sense that the people who accepted the risks of remaining in Syria to provide care are concerned ultimately with the limits of their services.

After assessing the full extent of the current challenges faced by Syrian healthcare workers, the workshops the research team hosted came up with the following recommendations:

Read the full report here and watch Len Rubenstein’s testimony at the UN Security Council here.