Attacks on healthcare facilities and personnel have become a defining feature of contemporary armed conflicts, highlighting persistent gaps between the legal protections afforded under international humanitarian law and operational realities. While often framed through the concept of "medical neutrality", legal protection is grounded in specific treaty and customary rules obligating parties to respect and protect medical personnel, units, and transports, as well as the wounded and sick. [1 , 2 , 3 ] This article review analyzes the historical evolution, doctrinal framework, and operational implications of healthcare protection in armed conflict. Drawing on the Geneva Conventions of 1949, their Additional Protocols of 1977, customary international law, institutional reports, and academic literature, the study provides a practical and analytical approach to understanding the interaction between law, ethics, and emergency medicine practice. [4 , 5 , 6 ] From early conflicts such as the Crimean War and the American Civil War to the two World Wars, recurrent attacks on medical infrastructure catalyzed the development of formalized protections in the 1864 Geneva Convention and subsequent treaties. [7 , 8 , 9 , 10 , 11 ] The Geneva Conventions and their 1977 Additional Protocols established comprehensive safeguards for hospitals, ambulances, medical transports, and healthcare personnel. [12 , 13 , 14 , 15 , 16 ] Despite these legal frameworks, modern armed conflicts, including those in Syria, Yemen, Ukraine, Afghanistan, Gaza and Israel, and the Balkans, have demonstrated widespread and systematic violations of these protections. [17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 ] Under international humanitarian law (IHL), protection may be lost when healthcare facilities or personnel engage in acts harmful, or perceived to be harmful, to an opposing party, including co-location with combatant forces. 12 , 15 Such violations may constitute war crimes under international law. [25 , 26 , 27 ] The analysis demonstrates that legal protection is contingent upon compliance with IHL and the humanitarian function of medical services, not on the abstract notion of neutrality. It examines conditions under which protection may be lost, including acts harmful to the enemy, and highlights the operational consequences for emergency care delivery in both international and non-international armed conflicts. [28 , 29 , 30 , 31 ] Strengthening compliance requires legal clarity, operational integration, systematic documentation of violations, and proactive engagement by emergency medicine professionals. Recognizing the limits of both ethical and legal protection is critical for maintaining the safety and effectiveness of healthcare services in conflict zones.
Suter et al. (Mon,) studied this question.