In the wake of Russian invasion of Ukraine, writing in the Hastings Bioethics Forum, Moreno (March 2022) states that bioethics, a “now-mature field” has to “adapt to a new set of conditions as part of a new global framework.” This means that instead of focusing on the more dominant agenda which has been on “exotic and philosophical issues … ” the agenda should gear towards “the requirements of global public health.” After all, “bioethics values not only apply to clinical medicine and research” but they also have an impact on public health, economic development, and security such as through laws of armed conflict and the treatment of prisoners of war.

It is a pity that within the area of security, bioethical debates have lagged far behind. Henk Ten Have (2023) in his article “Bioethics and War” published in the Hastings Centre Report laments the same, “In bioethics, the issue of war has not been treated as a major concern” despite Van Rensselaer Potter, widely considered the founding father of bioethics, calling war at least fifty years ago “as one of the priority problems of the time, jeopardizing the survival of humanity” (1971, 150).

For Potter, bioethics was a “new science of survival” with issues including population, peace, pollution, poverty, politics and progress crucial to ensure a livable future for humankind (Ten Have 2012). For many bioethicists, the unwavering focus of bioethics on the “exotic” as identified by Moreno, rather than the more pressing issues stressed by Potter, have been a source of growing concern.

This concern has grown exponentially in recent months. As the world witnesses with horror a huge humanitarian crisis as a result of the Israel–Hamas conflict, voices of the bioethics community have largely been silent, or at best muffled. This symposium in the Journal of Bioethical Inquiry is laudable for bringing Gaza to centerstage, giving it the attention it deserves. The article was written in response to an invitation to contribute to the symposium.

Academia, in general, appears to be reluctant to question the premise of this conflict. In the press, Newman (March, 2024) documents the silence of academia by saying “Universities, museums and archives that are silent during this onslaught are complicit in these genocidal acts” (¶17).

We believe that members of the bioethics community ought not to be silent. It is, in fact, our moral duty to raise our voice and call out injustice when we see it happening.

In order to gain a view of the response of the bioethics community to the ongoing crisis, we performed a scoping exercise for this piece. We wanted an objective idea of the publications in peer reviewed bioethics journals and authentic blogs about the conflict. The timeframe for the search began from the beginning of the conflict in October 2023.

We recognize that academic articles are published generally after a long editorial and lengthy peer review process but that certain sections including commentaries and editorials may be published more quickly. Articles can also appear online before they go to print. Blogs do not require a peer review process and can appear in a more time-sensitive manner.

The bioethics journals we focused on included the first nine according to Google Metrics on Bioethics.Footnote 1 These then included Nursing Ethics, Journal of Medical Ethics, The American Journal of Bioethics, BMC Medical Ethics, Journal of Law, Medicine & Ethics, Bioethics, Hastings Centre Report, Medicine, HealthCare and Philosophy, and Journal of Bioethical Inquiry. We also chose Indian Journal of Medical Ethics and Developing World Bioethics due to their focus on the Global South.

The bioethics blogs that we focused on included The Hastings Bioethics Forum, BMJ Medical Ethics, BMJ Open, and Global Health blogs. Bioedge.org that reports bioethics related news was also included in our search. Another website, Bioethics Today which “includes original blog authorship by world-renowned bioethicists” was also included. All of these are regarded as authentic sources providing coverage to bioethics discourse.

Selected peer reviewed medical journals were also included in our exercise since several articles in these journals circulated on social media related to the crisis. This included The Lancet, JAMA, and New England Journal of Medicine (NEJM).

There is a prominent social media-based exchange of opinions which we acknowledge. The authors had debated including social media platforms such as X (formerly Twitter), Instagram, TikTok, and others in the search strategy. However, it is well established that these social media platforms are designed to ensure maximum user engagement by selectively targeting, using algorithms, content that either resonates with the users’ web profile, or drastically conflicts with it. In other words, the content we would access would be tailored for us to some extent. The bias that this would potentially bring would not have been able to be eliminated. Hence, we decided exclude social media content from our review.

One of the authors (SS) screened the titles and abstracts (if available) for all the articles published between October 2023 and March 30, 2024. The screened articles were then read in full by both authors to determine their scope.

Findings from our Scoping Exercise

Figure 1 shows a snapshot of our scoping exercise.

Fig. 1
figure 1

Snapshot of Scoping Exercise- Focus on Bioethics Publications

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Grey Literature

Of the twenty-four articles published in The Hastings Bioethics Forum, none focused on the on-going conflict. The BMJ Open Blog published fifteen articles but none on the conflict. The BMJ Global Health Blog featured nine articles, with one focused on the conflict (see Table 1 for article title and brief description). The BMJ Medical Ethics published articles, none of which concerned the conflict. Bioethics Today Blog carried twenty-two articles out of which five were related to the conflict. In bioedge.org, out of 108 bioethics reports, six concerned the conflict.

Table 1 Description of Included Articles Appearing in Bioethics Publications (peer reviewed and otherwise)
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Bioethics Journals

The Hastings Centre Report has released two issues in our selected period. Owing perhaps to the long peer review process, no articles were related to the conflict in the November–December 2023 issues. Journal of Medical Ethics has had four issues but no articles related to the conflict were published. The Journal of Bioethical Inquiry has published one article on this issue. Bioethics has had five issues but none carried anything on the Gaza conflict. Developing World Bioethics reflects the same trend. The Indian Journal of Medical Ethics, while publishing nothing in print, however, did publish one article focusing on the conflict in the “online first” edition (see Table 1 for article titles and descriptions).

Global Health and Medicine Journals

The Lancet has shown a consistent stream of articles related to Gaza conflict (See Table 2).

Table 2 Articles published in The Lancet
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The Journal of American Medical Association (JAMA) published a total of 746 articles in this period. The first article on Gaza, on November 8, 2023, was titled, “Health Professionals and War in the Middle East” (Wynia 2013) which led to a series of responses. The author questioned whether healthcare professionals have any responsibility to speak out against the on-going crisis. The article mentioned Israel’s promise not to bomb healthcare facilities unless they act as an accessory in war. It ends with how healthcare professionals ought to concentrate on saving lives in war just like in peace times.

As a response, at least nine letters to editors appeared in JAMA. The first appeared on December 6 stated that a “political or military science degree” which Wynia had suggested, is not required to “know that bombing hospitals and disproportionately killing innocent civilians is unethical.” It went onto state, “We believe that putting this question up for debate in a peer-reviewed medical journal is abhorrent and harmful” (Alser, Gilbert, and Loubani 2024, 77). Three others took issue with, “its substantial omissions regarding the humanitarian crisis and war crimes occurring in Gaza” (Chaudhry and Berger 2023, 77; Ledermen 2023; Tsega 2023). Another spoke about Hamas conducting war crimes in Israel (Glatt 2023). A brief letter by the original author also appeared (Wynia 2024).

On December 18, three more letters appeared. Others from Israel wrote about the Hamas attack deliberately targeted healthcare facilities (Jaffe and Alpert 2023). Another one regretted how calling for a ceasefire in Gaza was automatically labelled anti-Semitism (Farid 2023). Another physician from the United States mentioned how healthcare professionals are in a privileged position to “serve as a moral center in these sorts of conflicts.” (Gallagher 2023, 170).

Another article titled, “Wars in Gaza and Beyond: Why Protecting the Sacredness of Health Matters” talked about the sacredness of health. Characterizing health centres as sacred places, the authors stated “When health systems fall under siege or become decimated, physicians’ ethical obligations are fundamentally undermined” (Gostin and Goodwin 2023, pp. 192.

No articles appeared in the New England Journal of Medicine on the topic during the period under scrutiny.

Reflections from the Scoping Exercise

So far, only fifteen articles have been published in bioethics-related publications included in this scoping review related to the unfolding humanitarian crisis in Gaza. We are cognizant of the possibility of articles that may have appeared elsewhere.Footnote 2 These articles have generally been focused on the health impact resulting from disruption of healthcare services. While this impact is undoubtedly important, the fallout of relentless bombardment of Gaza strip has been much wider, with huge humanitarian consequences. These include the killing of innocent children, women, and men who have nothing to do with combat and the destruction of private and governmental infrastructures. Along with hospitals, educational institutions, powerplants, and homes have been decimated. Survivors have lost their livelihoods, as famine like situation on the ground has started to take its toll. These are just a few of the many fallouts that will be felt for decades to come.

While some of these issues have been mentioned in JAMA letters and in a few The Lancet writings, no serious contributions have appeared in peer reviewed bioethics journals, as per our scoping review. We consider discussions on such issues well within the domain of bioethics discourse. In fact, they ought to be considered a priority at the moment. Yet they remain elusive so far in peer reviewed literature.

Perhaps the peer review process may be contributing to the publication delay. While acknowledging the importance of maintaining a rigorous peer review system, if editors considered the unfolding Gaza crisis important enough, the process could be expedited, as was done during the recent pandemic. Most journals also now have an “Online First” section, and only one article on the subject was made available in this fashion.

In the special issue of Bioethics titled, “Bioethics Challenges in Times of War,” an article by Lederman and Lederman (November 2023) spoke about the responsibility of bioethicists, using Yemen as a case study. Penned most certainly before the October 2023 events that triggered the current Gaza conflict, the article also asks a question central to our line of argument “Should bioethics journals prioritize philosophical rigor above all, even at the cost of neglecting ongoing armed conflicts and major human rights violations?” (2; ¶7). They go on to ask “Or is there value in the mere description of such events (with a modicum of basic normative groundwork) aimed at increasing awareness in the field and paying our dues as privileged intellectuals?” (2; ¶ 7). We believe there is indeed a moral responsibility on the bioethics academic community to do just that.

Five months after the Russian invasion of Ukraine, Fins (2022) wrote, “Bioethics, Ukraine and the Peril of Silence” in the Cambridge Quarterly of Healthcare Ethics. Finns says, “If war is the ultimate public health crisis, then surely bioethics—and bioethicists—should have something to say about the tragedy in Ukraine” (1; ¶ 1). Replace Ukraine with Palestine, and you would have the same argument, yet not the same response.

The Ukraine invasion invoked a quick response from leading bioethicists such as Caplan (2022). Other examples also include Hastings Bioethics Forum publishing three articles within five months of the invasion (Moreno 2022; Eckenwiler and Wild 2022; Basarab 2022). The Hastings Centre Report also published one article in their June 2022 issue (Bloswick, et al. 2022). BioEdge also carried five items on the Russian invasion of Ukraine. The content of these articles are similar—unanimous support demonstrated towards Ukraine and complete denouncement of Russia by calling for academic boycott and restrict supply to medicines as well. Yet a similar response from the same community does not exist when it comes to raising a voice against a one-sided war in which unarmed civilians in Gaza are the victims.

The November 2023 editorial of Developing World Bioethics (Diniz 2023) appeared about a month after the Gaza situation emerged. Titled, “Bioethics and Witnessing” the author stated, “doing bioethics means being an accompaniment-witness with the duty to speak the truth” (295). The editorial boldly said “we cannot be afraid of the political consequences of our academic work” (295). While the focus of the editorial was different, it is, in the author’s own words, “a matter of taking responsibility of being an academic writer and speaker” (295). It is ironic that despite the editorial position, even this journal has chosen silence when it comes to Gaza.

This silence could be attributed to two reasons: Either academics are choosing not to write, or this is not a high priority area for editors.

We broadened the scope of our search to include other prominent medical and/or global health journals. The Lancet, a weekly publication, has had forty-seven articles devoted to the issue of Gaza. The majority of the articles they carry focused on health conditions in Gaza, while very few have examined wider issues related to the regional politics having an impact on medical ethics and lived lives.

Perhaps Richard Horton, editor-in-chief of The Lancet, chose to devote the space in the journal to take a stand. As he stated in 2014 about an earlier episode of the Gaza conflict, “How can you separate politics and health? These two go hand-in-hand” (¶31). More recently (February 2024) Horton reiterated, “We’re [at The Lancet] going to see health as political” (Cookson 2024, ¶3).

Similarly how can then we, as bioethicists, separate war from ethics? We believe if the bioethics community chooses silence over expression, ignoring our moral responsibilities, then we risk making the field meaningless. We echo the sentiments of the article by one of the co-authors, titled, “The meaninglessness of doing bioethics: Reality from a conflict zone.” As Jafarey (2019) wrote, “In the context of the West Bank and Gaza, bioethics looks more like an esoteric philosophical exercise for academics sitting in comfortable conference rooms in faraway luxury hotels, rather than an instrument to protect the vulnerable” (3).

In a particularly indicting essay, “The silence of the damned,” Hedges (2024) pointed out the silence from health professions globally with regards to Gaza. He complained “the American Medical Association shut down a debate on a ceasefire resolution among its members and has called for ‘medical neutrality,’ although it abandoned ‘medical neutrality’ to denounce Russia’s invasion of Ukraine” (Hedges 2024, ¶16). However, for those who speak out, there are consequences. Hedges himself was labelled anti-Semitic. This systemic silencing of prominent academic leaders who positioned themselves in a manner contrary to the narrative being espoused by powers that be, may certainly be acting as a deterrent to write.Footnote 3

A personal correspondence with an editor of a prominent bioethics journal revealed that the journal had approached five individuals to write about the current conflict. Only one accepted the invitation. The others either refused citing different reasons or did not respond at all. While it is not possible to comment on the exact cause of these refusals, we believe that bioethicists have a moral responsibility to speak out against injustices.

As we pen this piece, we are also aware of consequences due to our own positionality. As academics belonging to Global South, we face intersectional disadvantages due to our nationality, religious identity, socioeconomic and political status, and race. Consequences can include visa and travel challenges, with curtailed access to opportunities at the global stage and even academic isolation.

But, as Paulo Freire stated, “The educator has the duty of not being neutral,” we believe this duty is even more profound for bioethics educators. We can no longer sit “in comfortable conference rooms in faraway luxury hotels” pontificating on the esoteric, while humanity suffers.

We state our position clearly. War is abhorrent and its fallout never remains limited to combatants. In the case of Gaza, it is also one sided. Any kind of cooperation with war, silence or neutrality included, is morally objectionable. The global bioethics community has a larger moral duty to raise a voice against this ongoing injustice.