Ethical and legal dilemmas of civil disobedience: physicians’ decisions under occupation

1. Introduction

During times of war, under siege and amidst bombings, several physicians chose to disobey evacuation orders, risking their lives to avoid abandoning their patients [1–3]. These situations, rarely discussed in the literature, highlight the ethical conflict between the duty to obey official directives and the commitment to the medical oath.

This editorial aimed to examine the ethical, legal, and humanitarian implications of physicians’ decisions to disobey evacuation orders in war zones, shedding light on the tension between their professional duty to protect patients and the legal directives imposed by occupying forces.

2. Legal framework

Situations in which physicians may face evacuation orders issued by an occupying army are implicitly addressed by international humanitarian law (IHL). Through the Geneva Conventions (1949) and their additional protocols, IHL provides special protection to medical personnel [4], patients [5], and medical facilities, which cannot be attacked or used for military purposes [6–8]. In times of war, occupying forces have a duty to ensure the proper functioning of medical facilities, the continuity of care, and the protection of the wounded and the sick [6]. Therefore, an evacuation order could be challenged for its illegitimacy if it: i) Endangers patients [5] ii) Is not based on compelling military justifications, and iii) No secure alternative is provided for the protection and transfer of patients [5]. Moreover, if the evacuation order directly or indirectly leads to the death or unnecessary suffering of patients, it could be classified as a war crime [9]. Legally, an occupying force may impose new regulations to maintain order and security in the occupied territory [10]. However, it is essential that these measures comply with the obligations of IHL.

For physicians, evacuation orders for hospitals during wartime present a complex ethical and legal dilemma [3], as abandoning patients (except in cases of major constraints, such as an imminent risk to one’s own life) constitutes a refusal to provide assistance to those in danger [3], and violates their obligation to protect the life and health of the patients under their care [3]. This can lead to criminal charges for endangering the lives of others [3], manslaughter, or even accusations of complicity in war crimes [1].

It is true that physicians do not have the legal authority to judge the legality of an order from a higher authority; however, they retain the right to assess the conformity of the order with medical ethics and universal humanitarian principles [3]. According to IHL, a physician is not obliged to obey an order from a superior force if it involves serious violations of human rights [1,11]. In this situation, the physician’s disobedience is ‘in accordance’ with their professional obligations (to care for and protect human lives) and humanitarian duties (IHL), and is justified by their moral and legal duty to protect their patients [3].

Under occupation, physicians are granted special protection under IHL and are assigned the status of ‘protected civilians’ [12,13]. Physicians retain their independence (bound by their medical oath, protected by IHL) and are not considered subordinate to the occupying force, unless they have voluntarily agreed to collaborate with it [12]. Forcing physicians to violate their professional oath or divert them from their primary mission could constitute an abuse of power [12,13]. Therefore, in the case of disobedience, occupying forces cannot legally judge them for insubordination if the given order violated IHL, and any attempt to punish them for their ‘disobedience’ could constitute a serious violation of international law (potentially leading to a war crime under the Geneva Conventions), opening the door to legal recourse before international courts [12,13].

3. Consequences for the disobedient physician

Civil disobedience by physicians in times of war is the ultimate expression of medical and humanitarian ethics, often at the cost of immense personal sacrifices [2,14]. It is a personal conviction that the moral duty takes precedence over obedience to immoral hierarchical orders, even if it means facing consequences that may threaten individual survival [14]. This decision reflects a profound sense of personal sacrifice in the context of collective suffering [2,14]. Although IHL provides protections for physicians during armed conflicts, its enforcement is limited due to its non-coercive executive tools, which often depend on the ‘will’ of the parties to the conflict and the international community [13]. Cases where physicians have received explicit support from IHL after disobeying orders are rare [2]. In such situations, physicians often find themselves facing their own fate (Table 1) [15–22].

Table 1.

Some iconic figures of civil disobedience by physicians in times of war.

Case	Context	Repercussions
Dr. Elsie Inglis Scottish physician and activist (1915–1917 – World War I) [15]	1915: Dr Inglis was managed a hospital on the frontlines in Serbia. When enemy troops invaded the area; they demanded the evacuation of the hospital. Dr Inglis refused to abandon her patients, most of whom were wounded Serbian soldiers [15].	November 1915: Dr Inglis was captured and treated as a prisoner of war under harsh detention conditions [15]. February 1916: Dr Inglis was released as part of a prisoner exchange, thanks to international pressure from Allied governments (Great Britain and France), the International Red Cross, and other humanitarian organizations [15]. Dr Inglis received numerous honors and awards, both during her lifetime and posthumously [15].
Dr. Haakon Saethre Norwegian neuroscientist (1939–1945 – World War II) [16]	April 1940: After the German invasion, Norway was placed under a Nazi occupation regime that sought to impose its ideology and control over all aspects of Norwegian society, including the medical sector [16]. In response, physicians organized into a resistance movement that ranged from clandestine military actions to civil disobedience [16]. Dr. Saethre was an iconic figure of this resistance, refusing to collaborate with the occupying forces [16]. Dr. Saethre helped individuals of Jewish faith escape or hide them in his hospital by presenting them as patients [16].	Dr. Saethre was arrested by the Nazi military for refusing to evacuate his hospital, where he was hiding members of the resistance, some of whom were injured [16]. At the beginning of 1945: Dr. Saethre was executed [16]. Dr. Saethre’ memory and legacy as a resistance hero are honored in Norway through various commemorative monuments and scholarships created in his name [16].
Medical teams of the hospitals in Saint-Lô and Caen (Normandy bombing, World War II, 1944) [17]	June 1944: Normandy was heavily bombed by the Allies to weaken the German defenses. This caused massive losses among civilians (thousands of wounded and dead) and destroyed much of the infrastructure, including hospitals, which had become places of relief and refuge [17]. .The medical teams had been ordered to evacuate the premises for their safety [17]. Several physicians chose to disobey the evacuation orders and remain with the wounded, believing that their moral and professional responsibility took precedence over their own safety [17].	June 6, 1944: The hospital in Saint-Lô was destroyed by the bombings. The doctors and nurses who remained on site died while protecting their patients [17]. June 7, 1944: At the Hôtel-Dieu in Caen, several doctors, nurses, and patients were killed during a raid. The surviving medical staff continued to provide care to the wounded under extremely precarious conditions [17]. These sacrifices were recognized after the war as acts of bravery and medical devotion [17].
Vietnamese and international physicians (Vietnam War 1955–1975) [15]	The Vietnam War was marked by the disobedience of Vietnamese physicians and their international counterparts (including Americans) in response to the atrocities of the war, particularly in reaction to the use of Agent Orange and intensive bombing campaigns [18].	Several local and foreign physicians were injured, imprisoned, tortured, or killed under the bombs [18].
Dr. Abbas Khan Syrian war (2011 – 2023) [19]	2012 (at the beginning of the civil war in Syria): Dr. Khan, who was living in England, traveled to Syria to help the civilian victims of bombings in Aleppo. He refused to obey the orders of the Syrian regime to stop providing care to civilians and political opponents [19].	November 2012: He was captured by Syrian forces. December 2013: He was imprisoned, tortured, and found dead in his cell under controversial circumstances (official sources claimed it was a suicide by hanging) [19].
Gaza Strip, Palestine (2023-to early 2025) [16,17]	In the Gaza war (Gaza genocide), medical teams on the ground refuse to abandon their patients despite the bombings of healthcare facilities [16,17].	Dr. Adnane Al Bursh, a renowned orthopedic surgeon, was imprisoned for 5 months and then declared deceased in May 2024 [17]. End of December 2024: Dr. Houssem Abou Safiya, a pediatrician and hospital director, was arrested. On February 11, 2025, he was allowed to meet his lawyer in Ofer Prison, located in the occupied West Bank [18].

4. Enhanced international support

Stronger international support and accountability measures are crucial to ensure that medical professionals in conflict zones can uphold their rights and responsibilities [23]. To achieve this, global medical organizations, human rights groups, and legal advocacy bodies should take a more proactive role in assisting healthcare workers who face legal or professional repercussions for adhering to their ethical duty to provide care [23]. This assistance could involve offering legal defense services, creating emergency protection systems, and establishing formal ethical guidelines that validate medical disobedience in cases where following orders would contradict fundamental humanitarian values [23]. Enhancing these protections would not only safeguard healthcare professionals but also reinforce the importance of medical ethics in conflict situations.

To conclude, physicians’ refusal to evacuate under war conditions underscores the profound ethical conflict between obedience to military orders and fidelity to medical oaths. While international humanitarian law provides a legal framework to protect healthcare workers and their patients, its practical enforcement often falls short, leaving medical professionals to rely on their moral convictions. Acts of disobedience in such contexts epitomize the self-sacrificing essence of medical ethics and humanitarianism, but they also expose these individuals to significant personal risks and legal uncertainties.

Funding Statement

The author(s) reported there is no funding associated with the work featured in this article.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Declaration

The authors wish to disclose that an artificial intelligence tool (i.e., ChatGPT 3.5 Ephemera) was utilized to enhance the clarity and coherence of the manuscript’s writing. The tool was used for language refinement purposes only, ensuring the text was clear and coherent without altering the scientific content or generating any new text. After AI-assisted editing, the authors thoroughly reviewed the manuscript to ensure that it fully aligned with their intended meaning[24].

Data availability statement

Data sharing not applicable to this article as no datasets were generated or analyzed during the current study.