Ten interviews were conducted with Role 1 general practitioners (GPs), deployed in combat units, and 10 other interviews were performed with Role 2 specialist doctors (SPs): six anesthesiologist-intensivists, two gastrointestinal surgeons, and two orthopedic surgeons. Demographic characteristics and interview lengths are summarized in Table 1. All participants had at least been involved in Operation Barkhane. All but two (n = 18, 90%) had last been deployed in the western theater (Mali), where most military operations are concentrated, the eastern theater (Chad) being the support base, where the command center of Operation Barkhane is located.
Within the dataset, we chose to highlight the ethical dilemmas experienced by participants using representative quotes. To ensure anonymity, respondents are referred to by their inclusion number (GP1, GP2 etc. for general practitioners and SP1, SP2 etc. for specialist doctors). All participants felt in retrospect that they had faced several ethical dilemmas when deployed in Operation Barkhane.
Professional identity
Participants were asked to describe how they perceived their dual status as a doctor and a soldier in overseas operations. None of the respondents considered themselves combatants, stating that while they did carry weapons, this was only to defend themselves and not to take any active part in combat operations:
“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.” MG6
All respondents felt comfortable in their roles as caregivers and soldiers, even though they reported their position as being apart in operations, their primary mission being to provide medical support to Barkhane forces:
“We are appreciated for our true worth by the soldiers we work with. We are above all doctors, but in a setting that forces us to remember that we are also soldiers, at the service of power and politics”. SPE3
Ethical dilemmas faced by participants in overseas operations
Thirty-six codes were identified and grouped into five topics that highlight the dilemmas encountered by respondents.
Faced with the impossibility of treating all presenting patients, which ones should be chosen? (Resource rationing and distributive justice)
In providing MAC, five respondents (MG2,3,9 and SP7,9) reported that they had had to make difficult decisions regarding which patients to take care of. Choices were influenced by third parties, local civilian recruitment officers (LCROs) or nurses, who wanted patients to be sorted by perceived social value, sex or age criteria unfavourable to women and children and discriminatory.
“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.” MG2
Other respondents reported financial discrimination. Consultation coupons were bought by patients from LCROs, and only those with the means to pay could access MAC, which is supposed to be free.
Still in the context of delivering MAC, four specialist doctors (SP2–4,6) mentioned having had to abandon too severely ill patients despite having been able to treat them, because this would have consumed considerable human and material resources at the expense of the many more patients with more easily treated conditions.
“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”. SP6
Regarding the treatment of multiple battle casualties, several respondents reported having had to prioritize French patients or foreign armed forces personnel, based on utilitarian principles. These situations were not perceived as true dilemmas, as respondents considered their training in this area sufficient:
“Regarding mass casualties, dilemmas can easily arise, but in this case training is adequate, in that the collective interest should come before any individual interest to avoid dilemmas. This happened once during a sudden influx of French casualties. One was considered hopeless. We operated on him last. He was clearly in a critical condition. We first considered his case hopeless but then took care of him after reclassifying him as operable. This raised questions, particularly since this soldier was SSA personnel and several members of the medical team, myself in particular, knew him well.” SP1
The question of prioritization based on nationality during mass casualty events was raised by several participants (GP6, SP3,7). Although none were forced to choose between a French and foreign casualty (PUC or other), this possibility was mentioned as a potential dilemma between the principles of non-discrimination on one hand and of duty to fellow soldiers on the other. All respondents who raised this question believed that they would choose to treat the French casualty first, at equal severity or even if the French patient’s condition was less severe:
“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.” SP7
One participant mentioned that triage for Role 2 evacuations was performed upstream by the combatants themselves, who in practice prioritized French casualties over PUC or the members of foreign armed forces:
“In tactical MEDEVAC priorities from the field to the Role 2 unit, Barkhane soldiers come first. It goes without saying. There’s a form of informal discrimination.” SP3
Should treatments be given if they are of no benefit to the patient, only to serve institutional military interests?
Almost all respondents mentioned being confronted with this dilemma during MAC missions (GP1–8, SP1,2,5,7,8). Most of these situations occurred in Barkhane’s western theater, where most so-called “opportunity” MAC missions are carried out (operations following reconnaissance missions for example, of limited duration), in contrast with the eastern theater where MAC missions have been in place already for several years, where continuity of care is guaranteed. These MAC interventions were described as being directed by military authorities, solely in their interests, to obtain information, facilitate diplomatic exchanges with village leaders or persons deemed “of interest” by the military, or as an opportunity to communicate with civilians and make the presence of French military forces more acceptable, in Mali in particular:
“Military authorities asked us for targeted medical operations to foster good relations and discussions. (…) So then this raises the question: why examine so-and-so who doesn’t really need it and not someone else in the village? GP1
Doctors in Role 2 units had been ordered by military authorities or the medical hierarchy to treat patients whose condition was very severe or preoccupying, beyond their treatment capacities, for diplomatic reasons or because they were relatives of local leaders.
Some military doctors considered themselves commodified by military authorities, despite being well aware that the secondary benefits for the military of MAC missions is clearly part of the SSA’s doctrine [28]. Some went as far as describing opportunity MAC activities as worthless and questioned their soundness and utility. The lack of follow-up for chronic pathologies made them impossible to treat, and seemed contrary to the proper practice and very foundations of general medicine. In these circumstances, MAC was therefore described as being devoid of any medical value, particularly when it simply involved distributing drugs:
“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.” GP7
The risk of interfering in local health systems or with non-governmental organizations was also raised as a potential hazard:
“In Mali, there are opportunity MAC operations where you go to hand out pills, you always wonder about medical legitimacy, especially in the desert. You tell yourself you’re going into a medical center bypassing what is going on at a local level, for very little benefit. Reasons for consulting, there were no real needs. I thought I would see poverty. There was a program run by the Red Cross. (…) There was no follow-up. We had to go for quantity. Time was limited and we were told that we had to see everyone that had turned up. The risk is that patients are not considered as humans but only in terms of the benefit they represent for the force.” GP6
One participant even mentioned the use by Barkhane forces of MAC as a means of coercion on local communities:
“There had been strikes among local civilian recruitment officers. Central command told us to cut off Role 2 MAC as retribution. There was a crisis meeting, and we were told that the first thing to do was to stop MAC. We didn’t do this.” GP9
How to deliver healthcare when the team’s safety or one’s own is in danger? (Beneficence and security or operational constraints)
Several respondents (GP2,7 and SP3,10) raised the question of the therapeutic relationship with PUC, made difficult by security constraints. Doctors wore a balaclava, and patients were handcuffed, preventing any sort of patient-doctor reciprocity:
“You treat patients wearing a balaclava, masked. There can’t be any empathy. There is no therapeutic relationship on equal footing. The only thing these prisoners saw were masked individuals. Exchanges are poor. There is no reciprocity. All the non-verbal is attenuated or annihilated.” SP3
Three combat unit doctors (GP3,4,5) mentioned having been ordered not to treat injured or sick patients because of strong security constraints, the surroundings not having been secured. One doctor also described having had to refuse to treat a civilian patient with severe malaria who had broken into the French military base:
“They found one day in a tent a man in a confused state, with a temperature, probably malaria. He had no animosity toward the forces. He was incoherent. I would have liked to keep him on the base to rehydrate him, put him on a drip and treat him. He wasn’t all that young. The instructions, the orders that were given were to not keep him (…). They told me that he had broken in, that we could not keep him (…). So I just gave him an oral treatment, in spite of his vomiting.” GP7
A Role 2 surgeon (SP6) reported having had to deal with a unique situation. While performing a hernia operation as part of MAC, the alarm for an airborne missile attack sounded. The instructions in this situation are to proceed immediately to a secure shelter outside the Role 2 base. The question he asked himself was: “should I go to the shelter and risk leaving the patient alone on the operating table?”. He and the nurse anaesthetist finally decided to stay with the patient rather than shelter.
During reconnaissance missions, two GPs (GP6,9) had to make the difficult decision to not or minimally treat civilian victims of rebel exactions. They described having discovered these by chance in the middle of the desert. Without any means of evacuating them, the question was raised whether they should evacuate the injured themselves and end the mission. In both situations, after discussions with commanders, the decision was made to leave the injured and find another solution to evacuate them, with no guarantee that this would be done.
Many interviewed doctors had to decide whether to preserve limited medical and evacuation capacity for possible French casualties (GP2,6,9,10, SP2,5,8). They limited treatment for PUC or civilians to preserve their compatriots’ safety. This highlights the difference in standards of care between French casualties and others, creating a certain form of discrimination:
“On my first mission in Mali, the first two casualties we treated were enemy fighters who had come under fire from Barkhane forces during the night. There were operational constraints with convoys, ongoing operations. The difficulty was to work out how to evacuate these men who needed to be hospitalized in the Role 2 in Gao. This was problematic between the deputy DMED, myself and the Role 2 head, and the convoy personnel. We had to make plans to work out whether to delay the convoy to facilitate these men’s evacuation, who were enemies, or to keep going with the mission as a priority and evacuate the casualties secondarily. I fully understood at the time that the mission cannot be delayed for these casualties, but I saw that the evacuation conditions were very basic, and we wouldn’t have done that had they been French. I decided not to give them a transfusion, even though they would have needed one. I decided not to do it to save resources for Barkhane forces. Should I have done more for them, could we have optimized oxygen transport, hemodynamics, would this have allowed the patient who was subsequently amputated to keep his leg?” SP5
What standard of care for patients when capacity is lacking for critical and/or follow-up care? (Non-maleficence, quality of life, intervention context)
Situations of this type only arose for patients whose evacuation to another treatment center other than the French Role 1 or Role 2 was impossible. These patients were civilians or PUC whose pathologies were so severe that non-intervention or decisions to limit treatment were considered, whereas in France they could have received the necessary treatment (GP1,5,10 and SP1–9).
“Within the limits of MAC, things can’t be done beyond reason. We ended up seeing a bedridden patient about 75 years old, who had had a stroke, probably some time ago, with pressure ulcers that had become infected. There are many things we could have done in France. Part of me wanted to take care of him. In Mali, there was nothing we could do.” GP1
“In Mali and Chad, we saw children who had been brought by their families for conditions that we could diagnose, such as for example a 5-year-old child who probably had very advanced stage Hodgkin’s lymphoma, with no possibility of treatment in the country. The families did not have the means to pay for treatment either. This created a dilemma because we could diagnose the condition but not treat it.” SP1
“We decided to stop treatment in a PUC. This was not easy for everyone. He had had several limbs amputated, a colostomy, a sacral pressure ulcer. He was dependent on opioids, with no chance of recovery because there was no possibility of rehabilitation. This was discussed as a group. Role 1 personnel did not understand the decision to limit treatment.” SP7
Some respondents related how they had had to downgrade the surgical management of PUC, since there was no possibility of transfer or evacuation (SP1,7,8):
“The third issue is with respect to PUC. It’s troubling from an ethical point of view. We had to deal with the fact that no evacuations or follow-up were possible, the inadequacy of the means available to treat certain PUC. This led us sometimes to make treatment decisions that were imposed on us by the situation, but that were not those the patients would have made. For example, one PUC subsequently had an arm amputated because we did not have the means to renew his treatment for long enough, a skin graft for example. “ SP1
The question of the limited competencies of surgical teams was also mentioned as a source of potential ethical dilemmas, in particular for the treatment of children or pathologies outside the scope of surgery or anaesthesiology. Should operations be performed that would clearly involve overreaching their abilities?
“In Chad we had set a rule of not taking children less than 2 years old or 12 kg. I remember a girl who had arrived with dental cellulitis. She couldn’t open her mouth so the dentist could not do anything and sent her to me for surgical treatment. I refused because she was less than 2 years old, I did not have any equipment for difficult intubations like a fiberscope and paediatric resources were limited. I felt like I was kicking the can down the road relative to French standards, but considering the means at my disposal, this seemed like the right decision.” SP5
Is it possible to treat patients that are openly hostile? (Impartiality and beneficence)
Several military doctors mentioned this problem as a source of ethical tension. The issue at stake was neutrality, which is one of the fundamental principles of medical practice. But are military doctors really neutral? They operate in an institution whose values they have chosen to adhere to and bond with fellow soldiers, implying a form of solidarity. As such, some military doctors had moments of doubt when they had to treat PUC or patients who clearly demonstrated their hostility to French soldiers (GP1,3,4,8 and SP2,6,7,10):
“We did a MAC in a village. We were asked to do this 10 days after one of our armored medical vehicles had been blow up by an improvised explosive device. For my team, it was difficult to go and help a community suspected of having committed this act.” GP4
A sense of perspective was required to ignore the acts they were supposed to have committed and preserve a certain level of objectivity and neutrality, to provide a good standard of care to these patients:
“We use our resources, energy to treat these people who are potentially involved in actions against Barkhane forces, all this while being as objective as possible”.SP2
This attitude was all the more difficult to maintain that some combat personnel reproached the medical teams for treating PUC according to the same standards as French casualties (GP3,7,9, SP1,5,6). In some cases, these criticisms came directly from the respondents’ own subordinates (SP3,7,10):
“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.”SP10
Participants’ approaches to facing and resolving dilemmas
In making decisions, several participants reported having found answers in laws and regulations, particularly in the law of armed conflict (LOAC) for the treatment of PUC (GP1,10, SP1,10). The importance of collegiality in the decisions, when time constraints allowed for this, was highlighted by several respondents (GP1,5,6,10, SP1,2,4–10). This collegiality was part of a group reflection process between field doctors with the same healthcare roles or in a multidisciplinary approach involving for example the psychiatrist based in Mali or a doctor from a different specialty who was also present at the time of the situations discussed. Medical command (DMED and PECC) was also a privileged interlocutor in reaching decisions for 11 of the interviewees (GP2,3,6–8,10, SP3,5,7–9), some of whom mentioned nevertheless that this depended on the DMED and PECC doctor’s personality and positioning with respect to military command. Seven respondents declared having experienced a lack of support from their medical hierarchy, described as retreating from its responsibilities and simply applying orders received from command headquarters to the detriment of practitioners’ decisional autonomy.
These situations were also discussed with military commandment or the combat personnel themselves, in reaching decisions for seven respondents (GP2,4,5,10, SP1,8,10), or during debriefings for two others (GP7,9).
Ethical problems were shared between healthcare branches with paramedic personnel, to reach a decision (GP1,2,4–8,10, SP1,2,5,6,8–10), but also discussed during formal or informal debriefing sessions (GP3,4,6, SP2,6,8).