Healthocide and medical neutrality: a call for action and reflection

SUMMARY BOX.

• War has devastating consequences on healthcare, with attacks becoming normalised and health weaponised. The scholarship emphasises the longterm human toll, the need for accountability, humanitarian aid, reconstruction, and the reaffirmation of medical neutrality to protect lives.

• This Comentary conceptualises the systematic and deliberate attacks on healthcare as ‘healthocide’.

• We urge the medical community to reflect on and act against the erosion of medical neutrality, emphasizing that while the concept can be politically fraught, the fundamental principle — that healthcare facilities must never be targeted in conflict — is non-negotiable and cannot be forsaken.

• Rather than passively observe the erosion and normalization of the weaponisation of health and healthcare, this Commentary calls for critical reflection and decisive action underscoring that silence implies complicity, approval or the toleration of double-standards — all of which stand in clear opposition to international humanitarian law and medical deontology.

Six million people live in Lebanon, including 1.5 million Syrian and 500 000 Palestinian refugees. Israel has attacked Lebanon multiple times, most recently from 8 October until 27 November 2024, when a 60-day ceasefire agreement was announced. Although Israeli strikes have decreased in frequency since then, the Israeli army continues to use drones for surveillance and ‘targeted killings’ and continues to occupy select areas in the south of the country. The fall of the Assad regime in Syria on 8 December 2024, has further destabilised an already tense situation, with thousands of Syrians seeking refuge in Lebanon.¹ As medical doctors and educators, we feel compelled to remind the medical community of its moral and ethical commitments, specifically its commitment to medical neutrality, a principle now at grave risk of erosion and irrelevance without concrete actions to resist these unprecedented attacks on the right to health and healthcare.

During the 2006 war on Lebanon, 78 health facilities were seriously damaged, and two hospitals destroyed,² this time, the scale is unprecedented. According to Lebanon’s Ministry of Public Health, between 8 October 2023, and 27 January 2025, 217 healthcare workers have been killed—including the general director of a university hospital that provides critical care to an underserved population in Baalbek. In addition, 177 ambulances have been damaged, 68 attacks on hospitals have been recorded, and 237 attacks on emergency medical services have taken place.³ This on top of the more than 4000 people killed, more than 16 000 wounded, more than a million forcibly displaced, and countless others traumatised by the campaign of bombardment, psychological warfare, and destruction.

Since Hamas' attacks on 7 October 2023, the Israeli onslaught in Gaza has killed at least 986 medical workers, including 165 doctors, 260 nurses, 184 health associates, 76 pharmacists, 300 management and support staff, and 85 civil defence workers.⁴ The United Nations (UN) has forcefully condemned these ‘relentless and deliberate attacks’ on healthcare facilities and medical workers, declaring them war crimes and crimes against humanity.⁵ Alarmingly, over 300 healthcare workers have been detained between October 2023 and February 2025, with many subjected to torture and inhumane treatment.⁶ Both in Gaza and Lebanon, healthcare facilities have not only been directly targeted, but access to care has also been obstructed, including incidents where ambulances have been prevented from reaching the injured or deliberately attacked. The most shocking such incident was the systematic killing and mass burial of 15 paramedics in Gaza on 23 March 2025. The UN accused Israel of deliberately killing the humanitarian workers and demanded answers and accountability.⁷ What is becoming clear is that healthcare workers and facilities are no longer afforded the protection guaranteed by international humanitarian law.

These attacks have been met with astounding silence or, at best, terse and often belated statements from American, European, or Israeli medical associations, professional groups, and journals.8,10Are medical doctors ready to forsake the principle of medical neutrality, first forged amidst the carnage of 19th century wars and profoundly reshaped following the liberation of Nazi death camps in 1945? And if so, at what cost? As difficult as this question is, it is one that physicians must address as they grapple with the normalisation of healthcare’s weaponisation in a world where warfare has changed dramatically, marked by the use of Artificial Intelligence for mass killing,¹¹ the reliance on drones and killing robots, the deployment of internationally banned weapons, which carry devastating public health and ecological consequences,¹² and of course the looming threat of nuclear weapons.

Medical neutrality refers to the principles and laws that protect healthcare workers and facilities from attack during armed conflict and civil unrest. Even if it cannot always be fully upheld, it has served as the foundation of medical humanitarianism throughout the latter half of the 20th century. While neutrality is not absolute—and healthcare professionals, including humanitarians, often operate within complex political landscapes—medical neutrality has emerged as both a concept and an ethic of care in times of war and crisis. It evolved alongside growing recognition of fundamental human rights, such as the rights to care, dignity, health, and life. Medical neutrality is understood not only as a legal and ethical framework protecting medical personnel, but also as a critical mechanism for ensuring that care reaches those most in need during conflict. Crucially, it also safeguards healthcare workers as they deliver care—wherever it is needed—and serves as a bulwark against targeted violence.

Médecins Sans Frontières (Doctors Without Borders) was founded in 1971 in response to the Biafra conflict as a conscious break from what was seen as the silence of the Red Cross (founded in 1863) during both the Holocaust and the Nigerian Civil War. In contrast to the Red Cross’s strict adherence to remaining neutral (i.e., taking no sides in armed conflicts), MSF was established to uphold the principle of témoignage, or bearing witness, thus following a more outspoken and advocacy-based approach to humanitarian work in the face of egregious abuses of human rights. While scholars, such as Didier Fassin (who also served as MSF’ vice president from 2001 to 2003) or Peter Redfield, have shown that ‘bearing witness’ is itself a political act and that ‘neutrality’ is neither apolitical nor always possible—especially in the face of human rights abuses^{13 14} —this Commentary does not focus on what it means to be neutral. It recognises that neutrality can be politically fraught. Instead, it examines how the medical community has responded to violations of medical neutrality and emphasises that upholding this principle does not imply indifference or neutrality towards its breaches. Quite the contrary, conscientious physicians have historically decried these abuses of medical neutrality, which led for example to the founding of MSF or Physicians for Human Rights in 1986.

The normalisation of healthcare attacks has alarmingly increased in the past few years, a trend that has been thoroughly documented.^{15 16} However, what we are witnessing today is more pernicious than mere normalisation of such attacks, something that could be described as ‘healthocide:’ the deliberate killing and/or destruction of health services and systems for ideological purposes. Health comes from Old English hǣlth, which is of Germanic origin and relates to the concept of ‘wholeness’—a state of being whole and complete. By ‘healthocide’ we also mean the fragmentation or destruction of this wholeness through the deliberate dismantling or devastation of a population’s health and well-being in its entirety. Gaza is the paragon of healthocide.

With the rapidly evolving nature of warfare, it is imperative for the medical community not only to condemn these blatant violations of medical neutrality but also, more urgently, to act and critically interrogate their implications for our roles as healthcare providers and educators. Normalising, undermining, or excusing healthocide sets a dangerous precedent—one that emboldens future violators and erodes the principle of medical neutrality, which is essential for ensuring impartial and humane care during conflict, and arguably beyond. Indeed, the consequences are grave. Not only is international humanitarian law at risk of becoming irrelevant, but so is the entire human rights-based framework that emerged in the aftermath of World War II. Instead of consistently upholding international humanitarian law, humanitarian organizations have warned that decision-making is increasingly driven by ‘transactional politics’—a shift that threatens the protection of human rights.¹⁷

The fundamental principle of ensuring that medical and healing spaces are not targeted in conflict should remain non-negotiable. This principle—an essential feature of medical neutrality and an age-old practice rooted in the sanctity of healing in ancient civilisations—aligns with both the Geneva Conventions and medical deontology. Moreover, medical neutrality is not ‘apolitical’; for us it means standing with humanity, social justice, and health-enabling policies. It is an ethic that aligns with the Kantian principle of treating humanity as an end, never merely as a means. In addition, upholding social justice is central to our mission as physicians and medical educators—from the time of Hippocrates to modern ethical frameworks. Foundational guidelines, such as the Belmont Report (1979) and the most recent revision of the Declaration of Helsinki (2024), primarily focus on research involving human subjects. Yet, these are grounded in three core principles that are especially relevant to vulnerable populations—and to the physicians who care for them: beneficence, justice, and non-maleficence.

Critical actions must be taken to counter the alarming erosion of medical neutrality and the principles underpinning medical practice, medical education, and ethical frameworks. These actions must include advocating for the enforcement of justice, and more pertinently to our era, international humanitarian law. Additionally, it is essential to document and expose abuses to medical neutrality by both state and non-state actors—such as those witnessed in El Salvador during the 1980s,¹⁸ or more recently in Sudan, Ukraine, Syria, Lebanon, and the occupied Palestinian territories.¹⁹ Silence in the face of violations of medical neutrality in these contexts can only be interpreted as complicity, tacit approval or the toleration of double-standards.

By advocating for the enforcement of justice and international humanitarian law we reaffirm our commitment to preserving the sanctity of health–even in the most challenging and hostile environments. In addition, we reaffirm a vision of medicine as a force for healing, equity, and public good, as Rudolf Virchow, the celebrated German physician and politician, envisioned—a vision concerned not only with treating diseases but above all with addressing the underlying sociopolitical conditions that perpetuate them, such as poverty, inequality, and war.²⁰

Data availability statement

There are no data in this work.