In more recent years several organizations have recorded a worrying number of sporadic attacks on health care facilities and personnel. Nearly 100 medical facilities belonging to, or supported by MSF have been bombed since 2015. The vast majority were in Syria, the others in Yemen, Afghanistan, Ukraine and Sudan20. Yet, it is still unclear if these events signal an increasing trend or a random occurrence of deliberate attacks against medical and humanitarian personnel21. Firstly, the typology of hostile acts is complex, with military strategies and counter-terrorism policies accounting for a minority of all recorded incidents22 [Table 1]. Secondly, we don’t know the extent of reporting biases, except to say that there is a probable deficit in the reporting of attacks against national staff. Thirdly, humanitarian relief activities have been expanding worldwide, with an increasing number of humanitarian personnel engaged in field operations. Comparing different epochs in terms of incidence rates is therefore a difficult exercise.
In the previous sections, I have put so far forward two ideas. The first one is that it is difficult to ascribe deliberate attacks against health care facilities to a single pattern of aggression, and clear lines of responsibilities. The second idea is that it is equally difficult to determine if war-time attacks against health care – and the repeated disregard of humanitarian principles that they represent – have become quantitatively more frequent, as seen in the lights of past or recent history. In the following sections, I will try to analyse the emergence of a qualitative shift in ideologies, represented by revisionist views of just war theories. These novel theories are not only disputing the principle of impartial medical care, but more broadly the core principles of IHL.
Traditional and revisionist just war theories
Mainstream moral theories contend that killing is wrong, with some exceptions, one being self-defense, another one being warfare. The conditions whereby a war is just have been codified as ‘jus ad bellum’ (what conditions entitle nations to resort to war) and ‘jus in bello’ (how individuals should behave once war is declared)25. There are 6 principles of jus ad bellum: just cause, legitimate authority, right intention, necessity or last resort, proportionality and reasonable hope of success. There are 3 principles of jus in bello: discrimination, necessity or minimal force, proportionality. The IHL pertains to the jus in bello, which relies on fundamental principles, including: (i) the distinction between combatants and civilians, and (ii) the moral equality of combatants. ‘Revisionist just war’ is a set of recent theories, which dispute the contemporary relevance of the traditional Just War doctrine (summarized in Table 2). McMahan provides a clear introduction to revisionist Just War theory in a series of two articles26. Fundamentally, revisionists assert that war is not (or no longer) different from individual defense, a theory called ‘reductionist individualism’. According to Helen Frowe27, ‘Reductive individualists hold that it is a mistake to think of war as a morally distinctive enterprise, governed by rules that are irreducible to the moral rules of ordinary life. Rather, the rules that govern harming in war are the rules that govern harming
Moral perspective: does proportionality count?
From a utilitarian perspective, one could claim that the (hypothetical) presence of a ‘high value target’ inside of the hospital made it necessary to outweigh other considerations and to use aerial force to kill the enemy. In such case, the repeated aerial bombings would still be unconscionable, by being out of proportion with the expected objective. Furthermore, Grégoire Chamayou23 describes the moral hazards of the “zerocasualty warfare”, a military doctrine relying on the possession of technological means (e.g. high altitude bombing, the use of drones), whereby civilian casualties are deemed ‘collateral damage’ of attacks conducted from a