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March 1, 2000

Physician Groups and the War in Kosovo: Ethics, Neutrality, and Interventionism

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JAMA. 2000;283(9):1200. doi:10.1001/jama.283.9.1200-JMS0301-4-1

Throughout the 1990s, the International Committee of the Red Cross, Doctors Without Borders, other medical aid groups, and United Nations agencies were present in Kosovo, a Serbian-ruled province in Yugoslavia with an Albanian majority. The aid groups supported Kosovo's "official" and "unofficial" health care systems, the unofficial being a network of primary health clinics staffed by ethnic Albanian physicians and nurses, many of whom had been fired from jobs at public hospitals and clinics after Kosovo's status as an autonomous province was revoked in 1989.1

Following the revocation of autonomy, Kosovo's citizens voted overwhelmingly to form an independent republic. Serbian authorities did not recognize the referendum and engaged in a well-documented campaign of human rights violations against Kosovo's ethnic Albanian majority population.2 In the late 1990s, an armed group of ethnic Albanians known as the Kosovo Liberation Army emerged and began armed confrontations with Serbian forces. The Serbian response was a widespread assault on Albanian villages, resulting in displacement of the Albanian population.3 Checkpoints prevented free movement of Albanian patients and physicians, and a campaign of detentions, torture, and killings was launched against Albanian physicians, who were seen as potential aids to an armed Albanian independence movement.4 In response, international medical groups began sending teams of physicians and nurses along with medications and supplies to reach large groups of displaced persons.

At this point, many difficult ethical issues arose for international medical organizations. International health care workers were frequently threatened by Serbian soldiers and accused of supporting the Albanian war effort.4 One physician reported that as a result, her organization began a policy of not treating soldiers (anonymous physician, oral communication, Pristina, Kosovo, December 1998).

Refusing to treat soldiers who have no other medical options is a breach of the fundamental medical tenet that "a physician shall give emergency care as a humanitarian duty unless he is assured that others are willing and able to give such care."5 However, whether to risk compromising an aid effort by treating soldiers is a complex question for aid organizations, particularly when even providing medical care to beleaguered civilians may be viewed as a war action. To decrease the risk of compromise, some aid groups in Kosovo insisted that soldiers wear civilian clothing when seeking medical care, a stipulation with which soldiers reportedly complied.

At times, international physicians develop sympathy for the violated and anger toward the perpetrators of the human rights violations they witness. If they remain in the region as physicians, however, they must carry out their duties according to standard medical ethics, especially when victims of human rights violations subsequently become perpetrators.

During the time I was in Kosovo, in 1998 and 1999, I interviewed international physicians who had treated hundreds of displaced persons, discovered massacred Albanian civilians, and been harassed by Serbian soldiers. Some viewed the majority of Kosovo's Serbian population as complicit in these atrocities. When Albanians returned to the province in June 1999 and engaged in revenge attacks against Serbian civilians, international physicians were in a unique position to condemn the attacks, support the few remaining Serbian physicians, protect vulnerable Serb patients, and remind local Albanian physicians of their responsibility to treat all patients regardless of ethnicity. Unfortunately, not all overcame their own biases to do so.

Promotion of human rights has become an intimate concern of many physician groups, and conflicts may emerge between loyalty to human rights and loyalty to medical principles. Physicians for Human Rights (PHR) was founded in the 1980s by health care professionals who use their expertise to research and publicize human rights violations. After diplomatic efforts failed to end massacres and human rights violations against Kosovar Albanian civilians, PHR publicly released a letter to President Clinton calling for military intervention in the form of an international ground force.6 The statement of support for military action by a group of doctors, whose highest duty is generally considered to be the preservation of human life, surprised many.

Although the PHR statement was not founded on a medical principle, it was arguably founded on the higher moral duty to oppose attacks on civilians based on their religion or ethnicity. The idea of a medical group supporting armed intervention for such a purpose should not be rejected on principle. Military intervention must not be the first nor the only choice, but it needs to remain a choice for those who would act to prevent crimes against humanity.

Funding/Support: This work was supported by funding from the Sandler Family Supporting Foundation.
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United Nations, General Assembly resolution 49/204: situation of human rights in Kosovo.  December23 1994;Available at: http://www.un.org/ga/49/r204.pdf. Accessed January 14, 2000.
International Crisis Group, Kosovo's long hot summer: briefing on military, humanitarian, and political developments in Kosovo.  September2 1998;Available at: http://www.intl-crisis-group.org/projects/sbalkans/reports/kos05mai.htm. Accessed January 14, 2000.
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World Medical Association, International code of medical ethics.  January10 1983;Available at: http://www.wma.net/e/policy/17-a_e.html. Accessed January 14, 2000.
Rubenstein  LS PHR calls for ground troops in Kosovo: text of letter to President Clinton [Physicians for Human Rights Web site].  January22 1999;Available at: http://www.phrusa.org/new/kosolet.html. Accessed January 14, 2000.