Medical Sanctions Against Russia: Arresting Aggression or Abrogating Healthcare Rights?

Abstract

Since 2022, the EU, US, and other nations have imposed medical sanctions on Russia to block the export of pharmaceuticals and medical devices and curtail clinical trials to degrade Russia’s military capabilities. While international law proscribes sanctions that cause a humanitarian crisis, an outcome averted in Russia, the military effects of medical sanctions have been lean. Strengthening medical sanctions risks violating noncombatant and combatant rights to healthcare. Each group’s claim is different. Noncombatants and severely injured soldiers who cannot return to duty enjoy the right to adequate health care that sanctions cannot undermine. Combatants falling captive enjoy the same medical care that adversaries provide their own troops. Combatants yet to renounce hostilities, however, have no claim to medical attention and remain subject to sanctions. Nevertheless, medical sanctions prove unworkable in this complex environment of conflicting rights and command no place in a sustainable sanction regime.

Keywords:

• Sanctions; military ethics; law of armed conflict; healthcare rights; noncombatant immunity; conflict medicine; Russia–Ukraine war

With the imposition of sanctions following the invasion of Ukraine in 2022, a lively debate erupted surrounding the supply of medical products to Russia. In a Medscape op-ed, Art Caplan (2022) explained, “The Russian people need to be pinched not only by the loss of cheeseburgers and boutique coffee but by products they use to maintain their well-being… [I]f you tolerate a government that is bombing and shelling a peaceful neighbor to oblivion, then pharma must ensure that efforts to make Putin and his kleptocratic goons feel the wrath of their fellow citizens (also Sonnenfeld and Tian 2022).” In contrast, companies like Bayer reiterated their duty to supply medicines and supplies because “withholding essential health products from the civilian populations would only multiply the war’s ongoing toll on human life (Browne 2022).” Writing in BMJ Global Health a few months later, Germani and colleagues (2022) called on the international community to avoid “economic sanctions that violate the right to health.”

Many questions emerge from these short sentences. First, are Russian sanctions effective? Any discussion about whether sanctions are permissible presupposes they can effectively compel the targeted nation to comply with sanctioning nations’ demands. The data remain dubious and demonstrate no unequivocal correlation between sanctions and compliance (Pape 1997; Peksen 2009). While some proponents point to guarded instances of success (and apartheid-era South Africa is the common example), opponents of sanctions argue that coercive economic measures only strengthen a targeted nation’s resolve to resist and/or allow dictators to exploit sanctions to solidify their hold on power by blaming their opponents for economic hardship (Erdbrink 2012; Weiss 1999).

Despite these adverse assessments, economic sanctions have increased dramatically since 1990 (Gordon 2011; Lopez 2012). In Iran and now Russia, the international community strives to make sanctions smarter by focusing on arms embargoes, commodity sanctions (e.g., oil), travel restrictions, aviation bans, and financial warfare to target those responsible for threatening international peace and security. Examining targeted sanctions more closely, Biersteker, Tourinho, and Hudáková (2013) distinguished among three goals. Nations imposing sanctions aim to (1) coerce behavioral change (desist from aggression, extradite wanted criminals) and/or (2) constrain a proscribed activity by denying access to funds or materiel (e.g., nuclear refinement), and/or (3) signal the world community’s disapproval of nations violating international norms (e.g., human rights). Sanctions, especially those seeking coercion, are mostly ineffectual; only 10%, 28%, and 27% of coercive, constraining, and signaling sanctions, respectively, are unambiguously effective.

Still, the same data suggest that some sanctions might work. Driving sanctions worldwide, the perennial hope of success raises additional questions about medical sanctions. What costs and benefits come with adding medical products—pharmaceuticals, medical devices and supplies, and clinical research—to the items restricted for export to Russia? Assuming that benefits are appreciable and costs proportionate, are civilians ever a legitimate target of painful sanctions, or are their healthcare rights inviolable in wartime? Questions like these are not new and arise whenever sanctions are on the table.

Addressing them, the discussion opens with a snapshot of the medical sanctions imposed on Russia since early 2022. Subsequent sections then outline the legal and ethical principles governing sanctions and the hardships they may permissibly impose. As a rule, mass starvation and deprivation are the litmus tests of proscribed sanctions, and by those criteria, Russian misery still falls far short. Nevertheless, medical sanctions run up against the universal right to health care. While healthcare rights might block efforts to sanction medical products, their impact varies with the disparate status of civilians and combatants. International humanitarian law during war abridges each population’s healthcare rights. This leaves them liable to limited sanctions but only if export controls are effective, necessary, and proportionate, conditions that remain hard-pressed to substantiate.

MEDICAL SANCTIONS IN RUSSIA: ASSESSING THE CIVILIAN AND MILITARY IMPACT

Nations and international bodies enact sanctions during war and peace. Under its broad powers to meet any “threat to peace, breach of the peace or act of aggression” the UN Security Council may pursue the “complete or partial interruption of economic relations (UN Charter, Art. 41).” With permanent Russian Security Council membership preventing UN-imposed sanctions, the EU, US and other nations instituted sanctions and trade controls to restrict the sale, supply, transport or export of items contributing to Russia’s military and technological enhancement or the development of its defense and security sector. Managed through the US Bureau of Industry and Security, the avowed purpose of American sanctions was “to further undermine the Russian and Belarusian industrial bases and their ability to continue to support Russia’s military aggression in Ukraine … directly or indirectly degrade Russia’s war effort and … cut off Russia’s access to any items of potential military significance … and expand the economic impact of controls denying Russia additional resources it needs to continue waging war (Bureau of Industry and Security 2023b, May 23).”

Sanctioned products may be singularly military or dual-use items serving civilian and military purposes. Because restrictions on dual-use products can devastate the civilian population, EU sanctions exempted medical and pharmaceutical products unless the specified end-user was a Russian defense or security agency (EU Council, 2023).¹ Similarly, US authorities reviewed medical products on a case-by-case basis to determine whether they would benefit the Russian or Belarusian government or defense sector (Bureau of Industry and Security, 2022, March 3).² Over time, the list of restricted items grew to include many medical products, including imaging equipment, cameras, and surgical supplies (Bureau of Industry and Security 2023b, May 23).³

Despite the broad appeal of economic and medical sanctions, doubts constantly nag about their effectiveness. Ordinarily, targeted nations, often rogue or authoritarian states, are far less sensitive to public opinion than targeting nations. As a result, there is no ready mechanism for an aggrieved citizenry to pressure their government into compliance. Sanctions work slowly and often leave considerable hardship in their wake, particularly on vulnerable populations. Little is known of the impact of medical sanctions on the civilian or military sectors or whether unique conditions hinder their implementation. Russia is a case in point.

Effects of Medical Sanctions on the Civilian Sector in Russia

A year into the Ukraine-Russia war, the US Department of the Treasury (2023) determined that Russia “has faced shortages of essential military parts, experienced shutdowns of military-industrial facilities, encountered supply chain obstacles, suffered loss of high technology chips and components, and forced to rely on inferior suppliers and weapons.” By most accounts, however, the impact of medical sanctions has been limited to supply chain and logistical impediments, reliance on inferior products, and disruption of clinical research. While it is difficult to disentangle the impact of medical sanctions from economic sanctions more generally, it appears that none of the former has had significant consequences.

Analyzing the civilian sector through 2022, the DSM Group (2023, 3), an internationally recognized Russian pharmaceutical marketing agency, concluded: “the sanctions related to political events have had no direct impact on the availability of drugs to people, but rather indirect effects” attributable to “logistical” difficulties including shipping and finance (due to travel bans and financial restrictions), shortages of packaging cartons, vials and caps. In November 2022 and March 2023, the Russian Minister of Health acknowledged delays in the supply of foreign medicines but denied any risk of shortages (Shushkina 2023; TASS 2022). But by November 2023, the Health Ministry changed course and acknowledged previously reported shortages of medicines (antibiotics, cancer treatments, insulin drugs) and medical devices, delayed “import-extensive” surgeries, difficulties faced by patients having to wait for alternatives or adjust to abrupt changes in their drug regimes, and inferior Chinese drugs and equipment (Holod 2023; Holt 2023; Karkov 2023; RBC 2022; Talanova 2023; van Brugen 2023).⁴

However, shortages of specific Western pharmaceuticals, such as the antibiotic Amoxiclav or the breast cancer drug Tamoxifen, tell only half the story (Khabibullina 2023; RBC 2023). More than half the medicines sold in Russia are manufactured domestically, and 80% depend on imported raw materials (Snegovaya et al. 2023). Short of Western components, Russian pharmaceutical companies have been slow to retool and recertify old drugs made with new ingredients. At the same time, Chinese companies cannot provide all the necessary alternative compounds.

Equipment maintenance is equally problematic. 75% of Russian medical equipment was imported in 2021 (Bank of Finland 2022, n2). Lack of original spare parts and government policy prohibiting the transfer of medical equipment out of Russia have stalled necessary repairs and maintenance. Dual-use spare parts (e.g., lasers and optical equipment) are not easily exported to Russia. Other spare parts come through third parties at high prices and with significant delays. Lack of non-original medical consumables such as reagents, flasks, and paper for electrocardiography render some equipment inoperable. One medical equipment manufacturer explained, “You can’t improvise here; Chinese won’t work. There are special electronic protections that prevent launching with anything but original factory reagents” (AIDS Center 2022; Vademecum 2022).

These sanction-related complications are not insurmountable, but it may be several years before domestic production and Asian suppliers can provide the pharmaceuticals and equipment necessary to offset the effects of sanctions. But the future is uncertain. Clinical trials in Russia have diminished significantly as the large drug companies pulled out. Despite sanction exemptions for life-saving medicines, supply, recruitment, and financial obstacles coupled with the reluctance of the large drug companies to make further investments in Russia or cooperate with local investors have brought new clinical trials to a slow halt. By March 2023, clinical trials dropped to seven foreign-sponsored studies in Russia, down from 32 in the period September 2022–February 2023 and 102 in March to August 2022 (Urtė Fultinavičiūtė and Maragkou 2023; Mulero 2022; Pharmaceutical Technology 2022; Talbot et al. 2022). The rapid cessation of clinical trials raises two pressing concerns: patient health and future research. Fearing that pharmaceutical companies would pull out entirely, local researchers sought and received their assurances to complete ongoing trials and provide post-trial medication (Kerpel-Froius et al. 2022; Merck 2022; Pfizer Statement on the War of Ukraine 2022; Sanofi 2022). However, there is no way to guarantee the fruits of future research. Denied cutting-edge data and international collaboration, Russian medical scientists feared losing access to emerging biotechnologies and some 300 drugs slated for development in the coming decade (Gritsenko 2022; Kiseleva 2023; Misik 2022).

In the civilian sector, economic sanctions created immediate shortages of some medicines and supplies, intermediate-term impediments to timely, quality care due to financial and shipping restrictions, lack of spare parts, untested supply chains, and local delays approving new medicines, and long-term harms following the shutdown of clinical trials in Russia. However, no evidence currently suggests that Russia faces a humanitarian disaster on par with mass starvation or dire hardship. Real income declined 1% in 2022 but started to climb again in Q1 2023 (Wiśniewska 2023). At the same time, heavy borrowing has sustained funding for social welfare, health, education, and consumer production (Bloomberg 2023; Bank of Finland 2023). Medical sanctions, however, are not intended to overturn civilian life but to erode military capabilities appreciably. That goal seems elusive.

Effects of Sanctions on Military Capabilities

Despite Western efforts to target armed forces, there are little reliable data to gauge the effects of Western medical sanctions on Russian military capabilities or to specify those medical products that might aid the Russian military. Except for any medical product used to develop chemical and biological weapons (e.g., agents, antidotes, or vaccines) and, therefore, banned outright for export (CFR 2023, § 744.4), no medical products solely profit the military or defense sector. Every other medical product is potentially dual-use. Every military organization will benefit from the same medical products that support civilian health care. Trauma care, preventive care, and performance enhancement medicines (e.g., anti-fatigue agents) would be particularly advantageous militarily. To prevent the delivery of medicines and devices that would aid the military, the US Bureau of Industry and Security (2023c, July 19) restricts exports to nonmilitary end-users and requires exporters to certify that “end users will use the items to provide direct patient care to civilian patients in a civilian treatment facility.” Parties that provide direct patient care to military patients (i.e., military hospitals) remain sanctioned.

The direct effects of medical sanctions targeting specific end-users (the defense sector), specific usages (military medicine, battlefield care), and specific equipment (e.g., lasers) are not easy to discern. The Russians do not report causality figures, wound types, treatment outcomes, or return-to-duty rates. Open Western sources remain un-informed. As of August 2023, Physicians for Human Rights, for example, had no data detailing the health effects of Western sanctions on the Russian military or civilian populations (T. Wilson, Personal communication, Tessa Wilson, Senior Program Officer, Physicians for Human Rights, August 10, 2023). Regarding equipment, shortages of laser-based medical technologies were circulating in Russia by April 2022 (Medical Device Network 2022a). At the same time, complaints about inferior Chinese equipment and shortages of trauma equipment and hemostatic agents, first aid kits, tourniquets, antibiotics, and other medical supplies increased as military casualties grew and Russia could not purchase, ship, and maintain these products in the required amounts (Kisin 2023; Kulakova 2023; Shamardina 2023). As a result, claims one industry source, “large numbers of Russian troops faced long wait times to receive treatment for their wounds, mostly across the Western Oblast in Russia and in Belarus… that will only lead to more health complications, such as aggravated wounds and growing infections, and ultimately increased mortality rates (Medical Device Network 2022b).” In response, some families purchased medicines at their own expense from understocked and overpriced pharmacies (Zasekin News Agency 2022).

Government sources echo officials’ rosier assessments of the civilian sector. In response to questions about adequate medical supplies in the war zone in March 2023, Dmitry Khubezov, Chairman of the State Duma Committee on Health Protection, replied: “I do not have all the information, but where I have been, in military hospitals, there is definitely everything. And that’s where I was, the supply is good… We asked volunteers to buy some advanced, high-tech things. They brought everything at once - literally in two or three days. As for civilian hospitals… Well, it’s never ideal anywhere” (Baeva 2023).

In the military sector, the same logistical and financial factors hobbling the civilian sector are compounded by Russia’s general lack of military preparedness and inability to obtain quality replacements for supplies burned up in Russian operations. Without accurate data, one cannot know whether soldiers were killed in action or died of wounds because of slow evacuation (lack of transport), insufficient force protection (lack of personal and vehicle armor), or shortages and poor quality of medical products. Sanctions targeted dual-use medical products, but as in the civilian sector, debilitating shortages came not so much from direct bans on certain medical products but from the sanction-induced logistical and supply chain disruption, and financial obstacles affecting the Russian military since the war began (Bowen 2023; Dalsjö, Jonsson, and Norberg 2022; Jones 2022).

In this messy and clouded environment, assessing the impact of sanctions is as imprecise in Russia as elsewhere. The appeal of sanctions comes as much from their hoped-for efficacy as from the broad recognition that sanctions are preferable to armed force, no matter how indeterminate. Sanctions might be ratcheted up or down as conditions warrant, while armed force is a last resort that only escalates. If sanctions have not yet rattled the Russians, maybe the answer is to turn up the heat. The question is, may medical sanctions ever play a part?

The answer is yes, but much depends on (a) the identity of the target and (b) the prospect of success. The law and ethics of war do not recognize civilians’ absolute right to all-encompassing health care any more than their absolute right to life. Nevertheless, sanctions may not be so severe as to precipitate a humanitarian disaster, a concept lacking firm criteria but one necessary to tease out. But whether facing a crisis or simply inconvenience, civilian-centered medical sanctions are usually quite porous and do not play an overwhelming role in sanction regimes. The status of combatants, on the other hand, is more precarious. Subject to lethal attack, privation, injury, and death, combatants face debilitation as a matter of course. Depriving them of quality medical care drains morale, shrinks the number of personnel fit for duty, and degrades military capabilities. Despite these potential military benefits, however, severely wounded soldiers, like civilians, enjoy a distinct but narrow right to health care that sanctions cannot undermine. Cognizant of the tension between military necessity and healthcare rights, the prevailing legal and ethical norms, nonetheless, establish ground rules for limited medical sanctions in wartime.

THE LEGAL AND ETHICAL FRAMEWORK FOR SANCTIONS

As a tactic of war, sanctions occupy an odd place in international law. Sanctions are not strictly military operations and remain largely ignored by the law of armed conflict. Often employed to prevent war, sanctions are a coercive, penultimate measure that international law and custom encourage before nations turn to military force. During war, however, sanctions join sieges and blockades as a means to enervate the civilian population directly with the hope, the same hope Caplan embraces, that sanctions will squeeze civilians so severely, but not so severely to cause mass starvation and deprivation, that their government will have no choice but to comply with the sanctioning party’s demands.

The overwhelming advantage of sanctions, and their greatest moral defect, is how they target innocent civilians directly and deliberately, a protection civilians enjoy against armed force. So, while nations may not employ armed force against a civilian population directly, they may impose crippling sanctions short of precipitating a humanitarian crisis. The underlying philosophical argument is two-hatted. On the one hand, an enemy civilian population shoulders some responsibility to oppose an unjust, rapacious, and aggressive regime. Caplan’s argument is not unique in this way. However, it’s a brittle argument because civilians in war are generally innocent and often impotent. They assume no military role and pose no mortal threat to adversaries.

For this reason, international humanitarian law (IHL) affords civilians immunity from direct and deliberate attack. However, imputing culpability to justify sanctions against civilians erases the innocence propelling noncombatant immunity. In this view, civilians are mostly innocent and so cannot be attacked directly with lethal force, but they are not so innocent that sanctions cannot severely inconvenience them. Establishing culpability also requires the cognitive capability of civilians to discern their government’s injustice. It is not unreasonable to think that Russians or Iraqis should readily grasp that Vladimir Putin or Saddam Hussein are tyrants they must oppose. But it is often unreasonable to think that they can significantly influence policy in wartime, particularly in authoritarian regimes. Regardless, there are no practical means to distinguish between those civilians who recognize a regime’s injustice and are therefore culpable, and those who do not or cannot and are therefore innocent.

Modern international humanitarian law, however, affords a different route. A lesser evil argument anchored in military necessity underlies most justifications for harming civilians in war. Civilians are not liable for direct harm but may suffer collateral (or incidental) harm during necessary military operations when military advantages outweigh civilian deaths and injuries. In this way, civilians’ right to life is not absolute. The harm caused by sanctions might be justified as the same kind of lesser evil to permit imposing hardship on civilians to enfeeble an adversary’s military capabilities and compel it to stand down. Attractive as the argument may seem, unintentional collateral killing and deliberate sanctioned-imposed suffering are not analogous. Sanctions are deliberate, self-serving and exploit civilian vulnerability for military advantage. Permissible collateral harm is none of these. So, the critical issue for sanctions is not the kind of harm civilians suffer, whether direct or collateral, but the severity of harm they must endure. Killing and injuring civilians are tightly regulated because they are irreversible. However, if the effects of sanctions are transitory and fall significantly short of death and starvation, then civilians become legitimate targets insofar as there is a reasonable expectation of success and the harm they suffer is necessary, effective, and proportionate.

A reasonable expectation of sanction success is a dynamic calculation that changes during conflict. As nations tighten or loosen trade controls, they must navigate between degrees of hardship and suffering. Within this ever-changing sphere of action, the sanctioning state must assess the necessity and proportionality of sanctions. Sanctions are necessary when no other intervention can achieve the same end at a lower cost. Proportionality imposes an additional constraint on necessity to prohibit harm to civilians that is “excessive in relation to the concrete and direct military advantage anticipated from a blockade (sanctions are not specifically mentioned) (Doswald-Beck 1995). In this view, proportionate sanctions cannot pursue overwhelming death, disease, or injury or deny the civilian population “other objects essential for its survival (San Remo Manual 1994, §102; Cohen 2009).” Do these objects include medical products?

Sanctioning Medical Products in Wartime

Although UN sanctions, as well as those instituted through the 42-nation 1996 Wassenaar Arrangement (Wassenaar Organization 2022) and earlier EU regulations (EU 2021, Regulation 821; Meissner and Urbanski 2022), exempted medical products from dual-use restrictions, wartime IHL, like the current sanction regimes, do not. For example, the 4th Geneva Convention (1949 Art. 23) instructs belligerents to permit free passage of medical supplies, food, and clothing. But the duty to provide free passage is not absolute. It may be restricted if there are substantial fears that (1) the consignments may be diverted, (2) control of end-users may not be effective, or (3) that a definite advantage may accrue to the military efforts or economy of the enemy. However, the 1958 Convention commentators were adamant that only food and clothing, not medical supplies, could “reinforce the economic potential of the enemy” and thereby sustain military strength (Art 23, 1958 Commentary:180; also Shotwell 1991).

Writing after World War II, when the per capita cost of health care in the US was only $84 (1950) (Reed and Hanft nd), the framers of the Geneva Conventions did not believe that medical products had any significant impact beyond health care. As such, depriving an enemy of medicines and supplies (unlike food or clothing) could not seriously undermine the enemy’s war economy. Medical sanctions, in other words, were unnecessary and, therefore, rare. Following the First Gulf War, for example, UN sanctions blocked Iraqi trade in nearly every product except “supplies intended strictly for medical purposes, and, in humanitarian circumstances, foodstuffs (UNSC 1990).” Similarly, the UN exempted or did not include medical products in sanctions on Libya (1992–1999) to press that government to extradite terror suspects and Iran (2005) to abandon their nuclear arms research (UNSC 1992, 1993, 2006). In these nations, where there was no active military conflict, broad economic sanctions, not medical sanctions, depressed industry, agriculture, manufacturing, education, social welfare, and health (Asadi-Pooya, Nazari, and Damabi 2022; Zoubir 2002).

The Russian situation differs in several respects. First, and in contrast to the post-WWII viewpoint, medical sanctions directly impacted the Russian war economy. The need to boost deficit spending to maintain prewar levels of health, welfare, and other social services increased the risk of high interest rates, rampant inflation, and economic instability (Kurmanaev 2023). Second, Russia is at war; Iraq, Libya, and Iran were not. The goal of sanctions was not only to undermine the war economy but to “cut off Russia’s access to any items of potential military significance and [deny] Russia additional resources it needs to continue waging war (Bureau of Industry and Security 2023b, May 23).” Apart from medicine’s economic impact, modern military medicine has advanced markedly to reduce significantly the number of soldiers dying of wounds, improve return-to-duty rates, and facilitate integration into civilian life (Gross 2021, 92–111). When medical sanctions offer clear military benefits, dual-use restrictions prevent sweeping exemptions. In Russia, initial dual-use restrictions were limited, curbing the export of laser-based or optical equipment, for example. But by May 2023, the list expanded from medical supplies necessary to maintain the health of active-duty personnel to include a raft of medical products primarily suitable for noncombatants, such as artificial joints, hearing aids, and pacemakers (Bureau of Industry and Security 2023a, May 19; Freifeld 2023). As medical sanctions gain a toehold, we are left to ask how much hardship effective sanctions, medical or otherwise, may inflict on noncombatants before precipitating a humanitarian crisis?

How Much Hardship Can Sanctions Cause?

There are no precise maps for navigating between inconvenience, moderate suffering, destitution, starvation, and death and destruction. Often, economic sanctions, whether accompanied by medical sanctions or not, undermine the population’s health and increase infant, child, and maternal mortality, premature death among adults, infectious diseases, malnutrition, etc. Weak populations are particularly vulnerable. Consider two cases: sanctions imposed on Iraq following the First Gulf War (1990) and the Israeli blockade of Gaza (2006).

By most assessments, Iraqi sanctions precipitated an overwhelming humanitarian crisis that tested the limits of permissible sanctions. In summarizing the consequences of Western sanctions against Saddam’s government, Gottstein (1999, 282) describes how “About 50,000 children under the age of five are dying every year due to the sanctions. A quarter of all emergency patients in the hospitals cannot be saved because of missing medicines. About 40% of the Iraqi people are hungry, as the food ration is enough for only 25% of their vital needs.” Estimates of the number of dead children range from 170,000 immediately following the First Gulf War to 300,000 excess deaths (beyond ordinary mortality) of children under five (Garfield 1999; Reiff 2003). Sanctions severely impacted health, education, welfare, emigration, and internal displacement (Cordesman and Hashim 1997, 145). Fixing responsibility, however, was another matter. While the UN released funds for health care, US officials blamed Saddam Hussein for exacerbating the healthcare crisis by diverting funds from medical care, hoarding medical supplies, and purchasing expensive equipment for resale to private hospitals (Albright 2000). In turn, Saddam Hussein manipulated civilian suffering to lobby for sanction relief.

In Gaza, on the other hand, the losses were primarily economic in the wake of a blockade Israel imposed after Hamas won the election to govern in 2006. The blockade severely reduced the output of the agricultural and fishing sectors, while the lack of building materials decimated the construction industry. Water supply, sewage facilities, and utility infrastructures broke down with sufficient frequency to raise alarms about potable water for Gaza’s inhabitants. Israel also blocked the import of dual-use medical products, including “x-ray machines, disinfectants, UPS (uninterrupted power supply) units to ensure the unbroken functioning of life-saving equipment.”⁵ Due to economic sanctions, unemployment reached 34% in the general population and 50% among the youth (UNOCHA 2012; ICRC 2010). Food insecurity, defined as “lack of access to sufficient, safe, and nutritious food, which meets dietary needs and food preferences for an active and healthy life” rose from 52% of the population in 2006 to 61% in 2009 (PHR 2010, 8). As a result of malnutrition, wasting, stunted growth and anemia rose during the years of the blockade (PHR 2010, 9, 30–32). On the other hand, infant mortality decreased by nearly 20% between 2007 and 2010, while life expectancy climbed from 72 years to 73.7 years (CIA 2007, 2010). These data, however, offer no evidence that economic warfare is benign. International relief organizations and smuggling prevented a humanitarian crisis by providing basic nutritional and medical needs so that by 2012, nearly 80% of Gazans were aid-dependent (WHO 2010).

These two cases exemplify disparate levels of hardship that sanctions cause. In Iraq, the outcomes were severe. Medical sanctions bit in Gaza but were alleviated by international aid organizations. Drawing on cases like these, we can glean more precise criteria to identify the permissible scope of medical sanctions in wartime. However, the criteria differ for civilians and combatants, and much depends on each group’s healthcare rights.

MEDICAL SANCTIONS AND HEALTHCARE RIGHTS

Civilians’ Right to Adequate Care

The right to health care is not all-encompassing but constrained by needs and resources. The United Nations Universal Declaration of Human Rights (Article 25) demands a standard of living adequate for the health and well-being of oneself and one’s family. The United Nations Committee on Economic, Social and Cultural Rights (CESCR 2000) entitles every human being to the “highest attainable standard of health” (Article 12.1) subject to “a State’s available resources” (Article 12.9). Similarly, IHL enjoins belligerents to respect civilians’ rights by requiring occupying forces to provide adequate food and medical supplies (4^th Geneva Convention 1949: Art 55). Adequate health care comprises the resources necessary to avoid rampant disease, injury, and death characteristic of a humanitarian crisis.

Preventing humanitarian crises and establishing the facilities for adequate care are prominent goals of postwar humanitarian aid. To achieve these goals, local governments and NGOs turn to WHO-endorsed “essential health packages” (EHP). EHPs embrace a “limited list of public health and clinical services which will be provided at primary and/or secondary care level (WHO 2008: 2),” to rebuild war-torn healthcare facilities and avoid humanitarian disasters. Considering sanctions, EHP guidelines help answer a different but related question: How far may sanctions degrade existing healthcare facilities before the crises assume catastrophic proportions? Because EHP lists vary with local conditions, there is no single answer regarding the floor of adequate, crisis-avoiding health care.

Seeking to establish efficacious medical care, EHPs emphasize preventive medicine and relatively far-reaching ambulatory care at the expense of acute and chronic care. Specific lists of supplies and essential medicines vary from place to place depending on the local needs and conditions, prevailing disease burden, and demography. Topping the list are “cost-effective and high-impact interventions” (e.g., immunization, sanitation, birth attendance, and antenatal visits) that dramatically reduce illness and improve life expectancy for infants, children, women, and young to middle-aged adults (UN 2015, 33). EHPs also attend to the underlying determinants of health: potable water, sanitation, nutrition, and health-related education and information (CESCR 2000: Art. 12, §11, §43; also Yamin and Norheim 2014).” When development aid is in short supply, EHPs often face tradeoffs. Emerging nations, for example, may favor maternal and pediatric health at the expense of the elderly or indigents suffering from chronic, debilitating, and expensive-to-treat diseases (Dalil et al. 2014, S132). As a result, adequate care is not necessarily adequate for all, leaving many to still suffer. A sanctioning regime, however, does not provide medical resources but restricts them. Their obligation demands that they preserve the baseline of adequate care for all.

Using the yardstick of adequate services permits states to make early, proactive assessments of medical sanctions. Rather than wait to evaluate snowballing mortality and morbidity following sanctions or blockades, sanctioning states have a far better chance of guaranteeing civilian healthcare rights by exempting any medical product, dual-use or not, necessary to meet the threshold of adequate health care. A civilian’s right to adequate health care also constrains non-medical sanctions. In Iraq, the UN did not impose medical sanctions. However, following the First Gulf War, Saddam Hussein successfully pushed the brunt of Western-imposed sanctions onto the civilian population to maintain resources for the military. The result was a grave crisis initiated by sanctions and exacerbated by willfully negligent domestic policy. Non-medical sanctions effectively destroyed the healthcare system. Under these conditions, the international community incurs the duty to relax sanctions (which the West eventually did) and rebuild the healthcare system (which the West incompletely accomplished only after occupying Iraq from 2003 to 2011 (Gross 2021, 229–255)).

Russia is not Iraq. In contrast to Saddam Hussein’s flagrant neglect of the citizenry, Russia registers concern, perhaps self-serving, for their people’s welfare. Therefore, Russia borrowed heavily to provide sanction relief and fund social welfare services, including health care (Bank of Finland 2023; Wiśniewska 2023). Absent any egregious violation of the Russian people’s right to adequate health care, Western nations have no prima facie obligation to curtail medical sanctions. They may even strengthen medical sanctions with the proviso that they do not undermine adequate health care and that the resulting sanctions are effective and necessary. On each score, the jury is still out. Although medical sanctions compel Russia to borrow at high rates, their effect is indirect and pales compared to the burdens the US Treasury and other agencies attribute to financial and economic sanctions. And as onerous as these latter sanctions have been, they have yet to push Russia toward compliance. At best, sanctions have signaled the world’s resistance to Russia’s violation of international norms of conduct (e.g., Berman and Siripurapu, 2023). Although the impact of medical sanctions remains relatively weak, export restrictions continue to intensify. As they do, sanctioning nations are obligated to ensure that sanctions do not undermine adequate civilian health care in Russia. But what of soldiers? The preceding discussion, says little about the right to impose medical sanctions on military personnel.

Soldiers’ Right to Health Care

Unlike civilians, soldiers do not enjoy any relief from the dire humanitarian conditions brought on by war. Nor are they necessarily always entitled to medical care when wounded. On the first count, war embraces austere conditions that military necessity may exacerbate. On the second, combatants’ right to health care is ambiguous and varies with their military roles.

Sanctions and Military Necessity

If necessity drives military-medical sanctions, they should compromise military capabilities by impairing morale or eroding performance. While inadequate medical care undoubtedly affects morale, morale disintegrates from systemic collapse: military defeat, incompetent leadership, lack of arms, transport, and protective equipment, and chronic mismanagement (Gross 2021, 100–103). Similarly, superior training, equipment, competent and devoted officers, and medical attention improve performance. It is, therefore, difficult to disentangle the effects of substandard care from the many other material and professional deficiencies that plague the Russian army.

At the same time, however, military-medical sanctions aim to degrade the care and treatment soldiers must receive to recover from their wounds and return to duty. The US Bureau of Industry and Security (2023c, July 19) says as much: “The US Government reviews all export license applications to evaluate whether approving the application would benefit the Russian or Belarusian government or defense sector, particularly concerning the usefulness of the items for the treatment of battlefield casualties.” Employing sanctions to degrade battlefield medicine substantially differs from using sanctions to undermine morale or performance. By addressing life-saving battlefield care, sanctions aim at a soldier’s right to health care that IHL imposes on compatriots and enemies alike.

Sanctions and the Right to Military Health Care

Article 12 of the 1st Geneva Convention (1949) addresses the care of wounded and sick combatants and affords them positive and negative protections. Positively, IHL enjoins belligerents to provide humane and impartial medical treatment and, negatively, to refrain from attacking sick and wounded combatants or abandoning them without medical assistance. The Article seems plain enough, but as the commentary explains, IHL imposes a two-fold test to determine who qualifies as sick and wounded, for only they enjoy the protections of Article 12. Cognizant of the constraints of war, a wounded or sick combatant must (1) require medical care and (2) refrain from any act of hostilities. Therefore, “persons who continue to engage in hostilities do not qualify as wounded or sick under humanitarian law, no matter how severe their medical condition may be. (Article 12, Commentary, 2016, §1341, 1345).

In practice, these provisions mean that lightly or moderately wounded enemy soldiers who nonetheless fulfill a military role, e.g., guarding the base, are not immune to lethal attack. By the same token, an enemy force might deny medical attention to the same soldiers by restricting the flow of medical products because IHL does not count them among the sick or wounded. From here, it is but a short step to dual-use sanctions that restrict the flow of nearly any medical product that may benefit a sick or injured soldier capable of fulfilling some military function.

These restrictions, however, are not entirely anchored in military necessity. Dual-use medical sanctions may certainly impair military capabilities. More profoundly, however, hostile forces have no legal claim to medical assistance from their enemies until they have fallen prisoner and no longer pose a threat. A legal disposition, however, is not a moral argument. Bioethics will understandably look askance at any claim that denies medical assistance to the ill or injured. The larger moral argument, however, turns on combatants’ forfeiture of rights and their liability to lethal, disabling harm in war. Combatants, whether cooks or commandos, compromise their right to life and, with it, the subsidiary right to health care vis a vis their enemies when they take up arms. Surrender or captivity restores these rights.

Since sanctioned armies have yet to renounce armed force, the nuanced distinction IHL incorporates is necessary to identify healthcare rights holders among sick and injured enemy forces who have yet to surrender. Hence, only those who “refrain from hostilities” and serve no military role or, I would add, can never assume a military role, qualify for medical assistance. Ignoring these distinctions, the current sanction regimes impermissibly deny medical products to the Russian military whether ill or injured personnel fulfill a military function or not. But the status of the enemy wounded matters. Many of these ill or injured retain their right to health care.

Without precise data, it is difficult to assign status to Russian casualties accurately. But drawing on twentieth-century wars, we can estimate their numbers. During WWII, for example, approximately 20% of the American combat injured were killed in action. Of the remaining living casualties, 65% were walking wounded who “should receive treatment, but their wounds are sufficiently minor that they are survivable without treatment for the most part,” 25% were severely wounded and required prompt surgical attention, and 10% were “probably beyond salvage, even with maximal care (Swan and Swan 1996; also Dupuy 1995, 140–141).” Among Russian forces, Radford et al. (2023) estimate more than 75,000 dead and 225,000 wounded in the first year of the war. Extrapolating from earlier wars suggests that well over 150,000 Russian soldiers were lightly or moderately injured.

If, how and when these soldiers returned to duty is not known. But only the sick or injured sufficiently fit to perform their duties lose their right to medical support from their adversary. They do not qualify as wounded or sick under humanitarian law. Medical assistance for these patients is sanctionable. On the other hand, severely ill or injured enemy soldiers who might never return to duty are noncombatants and should enjoy the same right to adequate health care as any civilian.⁶ Sanctions cannot deny basic care to either. As a result, the Bureau of Industry and Security’s directive to target “items for the treatment of battlefield casualties” is profoundly troubling and ethically indefensible.

In this complex environment populated by combatants, civilians, and battlefield casualties, it is doubtful that medical sanctions can be so precisely targeted to respect the rights of all while withholding medical products from injured combatants who nonetheless return to duty. Among noncombatants, their right to health care discredits sanctions that push health care below the threshold of adequacy. Among combatants, military necessity permits sanctions that deny medical attention to active duty personnel, whether healthy, sick, or battlefield injured, but not to those who can never resume duty. At the same time, nothing will probably prevent Russia from using its limited medical stock to return soldiers to duty at the expense of severely wounded soldiers or desperately ill civilians. The allocation of resources to return lightly and moderately wounded to duty is the fundamental principle of military-medical triage (Gross 2021, 92–112).

Sorting out competing rights and duties always directs our attention to the most vulnerable: sick and injured civilians or severely wounded combatants. Their fate should guide the implementation of medical sanctions. First, medical sanctions cannot impair or threaten to impair adequate treatment and care. Preserving baseline care requires the constant attention of sanctioning nations as they ratchet up any kind of export control. Generic economic sanctions can be as pernicious as targeted medical sanctions. Second, sanctions affecting medical care beyond the baseline face their own constraints. Medical sanctions target vulnerable individuals directly and, therefore, may cause substantial harm, particularly to weak populations who lack the wherewithal to reach alternative care. Insofar as sanctioning nations preserve a baseline of adequate care, they may respond by writing off any additional harmful effects of sanctions as a lesser evil. In this view, medical sanctions are permissible if they offer military benefits that overwhelm the harm they cause. But it is a big “if.” The lesser evil defense gains no traction if medical sanctions are ineffective, unnecessary, disproportionate, or regress to violate soldiers’ or civilians’ fundamental healthcare rights. Each is a condition that sanctioning nations struggle to fulfill.

CONCLUSION

During war, two conditions govern the permissible use of armed force. Armed force must be (1) effective and necessary, and (2) cannot violate fundamental human rights. Sanctions are not armed force, but the logic is the same. Sweeping sanctions, like those imposed on Iraq, failed on all conditions. They were not effective, necessary, or respectful of human rights and precipitated a grave humanitarian crisis. A debilitated citizenry had no means whatsoever to squeeze compliance from a recalcitrant regime apathetic to their fate. In response, “smart” sanctions that targeted financial resources and military products took hold in the international community. These sanctions common to United Nations efforts to bring Libya, Iran, and other recalcitrant nations to heel were sometimes more effective, not always necessary, but generally did not violate the fundamental right to adequate medical care.

Introducing medical products into sanction regimes turned on an expanded definition of dual-use objects because medicine and medical products played a much greater role in armed conflict and modern war economies than they did after WWII. Evaluating the ethics and effects of economic and medical sanctions in Russia is encumbered by incomplete data, an unavoidable impediment when making moral judgments about war in real-time rather than in retrospect. But a real-time judgment is necessary to make any cogent claim about continuing to restrict the export of medical products. Based on available data, Russian military capabilities have been most impaired by export controls and restrictions that obstructed financial transactions, shipping, transportation, and the flow of spare parts, equipment, and technology. Medical sanctions in Russia are accomplishing little, whether in terms of compliance, erosion, or signaling, but dangerously threaten the fundamental human right to adequate health care. This right is not derogable and not subject to sanctions under any circumstances.

Constantly subject to external factors beyond their control, sanction regimes face a persistent and, most likely, intractable challenge to preserve the threshold of adequate care for civilians and disabled combatants. Recall how the UN could not maintain adequate health care in Iraq. Israel only avoided a healthcare disaster in Gaza in 2012 when third-party NGOs provided humanitarian aid, and Russia is keeping local health care afloat through heavy borrowing. Such contributions are by no means guaranteed. Without them, sanctioning regimes would need to proactively intervene to provide adequate care or eschew sanctions as health care deteriorates. Short on distinct benefits, stymied by intricate avenues of implementation, and encumbered by the substantial and indefensible risks they place on all the sick and injured of conflict, medical sanctions have no ready place in modern diplomacy or war.

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Notes

1 Restricted end-users are listed in Annex IV of EU Council (2022) Regulation 2022/2474 of December 16, 2022; goods requiring special authorization appear in Annex XXIII. https://eur-lex.europa.eu/legal-content/EN/TXT/PDF/?uri=CELEX:32022R2474. The lists are updated regularly.

2 Similarly, UK regulation may grant an export license for “dual-use goods or technology for medical and pharmaceutical purposes, provided that this is for the benefit of the civilian population.” Export Control Unit (UK) (2023).

3 For additional examples of restricted medical products, see HTS codes 900110-902230.

4 The referenced links to Russian language sources are accessible through Google Translate. I am indebted to Ruslan Vinokur for Russian language research and for verifying the accuracy of all quoted material. Notes describing each Russian language publication are in the references. For a general guide, see the BBC, Russia Media Guide, 2023, while noting their caveat: “The Kremlin’s control over mass media in Russia, including online media, is near complete, and war and other foreign news-related content on popular Russian online platforms is broadly in line with the state’s messaging.” Additional information on some sites is available from the US Library of Congress (https://www.loc.gov/).

5 Gisha, an Israeli-based human rights organization, claimed that Israel also restricted the import of additional items at times, including incubators, infusion pumps, nebulizers, and electric wheelchairs (Gisha 2016, 2023also UNOCHA 2015).

6 There are no strict definitions for “severely wounded,” with estimates ranging from 10% to 25% of all wounded. Citing data from Vietnam and Israel, Koehler, Smith, and Bacaner (1994) conclude that only 15–17% of severely wounded American and Israeli soldiers requiring evacuation to second-echelon care were returned to duty.” During the wars in Iraq and Afghanistan, 21% of US soldiers evacuated to Landstuhl Germany for continuing care following severe injuries returned to duty (although not necessarily in combat positions) (Hennessy 2016).