Doctors in developed countries deal with ethical issues all the time, but seldom are they dramatic or gut-wrenching. An article in BMC Medical Ethics describes some of the ethical questions confronting doctors working with French military in Mali and Chad on Operation Barkhane.

There are about 200 doctors and nurses with the French military deployed in the Sahel region. France’s goal is to help combat Islamic terrorism, as well as assisting in political and economic development.

The countries in this area are some of the poorest in the world. One figure tells everything. The global figure for hospital beds is 26 per 10,000 people. In Mali it is 1 – and the hospitals are in the cities, away from most of the population.

All of the difficult decisions related to treatment of civilians or captives (PUC).

The following quotes are taken from interviews conducted by the authors of the article.

Whom does a military doctor serve?

“It is questionable how much sense there is to carry a weapon and a stethoscope in the same bag. I see myself as back-up, not as a combatant. My weapon is only there for self-defense.”

Whom should they treat?

“I had to deal with limited resources. On the first day, I have this image in my mind of me and my 25 consultation coupons in my hand and several hundred people around, and I had to choose. The Chadian nurse was saying: “you have to take local soldiers”, and I had 30 dying children.” 

Should seriously ill civilians be treated?

“I once had a patient with an ulcerated hip eschar with bone exposure; we decided to not treat him even though he was young, because that would have led us into a treatment course that we would not have been able to complete, with significant personnel time and material costs”.

Who gets treated first: French soldiers or enemy civilians?

“The question came up of what choice we would make if two casualties arrived, between a French and an enemy patient. If their conditions were similar or even if the French patient’s condition was less severe, we would have operated on the French casualty first. Even if on normative or ethical grounds we’re told we shouldn’t, we would have done it anyway. Compromising a comrade’s functional outcome to treat an enemy casualty, that would not have gone down well with other soldiers on the scene and would have been difficult on a personal level.”

Who determines the level of care: the generals or the doctors?

“The instructions we had from military authorities were to focus on quantity, see as many patients as possible. They had been on my case, they told me that I wasn’t going fast enough, that I should be seeing 70 patients in two hours. I disagreed. There should have been fewer people so as not to cut corners. Patients are well aware that if you just give them a box of pills, that’s not enough. For me, this may be naïve of me, but I was there for the patients. I know that MAC is politics to make the troops’ presence acceptable. No need for doctors in that.” 

Should enemy combatants receive the same level of care?

“Regarding the treatment of one PUC, I heard from my subordinates: ‘why are we treating terrorists: they asked for it!’ Some thought that we should not treat them. There was also racism. Not everyone is well-meaning. That would soon come back to me and I would make a point with the team to remind everyone of the rules.”