Physicians duty in war

A woman is taken to Ayder Referral Hospital, in Mekelle, after an airstrike in Togoga, Ethiopia’s Tigray region June 22, 2021. Picture taken June 22, 2021. Tigray Guardians 24 via REUTERS

Being in the middle of the Tigray-Ethiopian conflict for three months and now following it I have pondered about were do health care workers duties fit into this all too common human situation. In the midst of war questions may come up about what are called conflicts of dual loyalty for doctors. However physicians of the Jewish, Christian, and Islamic faith recognize that they have a duty to their patients be they ally or enemy. This ethic goes back to the times of the medical scholars Hippocrates, Maimonides, and Al-Ṭabarī.

Religious medical scholars on ethics of the Jewish, Christian, and Islamic faiths

The Jewish rabbi physician Maimonides in discussing his interpretation of the Jewish law in the Mishneh Torah said that everyone who found anyone missing a possession should have it returned to him. That included health which meant physicians had to treat all comers including those of different faith and ethnicity. He said “ On the basis of this reasoning, the art of medicine is given a very large role with respect to the virtues, the knowledge of God, and attaining true happiness. To study it diligently is among the greatest acts of worship.”

Religious medical scholars on ethics of the Jewish, Christian, and Islamic faiths have given a very large role with respect to the virtues, the knowledge of God, and attaining true happiness.  Al-Ṭabarī , Islamic and medical scholar, expanded upon Hippocrates incorporating Islamic principles found in the  Qur’an of dignity of the individual, charity, dutiful study of the healing arts, and faith playing a role in the formation of a good healer.

Christians are familiar with the parable of the Good Samaritan where Jesus tells the story of an abandoned injured man presumable a Jew on the road between Jericho and Jerusalem a place of frequent violence who was ignored by a Jewish priest and a Levite. Traditionally there was hatred between Samaritans and Jews but when a Samaritan encounters him he decides to render him aid and pays his expenses to recover in an inn. Jesus demonstrates charity when asked Who is my neighbor? The response is that all men are our neighbors (All men are a part of God’s loved creation?)

The Islamic faith has long seen medical practice has having an intimate relationship with their faith. A good physician is a faithful one who shows mercy and charity to all men. Incorporating their beliefs into a commonly used oath of which a partial quote is “The doctor will protect human life in all stages, in all circumstances and conditions, and will do his utmost to rescue it from death, disease, pain, and anxiety. He will extend his medical care to the near and the far, to the virtuous and the sinner and to friend and enemy.”

There is a shared believe among the descendants of the covenant that Abraham made with God so many centuries ago that physicians have a common ethic to care for all who are in need.

Although  health care providers around the world have been consistent in following this universally accepted moral imperative especially since the medical experimentation done by the Nazis the same cannot be said about the destruction of medical facilities and killing of health care workers. Although the United Nations and member countries have signed multiple treaties forbidding these actions.  Despite these diplomatic measures ongoing research has shown their progression.

In Ethiopia during the onset of the Tigray-Ethiopia-Eritrea conflict I spoke with physicians and nurses who had to escape military bombardment and ransacking of medical facilities in Humera, Axum, Adigrat and other places often killing both staff and patients. One wonders what if any consequences will come of these illegal war crimes?

Reflections on the Age of Limits in Healthcare Resources

The academic new year at Mekelle University for residents (doctors who have graduated from medical school and now will undertake several years of specialty training) is just a few weeks away. They will transform from the theoretical and observing from the sideline to actually being involved in medical care to improve the quality and longevity of their patients. A part of the new experience will be their discovery that there is a limit of resources even in the richest countries and of course more severe in the developing countries. This same thing is happening not just in Mekelle, not just in Ethiopia, but around the world in all the teaching hospitals.

Although we like to pretend otherwise there is no escaping the inevitable fact that we are mortal and will at some point suffer significant illness followed by death. An Ethiopian diaspora calculated based upon the year 2000 that the per capita lifetime medical expenses where $316,000 in the state of Michigan (USA). Most of the cost occurs in the first year of life and after age 50. Women were more than men because they live longer. About one third occurs in middle age and about one half in the senior year of life.
It is hard to put a measure on the value of human life.

When discussions occurred about the use of dialysis as to whether should be payed for by government, analysts determined that spending $50,000 to give an additional year of quality life was worthwhile. This same measure was applied by several governments world wide. The actuarial value of a human life in developed countries is put somewhere between $ 500,000 and ten million dollars by actuarial experts. It is much less in developing countries where the economic output of an individual is much lower often less than a few hundred dollars a year.

The most recent budget for healthcare in Ethiopia was 1.4 billion dollar equivalents which cames out to about $14 per person for the approximately 100 million Ethiopian population. If you count out of pocket expenses it increases to about $24 per capita. This is of course much less than than the $4000-$5000 you see in European countries and the almost $10,000 in the United States. Yet even in these rich countries there are cries that funding is insufficient.

This means that physicians and the policy makers whom they advise have to learn to do more with less. They have to spend resources where they will have most impact. How are these decisions made? Medical ethicists talk about years of productive life as a reasonable way to compare, for example, spending money to help newborns versus the elderly. But not all cultures would agree with this concept totally. There is often a belief that older citizens should be rewarded for their service to society. Note the creation of Medicare and Social Security and its equivalents in the United States and many other developed countries.

Good medical care even in this age of limits is possible. It requires a sound knowledge of likely outcomes, compassion, and realistic communications with the patients and the community at large in both developing and developed countries. The inevitable consequences of our mortality and economic reality of limits leaves no room for anything other than truthful sincerity.