Introduction
Armed conflicts expose populations to prolonged and repeated violence, leaving deep and lasting psychological wounds that may even continue into future generations.Footnote 1 Medical personnel play a vital role in alleviating this suffering by providing care and treatment to wounded soldiers and affected populations,Footnote 2 but they often face significant mental health challenges themselves while performing their duties in conflict settings.Footnote 3 The psychological well-being of medical personnel is fundamental for delivering high-quality care, especially during protracted armed conflicts.
In recognition of their essential role in the care and treatment of the wounded and sick, medical personnel are granted special protection under international humanitarian law (IHL);Footnote 4 in particular, they are to be respected and protected from attack and violence in all circumstances.Footnote 5 Despite this protection, armed conflicts have witnessed a rise in attacks on health care and medical personnel.Footnote 6 In recent decades, numerous initiatives have been undertaken to document attacks on health care and raise awareness about their consequences:Footnote 7 in 2016, for example, the United Nations (UN) Security Council adopted Resolution 2286 on the protection of health care in situations of armed conflict, condemning the growing violence, attacks and threats against medical personnel and recognizing the long-term consequences that such acts can have on the civilian population and the health-care systems of the countries concerned.Footnote 8 Such initiatives, however, have not stopped the attacks on health care that continue to dominate contemporary armed conflicts. In 2024 alone, more than 900 attacks on health-care facilities were documented across multiple conflict-affected countries, resulting in over 870 deaths and more than 770 persons injured among health-care workers.Footnote 9
Beyond this physical harm, medical personnel in armed conflict are often subjected to intense psychological strain, which can even outweigh the physical.Footnote 10 They work continuously under highly stressful and dangerous conditions and are regularly exposed to traumatic events while providing life-saving care to affected patients, often amid shortages of trained personnel and inadequate resources.Footnote 11 Their psychological distress is further compounded by the direct violence to which they are subjected, the proximity of attacks and the suffering they witness among patients, colleagues and the broader community.
The potential legal protection offered by IHL against these psychological health consequences for medical personnel remains largely unexplored in legal scholarship. Instead, existing analyses focus on the physical consequences of attacks on health-care facilities and medical personnel.Footnote 12 By contrast, the extent to which medical personnel are protected against direct psychological harm – such as that resulting from violence and threats – and incidental psychological harm – arising from the conditions in which medical personnel operate – has received only limited attention.Footnote 13 This article addresses this gap by examining whether IHL’s special protection regime, which obliges conflict parties to “respect and protect” medical personnel, could provide protection against both direct and indirect forms of psychological harm.
For the purposes of this article, “direct psychological harm” refers to psychological harm resulting from intentional acts such as violence, threats or intimidation specifically directed at medical personnel. “Incidental psychological harm” refers to psychological harm caused without any prior intention to target the individual, including so-called “vicarious trauma”, which arises from exposure to the traumatic experiences of others or from the inherent stresses of performing duties in armed conflict.Footnote 14
The article advances, as a de lege ferenda proposal, that the obligation to respect and protect medical personnel should be interpreted to encompass protection against both direct and incidental psychological harm. This interpretation is supported on several grounds. First, it reflects IHL’s growing recognition of the “person” in a broader sense, a development that has also gradually found its way into the legal framework applicable to medical personnel. Second, it follows from the broad formulation of the obligation to respect and protect. Finally, it aligns with IHL’s object and purpose of alleviating suffering in armed conflict.
The article first examines the manifestations of psychological harm and the circumstances in which such harm arises among medical personnel in armed conflict. It then discusses the special protection regime applicable to medical personnel. The article subsequently considers the evolving interpretation within IHL of the “person” in a broader sense, before analyzing the extent to which the obligation to respect and protect may encompass protection against both direct and incidental psychological harm.
Psychological harm experienced by medical personnel in armed conflict: Lessons from practice
Attacks on health care have a profound impact on the personal and professional lives of medical personnel, the communities they serve and even the country as a whole.Footnote 15 Health systems are weakened or disrupted, infectious diseases may re-emerge, and public trust in health care can decline, affecting individuals’ willingness to seek medical attention.Footnote 16 In 2025, the World Health Organization (WHO) documented over 1,300 attacks on health care, with more than 600 of them having specifically impacted medical personnel.Footnote 17 Such attacks have consequences that go beyond physical damage and loss of life, causing medical personnel to suffer psychological harm.
In particular, medical personnel frequently suffer from post-traumatic stress disorder (PTSD), with some continuing to exhibit symptoms several years later.Footnote 18 In addition, exposure to violence has been shown to significantly increase the likelihood of anxiety and depression.Footnote 19 A scientific study examining the impact of the 2023 civil war on medical personnel in Sudan found that over half of such personnel exhibited symptoms of anxiety, while 33% experienced depression.Footnote 20 Similarly, between 2023 and 2025, alarmingly high levels of psychological health consequences were reported among medical personnel in Gaza, with 84.6% experiencing moderate to severe anxiety, 76.8% reporting stress and 73.3% suffering from depression.Footnote 21 These mental health effects have important implications for health-care delivery, as they may impair clinical performance and increase the risk of medical errors.Footnote 22
Mental health consequences are further intensified by the stigma surrounding psychological harm. For instance, medical personnel in Syria reported feeling hesitant or embarrassed in disclosing symptoms of psychological distress and seeking psychological support.Footnote 23 Such reluctance often occurs alongside a shortage of available psychological support services, further restricting access to adequate care. Having outlined the psychological distress symptoms experienced by medical personnel, the following sections explore the acts and circumstances that give rise to them.
Direct psychological harm resulting from intentional acts
Medical personnel working in armed conflict face heightened risks of deliberate attacks and targeted violence.Footnote 24 Their elevated vulnerability stems from the nature of their work. They manage valuable resources, such as medicines and transportation, and are exposed to potential attacks while travelling to deliver supplies or conduct outreach activities. In some cases, medical personnel are killed as a direct result of air strikes on hospitals while treating patients, or they are deliberately targeted through physical violence, killings, sexual violence and/or torture, resulting in severe psychological harm.Footnote 25
Furthermore, medical personnel report fear of arrest, as the provision of medical care to opponents of the government or certain armed groups is often criminalized.Footnote 26 In addition to facing arrest, they risk having their medical licenses revoked or being dismissed from their positions.Footnote 27 In some instances, their family members are targeted, kidnapped or arrested in an effort to coerce them into ceasing the treatment of individuals from the opposing side or prioritizing care of their own armed forces.Footnote 28 The constant fear of being arrested or detained not only affects their mental well-being but can also influence their decision-making and ability to perform their functions.Footnote 29
In addition, medical personnel are frequently subjected to physical and verbal threats against themselves or their family members, as well as harassment, contributing to high levels of burn-out and emotional exhaustion.Footnote 30 For instance, it has been reported that ambulance drivers and physicians conducting home visits are obstructed at checkpoints, preventing them from reaching their patients.Footnote 31 In certain cases, harassment even extends to the homes of medical personnel, which are subjected to raids, shelling or gunfire, forcing many to flee temporarily or permanently.Footnote 32
Incidental psychological harm resulting from the broader context of the armed conflict
Medical personnel also suffer from psychological harm as a result of having to perform their duties in armed conflict. For instance, many report fearing for their own lives and those of their family members when missile strikes occur in the vicinity of hospitals or their homes, leading some to live under constant fear, stress and anxiety.Footnote 33 In certain situations, medical staff have been forced to abandon health-care facilities under attack, leaving patients behind to save their own lives; such circumstances can result in profound feelings of guilt. The use of “double-tap attacks”, where an initial strike is followed by another minutes or hours later, may further intensify psychological trauma.Footnote 34 These tactics subject medical personnel to anticipatory stress, helplessness, and fear of renewed attacks, while they are required to work rapidly to evacuate patients in order to prevent additional casualties.Footnote 35 In armed conflicts where chemical weapons are used, stress can be further intensified, as medical personnel must treat patients exposed to chemical agents without adequate protective equipment, increasing both their physical risk and psychological strain.Footnote 36
Moreover, stress symptoms are often exacerbated by the scarcity of medical personnel. While many remain in their posts out of a sense of professionalism, previous research suggests that for some, the psychological burden may become overwhelming, prompting them to resign and seek employment in more stable areas.Footnote 37 Those who remain frequently report feelings of helplessness due to the number of patients they are unable to care for.Footnote 38 Excessive workloads and resource shortages may contribute to burn-out, anxiety and depression as well as an increased risk of professional errors.Footnote 39
A related aspect is the psychological distress that medical personnel may experience when facing ethical dilemmas. Seizures and destruction of health-care facilities, imposition of blockades and destruction of medical equipment prevent medical personnel from ensuring proper triage and providing adequate care for patients.Footnote 40 Moreover, the scarcity of medical equipment forces them to make extremely difficult decisions, providing care only to those most in need, while others must go without.Footnote 41 Sometimes, the situation becomes so dire that physicians have to perform life-saving surgeries without anaesthesia, causing them to suffer from feelings of helplessness and secondary traumatic stress.Footnote 42 On top of that, medical personnel frequently have to convey bad news to family members, such as informing them of the lack of resources necessary to treat their loved ones, which can be a highly distressing task.
Medical personnel are also susceptible to trauma arising from continuous exposure to their patients’ suffering. In armed conflict, fear for personal safety leads individuals to delay seeking medical care, allowing easily treatable conditions to develop into complicated or untreatable cases.Footnote 43 Furthermore, medical personnel understandably experience immense psychological trauma and grief when witnessing the suffering of their colleagues.Footnote 44
In light of the severity and pervasiveness of the psychological harm experienced by medical personnel, as well as its potential impact on their ability to perform their functions, the question arises as to whether IHL affords protection against such harm. This article argues that it should, and proposes that the special protection regime reflected in the obligation to respect and protect medical personnel provides the appropriate legal framework for achieving such protection.
The special protection of medical personnel under IHL
IHL serves to limit the suffering inherent in armed conflict and to protect those who are not, or are no longer, taking part in hostilities. The protection of the wounded and sick has been one of IHL’s core principles since its early development, as first codified in the 1864 Geneva Convention for the Amelioration of the Condition of the Wounded and Sick in Armies in the Field.Footnote 45 This protection was subsequently expanded to also cover the care of the wounded and sick at sea, as well as that of wounded and sick civilians.Footnote 46 It is now an established rule of customary international law that the wounded and sick must be respected and protected in all circumstances;Footnote 47 in addition, they must be treated humanely and cared for without any distinction based on sex, race, nationality, religion, political opinions or any other similar criteria.Footnote 48
Importantly, the Geneva Convention of 1864 not only provided for the protection of the wounded and sick but also entrusted their care and treatment to medical personnel, obliging the latter to provide care regardless of the allegiance of the person they are treating. It further recognized ambulances, hospitals and medical staff as neutral and required their respect and protection.Footnote 49 Such safeguards are essential, as the protection of the wounded and sick would be diluted if those entrusted with their care were not themselves protected.Footnote 50 Consequently, IHL establishes a subsidiary protection regime for medical personnel.Footnote 51
Accordingly, medical personnel are afforded similar special protection to that afforded to the wounded and sick, and must likewise be respected and protected in all circumstances during armed conflict.Footnote 52 In the context of an international armed conflict (IAC), this rule is expressly provided for permanent military medical personnel, auxiliary medical personnel, personnel of aid societies, medical personnel at sea and civilian medical personnel.Footnote 53 For instance, Article 24 of Geneva Convention I (GC I) with respect to permanent military medical personnel stipulates:
Medical personnel exclusively engaged in the search for, or the collection, transport or treatment of the wounded or sick, or in the prevention of disease, [and] staff exclusively engaged in the administration of medical units and establishments, … shall be respected and protected in all circumstances.Footnote 54
It has been confirmed in the 2025 International Committee of the Red Cross (ICRC) Commentary on Geneva Convention IV (GC IV) that similar protection, in the context of a non-international armed conflict (NIAC), can be derived from the customary international law obligation in Article 3 common to the four Geneva Conventions (common Article 3), which requires that the wounded and sick “shall be collected and cared for”.Footnote 55 This obligation confirms that the protection of medical personnel operates as a subsidiary safeguard, designed to guarantee that the wounded and sick receive the care to which they are entitled. With the adoption of Additional Protocol II to the Geneva Conventions (AP II), the obligation to respect and protect medical personnel was explicitly extended to NIACs.Footnote 56 In any case, it is now generally accepted that the overarching rule that “[m]edical personnel exclusively assigned to medical duties must be respected and protected in all circumstances” has crystallized in customary international law, applying to both IACs and NIACs.Footnote 57
The obligation that medical personnel must be respected and protected “in all circumstances” underscores that this protection cannot be overridden for operational reasons or reasons of military necessity.Footnote 58 Medical personnel can lose their protection only in very limited circumstances – namely, when they commit acts harmful to the enemy outside their humanitarian duties.Footnote 59 This regime is more stringent than the general protection afforded to civilians; unlike civilians, loss of protection for medical personnel occurs only after a due warning has been issued and remains unheeded for a reasonable period.Footnote 60 Moreover, a single harmful act results in only temporary loss of protection, meaning that once the act ceases to produce its harmful effects, protection must be restored.Footnote 61 These strict rules demonstrate the rationale of the special protection regime, which is to enable medical personnel to perform their duties.
The critical nature of medical personnel’s functions is further illustrated when permanent military medical personnel or personnel of aid societies fall into enemy hands.Footnote 62 Rather than acquiring prisoner of war status under Geneva Convention III (GC III), these personnel are subject to a special retention regime which allows them to continue performing medical duties for wounded and sick prisoners of war, according to the patients’ medical and spiritual needs and their number.Footnote 63 This continuation of duties underscores the essential character of medical personnel’s work – even in captivity, they must provide medical care, including mental health and psychological support.Footnote 64
Before addressing the specific scope and content of the obligation to respect and protect medical personnel, this article traces the increasing recognition within IHL of the “person” in a broader sense, including both physical and mental integrity. Building on this development, it then argues, de lege ferenda, that the obligation to respect and protect should be interpreted as including protection against both direct and incidental psychological harm.
IHL and the recognition of the “person” in a broader sense
While, historically, IHL has centred on protecting persons from physical harm arising from armed conflict, its understanding of harm has gradually evolved to include psychological harm. Today, IHL is increasingly regarded as safeguarding the “person” in a broader sense, encompassing both their physical and mental integrity.Footnote 65 This interpretation is supported by the 1958 ICRC Commentary on GC IV, which emphasizes that the Geneva Conventions’ focus on the protection of persons reflects an understanding of the individual in “its widest sense”, referring to “the rights and qualities which are inseparable from the human being by the very fact of his existence and his mental and physical powers; it includes, in particular, the right to physical, moral and intellectual integrity”.Footnote 66
This broader understanding of the “person”, together with the growing recognition of mental health within IHL, also finds expression in provisions governing medical duties in armed conflict and in rules prohibiting the intentional infliction of severe psychological harm, under which medical personnel are protected as persons not actively participating in hostilities.
Definitions of “wounded and sick” and “medical personnel”
The evolution of IHL towards recognizing mental health is reflected in the scope of medical services delivered by medical personnel in armed conflict. First, mental health conditions are encompassed within the definition of the “wounded” and “sick”. As noted in the 2025 ICRC Commentary on GC IV, the IHL definition of “wounded and sick” is broader than the ordinary meaning of these terms, covering a wide range of medical conditions that includes both physical conditions and mental ones such as PTSD.Footnote 67 This inclusive interpretation is also reflected in the definition of “wounded” and “sick” in Article 8(a) of Additional Protocol I (AP I).Footnote 68
Interestingly, to fall under the protection afforded to the wounded and sick, it is irrelevant how the mental conditions were caused – the sole criterion is that the person is in need of medical care, irrespective of the origin of their condition.Footnote 69 Accordingly, protection extends not only to individuals whose mental conditions result directly from military operations, but also to those whose conditions or treatment are affected indirectly by the armed conflict, for example through the destruction of medical facilities on which their treatment depends or limited access to essential medicines.Footnote 70 Mental conditions therefore need not stem from attacks on the battlefield but may arise from indirect consequences of the conflict.
Furthermore, given the role of medical personnel in providing care to the wounded and sick, it is unsurprising that addressing mental health and psychological harm is recognized as part of their responsibilities in armed conflict. Like the notion of “wounded and sick”, the term “permanent military medical personnel” in GC I is defined broadly, encompassing various categories of persons within its protective framework.Footnote 71 Notably, the first category mentioned includes “medical personnel engaged in the search, collection, transport or treatment of the wounded of sick, or in the prevention of disease”.Footnote 72 The 2016 ICRC Commentary on GC I explicitly notes that “treatment” may include psychological treatment and that “prevention of disease” can cover the activities of psychologists involved in preventing trauma, such as combat-related stress and mental disorders.Footnote 73 While this provision focuses on the medical service provided to the wounded and sick, it nevertheless acknowledges the importance of treating and preventing psychological harm in the context of armed conflict.
Building on this, the importance of addressing psychological harm may also be reflected within the customary law obligation to provide care to the wounded and sick. The wounded, sick and shipwrecked are entitled to receive adequate medical care required by their medical condition.Footnote 74 One author argues, based on the broad definition of “wounded and sick” given in Article 8(a) of AP I, that “adequate care” may include “short- and long-term medical, mental, and rehabilitative care for those with conflict-related physical and psychological health problems, including victims of sexual violence”.Footnote 75
While these references to psychological harm do not establish a prohibition against causing such harm to medical personnel, nor create an explicit obligation to protect them from it, they signal a growing recognition of the importance of psychological health in the special protection regime of medical personnel. They also demonstrate IHL’s capacity to address psychological harm, whether inflicted directly or indirectly.
Prohibitions on the intentional infliction of severe psychological harm
IHL’s growing recognition of the person in a broader sense, encompassing both physical and mental integrity, is reflected in the prohibitions against the intentional infliction of certain severe forms of psychological harm on protected persons. Even outside the special protection framework, medical personnel are already protected against such severe forms of harm.
In particular, in the context of a NIAC, common Article 3 contains several minimum provisions protecting persons who are taking no active part in the hostilities, including medical personnel, from harm to their mental integrity.Footnote 76 Of particular note is the prohibition against exercising violence to the person, which interprets “person” broadly to include the protection of both physical and mental integrity.Footnote 77 The rationale behind this is that violations of a person’s mental well-being would be irreconcilable with the fundamental principle of humane treatment underlying common Article 3.Footnote 78 It is widely accepted that the acts specifically mentioned under this provision, such as cruel treatment and torture, encompass conduct detrimental to the mental integrity of persons.Footnote 79 For example, the definition of cruel treatment, namely “treatment which causes serious mental or physical suffering or constitutes a serious attack upon human dignity”, demonstrates that suffering need not be physical, and that mental suffering in itself can be sufficient to qualify as cruel treatment.Footnote 80 Accordingly, subjecting medical personnel to any of the aforementioned acts, which causes them to suffer serious psychological harm, would be prohibited under this minimum standard.
In addition, certain acts intentionally inflicting severe psychological harm amount to grave breaches of the Geneva Conventions, and are further prohibited as war crimes in IACs.Footnote 81 While these prohibitions are not specific to medical personnel, they apply to them for the same reason discussed above with respect to common Article 3: because of their protected status under IHL. A first category of acts prohibited as grave breaches comprises torture and inhuman treatment. The severe pain or suffering which is covered under torture may be either physical or mental,Footnote 82 while inhuman treatment similarly covers serious mental or physical harm that falls short of the threshold required for torture.Footnote 83 A second category concerns biological experiments on protected persons, where the experiment seriously endangers their physical or mental health or integrity.Footnote 84 Finally, it is prohibited to wilfully cause individuals “great suffering or serious injury to [their] body or health”.Footnote 85 Again, suffering may be physical or mental, and “injury to health” encompasses harm to both aspects of the protected person’s well-being.Footnote 86 This prohibition thus underscores the obligation to treat protected persons humanely and to safeguard their physical and mental integrity at all times.Footnote 87
While the foregoing prohibitions concern only the most severe forms of intentional psychological harm that persons taking no active part in hostilities, such as medical personnel, may suffer, they nevertheless demonstrate that IHL is capable of addressing some forms of direct psychological harm caused to medical personnel. Moreover, these rules highlight the growing significance of protecting individuals from severe psychological harm, the violation of which can give rise to accountability for the most serious violations of IHL.
The obligation to respect and protect medical personnel: Extending protection to psychological harm?
Building on the previous section, this part of the article argues that IHL’s evolving recognition of the “person” in a broader sense informs the regime applicable to medical personnel under IHL. Accordingly, it advances the argument that the obligation to respect and protect should be interpreted as encompassing protection against both direct and incidental psychological harm.
As noted above, medical personnel benefit from a special protection regime which obliges the parties to the conflict to ensure their respect and protection. The Geneva Conventions, however, do not explicitly define the notion of “respect and protect”, nor do they provide an exhaustive list of prohibited acts. The notion of “respect” refers primarily to the obligation to refrain from acts of violence; more specifically, it proscribes making medical personnel the object of an attack, whether the attack is deliberate, indiscriminate or in contravention of the principle of proportionality.Footnote 88 It is likewise prohibited to kill, injure or otherwise harm them, as well as to kidnap them, physically or sexually assault them or subject them to torture.Footnote 89 The duty to “protect”, on the other hand, imposes an obligation to take active steps to ensure that others do not impede the work of medical personnel, and to shield them from harm.Footnote 90
This interpretation of the obligation to respect and protect seems to suggest that the obligation primarily covers protection against attacks and physical harm.Footnote 91 Neither the Geneva Conventions nor their ICRC Commentaries discuss whether this obligation also encompasses protection against psychological harm;Footnote 92 likewise, there is currently no international practice confirming that such harm falls within its scope.Footnote 93 Nevertheless, it will be demonstrated in the next sections that extending this protection to include psychological harm would not require legal innovation but would primarily be a matter of interpretation, which should be guided by IHL’s object and purpose.
The obligation to respect and protect is formulated in a broad manner
Although there is no specific mention of protection against psychological harm to medical personnel in the Geneva Conventions, the ICRC Commentaries emphasize that the multifaceted nature of the notions of “respect” and “protect” cannot be reduced to a simple checklist of measures. The Commentaries “merely serve to highlight, by way of example” some of the different aspects involved in implementing the obligation.Footnote 94 In other words, the examples provided above are illustrative rather than exhaustive.
Moreover, the protection afforded to medical personnel implies that they cannot be harmed in any way and that parties to the conflict must take feasible steps to “protect” them from harm.Footnote 95 The Geneva Conventions do not specify the types of harm from which they must be protected, but the broad framing of “harm” may leave the door open for an interpretation that extends protection to psychological harm – for instance, Black’s Law Dictionary defines “harm” as “injury, loss, damage; material or tangible detriment”, and explicitly includes mental harm, defined as “any impairment of a person’s mind, [especially] when the impairment has resulted from something external, such as injury”. Black’s further notes that harm may be accidental, meaning that it is not caused by a purposeful or tortious act.Footnote 96 Importantly, as discussed above, in light of IHL’s recognition of the person in a broader sense, which encompasses both physical and mental integrity, the notion of harm should reasonably be understood to include psychological harm.
In this regard, the ICRC Commentaries provide some indications that intentionally causing psychological harm to medical personnel would be prohibited under the obligation to respect and protect; for instance, the obligation to respect prohibits threats and acts of intimidation, indicating protection beyond purely physical harm.Footnote 97 This interpretation is reinforced by the case law of international criminal tribunals, which recognizes that threats and intimidation may cause serious psychological harm to victims.Footnote 98 Furthermore, guidance may be drawn from the interpretation of Article 12(2) of GC I on the protection of the wounded and sick, which prohibits any form of violence, whether physical or psychological.Footnote 99
In addition, the obligation to respect requires parties to comply with the legal framework governing medical ethics,Footnote 100 and to this end, several provisions are designed to eliminate fear or coercion faced by medical personnel in the performance of their duties.Footnote 101 For example, it is prohibited to threaten, harass or punish medical personnel for carrying out their functions,Footnote 102 and it is also prohibited to compel them either to act contrary to medical ethics or to refrain from acts required by medical ethics, such as providing care to members of the adverse party.Footnote 103
While extending protection to direct psychological harm poses few interpretative difficulties, applying it to incidental psychological harm would present additional complexities. A central question is whether the duty to protect is capable of addressing psychological harm that occurs indirectly. This question should be answered in the affirmative, drawing on the interpretation of the obligation to protect the wounded and sick.Footnote 104 In this regard, it has been suggested that the obligation to protect could cover not only harm posed by other individuals – such as a party’s own soldiers, enemy combatants or civilians – but also indirect harm arising in the context of an armed conflict, such as through ongoing hostilities or natural hazards.Footnote 105 If the obligation to protect can encompass such indirect forms of harm arising from the broader conflict environment, it could likewise extend to incidental psychological harm suffered as a consequence of those same circumstances.Footnote 106
Moreover, in relation to the wounded and sick, the 2016 Commentary on GC I even notes that the duty to protect “could be interpreted as a requirement to protect them from the dangers arising from their medical condition”, which implies the provision of necessary medical treatment.Footnote 107 Although this provision concerns the wounded and sick rather than medical personnel, it illustrates that the obligation to protect may also require measures addressing risks arising from the circumstances of armed conflict or from the individual’s condition. By analogy, this broader understanding of the duty to protect lends support to the view that the obligation should, in principle, encompass incidental psychological harm affecting medical personnel when such harm results from the conflict environment.
The obligation to protect medical personnel also requires that parties to the conflict take measures to ensure that they can carry out their medical duties.Footnote 108 This obligation is articulated in Article 9(1) of AP II, which requires parties to grant medical personnel “all available help for the performance of their duties”.Footnote 109 Article 15 of AP I affords similar protection to civilian medical personnel in areas “where civilian medical services are disrupted by reason of combat activity”.Footnote 110 The Commentary on AP I clarifies that the object of this provision is to enable civilian medical personnel to fulfil their task, not only by ensuring their respect and protection, but also by providing the necessary assistance.Footnote 111 The 2025 Commentary on GC IV illustrates that the obligation to protect includes both passive measures to avoid impeding access to affected areas and active measures to facilitate the performance of medical duties, such as providing shelter and transport to the wounded and sick.Footnote 112
Considering that the obligation to protect requires parties to take active measures to enable medical personnel to carry out their duties, and that similar obligations toward the wounded and sick may be interpreted as encompassing risks arising from their medical condition, it may be argued that the obligation to protect medical personnel could, in some instances, extend to measures supporting their mental health, including the provision of psychological support.
In view of IHL’s object and purpose, the obligation to respect and protect should be interpreted to include psychological harm
In any event, protection against both direct and incidental psychological harm should be considered part of the obligation to respect and protect, in view of the object and purpose of the Geneva Conventions. Pursuant to Article 31(1) of the Vienna Convention on the Law of Treaties (VCLT), the Geneva Conventions must be interpreted “in good faith in accordance with the ordinary meaning to be given to the terms of the [Conventions] in their context and in the light of [the Conventions’] object and purpose”.Footnote 113 The overarching purpose of IHL, as reflected in the Geneva Conventions, is to alleviate the suffering of persons who are not, or are no longer, actively taking part in the hostilities. This is especially evident from the titles of the respective Conventions: while GC I and II focus on the protection of wounded, sick and shipwrecked members of the armed forces, GC IV serves to protect civilians against the consequences of armed conflict.Footnote 114
Moreover, the special protection afforded to medical personnel, as well as to medical units and transports, specifically serves the purpose of alleviating the suffering of one category of persons not actively participating in hostilities, namely the wounded and sick. The significance of this protective framework within IHL should not be under-estimated.
In light of IHL’s purpose to alleviate human suffering in armed conflict, the protection granted to medical personnel is of paramount importance. When medical personnel are unable to provide care to the wounded and sick, the consequences can be disastrous for both the affected population and the broader health system.Footnote 115 The special protection of medical personnel thus reflects the critical role they play in the challenging context of armed conflict, where the number of casualties and the need for medical care are exceptionally high.Footnote 116
Limiting the obligation to respect and protect medical personnel to physical harm alone does not reflect the contemporary understanding of the suffering caused by armed conflict, which the Geneva Conventions seek to mitigate. Over recent decades, there has been increasing awareness of the impact of armed conflict on individuals’ mental health.Footnote 117 Importantly, the special protection framework applicable to the wounded and sick recognizes such psychological harm and provides protection against it. Accordingly, medical personnel care not only for patients suffering from mental health conditions caused by direct acts of violence, but also for those affected indirectly by the conflict environment.Footnote 118
Unsurprisingly, medical personnel are not spared from these effects. As noted above, they experience psychological harm as a result of direct violence, exposure to traumatic events and the stressful conditions under which they perform their duties.Footnote 119 In some cases, the impact on their mental health may be even more severe than physical injury.Footnote 120 When psychological harm impairs medical personnel to such an extent that it affects their ability to perform their medical duties (the possibility of which is shown by the scientific studies mentioned above), IHL’s humanitarian purpose of alleviating the suffering caused by armed conflict and protecting the wounded and sick cannot be fulfilled.
Additional support for this interpretation may be drawn from the principle of “good faith”. As noted above, under Article 31(1) of the VCLT, the Geneva Conventions must be interpreted in good faith;Footnote 121 this means that they must be construed in a way that ensures that the protections they afford to individuals affected by armed conflict are fully effective.Footnote 122 In light of this, and given the impact of psychological harm on medical personnel, interpreting the obligation to respect and protect in good faith – which entails ensuring the effective protection of the wounded and sick – supports an interpretation that the obligation should extend to such harm. Indeed, effective care and treatment of the wounded and sick necessarily presupposes that the medical personnel responsible for their care are themselves in a sound state of (mental) health.Footnote 123
Psychological harm under the obligation to respect and protect: Implementation in practice
Without purporting to provide an exhaustive account of parties’ obligations in armed conflict, this section offers illustrative examples of what the obligation to respect and protect medical personnel from psychological harm might include. It seeks to invite further reflection on how direct and incidental psychological harm could be more explicitly recognized and addressed within the special protection framework.
The operationalization of the obligation to prevent direct psychological harm to medical personnel follows from the obligation’s character as a negative obligation of result.Footnote 124 The duty to respect requires parties to refrain from conduct that causes such harm; accordingly, any intentional act directed at medical personnel, whether specifically aimed at affecting their mental well-being (including threats, intimidation, harassment, coercion and psychological torture) or aimed at inflicting physical injury (such as attacks or assault) and thereby also resulting in psychological harm, is absolutely prohibited.
By contrast, the protection against incidental psychological harm raises more complex issues of operationalization. The prevention of such harm requires measures that go beyond prohibiting specific harmful acts and instead address the broader armed conflict environment in which medical personnel deliver medical care. Such measures could, for instance, include integrating awareness of the mental health impacts of armed conflict on medical personnel into military training and ensuring that such considerations are reflected in operational planning.Footnote 125 They reflect a due diligence obligation requiring parties to the conflict to take feasible steps to reduce incidental psychological harm in the planning and conduct of military operations affecting medical personnel and the hospitals in which they work.Footnote 126 In addition, they may include measures to reduce the inherent psychological strain experienced by medical personnel during armed conflict, thereby enabling them to perform their functions effectively, for example by addressing shortages of personnel and medical equipment.Footnote 127 Moreover, in certain instances, ensuring that medical personnel can continue to carry out their duties may require psychological support mechanisms, including resilience programmes and appropriate treatment for psychological harm.Footnote 128
Psychological harm under the obligation to respect and protect: Addressing criticisms
Having demonstrated that the obligation to respect and protect medical personnel should be interpreted de lege ferenda to include protection against psychological harm, and having discussed how this could be operationalized in practice, this section attempts to briefly address some of the criticisms that may be raised regarding this interpretation.
As with the protection of civilians, extending protection to cover psychological harm to medical personnel may be subject to criticism.Footnote 129 A concern frequently raised in discussions of psychological harm to the civilian population is that fear and psychological harm are, to some extent, inherent in armed conflict. In the Milošević case, the International Criminal Tribunal for the former Yugoslavia (ICTY) observed that “a certain degree of fear and intimidation among the civilian population is present in nearly every armed conflict”;Footnote 130 such criticism may be particularly relevant when considering incidental psychological harm experienced by medical personnel. It should be emphasized that, for incidental psychological harm to be covered under the protection framework, it must be serious and cannot be reduced to mere feelings of discomfort.Footnote 131 In light of the rationale underlying the obligation to respect and protect, incidental psychological harm should, at a minimum, significantly impair medical personnel’s ability to perform their essential duties of providing care and treatment to the wounded and sick. Examples include psychological conditions like PTSD or severe anxiety disorders.Footnote 132
Relatedly, an additional concern regarding the legal recognition of psychological harm is that it may not be sufficiently tangible and foreseeable to be incorporated into the IHL protective framework.Footnote 133 This concern arises from the inherently subjective nature of psychological harm, which varies across individuals and may make it difficult to establish predictability and a causal link between a specific event and the resulting psychological harm.Footnote 134 The issue is most pronounced for incidental psychological harm, which arises from the broader context of armed conflict rather than from deliberate acts. By contrast, direct psychological harm is more straightforward to address, as its inclusion within the obligation to respect and protect can be achieved by interpreting the notion of “respect” as prohibiting conduct that deliberately causes psychological harm to medical personnel.
Nevertheless, potential criticism that incidental psychological harm would be too intangible or unpredictable to be included under the obligation to protect should be rejected. Consider, for example, a soldier suffering from PTSD. Due to his mental condition, he would be regarded as wounded and sick under the definition found in the Geneva Conventions,Footnote 135 and as a result, he would benefit from protection under the obligation to respect and protect, meaning that he should be shielded from further harm.Footnote 136 If psychological harm is sufficiently tangible to trigger protection for the wounded and sick, the same reasoning should a fortiori extend to medical personnel.
Moreover, it should be borne in mind that the obligation to protect requires parties to take preventive measures to minimize, as far as possible, psychological harm to medical personnel. Scientific studies on trauma prevalence among medical personnel in armed conflict can provide guidance on the likely occurrence and severity of incidental psychological harm in specific circumstances, and established conceptual frameworks for understanding psychological harm, most notably those relating to PTSD, can help identify when such harm reaches a level that impairs medical personnel’s ability to provide care.Footnote 137 This, in turn, can inform both the identification of when preventive measures are necessary and the design of those measures.
Another aspect of criticism could concern the additional burden that conflict parties might face if psychological harm were interpreted as falling within the protection to be accorded to medical personnel. As noted, the duty to refrain from causing direct psychological harm is straightforward to observe, as it merely requires abstaining from conduct that causes such harm. The obligation to protect medical personnel from incidental psychological harm, on the other hand, would require active measures and resources, such as organizing resilience campaigns, providing psychological treatment and establishing mental health centres.
One might argue that imposing additional burdens on parties in the already constrained context of armed conflict could, at first glance, appear to exceed the scope of IHL; however, IHL already anticipates obligations addressing indirect consequences of armed conflict, such as organizing vaccination campaigns.Footnote 138 In any event, compliance with the obligation to protect medical personnel from incidental psychological harm should be assessed on a case-by-case basis, taking into account the resources and capacities available to the party concerned. In light of the balance that IHL seeks to strike between military necessity and humanitarian considerations, it would be excessive to require parties to take every technically possible measure to prevent psychological harm among medical personnel.Footnote 139 The relevant criterion to be taken into account is feasibility, which depends on factors such as the imminence and severity of the psychological harm, control over territory where the hospital is located, and the State’s capacity and resources.Footnote 140 At a minimum, parties should aim to raise awareness of the psychological health effects on medical personnel enjoying special protection and take reasonable measures to mitigate them.
Ultimately, although safeguarding medical personnel against psychological harm may impose additional burdens on parties, such measures benefit all sides. Medical personnel are obliged, in accordance with medical ethics, to provide care and treatment to all wounded and sick persons, irrespective of whether those persons belong to their own forces or to those of the adverse party.Footnote 141 Protecting such personnel from psychological harm helps to ensure that they can continue performing these duties, which in turn serves the interests of all parties: wounded and sick combatants are more likely to recover and potentially return to the battlefield, while civilian suffering is also mitigated.
Conclusion
Medical personnel face significant psychological harm while performing their duties during armed conflict, whether directly through acts of violence or threats, or indirectly through the pressures of working under conflict conditions and witnessing the suffering of those affected by the armed conflict. Such harm not only affects their well-being but also undermines their ability to provide care, with consequences for patients, health systems and communities more broadly.
In recognition of their indispensable role in armed conflict, medical personnel are entitled to special protection, reflected in the obligation to respect and protect them at all times. This article has called for an interpretation of this obligation that encompasses protection against both direct and incidental psychological harm. Rather than this being an unduly idealistic proposal, it has been shown that IHL already contains the necessary characteristics to accommodate such protection. First, the inclusion of protection against psychological harm should be understood as a natural consequence of the recognition within IHL of the “person” in a broader sense, safeguarding both their physical and mental integrity. This recognition has also found its way into the protection framework for medical personnel, as evidenced by several provisions referring to the safeguarding of the mental health of protected persons. In addition, the inclusive interpretation proposed by this article is supported by the broad formulation of the obligation to respect and protect, as well as by the object and purpose of the Geneva Conventions; indeed, such an extension is necessary if IHL is to preserve its legitimacy as a body of law aimed at alleviating human suffering.
Incorporating psychological harm under the obligation to respect and protect will not be an easy task, particularly with regard to incidental psychological harm. While protection against direct psychological harm can be accommodated as a prohibition under the obligation to respect, addressing incidental psychological harm requires active measures by conflict parties. Despite remaining uncertainties regarding practical implementation, objections grounded in the alleged intangibility of psychological harm or in the perceived additional burden for conflict parties cannot justify rejecting this interpretation. Recognizing the mental health of medical personnel as an integral aspect of their special protection under IHL ultimately serves the interests of all those in need of medical assistance during armed conflict.
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