Rule 28. Medical Units
Rule 28. Medical units exclusively assigned to medical purposes must be respected and protected in all circumstances. They lose their protection if they are being used, outside their humanitarian function, to commit acts harmful to the enemy.
Summary
State practice establishes this rule as a norm of customary international law applicable in both international and non-international armed conflicts.
International armed conflicts
This rule goes back to the protection of “hospitals and places where the sick and wounded are collected” in the Hague Regulations.[1]  It is set forth in the First and Fourth Geneva Conventions.[2]  Its scope was expanded in Additional Protocol I to cover civilian medical units in addition to military medical units in all circumstances.[3]  This extension is widely supported in State practice, which generally refers to medical units without distinguishing between military or civilian units.[4]  It is also supported by States not, or not at the time, party to Additional Protocol I.[5] 
Under the Statute of the International Criminal Court, intentionally directing attacks against “hospitals and places where the sick and the wounded are collected, provided they are not military objectives” and against “medical units … using the distinctive emblems of the Geneva Conventions in conformity with international law” constitutes a war crime in international armed conflicts.[6] 
This rule is contained in numerous military manuals.[7]  Sweden’s IHL Manual identifies the protection of medical units as set out in Article 12 of Additional Protocol I as a codification of a pre-existing rule of customary international law.[8]  It is an offence under the legislation of many States to violate this rule.[9]  The rule has been invoked in official statements.[10] 
Non-international armed conflicts
This rule is implicit in common Article 3 of the Geneva Conventions, which requires that the wounded and sick be collected and cared for, because the protection of medical units is a subsidiary form of protection afforded to ensure that the wounded and sick receive medical care.[11]  The rule that medical units must be respected and protected at all times, and must not be the object of attack, is explicitly set forth in Additional Protocol II.[12]  In addition, under the Statute of the International Criminal Court, intentionally directing attacks against “hospitals and places where the sick and the wounded are collected, provided they are not military objectives” and against “medical units … using the distinctive emblems of the Geneva Conventions in conformity with international law” constitutes a war crime in non-international armed conflicts.[13]  In addition, this rule is contained in other instruments pertaining also to non-international armed conflicts.[14] 
The protection of medical units is set forth in military manuals which are applicable in or have been applied in non-international armed conflicts.[15]  It is an offence under the legislation of many States to violate this rule.[16]  Furthermore, the rule is supported by a number of official statements made in the context of non-international armed conflicts.[17] 
No official contrary practice was found with respect to either international or non-international armed conflicts. Alleged attacks against medical units have generally been condemned by States.[18]  They have also been condemned by international organizations, for example, in the context of the conflicts in Afghanistan, Burundi, El Salvador, Kampuchea, Korea, Rwanda, Somalia, Vietnam and the former Yugoslavia, between The Islamic Republic of Iran and Iraq and in the Middle East.[19]  The ICRC has called upon parties to both international and non-international armed conflicts to respect this rule.[20] 
Definition of medical units
The term “medical units” refers to establishments and other units, whether military or civilian, organized for medical purposes, be they fixed or mobile, permanent or temporary. The term includes, for example, hospitals and other similar units, blood transfusion centres, preventive medicine centres and institutes, medical depots and the medical and pharmaceutical stores of such units.
This definition, which builds upon Article 19 of the First Geneva Convention and Article 18 of the Fourth Geneva Convention, is set out in Article 8(e) of Additional Protocol I.[21]  It is widely used in State practice.[22]  In the absence of a definition of medical units in Additional Protocol II, this term may be understood as applying in the same sense in non-international armed conflicts.[23] 
While a lot of practice does not expressly require medical units to be recognized and authorized by one of the parties, some of it refers to the provisions of Additional Protocol I,[24]  or does require such authorization in another way.[25]  Unauthorized medical units must therefore be regarded as being protected according to the rules on the protection of civilian objects (see Chapter 2), but do not have the right to display the distinctive emblems.
Criminal codes often require medical establishments to be properly marked with the distinctive emblems.[26]  However, having regard to the principle that means of identification do not, of themselves, confer protected status but only facilitate identification, this can be of importance only for criminal responsibility in the event of an attack on a medical unit (see commentary to Rule 30).
Respect for and protection of medical units
State practice contains the following specifications with respect to the meaning of the terms “respect and protection”. According to Germany’s military manuals, the terms “respect and protection” mean that medical units may not be attacked and that their unhampered employment must be ensured.[27]  Switzerland’s Basic Military Manual contains a similar understanding, specifying that “[medical units] shall not be attacked, nor harmed in any way, nor their functioning be impeded, even if they do not momentarily hold any wounded and sick”.[28]  Similarly, the US Air Force Commander’s Handbook provides that medical units “should not be deliberately attacked, fired upon, or unnecessarily prevented from performing their medical duties”.[29] 
The military manuals of Benin, Nigeria, Senegal and Togo state that medical units must remain untouched and that armed persons may not enter them, but that their content and actual use may be checked through an inspection.[30] 
The First and Fourth Geneva Conventions and Additional Protocol I require that, as far as possible, medical units not be located in the vicinity of military objectives.[31]  This requirement is repeated in numerous military manuals.[32]  Article 12(4) of Additional Protocol I further provides that medical units may under no circumstances be used in an attempt to shield military objectives from attack.[33]  This requirement is explicitly subscribed to in the practice of the Netherlands and the United States.[34]  Some military manuals stipulate that medical units may not be used for military purposes or to commit acts harmful to the enemy.[35]  Other manuals consider that the improper use of privileged buildings for military purposes is a war crime.[36] 
Loss of protection due to medical units
State practice establishes the exception under customary international law that the protection of medical units ceases when they are being used, outside their humanitarian function, to commit acts harmful to the enemy. This exception is provided for in the First and Fourth Geneva Conventions and in both Additional Protocols.[37]  It is contained in numerous military manuals and military orders.[38]  It is also supported by other practice.[39] 
While the Geneva Conventions and Additional Protocols do not define “acts harmful to the enemy”, they do indicate several types of acts which do not constitute “acts harmful to the enemy”, for example, when the personnel of the unit is armed, when the unit is guarded, when small arms and ammunition taken from the wounded and sick are found in the unit and when wounded and sick combatants or civilians are inside the unit.[40]  According to the Commentary on the First Geneva Convention, examples of acts harmful to the enemy include the use of medical units to shelter able-bodied combatants, to store arms or munitions, as a military observation post or as a shield for military action.[41] 
It is further specified in State practice that prior to an attack against a medical unit which is being used to commit acts harmful to the enemy, a warning has to be issued setting, whenever appropriate, a reasonable time-limit and that an attack can only take place after such warning has remained unheeded.[42]  These procedural requirements are also laid down in the Geneva Conventions and Additional Protocols.[43] 

[1] 1899 and 1907 Hague Regulations, Article 27 (cited in Vol. II, Ch. 7, §§ 377–378).
[2] First Geneva Convention, Article 19 (ibid., § 379); Fourth Geneva Convention, Article 18 (ibid., § 380).
[3] Additional Protocol I, Article 12 (adopted by consensus) (ibid., § 381).
[4] See, e.g., the military manuals of Belgium (ibid., § 396), Burkina Faso (ibid., § 400), Cameroon (ibid., § 401), Canada (ibid., § 403), Colombia (ibid., §§ 404–405), Dominican Republic (ibid., § 409), Ecuador (ibid., § 410), Germany (ibid., §§ 414–415), Hungary (ibid. § 416), Israel (ibid., § 417), Italy (ibid., § 419), Lebanon (ibid., § 424), Netherlands (ibid., §§ 428–429), Nigeria (ibid., § 434), Romania (ibid., § 435), Russian Federation (ibid., § 436), Senegal (ibid., §§ 437–438) and United States (ibid., §§ 448–451); the legislation of Australia (ibid., 456), Azerbaijan (ibid., § 457), Canada (ibid., § 461), Chile (ibid., § 462), China (ibid., § 463), Colombia (ibid., § 464), Congo (ibid., § 465), Cuba (ibid., § 467), Dominican Republic (ibid., § 468), El Salvador (ibid., § 469), Estonia (ibid., § 471), Ethiopia (ibid., § 472), Georgia (ibid., § 473), Germany (ibid., § 474), Guatemala (ibid., § 475), Iraq (ibid., § 476), Mexico (ibid., § 480), Netherlands (ibid., §§ 481–482), New Zealand (ibid. § 483), Nicaragua (ibid., § 484), Peru (ibid., § 487), Philippines (ibid., § 488), Poland (ibid., § 489), Portugal (ibid., § 490), Romania (ibid., § 491), Spain (ibid., § 493), Tajikistan (ibid., § 495), Ukraine (ibid., § 497), United Kingdom (ibid., § 498), Uruguay (ibid., § 500) and Bolivarian Republic of Venezuela(ibid., § 501); see also the draft legislation of Argentina (ibid., § 454), Burundi (ibid., § 460), El Salvador (ibid., § 470), Nicaragua (ibid., § 485), Trinidad and Tobago (ibid., § 496), and the statements of Argentina (ibid., § 505), Canada (ibid., § 506), China (ibid., §§ 507–508), Egypt (ibid., § 511), Finland (ibid., § 512), France (ibid., § 513), Hungary (ibid., § 515), Iraq (ibid., § 517), United States (ibid., § 529) and Bolivarian Republic of Venezuela(ibid., § 530).
[5] See, e.g., the practice of France (ibid., § 412), Kenya (ibid., § 421), United Kingdom (ibid., §§ 445 and 524) and United States (ibid., § 527).
[6] ICC Statute, Article 8(2)(b)(ix) (ibid., § 384).
[7] See, e.g., the military manuals of Argentina (ibid., §§ 392–393), Australia (ibid., §§ 394–395), Belgium (ibid., §§ 396–397), Benin (ibid., § 398), Bosnia and Herzegovina (ibid., § 399), Burkina Faso (ibid., § 400), Cameroon (ibid., § 401), Canada (ibid., §§ 402–403), Colombia (ibid., §§ 404–405), Congo (ibid., § 406), Croatia (ibid., §§ 407–408), Dominican Republic (ibid., § 409), Ecuador (ibid., § 410), France (ibid., §§ 411–413), Germany (ibid., §§ 414–415), Hungary (ibid., § 416), Israel (ibid., §§ 417–418), Italy (ibid., §§ 419–420), Kenya (ibid., § 421), Republic of Korea (ibid., § 422), Lebanon (ibid., §§ 423–424), Madagascar (ibid., § 425), Mali (ibid., § 426), Morocco (ibid., § 427), Netherlands (ibid., §§ 428–429), New Zealand (ibid., § 430), Nicaragua (ibid., § 431), Nigeria (ibid., §§ 432–434), Romania (ibid., § 435), Russian Federation (ibid., § 436), Senegal (ibid., §§ 437–438), South Africa (ibid., § 439), Spain (ibid., § 440), Sweden (ibid., § 441), Switzerland (ibid., § 442), Togo (ibid., § 443), United Kingdom (ibid., §§ 444–445), United States (ibid., §§ 446–451) and Yugoslavia (ibid., § 452).
[8] Sweden, IHL Manual (ibid., § 441).
[9] See, e.g., the legislation of Argentina (ibid., § 453), Australia (ibid., §§ 455–456), Azerbaijan (ibid., § 457), Bangladesh (ibid., § 458), Bosnia and Herzegovina (ibid., § 459), Canada (ibid., § 461), Chile (ibid., § 462), China (ibid., § 463), Colombia (ibid., § 464), Congo (ibid., § 465), Croatia (ibid., § 466), Cuba (ibid., § 467), Dominican Republic (ibid., § 468), El Salvador (ibid., § 469), Estonia (ibid., § 471), Ethiopia (ibid., § 472), Georgia (ibid., § 473), Germany (ibid., § 474), Guatemala (ibid., § 475), Iraq (ibid., § 476), Ireland (ibid., § 477), Italy (ibid., § 478), Lithuania (ibid., § 479), Mexico (ibid., § 480), Netherlands (ibid., §§ 481–482), New Zealand (ibid., § 483), Nicaragua (ibid., § 484), Norway (ibid., § 486), Peru (ibid., § 487), Philippines (ibid., § 488), Poland (ibid., § 489), Portugal (ibid., § 490), Romania (ibid., § 491), Slovenia (ibid., § 492), Spain (ibid., § 493), Sweden (ibid., § 494), Tajikistan (ibid., § 495), Ukraine (ibid., § 497), United Kingdom (ibid., § 498), United States (ibid., § 499), Uruguay (ibid., § 500), Bolivarian Republic of Venezuela(ibid., § 501) and Yugoslavia (ibid., § 502); see also the draft legislation of Argentina (ibid., § 454), Burundi (ibid., § 460), El Salvador (ibid., § 470), Nicaragua (ibid., § 485) and Trinidad and Tobago (ibid., § 496).
[10] See, e.g., the statements of Argentina (ibid., § 505), Canada (ibid., § 506), China (ibid., §§ 507–508), Egypt (ibid., §§ 510–511), Finland (ibid., § 512), France (ibid., § 513), Hungary (ibid., § 515), Iraq (ibid., § 517), Norway (ibid., § 521), Rwanda (ibid., § 522), Saudi Arabia (ibid., § 523), United States (ibid., §§ 525–529) and Bolivarian Republic of Venezuela(ibid., § 530); see also the reported practice of Israel (ibid., § 518).
[11] This reasoning is put forward, e.g., in the military manuals of Belgium (ibid., § 397), Colombia (ibid., § 404), Israel (ibid., § 418) and Nicaragua (ibid., § 431).
[12] Additional Protocol II, Article 11(1) (adopted by consensus) (ibid., § 382).
[13] ICC Statute, Article 8(2)(e)(ii) and (iv) (ibid., §§ 384 and 831).
[14] See, e.g., Agreement on the Application of IHL between the Parties to the Conflict in Bosnia and Herzegovina (ibid., § 389).
[15] See, e.g., the military manuals of Argentina (ibid., § 393), Australia (ibid., §§ 394–395), Benin (ibid., § 398), Bosnia and Herzegovina (ibid., § 399), Canada (ibid., §§ 402–403), Colombia (ibid., §§ 404–405), Croatia (ibid., §§ 407–408), Ecuador (ibid., § 410), Germany (ibid., §§ 414–415), Hungary (ibid., § 416), Italy (ibid., §§ 419–420), Kenya (ibid., § 421), Republic of Korea (ibid., § 422), Lebanon (ibid., §§ 423–424), Madagascar (ibid., § 425), Netherlands (ibid., § 428), New Zealand (ibid., § 430), Nigeria (ibid., §§ 432–433), Russian Federation (ibid., § 436), Senegal (ibid., § 438), South Africa (ibid., § 439), Spain (ibid., § 440), Togo (ibid., § 443) and Yugoslavia (ibid., § 452).
[16] See, e.g., the legislation of Australia (ibid., § 456), Azerbaijan (ibid., § 457), Bosnia and Herzegovina (ibid., § 459), Canada (ibid., § 461), Colombia (ibid., § 464), Congo (ibid., § 465), Croatia (ibid., § 466), Estonia (ibid., § 471), Ethiopia (ibid., § 472), Georgia (ibid., § 473), Germany (ibid., § 474), Ireland (ibid., § 477), Lithuania (ibid., § 479), Netherlands (ibid., § 482), New Zealand (ibid., § 483), Nicaragua (ibid., § 484), Norway (ibid., § 486), Poland (ibid., § 489), Portugal (ibid., § 490), Slovenia (ibid., § 492), Spain (ibid., § 493), Sweden (ibid., § 494), Tajikistan (ibid., § 495), United Kingdom (ibid., § 498), Bolivarian Republic of Venezuela(ibid., § 501) and Yugoslavia (ibid., § 502); see also the legislation of Argentina (ibid., § 453), Cuba (ibid., § 467), Guatemala (ibid., § 475), Italy (ibid., § 478), Peru (ibid., § 487), Romania (ibid., § 491) and Uruguay (ibid., § 500), the application of which is not excluded in time of non-international armed conflict, and the draft legislation of Argentina (ibid., § 454), Burundi (ibid., § 460), El Salvador (ibid., § 470), Nicaragua (ibid., § 485) and Trinidad and Tobago (ibid., § 496).
[17] See, e.g., the statements of Argentina (ibid., § 505), Canada (ibid., § 506), Finland (ibid., § 512), France (ibid., § 513), Hungary (ibid., § 515), Rwanda (ibid., § 522) and Bolivarian Republic of Venezuela(ibid., § 530).
[18] See, e.g., the statements of Argentina (ibid., § 505), Canada (ibid., § 506), China (ibid., §§ 507–508), Egypt (ibid., § 510), Finland (ibid., § 512), France (ibid., § 513), Hungary (ibid., 515), Islamic Republic of Iran (ibid., § 516), Iraq (ibid., § 517), Norway (ibid., § 521), Rwanda (ibid., § 522), Saudi Arabia (ibid., § 523), United States (ibid., § 525) and Bolivarian Republic of Venezuela (ibid., § 530).
[19] See, e.g., UN Security Council, Res. 467 (ibid., § 533), Res. 771 (ibid., § 534) and Res. 794 (ibid., § 535); UN General Assembly, Res. 39/119 (ibid., § 537), Res. 40/139 (ibid., § 538) and Res. 41/157 (ibid., § 538); UN Commission on Human Rights, Res. 1983/5 (ibid., § 539), Res. 1987/51 (ibid., § 540) and Res. 1992/S-1/1 (ibid., § 542).
[20] See the practice of the ICRC (ibid., §§ 554–556, 559–564 and 566–573).
[21] Additional Protocol I, Article 8(e) (adopted by consensus).
[22] See, e.g., the practice of Australia (cited in Vol. II, Ch. 7, § 395), Canada (ibid., § 402), Kenya (ibid., § 421), New Zealand (ibid., § 430), South Africa (ibid., § 439), Spain (ibid., § 440), Romania (ibid., § 491) and United States (ibid., § 383).
[23] See the declaration to this effect by the United States (ibid., § 383); see also Yves Sandoz, Christophe Swinarski, Bruno Zimmermann (eds.), Commentary on the Additional Protocols, ICRC, Geneva, 1987, §§ 4711–4712.
[24] Article 12(2) of Additional Protocol I requires that civilian medical units be “recognized and authorized by the competent authority of one of the Parties to the conflict” or that they be “recognized in conformity with” Article 9(2) of Additional Protocol I or with Article 27 of the First Geneva Convention, i.e., recognized by a neutral or other State not party to the conflict, by an aid society of such a State, or by an impartial international humanitarian organization.
[25] See, e.g., the practice of France (cited in Vol. II, Ch. 7, § 413), Ireland (ibid., § 477), Nigeria (ibid., § 433), Norway (ibid., § 486), Sweden (ibid., § 441) and United States (ibid., § 527).
[26] See, e.g., the legislation of Argentina (ibid., § 453), Azerbaijan (ibid., § 457), Chile (ibid., § 462), Colombia (ibid., § 464), Dominican Republic (ibid., § 468), Germany (ibid., § 474), Peru (ibid., § 487) and Romania (ibid., § 491); see also the draft legislation of Argentina (ibid., § 454) and Nicaragua (ibid., § 485).
[27] See the military manuals of Germany (ibid., §§ 414–415).
[28] Switzerland, Basic Military Manual (ibid., § 442).
[29] United States, Air Force Commander’s Handbook (ibid., § 448).
[30] See the military manuals of Benin (ibid., § 398), Nigeria (ibid., § 433), Senegal (ibid., § 438) and Togo (ibid., § 443).
[31] First Geneva Convention, Article 19 (ibid., § 379); Fourth Geneva Convention, Article 18 (ibid., § 380); Additional Protocol I, Article 12(4) (adopted by consensus) (ibid., § 381).
[32] See, e.g., the military manuals of Argentina (ibid., § 392), Canada (ibid., § 403), Ecuador (ibid., § 410), Germany (ibid., §§ 414–415), Netherlands (ibid., § 428), Nigeria (ibid., § 434), Russian Federation (ibid., § 436), Switzerland (ibid., § 442), United Kingdom (ibid., § 444), United States (ibid., §§ 446 and 451) and Yugoslavia (ibid., § 452).
[33] Additional Protocol I, Article 12(4) (adopted by consensus) (ibid., § 381).
[34] Netherlands, Military Manual (ibid., § 428); United States, Department of Defense, Statement (ibid., § 528).
[35] See the military manuals of Ecuador (ibid., § 603), Germany (ibid., §§ 605–606), Kenya (ibid., § 607), Netherlands (ibid., § 609) and United States (ibid., § 622).
[36] See, e.g., the military manuals of Canada (ibid., § 601), New Zealand (ibid., § 610), Nigeria (ibid., § 611), United Kingdom (ibid., §§ 615–616) and United States (ibid., §§ 617–618 and 620).
[37] First Geneva Convention, Article 21 (ibid., § 586); Fourth Geneva Convention, Article 19 (ibid., § 588); Additional Protocol I, Article 13 (adopted by consensus) (ibid., § 589); Additional Protocol II, Article 11(2) (adopted by consensus) (ibid., § 590).
[38] See, e.g., the military manuals of Argentina (ibid., §§ 594–595), Australia (ibid., 596–597), Bosnia and Herzegovina (ibid., § 599), Cameroon (ibid., § 600), Canada (ibid., §§ 601–602), Ecuador (ibid., § 603), Germany (ibid., § 605), Kenya (ibid., § 607), Netherlands (ibid., § 608), New Zealand (ibid., § 610), Nigeria (ibid., § 611), South Africa (ibid., § 612), Spain (ibid., § 613), Switzerland (ibid., § 614), United Kingdom (ibid., §§ 615–616), United States (ibid., §§ 617, 619 and 621–622) and Yugoslavia (ibid., § 623).
[39] See, e.g., the practice of Yugoslavia (ibid., § 631) and the reported practice of Bosnia and Herzegovina, Republika Srpska (ibid., § 629) and a State (ibid., § 632).
[40] First Geneva Convention, Article 22 (ibid., § 587); Fourth Geneva Convention, Article 19 (ibid., § 588); Additional Protocol I, Article 13(2) (adopted by consensus) (ibid., § 589).
[41] Jean S. Pictet (ed.), Commentary on the First Geneva Convention, ICRC, Geneva, 1952, pp. 200–201; see also the military manuals of South Africa (cited in Vol. II, Ch. 7, § 612), Switzerland (ibid., § 614) and United States (ibid., § 619).
[42] See, e.g., Agreement on the Application of IHL between the Parties to the Conflict in Bosnia and Herzegovina (ibid., § 592) and the military manuals of Argentina (ibid., § 595), Australia (ibid., §§ 596–597), Canada (ibid., §§ 601–602), Ecuador (ibid., § 603), Germany (ibid., § 605), Netherlands (ibid., § 608), New Zealand (ibid., § 610), Nigeria (ibid., § 611), Spain (ibid., § 613), Switzerland (ibid., § 614), United States (ibid., §§ 619 and 621–622) and Yugoslavia (ibid., § 623).
[43] First Geneva Convention, Article 21 (ibid., § 586); Fourth Geneva Convention, Article 19 (ibid., § 588); Additional Protocol I, Article 13(1) (adopted by consensus) (ibid., § 589); Additional Protocol II, Article 11(2) (adopted by consensus) (ibid., § 590).