Practice Relating to Rule 29. Medical Transports

Geneva Convention I
Article 35 of the 1949 Geneva Convention I provides:
Transports of wounded and sick or of medical equipment shall be respected and protected in the same way as mobile medical units.
Should such transports or vehicles fall into the hands of the adverse Party, they shall be subject to the laws of war, on condition that the Party to the conflict who captures them shall in all cases ensure the care of the wounded and sick they contain.
The civilian personnel and all means of transport obtained by requisition shall be subject to the general rules of international law. 
Convention (I) for the Amelioration of the Condition of the Wounded and Sick in Armed Forces in the Field, Geneva, 12 August 1949, Article 35.
Geneva Convention IV
Article 21 of the 1949 Geneva Convention IV provides:
Convoys of vehicles or hospital trains on land or specially provided vessels on sea, conveying wounded and sick civilians, the infirm and maternity cases, shall be respected and protected in the same manner as the hospitals provided for in Article 18, and shall be marked, with the consent of the State, by the display of the distinctive emblem provided for in Article 38 of the Geneva Convention for the Amelioration of the Condition of the Wounded and Sick in Armed Forces in the Field of August 12, 1949. 
Convention (IV) relative to the Protection of Civilian Persons in Time of War, Geneva, 12 August 1949, Article 21.
Additional Protocol I
Article 21 of the 1977 Additional Protocol I provides: “Medical vehicles shall be respected and protected in the same way as mobile medical units under the Conventions and this Protocol.” 
Protocol Additional to the Geneva Conventions of 12 August 1949, and relating to the Protection of Victims of International Armed Conflicts (Protocol I), Geneva, 8 June 1977, Article 21. Article 21 was adopted by consensus. CDDH, Official Records, Vol. VI, CDDH/SR.38, 24 May 1977, p. 85.
Additional Protocol II
Article 11(1) of the 1977 Additional Protocol II provides: “Medical … transports shall be respected and protected at all times and shall not be the object of attack.” 
Protocol Additional to the Geneva Conventions of 12 August 1949, and relating to the Protection of Victims of Non-International Armed Conflicts (Protocol II), Geneva, 8 June 1977, Article 11(1). Article 11 was adopted by consensus. CDDH, Official Records, Vol. VII, CDDH/SR.51, 3 June 1977, p. 113.
Agreement on the Application of IHL between the Parties to the Conflict in Bosnia and Herzegovina
Paragraph 2.2 of the 1992 Agreement on the Application of IHL between the Parties to the Conflict in Bosnia and Herzegovina provides: “… medical transportation may in no circumstances be attacked, they shall at all times be respected and protected. They may not be used to shield combatants, military objectives or operations from attack.” 
Agreement between Representatives of Mr. Alija Izetbegović (President of the Republic of Bosnia and Herzegovina and President of the Party of Democratic Action), Representatives of Mr. Radovan Karadžić (President of the Serbian Democratic Party), and Representative of Mr. Miljenko Brkić (President of the Croatian Democratic Community), Geneva, 22 May 1992, § 2.2.
UN Secretary-General’s Bulletin
Section 9.5 of the 1999 UN Secretary-General’s Bulletin provides: “The United Nations force shall respect and protect transports of wounded and sick or medical equipment in the same way as mobile medical units.” 
Observance by United Nations Forces of International Humanitarian Law, Secretary-General’s Bulletin, UN Secretariat, UN Doc. ST/SGB/1999/13, 6 August 1999, Section 9.5.
Argentina
Argentina’s Law of War Manual (1969) restates Article 35 of the 1949 Geneva Convention I and Article 21 of the 1949 Geneva Convention IV. 
Argentina, Leyes de Guerra, RC-46-1, Público, II Edición 1969, Ejército Argentino, Edición original aprobado por el Comandante en Jefe del Ejército, 9 May 1967, §§ 3.016 and 4.006.
Argentina
Argentina’s Law of War Manual (1989) states, with respect to non-international armed conflicts in particular: “Medical means of transportation shall be respected and protected and may not be made the object of attack, provided they are not being used to commit hostile acts.” 
Argentina, Leyes de Guerra, PC-08-01, Público, Edición 1989, Estado Mayor Conjunto de las Fuerzas Armadas, aprobado por Resolución No. 489/89 del Ministerio de Defensa, 23 April 1990, § 7.07.
Australia
Australia’s Commanders’ Guide (1994) provides: “civilian medical … transports and supplies are not to be made the target of attack or unnecessarily destroyed. Military medical … facilities and equipment are also entitled to general protection under the Geneva Conventions.” 
Australia, Law of Armed Conflict, Commanders’ Guide, Australian Defence Force Publication, Operations Series, ADFP 37 Supplement 1 – Interim Edition, 7 March 1994, §§ 614–615.
Australia
Australia’s Defence Force Manual (1994) provides: “civilian medical … transports and supplies are not to be made the target of attack or unnecessarily destroyed.” 
Australia, Manual on Law of Armed Conflict, Australian Defence Force Publication, Operations Series, ADFP 37 – Interim Edition, 1994, § 963; see also § 902.
The manual defines medical transports as “any means of transportation, whether military or civilian, permanent or temporary, assigned exclusively to medical transportation and under the control of a competent authority of a party to the conflict”. 
Australia, Manual on Law of Armed Conflict, Australian Defence Force Publication, Operations Series, ADFP 37 – Interim Edition, 1994, Glossary.
Australia
Australia’s LOAC Manual (2006) states:
5.41 Medical units, materials and means of transportation are protected. This applies to any form of medical transportation, whether by sea, land or air …
5.43 Transports of wounded and sick or of medical equipment shall be respected and protected in the same way as mobile medical units. Should such transports or vehicles fall into the hands of the adverse party, they shall be subject to the laws of war, on condition that the party to the conflict who captures them shall in all cases ensure the care of the wounded and sick they contain.
9.68 … [C]ivilian medical … transports and supplies are not to be made the target of attack or unnecessarily destroyed.
9.79 Medical … transports are any means of transportation, military or civilian, permanent or temporary, assigned exclusively to medical transportation and under control of a competent authority of a party to the conflict. 
Australia, The Manual of the Law of Armed Conflict, Australian Defence Doctrine Publication 06.4, Australian Defence Headquarters, 11 May 2006, §§ 5.41, 5.43, 9.68 and 9.79.
The LOAC Manual (2006) replaces both the Defence Force Manual (1994) and the Commanders’ Guide (1994).
Belgium
Belgium’s Law of War Manual (1983) states: “Transport over land of the wounded and sick and medical material enjoys the same protection as medical units and material: it may not be made the object of attack.” 
Belgium, Droit Pénal et Disciplinaire Militaire et Droit de la Guerre, Deuxième Partie, Droit de la Guerre, Ecole Royale Militaire, par J. Maes, Chargé de cours, Avocat-général près la Cour Militaire, D/1983/1187/029, 1983, p. 48.
Belgium
Belgium’s Teaching Manual for Soldiers states:
The protection accorded to the wounded would be illusory if the civilian and military medical services which are specifically set up to treat them could be attacked. Hence, medical services, identified by the Red Cross (or Red Crescent in certain countries), are not considered combatants or military objectives even if they wear the enemy uniform or bear its insignia. Enemy medical transports … may not be attacked. 
Belgium, Droit de la Guerre, Dossier d’Instruction pour Soldat, à l’attention des officiers instructeurs, JS3, Etat-Major Général, Forces Armées belges, undated, p. 17; see also p. 8.
Benin
Benin’s Military Manual (1995) lists the military and civilian medical service as specially protected objects. 
Benin, Le Droit de la Guerre, III fascicules, Forces Armées du Bénin, Ministère de la Défense nationale, 1995, Fascicule I, p. 13.
The manual states: “Specially protected means of transport shall be authorized to carry out their mission as long as necessary. Their mission, content and actual use may be checked through an inspection.” 
Benin, Le Droit de la Guerre, III fascicules, Forces Armées du Bénin, Ministère de la Défense nationale, 1995, Fascicule II, p. 9.
Burkina Faso
Burkina Faso’s Disciplinary Regulations (1994) provides that, under the laws and customs of war, soldiers in combat must respect medical transports. 
Burkina Faso, Règlement de Discipline Générale dans les Forces Armées, Décret No. 94-159/IPRES/DEF, Ministère de la Défense, 1994, Article 35.
Burundi
Burundi’s Regulations on International Humanitarian Law (2007) states with respect to “units and means of medical transport”: “They must at all times be respected and protected.” 
Burundi, Règlement n° 98 sur le droit international humanitaire, Ministère de la Défense Nationale et des Anciens Combattants, Projet “Moralisation” (BDI/B-05), August 2007, Part I bis, p. 5; see also Part I bis, pp. 11, 15, 19, 25, 31, 35, 80 and 100.
The Regulations adds that units and means of medical transport “must not be made the object of attack”. 
Burundi, Règlement n° 98 sur le droit international humanitaire, Ministère de la Défense Nationale et des Anciens Combattants, Projet “Moralisation” (BDI/B-05), August 2007, Part I bis, p. 5; see also Part I bis, pp. 15, 25, 31, 35, 57, 58, 80 and 100.
The Regulations further states: “Such protection ceases if [medical units and means of transport] are used outside of humanitarian purposes in harmful acts against the adversary.” 
Burundi, Règlement n° 98 sur le droit international humanitaire, Ministère de la Défense Nationale et des Anciens Combattants, Projet “Moralisation” (BDI/B-05), August 2007, Part I bis, p. 35.
The Regulations also states: “Transportation of the civilian wounded and sick, the infirm, elderly, children and maternity cases in convoys of vehicles and hospital trains must be respected and protected in the same manner as provided for hospitals.” 
Burundi, Règlement n° 98 sur le droit international humanitaire, Ministère de la Défense Nationale et des Anciens Combattants, Projet “Moralisation” (BDI/B-05), August 2007, Part I bis, p. 35; see also Part I bis, p. 19.
Cameroon
Cameroon’s Disciplinary Regulations (1975) provides that, under the laws and customs of war, each soldier must respect medical transports. 
Cameroon, Règlement de discipline dans les Forces Armées, Décret No. 75/700, 6 November 1975, Article 31.
Cameroon
Cameroon’s Instructor’s Manual (1992) provides that medical transports exclusively used to transport wounded, sick and shipwrecked and medical material enjoy the protection granted thereto by the laws of war. 
Cameroon, Droit international humanitaire et droit de la guerre, Manuel de l’instructeur en vigueur dans les Forces Armées, Présidence de la République, Ministère de la Défense, Etat-major des Armées, Troisième Division, Edition 1992, p. 68, § 243.1.
Cameroon
Cameroon’s Instructor’s Manual (2006) states:
352.2 – Special protection: (persons and objects specially protected.)
Certain categories of persons and objects benefit from special protection under the law of armed conflict and international humanitarian law, both in the civilian domain and in the military domain.
352.20 Military medical services
The totality of land, air and sea means of transport dedicated to the transport of victims of armed conflicts (except for prisoners of war), medical and religious personnel and medical equipment or furniture constitute medical transports [and are specially protected]. 
Cameroon, Droit des conflits armés et droit international humanitaire, Manuel de l’instructeur en vigueur dans les forces de défense, Ministère de la Défense, Présidence de la République, Etat-major des Armées, 2006, p. 92, § 352.2 and p. 93, § 352.20; see also p. 135, § 412.20 and p. 188, § 492.B.
The manual also states: “Medical transport must not be used … in combat.” 
Cameroon, Droit des conflits armés et droit international humanitaire, Manuel de l’instructeur en vigueur dans les forces de défense, Ministère de la Défense, Présidence de la République, Etat-major des Armées, 2006, p. 222, § 221.
Cameroon
Cameroon’s Disciplinary Regulations (2007) states:
Article 31: Humanitarian rules
Every soldier must:
- respect medical units, establishments and transports, hospital zones and localities, places where the wounded and sick, civilian or military, are collected, the emblems of the Red Cross, the Red Crescent and national Red Cross and Red Crescent societies, which are protective signs as such, as well as medical personnel;
For the application of the rules addressed in the two preceding paragraphs,
it is evidently necessary that the structures and buildings are not being used for military purposes;
These rules apply to the extent possible to operations undertaken by aircraft and navy ships against targets on land or at sea. 
Cameroon, Règlement de discipline générale dans les forces de défense, Décret N° 2007/199, Président de la République, 7 July 2007, Article 31.
Canada
Canada’s LOAC Manual (1999) states:
92. Medical transports of all types (land, sea, air) are protected and must not be attacked.
93. Medical transports should not be armed (i.e. crew-served weapons) because of the danger that they be mistaken as fighting vehicles. Medical personnel in the medical transports can, however, retain their personal weapons. 
Canada, The Law of Armed Conflict at the Operational and Tactical Level, Office of the Judge Advocate General, 1999, p. 4-9, §§ 92–93; see also p. 9-4, §§ 35–36.
With respect to non-international armed conflicts in particular, the manual states: “Medical … transports are to be respected and protected at all times and not be made the object of attack.” 
Canada, The Law of Armed Conflict at the Operational and Tactical Level, Office of the Judge Advocate General, 1999, p. 17-4, § 34.
Canada
Canada’s Code of Conduct (2001) states:
Opposing forces transports for the wounded and sick, or of medical equipment, shall be respected as soon as they are identified as such and protected in the same manner as mobile medical units … As a general rule medical transports should not have any weapons “mounted” on them to avoid being mistaken for fighting vehicles. 
Canada, Code of Conduct for CF Personnel, Office of the Judge Advocate General, 4 June 2001, Rule 10, §§ 5–6.
Canada
Canada’s LOAC Manual (2001) states in its chapter on targeting:
1. Medical transports of all types (land, sea and air) are protected and must not be attacked.
2. Medical transports should not be armed (i.e., crew-served weapons) because of the danger that they may be mistaken as fighting vehicles. Medical personnel in the medical transports can, however, retain their personal weapons. 
Canada, The Law of Armed Conflict at the Operational and Tactical Levels, Office of the Judge Advocate General, 13 August 2001, § 448.1–2.
In its chapter on the treatment of the wounded, sick and shipwrecked, the manual states:
918. Protection of medical establishments, transport, aircraft and hospital ships
1. Medical establishments on land, hospital ships, medical aircraft, and medical transports must be respected and protected at all times and must not be attacked. If they are used for purposes hostile to the adverse party and outside their humanitarian purpose, protection may cease. Protection will only cease, however, following a clear warning which has remained unheeded.
919. Medical units, establishments, and transport
1. Medical units and establishments, whether military or civilian, organized for medical purposes, may be fixed or mobile, permanent or temporary. Medical transports are any means of transportation, military or civilian, permanent or temporary, assigned exclusively to medical transportation and under control of a competent authority of a party to the conflict. The rights guaranteed by the Conventions apply equally to both temporary and permanent personnel, units and transports.
2. The material of mobile medical units falling into enemy hands must be reserved for the care of wounded and sick. 
Canada, The Law of Armed Conflict at the Operational and Tactical Levels, Office of the Judge Advocate General, 13 August 2001, §§ 918–919.
In its chapter entitled “Treatment of civilians in the hands of a party to the conflict or an occupying power”, the manual provides:
Convoys of vehicles or hospital trains on land, and specially provided vessels at sea, conveying wounded and sick civilians, must be protected and respected in the same way as civilian hospitals. Subject to the consent of the State they must bear the distinctive Red Cross or Red Crescent emblem provided for hospitals. 
Canada, The Law of Armed Conflict at the Operational and Tactical Levels, Office of the Judge Advocate General, 13 August 2001, § 1112.1.
In its chapter on non-international armed conflicts, the manual states:
Medical units and transports are to be respected at all times and not be made the object of attack. This protection shall only cease if they commit hostile acts outside their humanitarian function. In such circumstances, a warning must be given, and protection only ceases if such warning remains unheeded. 
Canada, The Law of Armed Conflict at the Operational and Tactical Levels, Office of the Judge Advocate General, 13 August 2001, § 1719.2.
Canada
Rule 10 of Canada’s Code of Conduct (2005) states:
5. Opposing forces transports for the wounded and sick, or of medical equipment, shall be respected as soon as they are identified as such and protected in the same manner as mobile medical units. If captured the wounded and sick in the transports will be properly cared for.
6. … As a general rule medical transports should not have any weapons “mounted” on them to avoid being mistaken for fighting vehicles. 
Canada, Code of Conduct for CF Personnel, Office of the Judge Advocate General, 2005, Rule 10, §§ 5–6.
Central African Republic
The Central African Republic’s Instructor’s Manual (1999) states in Volume 2 (Instruction for group and patrol leaders) that “protection also extends to medical … means of transport”. 
Central African Republic, Le Droit de la Guerre, Fascicule No. 2: Formation pour l’obtention du certificat technique No. 2 (Chef de Groupe), du certificat Inter-Armé (CIA), du certificat d’aptitude de Chef de Patrouille (CACP), Ministère de la Défense, Forces Armées Centrafricaines, 1999, Chapter I, Fundamental Rules, § 3.
Also in Volume 2, the manual states: “Specially protected means of transport are authorized to carry out their mission as long as necessary. Their mission, content and actual use may be checked through an inspection.” 
Central African Republic, Le Droit de la Guerre, Fascicule No. 2: Formation pour l’obtention du certificat technique No. 2 (Chef de Groupe), du certificat Inter-Armé (CIA), du certificat d’aptitude de Chef de Patrouille (CACP), Ministère de la Défense, Forces Armées Centrafricaines, 1999, Chapter II, Section II, § 2.1.
In Volume 3 (Instruction for non-commissioned officers studying for the level 1 and 2 certificates and for future officers of the criminal police), the manual states: “Medical means of transport must not be used to gather or transmit military intelligence or to transport material to this end.” 
Central African Republic, Le Droit de la Guerre, Fascicule No. 3: Formation pour l’obtention du Brevet d’Armes No. 1, du Brevet d’Armes No. 2 et le stage d’Officier de Police Judiciaire (OPJ), Ministère de la Défense, Forces Armées Centrafricaines, 1999, Chapter II, Section II, § 2.1.
Central African Republic
The Central African Republic’s Disciplinary Regulations (2009) states: “In accordance with the international conventions signed or approved by the Central African Government, it is stipulated that during combat servicemen must: … respect … medical transports”. 
Central African Republic, Décret 09.411 portant règlement de discipline générale dans les Armées, Ministre de la Défense Nationale, des Anciens Combattants, des Victimes de Guerre, du Désarmement et de la Restructuration de l’Armée, 10 December 2009, Article 12(10).
Chad
Chad’s Instructor’s Manual (2006) states that it is prohibited to attack “medical … transport vehicles”. 
Chad, Droit international humanitaire, Manuel de l’instructeur en vigueur dans les forces armées et de sécurité, Ministère de la Défense, Présidence de la République, Etat-major des Armées, 2006, p. 36; see also pp. 78 and 88.
The manual also states: “An enemy medical transport vehicle (jeep, ambulance, lorry or helicopter) may not be requisitioned, taken captive or used for armed operations if it is transporting wounded people.” 
Chad, Droit international humanitaire, Manuel de l’instructeur en vigueur dans les forces armées et de sécurité, Ministère de la Défense, Présidence de la République, Etat-major des Armées, 2006, p. 88.
Colombia
Colombia’s Circular on Fundamental Rules of IHL (1992) states that the protection due to the wounded and sick “also covers, as such, … medical transports”. 
Colombia, Transcripción Normas Fundamentales del Derecho Humanitario Aplicables en los Conflictos Armados, Circular No. 033/DIPL-SERPO-526, Policía Nacional, Dirección General, Santafé de Bogotá, 14 May 1992, § 3.
Colombia
Colombia’s Basic Military Manual (1995) states that “attacks, misappropriation and destruction” of medical transports constitutes a “grave breach”. 
Colombia, Derecho Internacional Humanitario – Manual Básico para las Personerías y las Fuerzas Armadas de Colombia, Ministerio de Defensa Nacional, 1995, p. 26, § 4.
Congo
Congo’s Disciplinary Regulations (1986) provides that medical transports must be respected. 
Congo, Décret No. 86/057 du 14 janvier 1986 portant Règlement du Service dans l’Armée Populaire Nationale, 1986, Article 32.
Côte d’Ivoire
Côte d’Ivoire’s Teaching Manual (2007) provides in Book I (Basic instruction):
Lesson 3. Rules of behaviour in combat
14. Respect medical transports. 
Côte d’Ivoire, Droit de la guerre, Manuel d’instruction, Livre I: Instruction de base, Ministère de la Défense, Forces Armées Nationales, November 2007, p. 26.
In book III, volume 2 (instruction of second-year trainee officers), the Teaching Manual provides:
II.2.1. Protection of hospitals and material used by medical personnel
Hospitals must not be attacked and medical personnel must be spared. As long as they have to fulfil their special task, they must not be used for a different purpose. This equally applies to medical transports.
Medical transport means any means of transportation assigned exclusively to the conveyance by land, water or air of the wounded, sick, shipwrecked, medical and religious personnel or medical material … 
Côte d’Ivoire, Droit de la guerre, Manuel d’instruction, Livre III, Tome 2: Instruction de l’élève officier d’active de 2ème année, Manuel de l’instructeur, Ministère de la Défense, Forces Armées Nationales, November 2007, pp. 29–30.
In Book IV (Instruction of heads of division and company commanders), the Teaching Manual provides:
II.2.6. Means of medical transportation
Means of medical transportation of all kinds (land, sea and air) are protected and must not be made the object of attack. …
Medical transportation should not be armed (i.e. by collective weapons) because of the risk that they are considered as combat vehicles. The medical personnel of medical transportations can, however, keep their individual weapons. 
Côte d’Ivoire, Droit de la guerre, Manuel d’instruction, Livre IV: Instruction du chef de section et du commandant de compagnie, Manuel de l’élève, Ministère de la Défense, Forces Armées Nationales, November 2007, p. 39.
Croatia
Croatia’s Commanders’ Manual (1992) provides: “Medical transports may not be used to collect or transmit intelligence data.” 
Croatia, Basic Rules of the Law of Armed Conflicts – Commanders’ Manual, Republic of Croatia, Ministry of Defence, 1992, § 34.
Djibouti
Djibouti’s Disciplinary Regulations (1982) states: “Combatants must … respect medical … transports”. 
Djibouti, Décret no. 82-028/PR/DEF du 5 mai 1982 portant règlement de la discipline générale dans les Forces armées, Article 30(2).
Dominican Republic
The Dominican Republic’s Military Manual (1980) instructs soldiers not to attack medical vehicles, whether on land or in the air. 
Dominican Republic, La Conducta en Combate según las Leyes de la Guerra, Escuela Superior de las FF. AA. “General de Brigada Pablo Duarte”, Secretaría de Estado de las Fuerzas Armadas, May 1980, p. 4.
Ecuador
Ecuador’s Naval Manual (1989) states:
Medical vehicles … may not be deliberately bombarded. Belligerents are required to ensure that such medical facilities are, as far as possible, situated in such manner that attacks against military targets in the vicinity do not imperil their safety. 
Ecuador, Aspectos Importantes del Derecho Internacional Marítimo que Deben Tener Presente los Comandantes de los Buques, Academia de Guerra Naval, 1989, § 8.5.1.4.
The manual qualifies “deliberate attack upon … medical vehicles” as a war crime. 
Ecuador, Aspectos Importantes del Derecho Internacional Marítimo que Deben Tener Presente los Comandantes de los Buques, Academia de Guerra Naval, 1989, § 6.2.5.
Ethiopia
According to Ethiopia’s Standing Rules of Engagement (2007), ambulances do not constitute military objectives. 
Ethiopia, Standing Rules of Engagement, National Defense Force, Addis Ababa, 2007, § 8.4.5.
France
France’s Disciplinary Regulations (1975), as amended, provides that soldiers in combat must respect and protect medical transports. 
France, Règlement de Discipline Générale dans les Armées, Decree No. 75-675 of 28 July 1975, replacing Decree No. 66-749, completed by Decree of 11 October 1978, implemented by Instruction No. 52000/DEF/C/5 of 10 December 1979, and modified by Decree of 12 July 1982, Ministère de la Défense, Etat-Major de l’Armée de Terre, Bureau Emploi, Article 9 bis (1).
France
France’s LOAC Summary Note (1992) states: “Medical transports must not be used to collect military information.” 
France, Fiche de Synthèse sur les Règles Applicables dans les Conflits Armés, Note No. 432/DEF/EMA/OL.2/NP, Général de Corps d’Armée Voinot (pour l’Amiral Lanxade, Chef d’Etat-major des Armées), 1992, § 2.3.
France
France’s LOAC Manual (2001), with reference to Article 12 of the 1977 Additional Protocol I, includes medical means of transportation among objects which are specifically protected by the law of armed conflict. 
France, Manuel de droit des conflits armés, Ministère de la Défense, Direction des Affaires Juridiques, Sous-Direction du droit international humanitaire et du droit européen, Bureau du droit des conflits armés, 2001, p. 30.
Germany
Germany’s Military Manual (1992) states that “any transport of wounded, sick and medical equipment shall be respected and protected”. 
Germany, Humanitarian Law in Armed Conflicts – Manual, DSK VV207320067, edited by The Federal Ministry of Defence of the Federal Republic of Germany, VR II 3, August 1992, English translation of ZDv 15/2, Humanitäres Völkerrecht in bewaffneten KonfliktenHandbuch, August 1992, § 617.
Germany
Germany’s IHL Manual (1996) provides that medical vehicles “shall under no circumstance be attacked. Their unhampered employment shall be ensured at all times.” 
Germany, ZDv 15/1, Humanitäres Völkerrecht in bewaffneten Konflikten – Grundsätze, DSK VV230120023, Bundesministerium der Verteidigung, June 1996, § 503.
Germany
Germany’s Soldiers’ Manual (2006) states: “Fixed establishments, vehicles and mobile units of the medical service, without exception, may not be fought.” 
Germany, Druckschrift Einsatz Nr. 03, Humanitäres Völkerrecht in bewaffneten Konflikten – Grundsätze, Erarbeitet nach ZDv 15/2, Humanitäres Völkerrecht in bewaffneten Konflikten – Handbuch, DSK SF009320187, Bundesministerium der Verteidigung, R II 3, August 2006, p. 5.
Greece
The Hellenic Territorial Army’s Internal Service Code (1984), as amended, provides: “Members of the armed forces should: … Respect … the means of transport of medical services.” 
Greece, Hellenic Territorial Army Regulation of Internal Service Code, Presidential Decree 130/1984 (Military Regulation 20-1), as amended, Article 14(d).
Guinea
Guinea’s Soldier’s Manual (2010), under the heading “Distinctive signs”, shows an image of a car with a red crescent on a white ground and states: “Let these vehicles … move around and do not enter them.” 
Guinea, Soldier’s Manual, Ministry of National Defence, 2010, p. 14.
Guinea
Guinea’s Disciplinary Regulations (2012) states:
In accordance with the international agreements signed by the government of Guinea, military personnel in combat are required:
- to respect hospitals and places where the sick are collected, civilian or military wounded persons, … medical formations, buildings, equipment and transports[.] 
Guinea, Règlement de Service dans les Forces Armées, Volume 1: Règlement de Discipline Générale (Service Regulations in the Armed Forces, Volume 1: General Discipline Regulations), 2012 edition, Ministère de la Défense Nationale, approved by Presidential Decree No. D 293/PRG/SGG/2012, 6 December 2012, Article 12(a).
Hungary
Hungary’s Military Manual (1992) instructs soldiers to respect and protect medical transports, whether by land, sea or air. 
Hungary, A Hadijog, Jegyzet a Katonai, Föiskolák Hallgatói Részére, Magyar Honvédség Szolnoki Repülötiszti Föiskola, 1992, p. 19.
Israel
Israel’s Manual on the Rules of Warfare (2006) states that “ambulances and similar facilities” must not be used as military targets. 
Israel, Rules of Warfare on the Battlefield, Military Advocate-General’s Corps Command, IDF School of Military Law, Second Edition, 2006, p. 24.
The Manual on the Rules of Warfare (2006) is a second edition of the Manual on the Laws of War (1998).
Italy
Italy’s LOAC Elementary Rules Manual (1991) provides: “Medical transports may not be used to collect or transmit intelligence data.” 
Italy, Regole elementari di diritto di guerra, SMD-G-012, Stato Maggiore della Difesa, I Reparto, Ufficio Addestramento e Regolamenti, Rome, 1991, § 34.
Kenya
Kenya’s LOAC Manual (1997) states: “Protection from attack is given to … medical transports, e.g. ambulances”. 
Kenya, Law of Armed Conflict, Military Basic Course (ORS), 4 Précis, The School of Military Police, 1997, Précis No. 3, p. 9.
Lebanon
Lebanon’s Teaching Manual (1997) provides for respect for and protection of medical transports. 
Lebanon, Manuel de l’Instruction Nationale dans l’Armée Libanaise, 1997, p. 77.
Mali
Mali’s Army Regulations (1979) provides that, according to the laws and customs of war, soldiers in combat must respect medical transports. 
Mali, Règlement du Service dans l’Armée, 1ère Partie: Discipline Générale, Ministère de la Défense Nationale, 1979, Article 36.
Mexico
Mexico’s Army and Air Force Manual (2009), in a chapter on the 1949 Geneva Conventions, states: “The mobile medical units of the parties to the conflict in the field and fixed medical establishments must be respected and protected at all times. Vehicles used to transport the sick and wounded and medical supplies must be treated in the same way as mobile medical units.” 
Mexico, Manual de Derecho Internacional Humanitario para el Ejército y la Fuerza Área Mexicanos, Ministry of National Defence, June 2009, § 75.
In a section on the 1949 Geneva Convention I, the manual also states:
94. … mobile medical units of the medical service must not be attacked under any circumstances and must be respected and protected at all times by the parties to the conflict.
100. Land vehicles used for medical purposes (medical transports) must be respected and protected in the same way as mobile medical units.
101. Military medical vehicles that fall into the hands of the adverse party are subject to the laws of war, provided that the party to the conflict that captures them ensures the care of the wounded and sick being transported in them. 
Mexico, Manual de Derecho Internacional Humanitario para el Ejército y la Fuerza Área Mexicanos, Ministry of National Defence, June 2009, §§ 94 and 100–101.
Mexico
Mexico’s IHL Guidelines (2009), in a section entitled “Basic rules of conduct in armed conflict”, states: “Do not attack medical vehicles … Ensure their protection. 
Mexico, Cartilla de Derecho Internacional Humanitario, Ministry of National Defence, 2009, § 14(i).
Morocco
Morocco’s Disciplinary Regulations (1974) provides that, according to the laws and customs of war, soldiers in combat must respect medical transports. 
Morocco, Règlement de Discipline Général dans les Forces Armées Royales, Dahir No. 1-74-383 du 15 rejeb 1394, 5 August 1974, Article 25(1).
Netherlands
The Military Manual (1993) of the Netherlands states: “Medical transport and medical means of transportation (vehicles, ships and aircraft) must be respected and protected.” 
Netherlands, Toepassing Humanitair Oorlogsrecht, Voorschift No. 27-412/1, Koninklijke Landmacht, Ministerie van Defensie, 1993, p. VI-6.
The manual repeats this rule with respect to non-international armed conflicts. 
Netherlands, Toepassing Humanitair Oorlogsrecht, Voorschift No. 27-412/1, Koninklijke Landmacht, Ministerie van Defensie, 1993, p. XI-6.
Netherlands
The Military Handbook (1995) of the Netherlands provides: “Medical transports may not be attacked … Medical transports, whether on water, on land or in the air, must also be respected. Such transport may not, however, be used as normal military transport.” 
Netherlands, Handboek Militair, Ministerie van Defensie, 1995, pp. 7-40 and 7-41.
Netherlands
The Military Manual (2005) of the Netherlands states:
Section 6 - Medical transport
0624. Medical transport and medical means of transport (vehicles, vessels and aircraft) must be respected and protected. Medical means of transport form part of the equipment of medical units …
0625. A number of terms are important in this connection:
- medical transport covers the conveyance by land, water or air of the wounded, sick, medical personnel, religious personnel, medical equipment or medical supplies;
- medical transport means any means of transportation, whether military or civilian, permanent or temporary, assigned exclusively to medical purposes;
- medical vehicle means any medical transport by land;
- medical ships and boats mean any medical transports by water;
- medical aircraft means any medical transports by air.
0626. Medical transports should generally be permanently destined for medical purposes. It is also possible to allocate means of transport temporarily to medical transportation. In case of temporary allocation, clear instructions are required to prevent misuse of medical protection. In any case, the purpose of vehicles, ships and boats and aircraft must not change during an operation. In the course of an armed conflict, however, a change of purpose is possible. 
Netherlands, Humanitair Oorlogsrecht: Handleiding, Voorschift No. 27-412, Koninklijke Landmacht, Militair Juridische Dienst, 2005, §§ 0624–0626.
In its chapter on non-international armed conflict, the manual states:
Medical units and means of transport must be respected and protected. They may not be attacked. Their protection ends only when they are used to carry out hostile acts outside the scope of their humanitarian task. Even then, a warning must first be given. 
Netherlands, Humanitair Oorlogsrecht: Handleiding, Voorschift No. 27-412, Koninklijke Landmacht, Militair Juridische Dienst, 2005, § 1058.
In its chapter on peace operations, the manual states: “Attacks on medical facilities or transports are strictly prohibited.” 
Netherlands, Humanitair Oorlogsrecht: Handleiding, Voorschift No. 27-412, Koninklijke Landmacht, Militair Juridische Dienst, 2005, § 1223.
New Zealand
New Zealand’s Military Manual (1992) states:
Medical transports are any means of transportation, military or civilian, permanent or temporary, assigned exclusively to medical transportation and under control of a competent authority of a party to the conflict.
Convoys of vehicles or hospital trains on land, and specially provided vessels at sea, conveying wounded and sick civilians, the infirm, and maternity cases must be protected and respected in the same way as civilian hospitals. 
New Zealand, Interim Law of Armed Conflict Manual, DM 112, New Zealand Defence Force, Headquarters, Directorate of Legal Services, Wellington, November 1992, §§ 1007(1) and (2) and 1110(1).
With respect to non-international armed conflicts in particular, it states that “medical … transports are to be respected at all times and not made the object of attack”. 
New Zealand, Interim Law of Armed Conflict Manual, DM 112, New Zealand Defence Force, Headquarters, Directorate of Legal Services, Wellington, November 1992, § 1818(2).
Nicaragua
Nicaragua’s Military Manual (1996) states, with respect to international armed conflicts, that assistance to the wounded, sick and shipwrecked includes a requirement of “respect for and protection of means of transportation for the wounded and sick or medical material” and “respect for and protection of transportation over land … of civilian wounded and sick”. 
Nicaragua, Manual de Comportamiento y Proceder de las Unidades Militares y de los Miembros del Ejército de Nicaragua en Tiempo de Paz, Conflictos Armados, Situaciones Irregulares o Desastres Naturales, Ejército de Nicaragua, Estado Mayor General, Asesoría Jurídica del Nicaragua, 1996, Article 14(7) and (38).
Nigeria
Nigeria’s Manual on the Laws of War provides: “Convoys of wounded or medical equipment must be respected and protected as mobile medical units.” 
Nigeria, The Laws of War, by Lt. Col. L. Ode PSC, Nigerian Army, Lagos, undated, § 36.
Nigeria
Nigeria’s Military Manual (1994) provides:
Specifically protected … transports recognised as such must be respected … Specifically protected [transports] shall not be touched or entered, though they could be inspected to ascertain their contents and effective use. 
Nigeria, International Humanitarian Law (IHL), Directorate of Legal Services, Nigerian Army, 1994, p. 45, § (f).
Peru
Peru’s IHL Manual (2004) states:
a. Definitions
Medical transportation means the conveyance by land, water or air of the wounded, sick, shipwrecked, medical personnel, religious personnel, medical equipment or medical supplies.
Medical transports means any means of transportation, whether military or civilian, permanent or temporary, assigned exclusively to medical transportation and under the control of a competent authority of a party to the conflict.
Medical transports can be:
(1) permanent, when they are assigned exclusively to medical purposes for an indeterminate period;
(2) temporary, when they are devoted exclusively to medical purposes for limited periods.
It should be noted that all medical transports, whether permanent or temporary, must be assigned exclusively to medical purposes in order to be entitled to protection …
b. Respect and protection
Medical transports must be respected and protected. Respecting them means refraining from attacking or damaging them or preventing their passage. 
Peru, Manual de Derecho Internacional Humanitario para las Fuerzas Armadas, Resolución Ministerial Nº 1394-2004-DE/CCFFAA/CDIH-FFAA, Lima, 1 December 2004, § 87.a and b.
The manual further states “It is prohibited to move … medical transports … or take advantage of their presence to shield certain areas or military objectives from military operations.” 
Peru, Manual de Derecho Internacional Humanitario para las Fuerzas Armadas, Resolución Ministerial Nº 1394-2004-DE/CCFFAA/CDIH-FFAA, Lima, 1 December 2004, § 27.e.(10).
Peru
Peru’s IHL and Human Rights Manual (2010) states:
78. Medical means of transport
a. Definitions
Medical transportation means the conveyance by land, water or air of the wounded, sick, shipwrecked, medical personnel, religious personnel, medical equipment or medical supplies.
Medical transports means any means of transportation, whether military or civilian, permanent or temporary, assigned exclusively to medical transportation and under the control of a competent authority of a party to the conflict.
Medical transports can be:
(1) permanent, when they are assigned exclusively to medical purposes for an indeterminate period;
(2) temporary, when they are devoted exclusively to medical purposes for limited periods.
It should be noted that all medical transports, whether permanent or temporary, must be assigned exclusively to medical purposes in order to be entitled to protection …
b. Respect and protection
Medical transports must be respected and protected. Respecting them means refraining from attacking or damaging them or preventing their passage, that is to say allow them to carry out their designated task. Protecting them presupposes taking action to ensure their respect, which may mean to assist them against third parties or to defend them should this be necessary.
The obligation to respect medical means of transport does not ease unless they are used to commit acts harmful to the enemy (such as transporting soldiers in service or ammunition). 
Peru, Manual de Derecho Internacional Humanitario y Derechos Humanos para las Fuerzas Armadas, Resolución Ministerial No. 049-2010/DE/VPD, Lima, 21 May 2010, § 78, pp. 278–279.
The manual also states that it “is prohibited to move … medical transports … or take advantage of their presence to shield certain areas or military objectives from military operations.” 
Peru, Manual de Derecho Internacional Humanitario y Derechos Humanos para las Fuerzas Armadas, Resolución Ministerial No. 049-2010/DE/VPD, Lima, 21 May 2010, § 28(e)(3), p. 239.
Romania
Romania’s Soldiers’ Manual (1991) requires respect for medical vehicles and transports. 
Romania, Manualul Soldatului, Ghid de comportare în luptă, Asociaţia Română de Drept Umanitar (ARDU), 1991, p. 32.
Russian Federation
The Russian Federation’s Military Manual (1990) states that “attack, bombardment or destruction of … medical transports” is a prohibited method of warfare. 
Russian Federation, Instructions on the Application of the Rules of International Humanitarian Law by the Armed Forces of the USSR, Appendix to Order of the USSR Defence Minister No. 75, 1990, § 5(g).
Russian Federation
The Russian Federation’s Regulations on the Application of IHL (2001) states: “objects protected by international humanitarian law include … medical transports … Attacks against such objects are prohibited by international humanitarian law with the exception of cases stipulated by this law”. 
Russian Federation, Regulations on the Application of International Humanitarian Law by the Armed Forces of the Russian Federation, Ministry of Defence of the Russian Federation, Moscow, 8 August 2001, § 1.
With regard to internal armed conflict, the Regulations states: “Medical … transports shall be respected and protected at all times and shall not be the object of attack.” 
Russian Federation, Regulations on the Application of International Humanitarian Law by the Armed Forces of the Russian Federation, Ministry of Defence of the Russian Federation, Moscow, 8 August 2001, § 83.
Senegal
Senegal’s Disciplinary Regulations (1990) provides that soldiers in combat must respect and protect medical transports. 
Senegal, Règlement de Discipline dans les Forces Armées, Décret 90-1159, 12 October 1990, Article 34(1).
Senegal
Senegal’s IHL Manual (1999) states: “Medical means of transport (ambulances) shall be authorized to perform their function as long as necessary. Their mission, content and actual use may be verified by inspection.” 
Senegal, Le DIH adapté au contexte des opérations de maintien de l’ordre, République du Sénégal, Ministère des Forces Armées, Haut Commandement de la Gendarmerie et Direction de la Justice Militaire, Cabinet, 1999, p. 17.
Sierra Leone
Sierra Leone’s Instructor Manual (2007) states:
Any means of transportation, whether military or civilian, permanent or temporary, assigned exclusively for the transportation of medical personnel, wounded and sick and other facilities are referred to as medical transport. These may include aircraft, vehicles, ships etc.
Before any transport for medical purpose, it must be marked with the protective emblem which is the Red Cross on a white background.
Medical transport is not to be attacked but may lose its [protected] status if, for example, it carries arms or military equipment or the vehicle is used to gather intelligence about the location or deployment of the enemy.
It is a crime to attack a clearly marked medical transport or to use them for a non-medical purpose.
Medical transport, if captured, should be used to provide medical services to the wounded and sick. 
Sierra Leone, The Law of Armed Conflict. Instructor Manual for the Republic of Sierra Leone Armed Forces (RSLAF), Armed Forces Education Centre, September 2007, pp. 60–61.
South Africa
South Africa’s LOAC Manual (1996) provides:
53. All means of medical transport, whether permanent or temporary, must be assigned exclusively to medical purposes in order to be entitled to protection. A convoy carrying both wounded and able-bodied soldiers or arms would lose the right to protection to the detriment of the wounded. (Note: the presence of light arms which have just been taken from the wounded and not yet turned over to the proper authority is permitted.)
54. The term “respect” for the means of medical transport indicates that they may not be attacked or damaged, nor may their passage be obstructed; put positively, they must be permitted to carry out their assigned tasks. 
South Africa, Presentation on the South African Approach to International Humanitarian Law, Appendix A, Chapter 4: International Humanitarian Law (The Law of Armed Conflict), National Defence Force, 1996, §§ 53–54.
[emphasis in original]
South Africa
South Africa’s Revised Civic Education Manual (2004) states:
67. Medical Transportation. The following definitions are relevant under this heading:
a. “Medical transportation” means the conveyance by land, water or air of wounded, sick or shipwrecked persons, medical and religious personnel and medical material.
b. “Medical transports” cover any means of transport, military or civilian, permanent or temporary, assigned exclusively to medical transportation and under the control of a competent authority of a Party to a conflict.
68. All means of medical transport, whether permanent or temporary, must be assigned exclusively to medical purposes in order to be entitled to protection. A convoy carrying both wounded and able-bodied soldiers or arms would lose the right to protection to the detriment of the wounded. (Note: the presence of light arms which have just been taken from the wounded and not yet turned over to the proper authority is permitted).
69. The term “respect” for the means of medical transport indicates that they may not be attacked or damaged, nor may their passage be obstructed. They must be permitted to carry out their assigned tasks. Medical transports by land and medical ships and craft must be respected and protected in the same way as mobile medical units. Military ambulances falling into enemy hands are subject to the law of war on the condition that the Party capturing them assumes responsibility for the sick and wounded contained therein. 
South Africa, Revised Civic Education Manual, South African National Defence Force, 2004, Chapter 4, §§ 67–69.
South Africa
South Africa’s LOAC Teaching Manual (2008) states:
2.1 Basic Categories of Persons and Objects Recognised under the LOAC [law of armed conflict]
Specifically Protected Persons and Objects recognised under the LOAC
The following persons and objects fall within the specifically protected category under the LOAC:
- Medical transport;
Specifically Protected Persons and Objects
General Rule
The LOAC grants particular protection to specific categories of persons and objects[.] The reason for this special protection corresponds with the general aim of the LOAC, to wit, to allow commanders to wage war against the enemy with maximum effect, but at the same time to minimise the suffering of those who are caught up in a war without being any threat to the warring parties.
Persons who are specifically protected are persons who do not participate in hostilities and objects specifically protected are those that are not used for combat purposes. Such persons and objects are not used in attacks and cannot properly defend themselves against attacks.
2.2. Military Medical Services and Religious Personnel/objects
Military Medical and Religious Objects
What are Military Medical Objects?
- “Medical transport” is defined in [1977] Additional Protocol I article 8, read with [1949] Geneva Convention I article 35 and [1949] Geneva Convention II article 27. “Medical transport” means any means of transportation assigned exclusively to conveyance by land, air or water the:
- Wounded, sick or shipwrecked;
- Medical and religious personnel; or
- Medical material.
Nature of the Protection of Military Medical Objects (Buildings, Transport and Material) and Religious Objects
- All fixed military medical establishments, mobile medical units and transportation carrying wounded and sick, or medical equipment, may not be attacked but must at all times be respected and protected by the Parties to the conflict. (Geneva Convention I article 19.)
- The buildings, material and stores of fixed military establishments may not be diverted from the care of the wounded and sick. However, commanders of forces in the field may use it in cases of urgent military necessity, as long as they have made previous arrangements for the welfare of the enemy wounded and sick that are nursed in them (Geneva Convention I article 33). Military medical transport (excluding military medical aircraft and hospital ships) that are no longer needed for the sick and wounded becomes war booty.
- If a military medical establishment, unit or vehicle should fall into the hands of the enemy, the captor will be responsible for the care of the wounded and sick therein. The personnel of a captured military medical establishment, unit or vehicle must be permitted to continue with their duties until such time as the capturing Party assumes responsibility therefore. (Geneva Convention I article 19.)
- Military medical establishments and transport may be guarded by a picket, sentries or an escort who may protect the life of medical and religious personnel and the wounded and sick in such establishments … but may not oppose the capture thereof. (Geneva Convention I article 22.)
Loss of Protection (Geneva Convention I Article 21)
Geneva Convention 1 article 22, provides for specific aspects which do NOT cause medical institutions or units to lose their protection:
- Using Members of the Armed Forces to Guard a Military Establishment, Unit or Transportation
- Guards of [] medical establishments, units or transportation normally consist of the unit’s own (medical) personnel.
- However, where necessary, armed soldiers can be used as guards to protect it.
- They may use their weapons only in their own defence or in that of the medical personnel, wounded and sick in their charge.
Warning: Condition before Military Medical Personnel, Establishments, Units or Transport and Military Religious Personnel can forfeit their Protection (Geneva Convention I Article 21). Even if the abovementioned loses its right to protection, the following steps must be taken before such an establishment or unit can be attacked.
- Due warning must first be given to that institution or unit that it is to lose its protection and render it liable to attack;
- A reasonable time limit must be given for the institution or unit to put an end to its harmful acts; and
- The warning must remain unheeded.
Conclusion
Military medical and religious establishments, units and transport are also specifically protected, as long as they are exclusively used for medical purposes. They may not be attacked but must at all times be respected and protected by the Parties to the conflict. Reprisals against them are prohibited.
All Parties must ensure the safety of military medical and religious establishments, units and transport.
Captured military medical establishments, units or vehicles are the responsibility of the captor who must care for the wounded and sick therein. The captor must also allow the captured medical personnel to continue with their duties until such time as the capturing Party assumes the responsibility therefore.
Military medical and religious institutions, units and transportation can lose their right to protection if used to commit acts which are harmful to the enemy and which are outside their humanitarian duties. However, they do not forfeit their protection in the following instances:
- If they carry light weapons for personal protection.
- If small arms and ammunition of wounded and sick soldiers are found at or on the medical establishment, unit or transportation.
- If members of the armed forces are used to guard a military establishment, unit or transportation.
- The presence of a veterinary service in the military medical establishment or unit.
- If they are providing humanitarian services to civilian wounded and sick.
Before military medical establishments, units or transport can forfeit their protection, due warning must be given to that institution or unit that it is to lose its protection and render it liable to attack, a reasonable time limit must be given for the institution or unit to put an end to its harmful acts; and the warning must remain unheeded.
2.3 Specifically Protected Persons and Objects under:
a. Civilian Medical Services
Conclusion
The provisions governing military medical personnel, establishments and transport apply equally to civilian medical services. 
South Africa, Advanced Law of Armed Conflict Teaching Manual, School of Military Justice, 1 April 2008, as amended to 25 October 2013, Learning Unit 2, pp. 52–76.
[emphasis in original]
Spain
Spain’s LOAC Manual (1996) defines medical transports in accordance with Article 8 of the 1977 Additional Protocol I. 
Spain, Orientaciones. El Derecho de los Conflictos Armados, Publicación OR7-004, 2 Tomos, aprobado por el Estado Mayor del Ejército, Division de Operaciones, 18 March 1996, Vol. I, § 9.2.c.(1); see also § 4.5.b.(2)(b).
With reference to Article 21 of the 1977 Additional Protocol I, the manual states that medical transports over land “in general, enjoy the same protection and are subject to the same regulation as mobile medical units”. 
Spain, Orientaciones. El Derecho de los Conflictos Armados, Publicación OR7-004, 2 Tomos, aprobado por el Estado Mayor del Ejército, Division de Operaciones, 18 March 1996, Vol. I, § 9.2.c.(2); see also § 4.5.b.(2)(b).
Spain
Spain’s LOAC Manual (2007) states that attacks are prohibited against medical transports, which are defined in accordance with Article 8 of the 1977 Additional Protocol I. The manual adds that civilian medical transports “enjoy the same protection as their military counterparts, provided that they comply with the requirements entitling them to special protection”. 
Spain, Orientaciones. El Derecho de los Conflictos Armados, Tomo 1, Publicación OR7–004, (Edición Segunda), Mando de Adiestramiento y Doctrina, Dirección de Doctrina, Orgánica y Materiales, 2 November 2007, § 4.5.b.(2).(b); see also §§ 7.3.b.(4).(b) and 9.2.c.(1).
The manual further states that “the means of transport for the wounded and sick and medical supplies” become a military objective and may be attacked “when they transport troops or war material at the same time”. 
Spain, Orientaciones. El Derecho de los Conflictos Armados, Tomo 1, Publicación OR7–004, (Edición Segunda), Mando de Adiestramiento y Doctrina, Dirección de Doctrina, Orgánica y Materiales, 2 November 2007, § 4.5.b.(2).(a).
The manual also states: “In general, medical transports by land must be respected and protected in the same way as mobile medical units.” 
Spain, Orientaciones. El Derecho de los Conflictos Armados, Tomo 1, Publicación OR7–004, (Edición Segunda), Mando de Adiestramiento y Doctrina, Dirección de Doctrina, Orgánica y Materiales, 2 November 2007, § 9.2.c.(2).
Sweden
Sweden’s IHL Manual (1991) considers that Article 21 of the 1977 Additional Protocol I on the protection of medical vehicles has the status of customary law. 
Sweden, International Humanitarian Law in Armed Conflict, with reference to the Swedish Total Defence System, Swedish Ministry of Defence, January 1991, Section 2.2.3, p. 18.
Switzerland
Switzerland’s Basic Military Manual (1987) provides: “Transports of wounded and sick civilians, disabled, elderly, children and expectant mothers, by convoys and hospital trains, shall be respected and protected in the same way as hospitals.” 
Switzerland, Lois et coutumes de la guerre (Extrait et commentaire), Règlement 51.7/II f, Armée Suisse, 1987, Article 37.
The manual further provides that medical vehicles “shall be respected and protected. They shall not be attacked, nor harmed in any way, nor their functioning be impeded, even if they do not momentarily hold any wounded or sick.” 
Switzerland, Lois et coutumes de la guerre (Extrait et commentaire), Règlement 51.7/II f, Armée Suisse, 1987, Article 82.
Switzerland
Switzerland’s Aide-Memoire on the Ten Basic Rules of the Law of Armed Conflict (2005) states: “I spare and respect personnel and installations as well as equipment and means of transport of the medical services … without discrimination unless they open fire on my comrades or me.” 
Switzerland, The Ten Basic Rules of the Law of Armed Conflict, Aide-memoire 51.007/IIIe, Swiss Army, issued based on Article 10 of the Ordinance for Organization of the Federal Department for Defence, Civil Protection and Sports dated 7 March 2003, entry into force on 1 July 2005, Rule 7.
The Aide-Memoire further states with regard to the protective signs of the red cross and red crescent:
Correct behaviour
- Personnel, installations, material and means of transport of the medical services as well as carriers of signs or objects marked with distinctive signs must be respected and spared;
Prohibited is/are …
- Attacks against persons or objects carrying this sign[.] 
Switzerland, The Ten Basic Rules of the Law of Armed Conflict, Aide-memoire 51.007/IIIe, Swiss Army, issued based on Article 10 of the Ordinance for Organization of the Federal Department for Defence, Civil Protection and Sports dated 7 March 2003, entry into force on 1 July 2005, Chart of Protective Signs.
Switzerland
Switzerland’s Regulation on Legal Bases for Conduct during an Engagement (2005) states that, in application of the principle of distinction, a “[c]ivilian lorry marked with the red cross emblem” that “transports wounded soldiers” must not be shot at, explaining: “Transport of the wounded with the distinctive emblem: it is not a military objective”. 
Switzerland, Bases légales du comportement à l’engagement (BCE), Règlement 51.007/IVf, Swiss Army, issued based on Article 10 of the Ordinance on the Organization of the Federal Department for Defence, Civil Protection and Sports of 7 March 2003, entry into force on 1 July 2005, § 172.
The Regulation also states:
13 Protected persons
13.1 Behaviour with regard to the wounded, sick and shipwrecked and medical and religious personnel
176 Medical personnel, equipment and means of transport as well as localities used by the military service must be spared and must not be hindered in the fulfilment of their mission.
14 Protected objects
14.1 Medical establishments
203 All medical establishments must be respected and protected. They must not be attacked or damaged, nor prevented from pursuing their activities, even when no wounded or sick persons are currently being cared for therein. The right to protection applies to all fixed establishments, such as hospitals, medical posts and depots, as well as to all mobile medical units, such as medical vehicles, field hospitals and first-aid posts.
204 All medical establishments are signalled by means of a clearly visible distinctive emblem.
206 Medical material and means of transport must not be destroyed. Checks on the content of vehicles and containers of the medical services, however, are permitted. If no abuse of the distinctive emblem is found, they must be allowed to continue their journey, if the situation allows.
15 Methods of warfare
15.2 Prohibited methods of warfare
225 Indiscriminate attacks, i.e. attacks which cannot distinguish between protected persons/objects and military objectives, as well as attacks directed against protected persons/objects or acts of revenge are prohibited in any place and at any time.
17 Sanctions for violations of the international law of armed conflict
17.1 General provisions
237 The following in particular are criminal offences: … harmful acts against internationally protected persons and objects[.] 
Switzerland, Bases légales du comportement à l’engagement (BCE), Règlement 51.007/IVf, Swiss Army, issued based on Article 10 of the Ordinance on the Organization of the Federal Department for Defence, Civil Protection and Sports of 7 March 2003, entry into force on 1 July 2005, §§ 176, 203–204, 206, 225 and 237. The German language version of the third sentence of § 206 notes: “… , if the security situation [“Sicherheitslage“] allows”.
Togo
Togo’s Military Manual (1996) lists the military and civilian medical service as specially protected objects. 
Togo, Le Droit de la Guerre, III fascicules, Etat-major Général des Forces Armées Togolaises, Ministère de la Défense nationale, 1996, Fascicule I, p. 14.
The manual states: “Specially protected means of transport shall be authorized to carry out their mission as long as necessary. Their mission, content and actual use may be checked through an inspection.” 
Togo, Le Droit de la Guerre, III fascicules, Etat-major Général des Forces Armées Togolaises, Ministère de la Défense nationale, 1996, Fascicule II, p. 9.
Ukraine
Ukraine’s IHL Manual (2004) states: “‘Means of medical transportation’ means any transport used for medical (sanitary) transportation by land, sea or air … [M]eans of medical transportation may be escorted by guard or convoy.” 
Ukraine, Manual on the Application of IHL Rules, Ministry of Defence, 11 September 2004, § 1.2.35.
The manual further states: “Objects protected by international humanitarian law [include] means of medical transportation … Attacks against such objects shall be prohibited.” 
Ukraine, Manual on the Application of IHL Rules, Ministry of Defence, 11 September 2004, § 1.2.51.
United Kingdom of Great Britain and Northern Ireland
The UK Military Manual (1958) provides: “Vehicles equipped for the transport of wounded and sick, as well as their medical equipment, must be respected and protected in the same way as mobile medical units.” 
United Kingdom, The Law of War on Land being Part III of the Manual of Military Law, The War Office, HMSO, 1958, § 356.
The manual further states: “Convoys of vehicles or hospital trains on land … conveying wounded and sick civilians, the infirm, and maternity cases must be protected and respected in the same way as civilian hospitals.” 
United Kingdom, The Law of War on Land being Part III of the Manual of Military Law, The War Office, HMSO, 1958, § 33.
United Kingdom of Great Britain and Northern Ireland
The UK LOAC Pamphlet (1981) provides: “Protection from attack is given … to medical transport, e.g. ambulances”. 
United Kingdom, The Law of Armed Conflict, D/DAT/13/35/66, Army Code 71130 (Revised 1981), Ministry of Defence, prepared under the Direction of The Chief of the General Staff, 1981, Section 6, p. 23, § 8(a).
United Kingdom of Great Britain and Northern Ireland
The UK LOAC Manual (2004) states:
7.12. Medical transport means any means of transportation, whether military or civilian, permanent or temporary, assigned exclusively to the conveyance by land, water or air of the wounded, sick, shipwrecked, medical or religious personnel, medical equipment or medical supplies protected by the Geneva Conventions and Additional Protocol I and under the control of a competent authority of a party to the conflict. In Additional Protocol I, reference to “medical vehicles” expressly means “any medical transports by land”. Similarly, “medical ships and craft” means “any medical transports by water” and “medical aircraft” means “any medical transports by air”.
7.12.1. The assignment to medical purposes must be exclusive, although it may be permanent or temporary. The word “exclusive” is intended to restrict the definition of medical transport and its use so that the essential protection will not be eroded by abuses. “Permanent” means for an indeterminate period; “temporary” means limited periods but devoted exclusively to medical tasks during the whole of such periods.
Protection of Medical Units
7.13. Medical units are to be “respected and protected at all times and shall not be the object of attack.” Medical units, personnel and transport must not be used for non-medical purposes, otherwise their protection will be jeopardized. In addition, medical units must not “be used in an attempt to shield military objectives from attack” and, where possible, should be so sited that attacks against military objectives do not imperil their safety. The improper use of medical units to kill, injure or capture the enemy amounts to the war crime of perfidy.
7.13.1. Medical units are given this general protection to enable them to perform their humanitarian functions. Thus, the protection given to medical units ceases if “they are used to commit, outside their humanitarian function, acts harmful to the enemy”. Protection may only be withdrawn, however, after due warning has been given, setting, whenever appropriate, a reasonable time limit and after such warning has remained unheeded. 
United Kingdom, The Manual of the Law of Armed Conflict, Ministry of Defence, 1 July 2004, §§ 7.12–7.13.1.
With regard to internal armed conflict, the manual states:
15.29. It is prohibited to attack:
c. medical buildings, including hospitals and places where the wounded and sick are cared for, medical material, medical units, and transport.
15.29.1. The wounded, sick, and shipwrecked must be protected … Medical units, personnel and transports must be protected from attack and are entitled to display the protective emblem of the red cross or red crescent on a white background.
15.47. Medical units and transports “shall be respected and protected at all times and shall not be the object of attack”. However this protection may cease if “they are used to commit hostile acts, outside their humanitarian function”. Even then, the protection will only cease “after a warning has been given setting, whenever appropriate, a reasonable time limit, and after such warning has remained unheeded”. 
United Kingdom, The Manual of the Law of Armed Conflict, Ministry of Defence, 1 July 2004, §§ 15.29–15.29.1 and 15.47.
United States of America
The US Field Manual (1956) restates Article 35 of the 1949 Geneva Convention I and Article 21 of the 1949 Geneva Convention IV. 
United States, Field Manual 27-10, The Law of Land Warfare, US Department of the Army, 18 July 1956, as modified by Change No. 1, 15 July 1976, §§ 236 and 260.
United States of America
The US Air Force Commander’s Handbook (1980) provides that ambulances … “should not be deliberately attacked, fired upon, or unnecessarily prevented from performing their medical duties”. 
United States, Air Force Pamphlet 110-34, Commander’s Handbook on the Law of Armed Conflict, Judge Advocate General, US Department of the Air Force, 25 July 1980, § 3-2.
The Handbook further stresses that medical transports lose their special immunity if they are used to commit “acts harmful to the enemy outside their humanitarian functions”. In this respect, the manual gives the example of “firing at the enemy from an ambulance”. 
United States, Air Force Pamphlet 110-34, Commander’s Handbook on the Law of Armed Conflict, Judge Advocate General, US Department of the Air Force, 25 July 1980, § 3-2(d).
United States of America
The US Naval Handbook (1995) states: “medical vehicles … may not be deliberately bombarded. Belligerents are required to ensure that such medical facilities are, as far as possible, situated in such manner that attacks against military targets in the vicinity do not imperil their safety.” 
United States, The Commander’s Handbook on the Law of Naval Operations, NWP 1-14M/MCWP 5-2.1/COMDTPUB P5800.7, issued by the Department of the Navy, Office of the Chief of Naval Operations and Headquarters, US Marine Corps, and Department of Transportation, US Coast Guard, October 1995 (formerly NWP 9 (Rev. A)/FMFM 1-10, October 1989), § 8.5.1.4.
The manual qualifies “deliberate attack upon … medical vehicles” as a war crime. 
United States, The Commander’s Handbook on the Law of Naval Operations, NWP 1-14M/MCWP 5-2.1/COMDTPUB P5800.7, issued by the Department of the Navy, Office of the Chief of Naval Operations and Headquarters, US Marine Corps, and Department of Transportation, US Coast Guard, October 1995 (formerly NWP 9 (Rev. A)/FMFM 1-10, October 1989), § 6.2.5.
United States of America
The US Naval Handbook (2007) states that “medical vehicles … may not be deliberately bombarded. Belligerents are required to ensure that such medical facilities are, as far as possible, situated in such a manner that attacks against military targets in the vicinity do not imperil their safety.” 
United States, The Commander’s Handbook on the Law of Naval Operations, NWP 1-14M/MCWP 5-12.1/COMDTPUB P5800.7, issued by the Department of the Navy, Office of the Chief of Naval Operations and Headquarters, US Marine Corps, and Department of Homeland Security, US Coast Guard, July 2007, § 8.9.1.4.
The Handbook also states that examples of war crimes that could be considered as grave breaches of the 1949 Geneva Conventions include: “Deliberate attacks upon … medical vehicles.” 
United States, The Commander’s Handbook on the Law of Naval Operations, NWP 1-14M/MCWP 5-12.1/COMDTPUB P5800.7, issued by the Department of the Navy, Office of the Chief of Naval Operations and Headquarters, US Marine Corps, and Department of Homeland Security, US Coast Guard, July 2007, § 6.2.6(7).
Yugoslavia, Socialist Federal Republic of
The Socialist Federal Republic of Yugoslavia’s Military Manual (1988) restates Article 19 of the 1949 Geneva Convention I and extends the protection of military medical transports to civilian medical transports.  
Yugoslavia, Socialist Federal Republic of, Propisi o Primeri Pravila Medjunarodnog Ratnog Prava u Oruzanim Snagama SFRJ, PrU-2, Savezni Sekretarijat za Narodnu Odbranu (Pravna Uprava), 1988, §§ 184, 195 and 198; see also § 82 (conduct of hostilities).
Zimbabwe
Zimbabwe’s Code of Conduct for Combatants (1993) states: “Special protection is to be given to … medical transports”. 
Zimbabwe, Code of Conduct for Combatants, Joint publication of the Zimbabwe Defence Forces and the International Committee of the Red Cross Regional Delegation in Harare, 1993, p. 14.
Australia
Australia’s Criminal Code Act (1995), as amended to 2007, states with respect to other serious war crimes that are committed in the course of an international armed conflict:
268.66 War crimeattacking persons or objects using the distinctive emblems of the Geneva Conventions
(2) A person (the perpetrator) commits an offence if:
(a) the perpetrator attacks one or more buildings, medical units or transports or other objects; and
(b) the buildings, units or transports or other objects are using, in conformity with the Geneva Conventions or the Protocols to the Geneva Conventions, any of the distinctive emblems of the Geneva Conventions; and
(c) the perpetrator intends the buildings, units or transports or other objects so using such an emblem to be the object of the attack; and
(d) the perpetrator’s conduct takes place in the context of, and is associated with, an international armed conflict.
Penalty: Imprisonment for 20 years.
(3) Strict liability applies to paragraphs … (2)(b). 
Australia, Criminal Code Act, 1995, as amended to 2007, Chapter 8, § 268.66, p. 345.
The Act further states with respect to war crimes that are other serious violations of the laws and customs applicable in a non-international armed conflict:
268.78 War crimeattacking persons or objects using the distinctive emblems of the Geneva Conventions
(2) A person (the perpetrator) commits an offence if:
(a) the perpetrator attacks one or more buildings, medical units or transports or other objects; and
(b) the buildings, units or transports or other objects are using, in conformity with the Geneva Conventions or the Protocols to the Geneva Conventions, any of the distinctive emblems of the Geneva Conventions; and
(c) the perpetrator intends the buildings, units or transports or other objects so using such an emblem to be the object of the attack; and
(d) the perpetrator’s conduct takes place in the context of, and is associated with, an armed conflict that is not an international armed conflict.
Penalty: Imprisonment for 20 years.
(3) Strict liability applies to paragraphs (1)(b) and (2)(b). 
Australia, Criminal Code Act, 1995, as amended to 2007, Chapter 8, § 268.78, p. 355.
Bangladesh
Bangladesh’s International Crimes (Tribunal) Act (1973) states that the “violation of any humanitarian rules applicable in armed conflicts laid down in the Geneva Conventions of 1949” is a crime. 
Bangladesh, International Crimes (Tribunal) Act, 1973, Section 3(2)(e).
Belgium
Belgium’s Law relating to the Repression of Grave Breaches of International Humanitarian Law (1993), as amended in 2003, provides:
War crimes envisaged in the 1949 [Geneva] Conventions … and in the [1977 Additional Protocols I and II] … , as well as in Article 8(2)(f) of the [1998 ICC Statute], and listed below, … constitute crimes under international law and shall be punished in accordance with the provisions of the present title … :
8 ter intentionally directing attacks against … medical … transports. 
Belgium, Law relating to the Repression of Grave Breaches of International Humanitarian Law, 1993, as amended on 23 April 2003, Article 1 ter, § 1(8 ter).
Bosnia and Herzegovina
Bosnia and Herzegovina’s Criminal Code (2003) contains the following war crimes provision:
Whoever, in violation of the rules of international law in time of war or armed conflict, orders or perpetrates … any of the following acts:
(c) Unlawful and arbitrary destruction or large-scale appropriation of … means of medical transport … which is not justified by military needs,
shall be punished by imprisonment for a term of not less than ten years or long-term imprisonment. 
Bosnia and Herzegovina, Criminal Code, 2003, Article 174(c).
Burundi
Burundi’s Penal Code (2009) states:
“War crimes” means crimes which are committed as part of a plan or policy or as part of a large-scale commission of such crimes, in particular:
2. … [S]erious violations of the laws and customs applicable in international armed conflict, within the established framework of international law, namely, any of the following acts:
24°. Intentionally directing attacks against … medical transports. 
Burundi, Penal Code, 2009, Article 198(2)(24°).
Colombia
Colombia’s Emblem Decree (1998) provides: “All Colombian authorities and persons must protect … transports of medicine, food and humanitarian aid in situations of armed conflict or natural disaster.” 
Colombia, Emblem Decree, 1998, Article 10.
Croatia
Croatia’s Criminal Code (1997), as amended to 2006, states that a war crime is committed by:
Whoever, in violation of the rules of international law, in time of war or armed conflict, orders [or commits] … an illegal and wanton, large-scale destruction or appropriation of … medical vehicles … when there is no justification by military necessity. 
Croatia, Criminal Code, 1997, as amended in June 2006, Article 159.
Denmark
Denmark’s Military Criminal Code (1973), as amended in 1978, provides:
Any person who uses war instruments or procedures the application of which violates an international agreement entered into by Denmark or the general rules of international law, shall be liable to the same penalty [i.e. a fine, lenient imprisonment or up to 12 years’ imprisonment]. 
Denmark, Military Criminal Code, 1973, as amended in 1978, § 25(1).
Denmark’s Military Criminal Code (2005) provides:
Any person who deliberately uses war means [“krigsmiddel”] or procedures the application of which violates an international agreement entered into by Denmark or international customary law, shall be liable to the same penalty [i.e. imprisonment up to life imprisonment]. 
Denmark, Military Criminal Code, 2005, § 36(2).
Estonia
Under Estonia’s Penal Code (2001), “an attack against … a hospital ship or aircraft, or any other means of transport used for transportation of non-combatants” is a war crime. 
Estonia, Penal Code, 2001, § 106.
France
France’s Penal Code (1992), as amended in 2010, states in its section on war crimes common to both international and non-international armed conflicts:
Intentionally launching attacks against … medical transports displaying, in conformity with international law, the distinctive emblems provided for in the [1949 Geneva Conventions] or their [1977] Additional Protocols is punishable by 20 years’ imprisonment. 
France, Penal Code, 1992, as amended in 2010, Article 461-12.
Georgia
Georgia’s Criminal Code (1999) provides for the punishment of “wilful breaches of norms of international humanitarian law committed in an international or internal armed conflict … against … medical transports”. 
Georgia, Criminal Code, 1999, Article 411(2).
Germany
Germany’s Law Introducing the International Crimes Code (2002) provides:
Anyone who, in connection with an international or non-international armed conflict … carries out an attack against … medical units and transport designated with the distinctive emblems of the Geneva Conventions … in conformity with international humanitarian law, shall be liable to imprisonment for not less than three years. In less serious cases, particularly where the attack is not carried out with military means, the period of imprisonment shall be for not less than one year. 
Germany, Law Introducing the International Crimes Code, 2002, Article 1, § 11(1)(2).
Ireland
Ireland’s Geneva Conventions Act (1962), as amended in 1998, provides that any “minor breach” of the 1949 Geneva Conventions, including violations of Article 35 of the Geneva Convention I and Article 21 of the Geneva Convention IV, and of the 1977 Additional Protocol I, including violations of Article 21, as well as any “contravention” of the 1977 Additional Protocol II, including violations of Article 11, are punishable offences. 
Ireland, Geneva Conventions Act, 1962, as amended in 1998, Section 4(1) and (4).
Italy
Italy’s Law of War Decree (1938), as amended in 1998, states that the means of transportation of the military medical service must be “respected and protected”. 
Italy, Law of War Decree, 1938, as amended in 1998, Article 95.
Lithuania
Lithuania’s Criminal Code (1961), as amended in 1998, provides for the protection of medical transports. 
Lithuania, Criminal Code, 1961, as amended in 1998, 1961, Article 337.
Nicaragua
Nicaragua’s Military Penal Code (1996) provides for the punishment of any soldier who “knowingly violates the protection due to … medical transports … which are recognizable by the established signs or the character of which can unequivocally be distinguished from a distance”, provided that the protection due is not misused for hostile purposes. 
Nicaragua, Military Penal Code, 1996, Article 57(1).
Norway
Norway’s Military Penal Code (1902), as amended in 1981, provides:
Anyone who contravenes or is accessory to the contravention of provisions relating to the protection of persons or property laid down in … the Geneva Conventions of 12 August 1949 … [and in] the two additional protocols to these Conventions … is liable to imprisonment. 
Norway, Military Penal Code, 1902, as amended in 1981, § 108.
Peru
Peru’s Military and Police Criminal Code (2010), in a chapter entitled “Crimes against humanitarian operations and emblems”, states:
A member of the military or the police shall be punished with deprivation of liberty of not less than six years and not more than twenty-five years if, in a state of emergency and when the Armed Forces assume control of the internal order, he or she:
2. Attacks medical … means of transport which are identified with protective signs of the [1949] Geneva Conventions in accordance with International Humanitarian Law. 
Peru, Military and Police Criminal Code, 2010, Article 95(2).
Romania
Romania’s Penal Code (1968) provides for the punishment of:
The total or partial destruction of objects marked with the regular distinctive emblem, such as:
b) means of transport of any kind assigned to a medical service or the Red Cross or the organizations assimilated therewith which serve to transport the wounded, sick, or medical material [and/or] material of the Red Cross or of organizations assimilated therewith. 
Romania, Penal Code, 1968, Article 359.
Serbia
Serbia’s Criminal Code (2005) states that, in time of war, armed conflict or occupation, ordering or committing an attack “against … medical transportation” constitutes a war crime. 
Serbia, Criminal Code, 2005, Article 373.
Spain
Spain’s Military Criminal Code (1985) provides for the punishment of any soldier who “knowingly violates the protection due to … medical transports … which are recognizable by the established signs or the character of which can unequivocally be distinguished from a distance”, provided that the protection due is not misused for hostile purposes. 
Spain, Military Criminal Code, 1985, Article 77(3).
Spain
Under Spain’s Penal Code (1995), wilful violations of the protected status of medical transports are war crimes. 
Spain, Penal Code, 1995, Article 612.
Spain
Spain’s Penal Code (1995), as amended in 2003, states:
Anyone who [commits any of the following acts] during armed conflict shall be punished with three to seven years’ imprisonment:
1. Knowingly violating the protection owed to … medical means of transportation. 
Spain, Penal Code, 1995, as amended on 25 November 2003, Article 612(1).
Switzerland
Switzerland’s Military Criminal Code (1927), taking into account amendments entered into force up to 2011, states in a chapter entitled “War crimes”:
Art. 110
Articles 112–114 apply in the context of international armed conflicts, including in situations of occupation, and, if the nature of the offence does not exclude it, in the context of non-international armed conflicts.
Art. 112
1 The penalty shall be a custodial sentence of not less than three years for any person who in the context of an armed conflict directs an attack against:
d. medical units [and] buildings, material or vehicles marked with a distinctive sign provided for by international humanitarian law or whose protected character is recognizable even without a distinctive sign, hospitals and places where the sick and wounded are collected. 
Switzerland, Military Criminal Code, 1927, taking into account amendments entered into force up to 2011, Articles 110 and 112(1)(d). The word “and” in square brackets has been inserted to reflect the placement of “medical” in the official language versions of Article 112(1)(d).
Switzerland
Switzerland’s Penal Code (1937), taking into account amendments entered into force up to 2011, states under the title “War crimes”:
Art. 264b
Articles 264d–264j apply in the context of international armed conflicts, including in situations of occupation, and, if the nature of the offence does not exclude it, in the context of non-international armed conflicts.
Art. 264d
1 The penalty shall be a custodial sentence of not less than three years for any person who in the context of an armed conflict directs an attack against:
d. medical units [and] buildings, material or vehicles marked with a distinctive sign provided for by international humanitarian law or whose protected character is recognizable even without a distinctive sign, hospitals and places where the sick and wounded are collected. 
Switzerland, Penal Code, 1937, taking into account amendments entered into force up to 2011, Articles 264b and 264d (1)(d). The word “and” in square brackets has been inserted to reflect the placement of “medical” in the official language versions of Article 112(1)(d).
Tajikistan
Tajikistan’s Criminal Code (1998), in the section on “Serious violations of international humanitarian law”, provides for the punishment of “wilful breaches of norms of international humanitarian law committed in an international or non-international armed conflict, against … medical transports”. 
Tajikistan, Criminal Code, 1998, Article 403(2).
Uruguay
Uruguay’s Law on Cooperation with the ICC (2006) states:
26.2. Persons and objects affected by the war crimes set out in the present provision are persons and objects which international law protects in international or internal armed conflict.
26.3. The following are war crimes:
32. Intentionally directing attacks against medical … transport. 
Uruguay, Law on Cooperation with the ICC, 2006, Article 26.2 and 26.3.32.
Venezuela
Venezuela’s Code of Military Justice (1998), as amended, provides for the punishment of “those who should … attack … convoys of sick and wounded”. 
Venezuela, Code of Military Justice, 1998, as amended, Article 474(1).
Colombia
In 2007, in the Constitutional Case No. C-291/07, the Plenary Chamber of Colombia’s Constitutional Court stated that the obligation in the 1977 Additional Protocol II to protect medical transport “has attained customary status, mainly due to its impact on State practice and on conflicts in the last decades”. 
Colombia, Constitutional Court, Constitutional Case No. C-291/07, Judgment of 25 April 2007, p. 69.
Israel
In its judgment in the Physicians for Human Rights v Commander of IDF Forces in the Gaza Strip case in 2004, Israel’s High Court of Justice stated:
22. As for the shooting upon an ambulance, Col. Mordechai stressed that it was not intentional. There are clear instructions that shooting on ambulances is prohibited. “Ambulances are out of bounds” – so stated Col. Mordechai before us. Col. Mordechai informed us that tens of ambulances passed with no harm done to them. It is to be regretted if a single exception occurred …
23. There is no disagreement regarding the normative framework … In HCJ 2117/02 Physicians for Human Rights v. Commander of IDF Forces in the West Bank, Justice Dorner stated:
[I]nternational law provides protection for medical stations and personnel against attack by combat forces … [It is forbidden], under all circumstances, [to] attack stations and mobile medical units of the “Medical Service,” that is to say, hospitals, medical warehouses, evacuation points for the wounded and sick, and ambulances …. However, the “Medical Service” has the right to full protection only when it is exclusively engaged in the search, collection, transport and treatment of the wounded or sick …. [P]rotection of medical establishments shall cease if they are being “used to commit, outside their humanitarian duties, acts harmful to the enemy,” on condition that “a due warning has been given, naming, in all appropriate cases, a reasonable time limit and after such warning has remained unheeded.”
It appears to us that the passage of ambulances to and from Rafah proceeded properly. This was made possible, among other means, by the contact between the IDF [Israel Defense Forces] – via officers of the DCO [District Coordination Offices] – and the ambulances. This contact was proper, and it was put into effect properly. In addition, ambulances move freely to and from the area … The single instance of shooting on an ambulance was an exception. We have been convinced that the instructions forbidding such activity are clear and unequivocal. 
Israel, High Court of Justice, Physicians for Human Rights v. Commander of IDF Forces in the Gaza Strip, Judgment, 30 May 2004, §§ 22–23.
Israel
In its judgment in Physicians for Human Rights v. Prime Minister of Israel in 2009, concerning the humanitarian situation in the Gaza Strip consequent to the start of Israeli military operations (“Cast Lead”) there in December 2008, Israel’s High Court of Justice stated:
[T]he Supreme Court emphasized in Physicians for Human Rights v. IDF Commander in West Bank [2002], at p. 29, that the abuse that is sometimes made of … ambulances requires the IDF [Israel Defense Forces] to act in order to prevent such activity, but it does not in itself permit a sweeping violation of the principles of humanitarian law, and that “this position is required not only by international law, on which the petitioners rely, but also by the values of the State of Israel as a Jewish and democratic state.” 
Israel, High Court of Justice, Physicians for Human Rights v. Prime Minister of Israel, Judgment, 19 January 2009, § 18.
South Africa
In 1987, in the Petane case, the Cape Provincial Division of South Africa’s Supreme Court dismissed the accused’s claim that the 1977 Additional Protocol I reflected customary international law. The Court stated:
The accused has been indicted before this Court on three counts of terrorism, that is to say, contraventions of s 54(1) of the Internal Security Act 74 of 1982. He has also been indicted on three counts of attempted murder.
The accused’s position is stated to be that this Court has no jurisdiction to try him.
… The point in its early formulation was this. By the terms of [the 1977 Additional] Protocol I to the [1949] Geneva Conventions the accused was entitled to be treated as a prisoner-of-war. A prisoner-of-war is entitled to have notice of an impending prosecution for an alleged offence given to the so-called “protecting power” appointed to watch over prisoners-of-war. Since, if such a notice were necessary, the trial could not proceed without it, Mr Donen suggested that the necessity or otherwise for giving such a notice should be determined before evidence was led. …
On 12 August 1949 there were concluded at Geneva in Switzerland four treaties known as the Geneva Conventions. …
South Africa was among the nations which concluded the treaties. … Except for the common art 3, which binds parties to observe a limited number of fundamental humanitarian principles in armed conflicts not of an international character, they apply to wars between States.
After the Second World War many conflicts arose which could not be characterised as international. It was therefore considered desirable by some States to extend and augment the provisions of the Geneva Conventions, so as to afford protection to victims of and combatants in conflicts which fell outside the ambit of these Conventions. The result of these endeavours was Protocol I and Protocol II to the Geneva Conventions, both of which came into force on 7 December 1978.
Protocol II relates to the protection of victims of non-international armed conflicts. Since the State of affairs which exists in South Africa has by Protocol I been characterised as an international armed conflict, Protocol II does not concern me at all.
The extension of the scope of art 2 of the Geneva Conventions was, at the time of its adoption, controversial. …
The article has remained controversial. More debate has raged about its field of operation than about any other articles in Protocol I. …
South Africa is one of the countries which has not acceded to Protocol I. Nevertheless, I am asked to decide, as I indicated earlier, as a preliminary point, whether Protocol I has become part of customary international law. If so, it is argued that it would have been incorporated into South African law. If it has been so incorporated it would have to be proved by one or other of the parties that the turmoil which existed at the time when the accused is alleged to have committed his offences was such that it could properly be described as an “armed conflict” conducted by “peoples” against a “ra[c]ist regime” in the exercise of their “right of self-determination”. Once all this has been shown it would have to be demonstrated to the Court that the accused conducted himself in such a manner as to become entitled to the benefits conferred by Protocol I on combatants, for example that, broadly speaking, he had, while he was launching an attack, distinguished himself from civilians and had not attacked civilian targets. …
… I am prepared to accept that where a rule of customary international law is recognised as such by international law it will be so recognised by our law.
To my way of thinking, the trouble with the first Protocol giving rise to State practice is that its terms have not been capable of being observed by all that many States. At the end of 1977 when the treaty first lay open for ratification there were few States which were involved in colonial domination or the occupation of other States and there were only two, South Africa and Israel, which were considered to fall within the third category of ra[c]ist regimes. Accordingly, the situation sought to be regulated by the first Protocol was one faced by few countries; too few countries in my view, to permit any general usage in dealing with armed conflicts of the kind envisaged by the Protocol to develop.
Mr Donen contended that the provisions of multilateral treaties can become customary international law under certain circumstances. I accept that this is so. There seems in principle to be no reason why treaty rules cannot acquire wider application than among the parties to the treaty.
Brownlie Principles of International Law 3rd ed at 13 agrees that non-parties to a treaty may by their conduct accept the provisions of a multilateral convention as representing general international law. …
I incline to the view that non-ratification of a treaty is strong evidence of non-acceptance.
It is interesting to note that the first Protocol makes extensive provision for the protection of civilians in armed conflict. …
In this sense, Protocol I may be described as an enlightened humanitarian document. If the strife in South Africa should deteriorate into an armed conflict we may all one day find it a cause for regret that the ideologically provocative tone of s 1(4) has made it impossible for the Government to accept its terms.
To my mind it can hardly be said that Protocol I has been greeted with acclaim by the States of the world. Their lack of enthusiasm must be due to the bizarre mixture of political and humanitarian objects sought to be realised by the Protocol. …
According to the International Review of the Red Cross (January/February 1987) No 256, as at December 1986, 66 States were parties to Protocol I and 60 to Protocol II, which, it will be remembered, deals with internal non-international armed conflicts. With the exception of France, which acceded only to Protocol II, not one of the world’s major powers has acceded to or ratified either of the Protocols. This position should be compared to the 165 States which are parties to the Geneva Conventions.
This approach of the world community to Protocol I is, on principle, far too half-hearted to justify an inference that its principles have been so widely accepted as to qualify them as rules of customary international law. The reasons for this are, I imagine, not far to seek. For those States which are contending with “peoples[’]” struggles for self-determination, adoption of the Protocol may prove awkward. For liberation movements who rely on strategies of urban terror for achieving their aims the terms of the Protocol, with its emphasis on the protection of civilians, may prove disastrously restrictive. I therefore do not find it altogether surprising that Mr Donen was unable to refer me to any statement in the published literature that Protocol I has attained the status o[f] customary international [law].
I have not been persuaded by the arguments which I have heard on behalf of the accused that the assessment of Professor Dugard, writing in the Annual Survey of South African Law (1983) at 66, that “it is argued with growing conviction that under contemporary international law members of SWAPO [South-West Africa People’s Organisation] and the ANC [African National Congress] are members of liberation movements entitled to prisoner-of-war status, in terms of a new customary rule spawned by the 1977 Protocols”, is correct. On what I have heard in argument I disagree with his assessment that there is growing support for the view that the Protocols reflect a new rule of customary international law. No writer has been cited who supports this proposition. Here and there someone says that it may one day come about. I am not sure that the provisions relating to the field of application of Protocol I are capable of ever becoming a rule of customary international law, but I need not decide that point today.
For the reasons which I have given I have concluded that the provisions of Protocol I have not been accepted in customary international law. They accordingly form no part of South African law.
This conclusion has made it unnecessary for me to give a decision on the question of whether rules of customary international law which conflict with the statutory or common law of this country will be enforced by its courts.
In the result, the preliminary point is dismissed. The trial must proceed. 
South Africa, Supreme Court, Petane case, Judgment, 3 November 1987, pp. 2–8.
South Africa
In 2010, in the Boeremag case, South Africa’s North Gauteng High Court stated:
In Petane, … Conradie J found that the provisions of [the 1977 Additional] Protocol I are not part of customary international law, and therefore are also not part of South African law.
Referring to the fact that in December 1986 only 66 of the 165 States party to the Geneva Conventions had ratified Protocol I, the Court [in Petane] stated:
This approach of the world community to Protocol I is, on principle, far too half-hearted to justify an inference that its principles have been so widely accepted as to qualify them as rules of customary international law. The reasons for this are, I imagine, not far to seek. For those States which are contending with “peoples[’]” struggles for self-determination, adoption of the Protocol may prove awkward. For liberation movements who rely on strategies of urban terror for achieving their aims the terms of the Protocol, with its emphasis on the protection of civilians, may prove disastrously restrictive. I therefore do not find it altogether surprising that Mr Donen was unable to refer me to any statement in the published literature that Protocol I has attained the status of customary international law.
Important changes with respect to certain aspects applicable at the time of Petane have taken place. The ANC [African National Congress] has become South Africa’s ruling party and in 1995 ratified Protocol I. The total number of States that have ratified it, is now … 162.
This last aspect forms the basis on which the First Respondent [the State] and the applicants agree that Protocol I forms part of customary international law as well as of South African law. As requested, this position is accepted for the purposes of the decision, without deciding on the matter.
Despite these changes, it remains debatable whether the provisions of Protocol I have become a part of South African law in this way.
The consensus of both parties to the conflict is required. See Petane … and Article 96 of Protocol I. …
Parliament’s failure to incorporate Protocol I into legislation in accordance with Article 231(4) of the Constitution in fact points to the contrary, and is indicative that the requirements of usus and/or opinio juris have not been met. See Petane. 
South Africa, North Gauteng High Court, Boeremag case, Judgment, 26 August 2010, pp. 21–22.
[footnotes in original omitted]
The Court also held:
If the [1977 Additional Protocol I] applies in South Africa as customary international law, the two requirements that form the basis of customary law must be met. It is arguable that the requirement of usus has been met by the vast number of States that have acceded or ratified it. By ratifying Protocol I the Republic of South Africa has indicated its intention to apply the Protocol, thereby fulfilling the requirement of opinio juris. 
South Africa, North Gauteng High Court, Boeremag case, Judgment, 26 August 2010, p. 66.
Argentina
In 1993, during a debate in the UN Security Council on the situation in the former Yugoslavia, Argentina stated that “the deliberate attacks on … ambulances” could not go on with impunity. 
Argentina, Statement before the UN Security Council, UN Doc. S/PV.3203, 20 April 1993, p. 57.
Djibouti
In 2010, in the History and Geography Textbook for 8th Grade, Djibouti’s Ministry of National Education and Higher Education, under the heading “Basic rules of IHLˮ and in a section on “Specific protection”, stated that “means of medical transport (… ambulances, etc.) … shall be respected and protectedˮ. 
Djibouti, Ministry of National Education and Higher Education, History and Geography Textbook for 8th Grade, 2010, p. 194.
Egypt
In a note submitted to the ICRC in 1967, Egypt accused Israel of “bombardment of hospitals and ambulances in spite of the distinct markings of them” in violation of Article 19 of the 1949 Geneva Convention I and Articles 18 and 21 of the 1949 Geneva Convention IV and condemned it as a “flagrant violation of the elementary principle of humanity, and a serious breach of the laws of war and the Geneva Conventions of 1949”. 
Egypt, Note to the International Committee of the Red Cross, 7 July 1967, annexed to Letter dated 17 July 1967 to the UN Secretary-General, UN Doc. S/8064, 17 July 1967, § 2(a).
Egypt
In its written comments submitted to the ICJ in the Nuclear Weapons case in 1995, Egypt stated that it was “prohibited to attack convoys of vehicles, hospital trains, hospital ships, aircraft exclusively employed for the removal of wounded and sick civilians, or the transport of medical personnel and equipment”. 
Egypt, Written comments on other written statements before the ICJ, Nuclear Weapons case, September 1995, p. 21, § 50.
France
Under the instructions given to the French armed forces for the conduct of Opération Mistral, simulating a military operation under the right of self-defence or a mandate of the UN Security Council, medical transports and material shall be protected. 
France, État-major de la Force d’Action Rapide, Ordres pour l’Opération Mistral, 1995, Section 6, § 62.
Hungary
In 1992, during a debate in the UN Security Council on the situation in the former Yugoslavia, Hungary stated: “It goes without saying that the international community cannot disregard the responsibility of those who violate international humanitarian law, who order attacks on … ambulances … to mention only a few examples of criminal atrocities.” 
Hungary, Statement before the UN Security Council, UN Doc. S/PV.3106, 13 August 1992, p. 32.
Islamic Republic of Iran
According to the Report on the Practice of the Islamic Republic of Iran, the Islamic Republic of Iran accused Iraq on several occasions of attacking Iranian Red Crescent vehicles during the Iran–Iraq war. The Islamic Republic of Iran claimed that Iraq had violated IHL by committing these acts. 
Report on the Practice of the Islamic Republic of Iran, 1997, Chapter 2.7.
Israel
In 2009, in a report on Israeli operations in Gaza between 27 December 2008 and 18 January 2009 (the “Gaza Operation”, also known as “Operation Cast Lead”), Israel’s Ministry of Foreign Affairs stated: “The operational order confirmed that medical … vehicles should be provided absolute protection from attack, unless they were being used by the enemy for military activities.” 
Israel, Ministry of Foreign Affairs, The Operation in Gaza 27 December 2008–18 January 2009: Factual and Legal Aspects, 29 July 2009, § 224.
The report further stated:
[The] IDF [Israel Defense Forces] trains forces at all levels to exercise extra caution to avoid harming medical crews and facilities. In the Gaza Operation, the IDF reinforced those instructions. In many cases IDF forces suspended their operations against legitimate military objectives when a medical vehicle … [was] in the vicinity. In some of these instances, the IDF refrained from attacking medical vehicles even in cases where Hamas and other terrorist organisations were using them for military purposes. Such restraint was not required under the Law of Armed Conflict, under which protection to medical vehicles may cease if the vehicles are being “used to commit, outside their humanitarian function, acts harmful to the enemy.” 
Israel, Ministry of Foreign Affairs, The Operation in Gaza 27 December 2008–18 January 2009: Factual and Legal Aspects, 29 July 2009, § 371.
Lebanon
In 1972, during a debate in the UN Security Council on the situation in the Middle East, the representative of Lebanon stated that the Lebanese Red Cross had reported that its ambulances, cars and volunteers had been attacked by Israeli forces. 
Lebanon, Statement before the UN Security Council, UN Doc. S/PV.2376, 8 June 1982, p. 2.
In a subsequent debate in 1984, Lebanon complained that an ambulance attendant of the Lebanese Red Cross had been detained while he and a colleague were transporting a wounded man to the hospital in a car belonging to the Red Cross. 
Lebanon, Statement before the UN Security Council, UN Doc. S/PV.2552, 29 August 1984, § 26.
Switzerland
Switzerland’s ABC of International Humanitarian Law (2009) states:
Civilian objects
International humanitarian law distinguishes between Civilian objects and Military objectives, prohibiting acts of violence against the former. Other provisions provide special protection for certain specific civilian objects, some of which are expected to bear distinctive signs: medical units and means of transport, … . Civilian objects are all objects which are not military objectives. 
Switzerland, Federal Department of Foreign Affairs, ABC of International Humanitarian Law, 2009, p. 12.
United Kingdom of Great Britain and Northern Ireland
At the CDDH, the United Kingdom welcomed “the humanitarian advances made in such fields as medical aircraft, the extension of protection to a wider group of medical units and transports and the improved provisions on relief”. 
United Kingdom, Statement at the CDDH, Official Records, Vol. VII, CDDH/SR. 58, 9 June 1977, p. 302, § 114.
United States of America
Upon signature of the 1977 Additional Protocols I and II, the United States declared:
It is the understanding of the United States of America that the terms used in Part III of [the 1977 Additional Protocol II] which are the same as the terms defined in Article 8 [of the 1977 Additional Protocol I] shall so far as relevant be construed in the same sense as those definitions. 
United States, Declaration made upon signature of the 1977 Additional Protocols I and II, 12 December 1977, § B.
United States of America
In 1987, in submitting the 1977 Additional Protocol II to the US Senate for advice and consent to ratification, the US President expressed the view that the obligations in the Protocol were “no more than a restatement of the rules of conduct with which US military forces would almost certainly comply as a matter of national policy, constitutional and legal protections, and common decency”. 
United States, Message from the US President transmitting the 1977 Additional Protocol II to the US Senate for advice and consent to ratification, Treaty Doc. 100-2, 29 January 1987, Comment on Article 10.
Yugoslavia, Socialist Federal Republic of
In 1991, in a document entitled “Examples of violations of the rules of international law committed by the so-called armed forces of Slovenia”, the Ministry of Defence of the Socialist Federal Republic of Yugoslavia included the following example: “Fire has been opened on medical vehicles in spite of their Red Cross signs.”  
Yugoslavia, Socialist Federal Republic of, Minister of Defence, Examples of violations of the rules of international law committed by the so-called Armed Forces of Slovenia, 10 July 1991, § 1(iii).
UN Security Council
In a resolution adopted in 1992, the UN Security Council expressed “grave alarm at continuing reports of widespread violations of international humanitarian law occurring within the territory of the former Yugoslavia and especially in Bosnia and Herzegovina including … deliberate attacks on … ambulances”. The Council strongly condemned such violations and demanded that “all parties and others concerned in the former Yugoslavia, and all military forces in Bosnia and Herzegovina, immediately cease and desist from all breaches of international humanitarian law”. 
UN Security Council, Res. 771, 13 August 1992, preamble and §§ 2 and 3, voting record: 15-0-0.
UN Commission on Human Rights
In a resolution adopted in 1992, the UN Commission on Human Rights stated that it was “appalled at the continuing reports of widespread, massive and grave violations of human rights within the territory of the former Yugoslavia and especially in Bosnia and Herzegovina”, including reports of deliberate attacks on ambulances. 
UN Commission on Human Rights, Res. 1992/S-1/1, 14 August 1992, preamble, adopted without a vote.
UN Commission on Human Rights
In a resolution adopted in 2003 on the question of the violation of human rights in the occupied Arab territories, including Palestine, the UN Commission on Human Rights:
Also strongly condemns again the opening of fire by the Israeli army of occupation on ambulances and paramedical personnel and the practice of preventing ambulances and vehicles of the International Committee of the Red Cross from reaching the wounded and the dead in order to transport them to hospital, thus leaving the wounded bleeding to death in the streets. 
UN Commission on Human Rights, Res. 2003/6, 15 April 2003, § 10, voting record: 33-5-15.
UN Commission on Human Rights
In a resolution adopted in 2004 on the question of the violation of human rights in the occupied Arab territories, including Palestine, the UN Commission on Human Rights:
Also strongly condemns once more the Israeli army of occupation’s practices of opening fire on ambulances and paramedical personnel and preventing ambulances and vehicles of the International Committee of the Red Cross from reaching the wounded and the dead in order to transport them to hospital, thus leaving the wounded bleeding to death in the streets. 
UN Commission on Human Rights, Res. 2004/10, 15 April 2004, § 10, voting record: 31-7-15.
UN Human Rights Council
In a resolution adopted in 2006 on human rights violations emanating from Israeli military incursions in the Occupied Palestinian Territory, the UN Human Rights Council affirmed that “under international humanitarian law, the medical personnel and means of transport of the Palestine Red Crescent Society must be protected and respected in all circumstances”. 
UN Human Rights Council, Res. S-3/1, 15 November 2006, preamble, voting record: 32-8-6.
UN Commission on Human Rights (Special Rapporteur)
In 1993, in a report on the situation of human rights in the territory of the former Yugoslavia, the Special Rapporteur of the UN Commission on Human Rights reported that, in March 1993, a group of UN relief workers escorted by two armoured personnel carriers from the UK Battalion of UNPROFOR were allowed to enter Konjevic Polje. The aim was to evacuate wounded persons who urgently required treatment and who had been identified on an earlier visit. However, Serb forces refused to allow UNHCR to bring in ambulances or trucks. A crowd of at least 2,000 civilians gathered around the two UNPROFOR vehicles. Both the crowd and the vehicles were deliberately shelled by the Serb forces. One of the carriers was destroyed by an almost direct hit just moments after its occupants had moved to the other carrier. 
UN Commission on Human Rights, Special Rapporteur on the Situation of Human Rights in the Former Yugoslavia, Periodic report, UN Doc. E/CN.4/1994/3, 5 May 1993, §§ 21–22.
In a later report, in a section entitled “Human rights violations”, the Special Rapporteur noted direct attacks on a UNHCR driver in a clearly marked armoured vehicle. 
UN Commission on Human Rights, Special Rapporteur on the Situation of Human Rights in the Former Yugoslavia, Fifth periodic report, UN Doc. E/CN.4/1994/47, 17 November 1993, §§ 67 and 96.
UN Commission on Human Rights (Special Rapporteur)
In 1996, in report on the situation of human rights in the Sudan under the title “Human rights violations – Abuses by parties to the conflict other than the Government of Sudan”, the Special Rapporteur of the UN Commission on Human Rights noted that Operation Lifeline Sudan had reported that, despite security assurances from local authorities, a UNICEF ambulance had been ambushed and one of the wounded persons it was transporting had been killed. 
UN Commission on Human Rights, Special Rapporteur on the Situation of Human Rights in the Sudan, Report, UN Doc. E/CN.4/1996/62, 20 February 1996, § 78.
UN Verification Mission in Guatemala
In 1995, in the context of the conflict in Guatemala, MINUGUA examined the case of an attack on a duly identified ambulance of the volunteer fire brigade that was evacuating a wounded soldier. The Unidad Revolucionaria Nacional Guatemalteca (URNG) command denied responsibility. MINUGUA acknowledged that the proximity of fighting made it difficult to judge whether the shot was intentional. The Director of MINUGUA recommended to the URNG that it “should issue precise instructions to its combatants to refrain from … endangering ambulances and duly identified health workers who assist such wounded persons”. 
MINUGUA, Director, First report, UN Doc. A/49/856, 1 March 1995, Annex, §§ 130 and 194.
No data.
International Conference for the Protection of War Victims
The Final Declaration adopted by the International Conference for the Protection of War Victims in 1993 urged all States to “make every effort” to protect medical means of transport. 
International Conference for the Protection of War Victims, Geneva, 30 August–1 September 1993, Final Declaration, § II (9), ILM, Vol. 33, 1994, p. 301.
No data.
ICRC
To fulfil its task of disseminating IHL, the ICRC has delegates around the world teaching armed and security forces that:
67. “Medical transport” means any means of transportation assigned exclusively to conveyance by land, water or air of the wounded, sick, shipwrecked, of medical and religious personnel, or of medical material.
78. The law of war grants the same status to civilian and military medical services … The provisions governing military medical … transports apply equally to the corresponding categories of the civilian medical service. 
Frédéric de Mulinen, Handbook on the Law of War for Armed Forces, ICRC, Geneva, 1987, §§ 67 and 78.
Delegates also teach that “specifically protected … transports recognized as such must be respected”. 
Frédéric de Mulinen, Handbook on the Law of War for Armed Forces, ICRC, Geneva, 1987, § 474.
ICRC
In a press release in 1992, the ICRC enjoined the parties to the conflict in Chechnya “to ensure that medical … vehicles are respected and protected”. 
ICRC, Press Release No. 1793, Chechnya: ICRC urges respect for humanitarian rules, 28 November 1994; see also Communication to the Press No. 96/10, Chechen conflict: ICRC appeal, 8 March 1996 and Communication to the Press No. 96/27, Russian Federation/Chechnya: ICRC calls on Federal Authorities to extend ultimatum, 21 August 1996.
National Society (Mexico)
In a declaration issued in 1994 in the context of the conflict between the Mexican Government and the Ejército Zapatista de Liberación Nacional (EZLN), the Mexican Red Cross stated: “Protection must be extended to health personnel in general and, in particular, to Mexican Red Cross personnel as well as their … transport facilities.” 
Mexican Red Cross, Declaración de la Cruz Roja Mexicana en torno a los acontecimientos que se han presentado en el estado de Chiapas a partir del 1° enero de 1994, 3 January 1994, § 2(C).
ICRC
In 1994, in a Memorandum on Respect for International Humanitarian Law in Angola, the ICRC stated: “Ambulances and other medical units and means of transport shall be protected and respected … Medical units and means of transport shall not be the object of attack.” 
ICRC, Memorandum on Respect for International Humanitarian Law in Angola, 8 June 1994, § III, IRRC, No. 320, 1997, p. 504.
ICRC
In a press release issued in 2000 following allegations that the Palestine Red Crescent Society had been targeted in shooting incidents, the ICRC stated: “Any attacks … on ambulances … indeed constitute a grave violation of IHL.” 
ICRC, Press Release, Israel and Occupied Territories: Respect for medical personnel, ICRC Tel Aviv, 1 November 2000.
ICRC
In a communication to the press issued in 2000 in connection with the hostilities in the Near East, the ICRC stated:
Ambulances … of the medical services must be respected and protected. They must be allowed to circulate unharmed so that they can discharge their humanitarian duties. All those who take part in the confrontations must respect the medical services, whether deployed by the armed forces, civilian facilities, the Palestine Red Crescent Society or the Magen David Adom in Israel. To date, dozens of Palestine Red Crescent ambulances and many of its staff have come under fire while conducting their medical activities in the occupied territories. Ambulances belonging to the Magen David Adom have also been attacked. The ICRC once again calls on all those involved in the violence to respect … ambulances [and] other medical transports. 
ICRC, Communication to the Press No. 00/42, ICRC appeal to all involved in violence in the Near East, 21 November 2000.
Americas Watch
In 1985, in a report on violations of the laws of war in Nicaragua, Americas Watch, noted, with respect to attacks against vehicles of the Ministry of Health, that the vehicles were escorted by military vehicles. It stated:
Although in such circumstances, the relevant law gives any clearly marked medical vehicle immunity from attack, that immunity is set alongside the risk that it may become a collateral casualty during a legitimate attack on the military vehicles with it. 
Americas Watch, Violations of the Laws of War by Both Sides in Nicaragua: 1981–1985, New York, March 1985, pp. 82–83.
Instituto de Derechos Humanos de la Universidad Centroamericano
In a report on the Farabundo Martí Front for National Liberation (FMLN) offensive in El Salvador in November 1989, the Instituto de Derechos Humanos de la Universidad Centroamericano stated: “Three ambulances of the Salvadoran Red Cross in San Salvador and three others inside the country were machine-gunned.” 
Instituto de Derechos Humanos de la Universidad Centroamericana (UCA), “Los derechos humanos y la ofensiva del 11 de noviembre de 1989”, Estudios Centroamericanos, Universidad Centroamericana José Simeón Cañas, Vol. XLV, Nos. 495–496, January–February 1990, p. 64.
Institute of International Humanitarian Law
The Rules of International Humanitarian Law Governing the Conduct of Hostilities in Non-international Armed Conflicts, adopted in 1990 by the Council of the Institute of International Humanitarian Law, provide: “The obligation to respect and protect … medical … transports in the conduct of military operations is a general rule applicable in non-international armed conflicts.” 
Institute of International Humanitarian Law, Rules of International Humanitarian Law Governing the Conduct of Hostilities in Non-international Armed Conflicts, Rule A5, IRRC, No. 278, 1990, p. 391.
Mouvement Révolutionnaire National pour le Développement et la Démocratie (MRND)
In 1993, in the context of the conflict in Rwanda, the MRND, a Rwandan political party, vigorously condemned an attack on a Red Cross ambulance. It appealed to all political forces in Rwanda to condemn such acts. 
Mouvement révolutionnaire national pour le développement (Rwanda), Official Declaration, 7 July 1993.
Geneva Convention I
Article 36 of the 1949 Geneva Convention I provides:
Medical aircraft, that is to say, aircraft exclusively employed for the removal of wounded and sick and for the transport of medical personnel and equipment, shall not be attacked, but shall be respected by the belligerents, while flying at heights, times and on routes specifically agreed upon between the belligerents concerned.
Unless agreed otherwise, flights over enemy or enemy-occupied territory are prohibited.
Medical aircraft shall obey every summons to land. In the event of a landing thus imposed, the aircraft with its occupants may continue its flight after examination, if any.
In the event of an involuntary landing in enemy or enemy-occupied territory, the wounded and sick, as well as the crew of the aircraft shall be prisoners of war. The medical personnel shall be treated according to Article 24 and the Articles following. 
Convention (I) for the Amelioration of the Condition of the Wounded and Sick in Armed Forces in the Field, Geneva, 12 August 1949, Article 36.
Geneva Convention IV
Article 22 of the 1949 Geneva Convention IV provides:
Aircraft exclusively employed for the removal of wounded and sick civilians, the infirm and maternity cases or for the transport of medical personnel and equipment, shall not be attacked, but shall be respected while flying at heights, times and on routes specifically agreed upon between all the Parties to the conflict concerned … Unless agreed otherwise, flights over enemy or enemy occupied territory are prohibited. Such aircraft shall obey every summons to land. In the event of a landing thus imposed, the aircraft with its occupants may continue its flight after examination, if any. 
Convention (IV) relative to the Protection of Civilian Persons in Time of War, Geneva, 12 August 1949, Article 22.
Additional Protocol I
Article 25 of the 1977 Additional Protocol I provides:
In and over land areas physically controlled by friendly forces, or in and over sea areas not physically controlled by an adverse Party, the respect and protection of medical aircraft of a Party to the conflict is not dependent on any agreement with an adverse Party. For greater safety, however, a Party to the conflict operating its medical aircraft in these areas may notify the adverse Party, as provided in Article 29, in particular when such aircraft are making flights bringing them within range of surface-to-air weapons systems of the adverse Party. 
Protocol Additional to the Geneva Conventions of 12 August 1949, and relating to the Protection of Victims of International Armed Conflicts (Protocol I), Geneva, 8 June 1977, Article 25. Article 25 was adopted by consensus. CDDH, Official Records, Vol. VI, CDDH/SR.38, 24 May 1977, p. 89.
Additional Protocol I
Article 26 of the 1977 Additional Protocol I provides:
1. In and over those parts of the contact zone which are physically controlled by friendly forces and in and over those areas the physical control of which is not clearly established, protection for medical aircraft can be fully effective only by prior agreement between the competent military authorities of the Parties to the conflict, as provided for in Article 29. Although, in the absence of such an agreement, medical aircraft operate at their own risk, they shall nevertheless be respected after they have been recognized as such.
2. “Contact zone” means any area on land where the forward elements of opposing forces are in contact with each other, especially where they are exposed to direct fire from the ground. 
Protocol Additional to the Geneva Conventions of 12 August 1949, and relating to the Protection of Victims of International Armed Conflicts (Protocol I), Geneva, 8 June 1977, Article 26. Article 26 was adopted by consensus. CDDH, Official Records, Vol. VI, CDDH/SR.39, 25 May 1977, p. 94.
Additional Protocol I
Article 27 of the 1977 Additional Protocol I provides:
1. The medical aircraft of a Party to the conflict shall continue to be protected while flying over land or sea areas physically controlled by an adverse Party, provided that prior agreement to such flights has been obtained from the competent authority of that adverse Party.
2. A medical aircraft which flies over an area physically controlled by an adverse Party without, or in deviation from the terms of, an agreement provided for in paragraph 1, either through navigational error or because of an emergency affecting the safety of the flight, shall make every effort to identify itself and to inform the adverse Party of the circumstances. As soon as such medical aircraft has been recognized by the adverse Party, that Party shall make all reasonable efforts to give the order to land or to alight on water, referred to in Article 30, paragraph 1, or to take other measures to safeguard its own interests, and, in either case, to allow the aircraft time for compliance, before resorting to an attack against the aircraft. 
Protocol Additional to the Geneva Conventions of 12 August 1949, and relating to the Protection of Victims of International Armed Conflicts (Protocol I), Geneva, 8 June 1977, Article 27. Article 27 was adopted by consensus. CDDH, Official Records, Vol. VI, CDDH/SR.39, 25 May 1977, p. 95.
Additional Protocol I
Article 28 of the 1977 Additional Protocol I provides:
1. The Parties to the conflict are prohibited from using their medical aircraft to attempt to acquire any military advantage over an adverse Party. The presence of medical aircraft shall not be used in an attempt to render military objectives immune from attack.
2. Medical aircraft shall not be used to collect or transmit intelligence data and shall not carry any equipment intended for such purposes. They are prohibited from carrying any persons or cargo not included within the definition in Article 8, sub-paragraph f). The carrying on board of the personal effects of the occupants or of equipment intended solely to facilitate navigation, communication or identification shall not be considered as prohibited.
3. Medical aircraft shall not carry any armament except small arms and ammunition taken from the wounded, sick and shipwrecked on board and not yet handed to the proper service, and such light individual weapons as may be necessary to enable the medical personnel on board to defend themselves and the wounded, sick and shipwrecked in their charge. 
Protocol Additional to the Geneva Conventions of 12 August 1949, and relating to the Protection of Victims of International Armed Conflicts (Protocol I), Geneva, 8 June 1977, Article 28. Article 28 was adopted by consensus. CDDH, Official Records, Vol. VI, CDDH/SR.39, 25 May 1977, p. 97.
San Remo Manual
Paragraph 53(a) of the 1994 San Remo Manual provides that medical aircraft are exempt from attack. Paragraph 54 lists the following conditions of exemption:
Medical aircraft are exempt from attack only if they:
(a) have been recognised as such;
(b) are acting in compliance with an agreement …
(c) fly in areas under the control of own or friendly forces; or
(d) fly outside the area of armed conflict.
In other instances, medical aircraft operate at their own risk. 
Louise Doswald-Beck (ed.), San Remo Manual on International Law Applicable to Armed Conflicts at Sea, 12 June 1994, Prepared by international lawyers and naval experts convened by the International Institute of Humanitarian Law, Cambridge University Press, Cambridge, 1995, §§ 53(a) and 54.
San Remo Manual
Paragraph 178 of the 1994 San Remo Manual states:
Medical aircraft shall not be used to commit acts harmful to the enemy. They shall not carry any equipment intended for the collection or transmission of intelligence data. They shall not be armed, except for small arms for self-defence, and shall only carry medical personnel and equipment. 
Louise Doswald-Beck (ed.), San Remo Manual on International Law Applicable to Armed Conflicts at Sea, 12 June 1994, Prepared by international lawyers and naval experts convened by the International Institute of Humanitarian Law, Cambridge University Press, Cambridge, 1995, § 178.
Argentina
Argentina’s Law of War Manual (1969) restates Article 36 of the 1949 Geneva Convention I and Article 22 of the 1949 Geneva Convention IV. 
Argentina, Leyes de Guerra, RC-46-1, Público, II Edición 1969, Ejército Argentino, Edición original aprobado por el Comandante en Jefe del Ejército, 9 May 1967, §§ 3.017 and 4.006.
Australia
Australia’s Defence Force Manual (1994) states:
972. … Medical aircraft must be respected and protected at all times and must not be attacked. Their immunity ceases once they are used for purposes hostile to the adverse party and outside their humanitarian purpose.
977. Medical aircraft may fly over land physically controlled by their own or friendly forces, and over sea areas not under enemy control. However, it is advisable that the enemy be informed if such flights are likely to bring the aircraft within range of enemy surface-to-air weapon systems.
978. In accordance with LOAC, flight of such aircraft over enemy or enemy-occupied territory is forbidden without prior agreement. In the absence of such agreement, medical aircraft operating in parts of the zone controlled by friendly forces, and over areas the control of which is doubtful, do so at their own risk, but once they are recognised as medical aircraft they must be respected.
979. Provided prior agreement has been obtained from the enemy, medical aircraft belonging to a combatant remain protected while flying over land or sea areas under the physical control of the enemy. If it deviates for any reason from the terms of such an agreement, the aircraft shall take immediate steps to identify itself. Upon being recognised as a medical aircraft, the adverse party may order it to land, or take such other steps to safeguard its own interests, and must allow time for compliance before attacking the aircraft.
980. Known medical aircraft are entitled to protection while performing medical functions … Medical aircraft must not be used in order to gain any military advantage and while carrying out flights in accordance with the two preceding paragraphs, shall not, without prior agreement, be used to search for the wounded, sick and shipwrecked. 
Australia, Manual on Law of Armed Conflict, Australian Defence Force Publication, Operations Series, ADFP 37 – Interim Edition, 1994, §§ 972 and 977–980.
Australia
Australia’s LOAC Manual (2006) states:
Medical aircraft, that is, aircraft exclusively employed for the removal of wounded and sick for the transport of medical personnel and equipment, shall not be attacked, but shall be respected by the belligerents, while flying at heights, at times and on routes specifically agreed upon between the belligerents concerned. These aircraft should bear clearly marked, distinctive emblems, together with their national colours on their upper and lower surfaces. 
Australia, The Manual of the Law of Armed Conflict, Australian Defence Doctrine Publication 06.4, Australian Defence Headquarters, 11 May 2006, § 5.44.
In its chapter on “Protected Persons and Objects”, the manual states:
9.78 Medical … aircraft must be respected and protected at all times and must not be attacked. Their immunity ceases once they are used for purposes hostile to the adverse party and outside their humanitarian purpose.
9.83 Medical aircraft may fly over land physically controlled by their own or friendly forces, and over sea areas not under enemy control. However, it is advisable that the enemy be informed if such flights are likely to bring the aircraft within range of enemy surface-to-air weapon systems.
9.84 In accordance with the LOAC, flight of such aircraft over enemy or enemy-occupied territory is forbidden without prior agreement. In the absence of such agreement, medical aircraft operating in parts of the zone controlled by friendly forces, and over areas the control of which is doubtful, do so at their own risk, but once they are recognised as medical aircraft they must be respected.
9.85 Provided prior agreement has been obtained from the enemy, medical aircraft belonging to a combatant remain protected while flying over land or sea areas under the physical control of the enemy. If it deviates for any reason from the terms of such an agreement, the aircraft shall take immediate steps to identify itself. Upon being recognised as a medical aircraft, the adverse party may order it to land, or take such other steps to safeguard its own interests, and must allow time for compliance before attacking the aircraft.
9.86 Known medical aircraft are entitled to protection when performing medical functions … Medical aircraft must not be used in order to gain any military advantage and while carrying out flights in accordance with the two preceding paragraphs, shall not, without prior agreement, be used to search for the wounded, sick and shipwrecked. 
Australia, The Manual of the Law of Armed Conflict, Australian Defence Doctrine Publication 06.4, Australian Defence Headquarters, 11 May 2006, §§ 9.78 and 9.83–9.86; see also §§ 8.49 and 8.60–8.63.
The manual further states: “Among other war crimes generally recognised as forming part of the customary LOAC are … attacking a properly marked … medical aircraft”. 
Australia, The Manual of the Law of Armed Conflict, Australian Defence Doctrine Publication 06.4, Australian Defence Headquarters, 11 May 2006, § 13.30.
The LOAC Manual (2006) replaces both the Defence Force Manual (1994) and the Commanders’ Guide (1994).
Belgium
Belgium’s Law of War Manual (1983) states:
Medical aircraft are immune from attack during the flights agreed upon beforehand between belligerents. They may not fly over enemy controlled or occupied territory without authorization. They must obey each order to land … No authorization is necessary to fly over territory controlled by one’s own forces. Medical aircraft are still protected above contact zones, but the risk of sustaining damage are bigger in the absence of an agreement. 
Belgium, Droit Pénal et Disciplinaire Militaire et Droit de la Guerre, Deuxième Partie, Droit de la Guerre, Ecole Royale Militaire, par J. Maes, Chargé de cours, Avocat-général près la Cour Militaire, D/1983/1187/029, 1983, p. 49.
Canada
Canada’s LOAC Manual (1999) states: “Medical aircraft, correctly identified and exclusively used as such, are immune from attack.” 
Canada, The Law of Armed Conflict at the Operational and Tactical Level, Office of the Judge Advocate General, 1999, p. 7-5, § 43.
The manual further states:
41. Medical aircraft are free to fly over land physically controlled by their own or friendly forces, and over sea areas not under enemy control. It is advisable, however, that the adverse party be informed if such flights are likely to bring the aircraft within range of surface-to-air weapon systems of the adverse party.
42. Flight of medical aircraft over enemy or enemy-occupied territory is forbidden without prior agreement. In the absence of such agreement, medical aircraft operating in parts of the contact zone controlled by friendly forces, and over areas the control of which is doubtful, do so at their own risk. “Contact zone” means any area on land where the forward elements of opposing forces are in contact with each other, especially where they are exposed to direct fire from the ground.
43. Provided prior agreement has been obtained from the adverse party, medical aircraft belonging to a combatant remain protected while flying over land or sea areas under the physical control of the adverse party. If the aircraft lags or deviates for any reason from the terms of the agreement, the aircraft shall take immediate steps to identify itself. Upon being recognized as a medical aircraft, the adverse party may order it to land, or take such other steps to safeguard its own interests, but must allow time for compliance before attacking the aircraft.
44. Medical aircraft must not be used in order to gain any military advantage. While carrying out flights, medical aircraft shall not, without prior agreement, be used to search for the wounded, sick and shipwrecked. 
Canada, The Law of Armed Conflict at the Operational and Tactical Level, Office of the Judge Advocate General, 1999, p. 9-4, §§ 41–44 and p. 11-3, § 22.
The manual qualifies “attacking a properly marked … medical aircraft” as a war crime. 
Canada, The Law of Armed Conflict at the Operational and Tactical Level, Office of the Judge Advocate General, 1999, p. 16-4, § 21(e).
Canada
Canada’s LOAC Manual (2001) states in its chapter on air warfare:
1. Medical aircraft, correctly identified and exclusively used as such, are immune from attack.
2. The parties to a conflict may, by agreement, confer immunity from attack upon specific aircraft. Such aircraft remain protected so long as they take no part in hostilities and rigorously respect the conditions laid down in the agreement. 
Canada, The Law of Armed Conflict at the Operational and Tactical Levels, Office of the Judge Advocate General, 13 August 2001, § 715.
In its chapter on the treatment of the wounded, sick and shipwrecked, the manual states:
918. Protection of medical establishments, transport, aircraft and hospital ships
1. Medical establishments on land, hospital ships, medical aircraft, and medical transports must be respected and protected at all times and must not be attacked. If they are used for purposes hostile to the adverse party and outside their humanitarian purpose, protection may cease. Protection will only cease, however, following a clear warning which has remained unheeded.
921. Medical aircraft
1. Medical aircraft are free to fly over land physically controlled by their own or friendly forces, and over sea areas not under enemy control. It is advisable; however, that the adverse party be informed if such flights are likely to bring the aircraft within range of surface-to-air weapon systems of the adverse party.
2. Flight of medical aircraft over enemy or enemy-occupied territory is forbidden without prior agreement. In the absence of agreement, medical aircraft operating in parts of the contact zone controlled by friendly forces, and over areas the control of which is doubtful, do so at their own risk. “Contact zone” means any area on land where the forward elements of opposing forces are in contact with each other, especially where they are exposed to direct fire from the ground.
3. Provided prior agreement has been obtained from the adverse party, medical aircraft belonging to a combatant remain protected while flying over land or sea areas under the physical control of the adverse party. If the aircraft lags or deviates for any reason from the terms of the agreement, the aircraft shall take immediate steps to identify itself. Upon being recognized as a medical aircraft the adverse party may order it to land, or take such other steps to safeguard its own interests, but must allow time for compliance before attacking the aircraft.
4. Medical aircraft must not be used in order to gain any military advantage. While carrying out flights medical aircraft shall not, without prior agreement, be used to search for the wounded, sick and shipwrecked.
5. If a medical aircraft is ordered by an adverse party to land, it must obey such order and permit inspection. Wounded and sick on board may only be removed if this is essential to enable the inspection to proceed, and only if such removal does not adversely affect their welfare. If the inspection of a landed aircraft, discloses that the aircraft is in fact a medical aircraft, and is not in breach of any special agreement or in violation of the law relating to medical aircraft, the aircraft and its occupants belonging to the aircraft’s state or a neutral country must be allowed to leave.
6. If the aircraft does not satisfy these requirements it may be seized. If, however, the aircraft has been assigned as a permanent medical aircraft, it may be used by the captor only for this purpose. If the aircraft makes an involuntary landing in enemy or enemy-occupied territory, the sick, wounded and shipwrecked as well as the crew become PWs [prisoners of war] but the medical personnel must be treated in the same way as other medical personnel falling into enemy hands.
7. Medical aircraft shall not fly over neutral territory without prior approval. If a medical aircraft should fly over neutral territory without agreement for any reason, it must make every effort to give notice and identify itself. The medical aircraft must obey any order to land and it cannot be attacked until a reasonable time for compliance has elapsed. When the aircraft lands, it is liable to inspection and if found to be a medical aircraft may leave with its occupants, other than those who must be detained in accordance with International Law. If the wounded, sick or shipwrecked are removed for other than temporary reasons, they must be detained in a manner that precludes their taking any further part in the hostilities. Any restrictions applied by a neutral must be applied to all Parties to the conflict equally. 
Canada, The Law of Armed Conflict at the Operational and Tactical Levels, Office of the Judge Advocate General, 13 August 2001, §§ 918 and 921.
In its chapter entitled “Treatment of civilians in the hands of a party to the conflict or an occupying power”, the manual states:
Aircraft used exclusively for the removal of wounded and sick civilians, or for the transport of medical personnel and equipment must not be attacked when flying at heights, times and on routes specifically agreed upon between all the belligerents concerned. Such aircraft may be marked with the Red Cross or Red Crescent distinctive emblem. In the absence of agreement to the contrary, flights over enemy or enemy-occupied territory are prohibited. Such aircraft must obey every summons to land, but, after landing and examination, may continue their flight. 
Canada, The Law of Armed Conflict at the Operational and Tactical Levels, Office of the Judge Advocate General, 13 August 2001, § 1112.2.
In its chapter on “War crimes, individual criminal liability and command responsibility”, the manual qualifies “attacking a properly marked … medical aircraft” as a war crime. 
Canada, The Law of Armed Conflict at the Operational and Tactical Levels, Office of the Judge Advocate General, 13 August 2001, § 1609.3.e.
Croatia
Croatia’s Commanders’ Manual (1992) provides: “Medical transports may not be used to collect or transmit intelligence data.” 
Croatia, Basic Rules of the Law of Armed Conflicts – Commanders’ Manual, Republic of Croatia, Ministry of Defence, 1992, § 34.
Croatia
Croatia’s Soldiers’ Manual (1992) instructs soldiers to respect medical aircraft displaying the distinctive emblem. 
Croatia, Rules of Conduct for Soldiers, Republic of Croatia, Ministry of Defence, 1992, pp. 2 and 3.
Dominican Republic
The Dominican Republic’s Military Manual (1980) directs soldiers not to attack medical aircraft. 
Dominican Republic, La Conducta en Combate según las Leyes de la Guerra, Escuela Superior de las FF. AA. “General de Brigada Pablo Duarte”, Secretaría de Estado de las Fuerzas Armadas, May 1980, p. 4.
Ecuador
Ecuador’s Naval Manual (1989) qualifies “deliberate attack upon … medical aircraft” as a war crime. 
Ecuador, Aspectos Importantes del Derecho Internacional Marítimo que Deben Tener Presente los Comandantes de los Buques, Academia de Guerra Naval, 1989, § 6.2.5.
Ethiopia
According to Ethiopia’s Standing Rules of Engagement (2007), “ambulance airplanes” do not constitute military objectives. 
Ethiopia, Standing Rules of Engagement, National Defense Force, Addis Ababa, 2007, § 8.4.5.
France
France’s LOAC Summary Note (1992) states: “Medical transports must not be used to collect military information.” 
France, Fiche de Synthèse sur les Règles Applicables dans les Conflits Armés, Note No. 432/DEF/EMA/OL.2/NP, Général de Corps d’Armée Voinot (pour l’Amiral Lanxade, Chef d’Etat-major des Armées), 1992, § 2.3.
Germany
Germany’s Military Manual (1992) states:
The parties to the conflict are prohibited from using their medical aircraft to attempt to acquire any military advantage over an adverse party. The presence of medical aircraft shall not be used in an attempt to render military objectives immune from attack. 
Germany, Humanitarian Law in Armed Conflicts – Manual, DSK VV207320067, edited by The Federal Ministry of Defence of the Federal Republic of Germany, VR II 3, August 1992, English translation of ZDv 15/2, Humanitäres Völkerrecht in bewaffneten KonfliktenHandbuch, August 1992, § 620.
Greece
The Hellenic Navy’s International Law Manual (1995) provides:
[T]he protection of any type of hospital vessels and boats is conventionally consolidated. The same protection is extended to medical aircrafts (art. 36 of the Ist Geneva Convention and art. 24, 25, 27–30 of Ist Add. Protocol) and according to practice followed during the Falklands war also to helicopters used for carrying the wounded, shipwrecked and the dead. 
Greece, International Law Manual, Hellenic Navy General Staff, Directorate A2, Division IV, 1995, Chapter 7, Part I, § 7.
Guinea
Guinea’s Soldier’s Manual (2010), under the heading “Distinctive signs”, shows an image of a helicopter with a red crescent on a white ground and states: “Let these … aircraft move around and do not enter them.” 
Guinea, Soldier’s Manual, Ministry of National Defence, 2010, p. 14.
Hungary
Hungary’s Military Manual (1992) states that “medical aircraft flying over the high seas, on specified routes, according to an agreement or identified as such” must be protected. 
Hungary, A Hadijog, Jegyzet a Katonai, Föiskolák Hallgatói Részére, Magyar Honvédség Szolnoki Repülötiszti Föiskola, 1992, p. 71.
Indonesia
Indonesia’s Air Force Manual (1990) states that medical aircraft must not be attacked, provided they fly on routes, heights and at times agreed between belligerents. The manual further states that medical aircraft lose their immunity if they are used for purposes other than the transportation of the wounded, medical personnel or medical equipment. 
Indonesia, The Basics of International Humanitarian Law in Air Warfare, Indonesian Air Force, 1990, § 36.
The manual also states that no immunity is provided to medical aircraft which enter a war zone or enemy controlled territory without prior authorization or without agreement between the parties to the conflict or when they ignore instructions given by the parties to the conflict. 
Indonesia, The Basics of International Humanitarian Law in Air Warfare, Indonesian Air Force, 1990, § 46.
Italy
Italy’s LOAC Elementary Rules Manual (1991) provides: “Medical transports may not be used to collect or transmit intelligence data.” 
Italy, Regole elementari di diritto di guerra, SMD-G-012, Stato Maggiore della Difesa, I Reparto, Ufficio Addestramento e Regolamenti, Rome, 1991, § 34.
Italy
Italy’s IHL Manual (1991) provides: “Medical aircraft attached to the military [medical] service must be respected and protected.” 
Italy, Manuale di diritto umanitario, Introduzione e Volume I, Usi e convenzioni di Guerra, SMD-G-014, Stato Maggiore della Difesa, I Reparto, Ufficio Addestramento e Regolamenti, Rome, 1991, Vol. I, § 14.
Lebanon
Lebanon’s Teaching Manual (1997) provides for respect for aircraft displaying the distinctive emblem. 
Lebanon, Manuel de l’Instruction Nationale dans l’Armée Libanaise, 1997, p. 77.
Mexico
Mexico’s Army and Air Force Manual (2009), in a section on the 1949 Geneva Convention II, states:
Medical aircraft exclusively employed for the removal of the wounded, sick and shipwrecked and for the transport of medical supplies must be respected by the parties to the conflict, while flying at heights, at times and on routes specifically agreed upon between the parties to the conflict. Unless agreed otherwise, flights over enemy or enemy-occupied territory are prohibited. 
Mexico, Manual de Derecho Internacional Humanitario para el Ejército y la Fuerza Área Mexicanos, Ministry of National Defence, June 2009, § 129.
Netherlands
The Military Manual (1993) of the Netherlands restates the rules governing medical aircraft found in Articles 25–28 of the 1977 Additional Protocol I. 
Netherlands, Toepassing Humanitair Oorlogsrecht, Voorschift No. 27-412/1, Koninklijke Landmacht, Ministerie van Defensie, 1993, pp. VI-6 and VI-7.
Netherlands
The Military Manual (2005) of the Netherlands states:
0627. Medical aircraft
Special rules exist for the protection of medical aircraft. First, they distinguish between the places where such aircraft are flying:
- in zones under the control of friendly troops;
- in contact zones;
- in zones under the control of the adversary.
0628. Zones under friendly control
In a situation where medical aircraft are flying in zones under the control of friendly troops, no rules are prescribed, except that, for safety’s sake, the adversary may be informed when and where medical aircraft are carrying out flights.
0629. Contact zones
A contact zone means any area on land where the parties’ forces are fighting each other. If the parties in a conflict have reached no agreement on flights in the contact zone, medical aircraft fly at their own risk. An adversary which recognizes a medical aircraft must, of course, respect it.
0630. Zones under the adversary’s control
Subject to obtaining the adversary’s permission, medical aircraft enjoy total protection while flying over the area under the adversary’s control. If permission is not obtained, or if the aeroplane or helicopter strays from the prescribed route, or breaches other set conditions, it must identify itself as quickly as possible to the adversary which should make every reasonable effort to order a medical aircraft, identified as such, to land, or should take other measures before attacking the aircraft. If one of the parties to a conflict forces a medical aircraft to land and it emerges, on inspection, that the consignment does not meet certain specific requirements for medical flights, the plane may be seized. In the case of a dedicated medical plane, it may be used only as such thereafter.
0631. A number of further rules apply to the use of medical aircraft in general. Medical aircraft may not be used in an attempt to render military objectives immune from attack. It is also prohibited to use such aircraft to gather military intelligence or carry equipment for that purpose, or otherwise to procure any advantage against the adversary. Medical aircraft may carry only the wounded, the sick, medical personnel and religious personnel. Furthermore, only portable weapons and ammunition of the persons present on board the aircraft may be carried with them. 
Netherlands, Humanitair Oorlogsrecht: Handleiding, Voorschift No. 27-412, Koninklijke Landmacht, Militair Juridische Dienst, 2005, §§ 0627–0631.
In its chapter on neutrality, the manual states:
Except with consent and the possible attachment of conditions or restrictions, medical aircraft may not over-fly or land on the territory of a neutral State or other State not a party to the conflict. If consent is obtained, medical aircraft should be respected and protected. Nevertheless, they must obey any order to land.
If consent is not obtained, a medical aircraft should do everything to announce the flight and to identify itself. 
Netherlands, Humanitair Oorlogsrecht: Handleiding, Voorschift No. 27-412, Koninklijke Landmacht, Militair Juridische Dienst, 2005, § 0940.
New Zealand
New Zealand’s Military Manual (1992) states: “Medical aircraft, correctly identified and exclusively used as such, are for the main part immune from attack.” 
New Zealand, Interim Law of Armed Conflict Manual, DM 112, New Zealand Defence Force, Headquarters, Directorate of Legal Services, Wellington, November 1992, § 629.1.
The manual further states: “Medical aircraft must be respected and protected at all times and must not be attacked. Their immunity ceases once they are used for purposes hostile to the adverse Party and outside their humanitarian purposes.” 
New Zealand, Interim Law of Armed Conflict Manual, DM 112, New Zealand Defence Force, Headquarters, Directorate of Legal Services, Wellington, November 1992, § 1007(1).
The manual restates the rules governing medical aircraft found in Articles 25–28 of the 1977 Additional Protocol I. 
New Zealand, Interim Law of Armed Conflict Manual , DM 112, New Zealand Defence Force, Headquarters, Directorate of Legal Services, Wellington, November 1992, § 1009(1)-(5).
In addition, the manual specifies that:
Aircraft used exclusively for the removal of wounded and sick civilians, the infirm and maternity cases, or for the transport of medical personnel and equipment must not be attacked when flying at heights, times and on routes specifically agreed upon between all the belligerents concerned … In the absence of agreement to the contrary, flights over enemy or enemy-occupied territory are prohibited. Such aircraft must obey every order to land, but, after landing and examination, may continue their flight. 
New Zealand, Interim Law of Armed Conflict Manual, DM 112, New Zealand Defence Force, Headquarters, Directorate of Legal Services, Wellington, November 1992, § 1110(2).
According to the manual, “attacking a properly marked … medical aircraft” constitutes a war crime recognized by the customary law of armed conflict. 
New Zealand, Interim Law of Armed Conflict Manual, DM 112, New Zealand Defence Force, Headquarters, Directorate of Legal Services, Wellington, November 1992, § 1704(5).
Nicaragua
Nicaragua’s Military Manual (1996) states, with respect to international armed conflicts, that assistance to the wounded, sick and shipwrecked includes a requirement of “respect for medical aircraft assigned to the evacuation of the wounded and the sick and the transportation of medical personnel and equipment” and “respect for aircraft used to transfer civilian wounded and sick, disabled and elderly or to transport medical personnel or material”. 
Nicaragua, Manual de Comportamiento y Proceder de las Unidades Militares y de los Miembros del Ejército de Nicaragua en Tiempo de Paz, Conflictos Armados, Situaciones Irregulares o Desastres Naturales, Ejército de Nicaragua, Estado Mayor General, Asesoría Jurídica del Nicaragua, 1996, Article 14(8) and (39).
Peru
Peru’s IHL Manual (2004) states: “The following classes of enemy aircraft are exempt from attack: … medical aircraft”. 
Peru, Manual de Derecho Internacional Humanitario para las Fuerzas Armadas, Resolución Ministerial Nº 1394-2004-DE/CCFFAA/CDIH-FFAA, Lima, 1 December 2004, § 129.d.(1).(a); see also § 87.a and b.
The manual further states:
Medical aircraft are exempt from attack only if they:
(1) have been recognized as such;
(2) are acting in compliance with an agreement; parties to the conflict are encouraged to notify medical flights and conclude agreements at all times, especially in areas where control by any party to the conflict is not clearly established; when such an agreement is concluded, it shall specify the altitudes, times and routes for safe operation and should include means of identification and communication;
(3) fly in areas under the control of own or friendly forces;
(4) fly outside the area of armed conflict.
In other instances, medical aircraft operate at their own risk. 
Peru, Manual de Derecho Internacional Humanitario para las Fuerzas Armadas, Resolución Ministerial Nº 1394-2004-DE/CCFFAA/CDIH-FFAA, Lima, 1 December 2004, § 129.e.
The manual also states:
Agreements or notifications are required for medical aircraft flying over areas controlled by enemy forces or contact zones.
Medical aircraft may not be used under any circumstances to obtain military information or to search for wounded and shipwrecked persons unless a prior agreement has been made.
Medical aircraft can be inspected. They can be confiscated if the inspection discloses that the aircraft:
(1) is not a medical aircraft;
(2) is being used to gain a military advantage;
(3) has flown without or in breach of a prior agreement.
Aircraft seized in this manner become war booty. 
Peru, Manual de Derecho Internacional Humanitario para las Fuerzas Armadas, Resolución Ministerial Nº 1394-2004-DE/CCFFAA/CDIH-FFAA, Lima, 1 December 2004, § 110.c.
Peru
Peru’s IHL and Human Rights Manual (2010) states: “The following classes of enemy aircraft are exempt from attack: … medical aircraft”. 
Peru, Manual de Derecho Internacional Humanitario y Derechos Humanos para las Fuerzas Armadas, Resolución Ministerial No. 049-2010/DE/VPD, Lima, 21 May 2010, § 120(d)(1)(a), p. 311.
The manual also states:
g. Conditions for immunity [from attack] of medical aircraft
Medical aircraft are exempt from attack only if they:
(1) have been recognized as such;
(2) are acting in compliance with an agreement; parties to the conflict are encouraged to notify medical flights and conclude agreements at all times, especially in areas where control by any party to the conflict is not clearly established. When such an agreement is concluded, it shall specify the altitudes, times and routes for safe operation and should include means of identification and communication;
(3) fly in areas under the control of own or friendly forces;
(4) fly outside the area of armed conflict.
h. In other instances, medical aircraft operate at their own risk. 
Peru, Manual de Derecho Internacional Humanitario y Derechos Humanos para las Fuerzas Armadas, Resolución Ministerial No. 049-2010/DE/VPD, Lima, 21 May 2010, § 120(g)–(h), p. 312; see also § 149(d) and (f), pp. 335–336.
The manual further states:
149. Medical Aircraft
a. Medical aircraft must be protected and respected in accordance with the provisions in force.
e. Medical aircraft may not be used to commit acts harmful to the enemy. They may not carry equipment designed to obtain or transmit information. They may not be equipped with arms, with the exception of light weapons for self-defence, and they must only transport medical personnel and medical equipment. 
Peru, Manual de Derecho Internacional Humanitario y Derechos Humanos para las Fuerzas Armadas, Resolución Ministerial No. 049-2010/DE/VPD, Lima, 21 May 2010, § 149(a) and (e), pp. 335–336.
Russian Federation
The Russian Federation’s Military Manual (1990) states that “attack, bombardment or destruction of … medical aircraft displaying the distinctive emblems” is a prohibited method of warfare. 
Russian Federation, Instructions on the Application of the Rules of International Humanitarian Law by the Armed Forces of the USSR, Appendix to Order of the USSR Defence Minister No. 75, 1990, § 5(g).
Russian Federation
The Russian Federation’s Regulations on the Application of IHL (2001) states:
92. The following classes of enemy aircraft are exempt from attack:
- medical aircraft
They shall not be attacked only if:
a) for medical aircraft recognised as such:
- they are acting in compliance with an agreement between the parties to the conflict concerning medical flights. When such an agreement is concluded, it shall specify the altitudes, times and routes for safe operation and it shall include means of identification and communications;
- fly in areas under the control of own or friendly forces; or
- fly outside the area of armed conflict.
In case of doubt whether an aircraft exempt from attack is being used to make an effective contribution to military action, it shall be presumed not to be so used.
93. The aircraft falling under Paragraph 91 [sic] may be attacked by reason of a breach of a condition of exemption if:
- diversion for landing, visit and search, and possible capture, is not feasible;
- no other method is available for exercising military control;
- the circumstances of non-compliance are sufficiently grave that the aircraft has become, or may be reasonably assumed to be, a military objective;
- the collateral casualties or damage will not be disproportionate to the military advantage gained or anticipated.
Medical aircraft shall obey every summons to alight on land or water for inspection and search. Upon alighting on land or water the medical aircraft shall be inspected without delay and within the shortest possible time preventing any deterioration of condition of the wounded and sick. 
Russian Federation, Regulations on the Application of International Humanitarian Law by the Armed Forces of the Russian Federation, Ministry of Defence, Moscow, 8 August 2001, §§ 92–93.
The Regulations further states:
Medical aircraft … shall not be attacked if they:
- are innocently employed in their normal role;
- do not commit acts harmful to the enemy;
- immediately submit to identification and inspection when required;
- do not intentionally hamper the movement of combatants and obey orders to divert when required;
- do not violate a previously concluded agreement. 
Russian Federation, Regulations on the Application of International Humanitarian Law by the Armed Forces of the Russian Federation, Ministry of Defence, Moscow, 8 August 2001, § 92.
Sierra Leone
Sierra Leone’s Instructor Manual (2007) states:
Any means of transportation, whether military or civilian, permanent or temporary, assigned exclusively for the transportation of medical personnel, wounded and sick and other facilities are referred to as medical transport. These may include aircraft, vehicles, ships etc.
Before any transport for medical purpose, it must be marked with the protective emblem which is the Red Cross on a white background.
Medical transport is not to be attacked but may lose its [protected] status if, for example it carries arms or military equipment or the vehicle is used to gather intelligence about the location or deployment of the enemy.
It is a crime to attack a clearly marked medical transport or to use them for a non-medical purpose.
Medical transport, if captured, should be used to provide medical services to the wounded and sick. 
Sierra Leone, The Law of Armed Conflict. Instructor Manual for the Republic of Sierra Leone Armed Forces (RSLAF), Armed Forces Education Centre, September 2007, pp. 60–61.
South Africa
South Africa’s LOAC Manual (1996) provides: “Medical transport by air must also be respected, even in the absence of any overflying rights, after they have been recognised as medical aircraft.” 
South Africa, Presentation on the South African Approach to International Humanitarian Law, Appendix A, Chapter 4: International Humanitarian Law (The Law of Armed Conflict), National Defence Force, 1996, § 54.
South Africa
South Africa’s Revised Civic Education Manual (2004) states: “Medical transport by air must also be respected, even in the absence of any overflying rights, after they have been recognised as medical aircraft.” 
South Africa, Revised Civic Education Manual, South African National Defence Force, 2004, Chapter 4, § 69.
South Africa
South Africa’s LOAC Teaching Manual (2008) states:
Protected Medical Aircraft
- Extensive efforts to expand existing specific protection under treaty law for medical aircraft are currently underway.
- Generally, a medical aircraft (identified as such) should not be attacked unless under the circumstances at the time it represents an immediate military threat and other methods of control are not available.
- For example, this might occur when it approaches enemy territory or a combat zone without permission and disregards instructions, or initiates an attack.
- Attacks might also occur when the aircraft is not identified as a medical aircraft because of lack of agreement as to the height, time and route. 
South Africa, Advanced Law of Armed Conflict Teaching Manual, School of Military Justice, 1 April 2008, as amended to 25 October 2013, Learning Unit 4, p. 219.
Spain
Spain’s LOAC Manual (1996) restates the rules governing medical aircraft found in Articles 25–27 of the 1977 Additional Protocol I. 
Spain, Orientaciones. El Derecho de los Conflictos Armados, Publicación OR7-004, 2 Tomos, aprobado por el Estado Mayor del Ejército, Division de Operaciones, 18 March 1996, Vol. I, § 9.2.c.(3).
Spain
Spain’s LOAC Manual (2007) restates the rules governing medical aircraft found in Articles 25–27 of the 1977 Additional Protocol I. 
Spain, Orientaciones. El Derecho de los Conflictos Armados, Tomo 1, Publicación OR7–004, (Edición Segunda), Mando de Adiestramiento y Doctrina, Dirección de Doctrina, Orgánica y Materiales, 2 November 2007, § 9.2.c.(3).
The manual also states:
Before attacking medical aircraft flying over the contact zone without prior agreement or in deviation from the terms of agreements as regards flight corridors, identification, etc., the party must make “all reasonable efforts” to give the order to land and allow the aircraft time to comply with the order. 
Spain, Orientaciones. El Derecho de los Conflictos Armados, Tomo 1, Publicación OR7–004, (Edición Segunda), Mando de Adiestramiento y Doctrina, Dirección de Doctrina, Orgánica y Materiales, 2 November 2007, § 2.4.c.(7).
Sweden
Sweden’s IHL Manual (1991) states that Articles 25–27 of the 1977 Additional Protocol I on the protection of medical aircraft have the status of customary law. 
Sweden, International Humanitarian Law in Armed Conflict, with reference to the Swedish Total Defence System, Swedish Ministry of Defence, January 1991, Section 2.2.3, p. 18.
Switzerland
Switzerland’s Basic Military Manual (1987) provides:
Art. 91. Medical aircraft (airplanes, helicopters, etc.) exclusively used for the transport of the wounded and sick shall be respected and protected … The time, height and route of the flight, as well as the means of identification, must be agreed upon beforehand between the belligerents.
Art. 92. Unless there is an agreement to the contrary, flights over enemy territory are prohibited. Medical aircraft must obey each order to land. After inspection, they may continue their flight with their passengers. 
Switzerland, Lois et coutumes de la guerre (Extrait et commentaire), Règlement 51.7/II f, Armée Suisse, 1987, Articles 91–92.
Ukraine
Ukraine’s IHL Manual (2004) states: “‘Means of medical transportation’ means any transport used for medical (sanitary) transportation by land, sea or air … [M]eans of medical transportation may be escorted by guard or convoy.” 
Ukraine, Manual on the Application of IHL Rules, Ministry of Defence, 11 September 2004, § 1.2.35.
The manual further states: “Objects protected by international humanitarian law [include] means of medical transportation … Attacks against such objects shall be prohibited.” 
Ukraine, Manual on the Application of IHL Rules, Ministry of Defence, 11 September 2004, § 1.2.51.
United Kingdom of Great Britain and Northern Ireland
The UK Military Manual (1958) restates the rules on medical aircraft found in Article 36 of the 1949 Geneva Convention I and Article 22 of the 1949 Geneva Convention IV. 
United Kingdom, The Law of War on Land being Part III of the Manual of Military Law, The War Office, HMSO, 1958, §§ 34 and 358–359.
United Kingdom of Great Britain and Northern Ireland
The UK LOAC Pamphlet (1981) provides:
Helicopters are increasingly used for the evacuation of the wounded. Medical aircraft are protected in the same way as other medical transports, but, having regard to the range of anti-aircraft missiles, the problems of identification are greater. Overflight of enemy-held territory without prior agreement will mean loss of protection. Medical aircraft must obey summonses for inspection. Protocol I contains detailed new rules on medical aircraft and provides for light and radio recognition signals. 
United Kingdom, The Law of Armed Conflict, D/DAT/13/35/66, Army Code 71130 (Revised 1981), Ministry of Defence, prepared under the Direction of The Chief of the General Staff, 1981, Section 6, p. 24, § 12.
United Kingdom of Great Britain and Northern Ireland
The UK LOAC Manual (2004) states:
7.12. Medical transport means any means of transportation, whether military or civilian, permanent or temporary, assigned exclusively to the conveyance by land, water or air of the wounded, sick, shipwrecked, medical or religious personnel, medical equipment or medical supplies protected by the Geneva Conventions and Additional Protocol I and under the control of a competent authority of a party to the conflict. In Additional Protocol I, reference to “medical vehicles” expressly means “any medical transports by land”. Similarly, “medical ships and craft” means “any medical transports by water” and “medical aircraft” means “any medical transports by air”.
7.12.1. The assignment to medical purposes must be exclusive, although it may be permanent or temporary. The word “exclusive” is intended to restrict the definition of medical transport and its use so that the essential protection will not be eroded by abuses. “Permanent” means for an indeterminate period; “temporary” means limited periods but devoted exclusively to medical tasks during the whole of such periods.
Medical aircraft
7.22. Aircraft duly assigned to medical purposes, flying in combat zones are protected as soon as they are recognized as such. Medical aircraft flying over areas physically controlled by an adverse party, or over areas the control of which is not clearly established, may be ordered to land or to alight on water as appropriate to permit inspection. Medical aircraft must obey such orders. They must be given reasonable time for compliance but in default of such obedience the aircraft may be attacked. In all cases, protection for medical aircraft can be fully effective only by prior agreement between the competent military authorities of the parties to the conflict.  
United Kingdom, The Manual of the Law of Armed Conflict, Ministry of Defence, 1 July 2004, §§ 7.12–7.12.1 and 7.22.
In its chapter on air operations, the manual states:
12.28. The following classes of enemy aircraft are exempt from attack:
a. medical aircraft;
b. aircraft granted safe conduct by agreement between the parties to the conflict; and
c. civil airliners.
Conditions of exemption for medical aircraft
12.29. Medical aircraft are exempt from attack only if they:
a. have been recognized as such;
b. are acting in compliance with an agreement as specified in paragraph 12.112;
c. fly in areas under the control of own or friendly forces; or
d. fly outside the area of armed conflict.
12.29.1. In other instances, medical aircraft operate at their own risk.
Conditions of exemption for aircraft granted safe conduct
12.30. Aircraft granted safe conduct are exempt from attack only if they:
a. are innocently employed in their agreed role;
b. do not intentionally hamper the movements of combatants; and
c. comply with the details of the agreement, including availability for inspection.
Conditions of exemption for civil airliners
12.31. Civil airliners are exempt from attack only if they:
a. are innocently employed in their normal role; and
b. do not intentionally hamper the movements of combatants.
Loss of exemption
12.32. If aircraft exempt from attack breach any of the applicable conditions of their exemption as set forth in paragraphs 12.29 to12.31, they may be attacked only if:
a. diversion for landing, visit and search, and possible capture, is not feasible;
b. no other method is available for exercising military control;
c. the circumstances of non-compliance are sufficiently grave that the aircraft has become, or may be reasonably assumed to be, a military objective; and
d. the collateral casualties or damage will not be disproportionate to the military advantage gained or anticipated.
12.33. In case of doubt whether a vessel or aircraft exempt from attack is being used to make an effective contribution to military action, it shall be presumed not to be so used. 
United Kingdom, The Manual of the Law of Armed Conflict, Ministry of Defence, 1 July 2004, §§ 12.28–12.29.1 and 12.30–12.33.
The manual further states:
12.93. The following aircraft are exempt from capture:
a. medical aircraft; and
b. aircraft granted safe conduct by agreement between the parties to the conflict.
12.94. Aircraft listed in paragraph 12.93 are exempt from capture only if they:
a. are innocently employed in their normal role;
b. do not commit acts harmful to the enemy;
c. immediately submit to interception and identification when required;
d. do not intentionally hamper the movement of combatants and obey orders to divert from their track when required; and
e. are not in breach of a prior agreement. 
United Kingdom, The Manual of the Law of Armed Conflict, Ministry of Defence, 1 July 2004, §§ 12.93–12.94.
The manual defines medical aircraft as follows:
The term “medical aircraft” is defined as any means, whether service or civilian, of conveying by air the wounded, sick, shipwrecked, medical personnel, religious personnel, medical equipment or medical supplies protected by the Geneva Conventions and Additional Protocol I. Whether assigned on a permanent or temporary basis, such an aircraft must be assigned exclusively to that purpose and must be under the control of a competent authority of a party to the conflict. The term “shipwrecked” includes personnel in the sea or other waters after forced landing by or from aircraft. Helicopters used for medical purposes within the above conditions come within the definition of medical aircraft. Hovercraft do not. 
United Kingdom, The Manual of the Law of Armed Conflict, Ministry of Defence, 1 July 2004, § 12.104.
On the protection of medical aircraft, the manual states:
12.110. In and over land areas physically controlled by friendly forces, or in and over sea areas not physically controlled by an adverse party, the respect and protection of medical aircraft of a party to the conflict is not dependent on any agreement with an adverse party.
12.110.1. Where, however, proposed flight plans of medical aircraft will bring them within the range of an adverse party’s surface to air weapons systems it is only sensible for the party operating the aircraft to notify the adverse party. In any circumstances, specific agreement between the adversaries, and any other states involved, is, in practice, the most effective guarantee of the safety of medical aircraft.
Contact and similar zones
12.111. In and over those parts of the contact zone which are physically controlled by friendly forces and in and over those areas the physical control of which is not clearly established, protection for medical aircraft can only be effective in so far as this has been agreed in advance by the parties. In the absence of an agreement medical aircraft operate at their own risk but they must nevertheless be respected when recognized.
12.111.1. The “contact zone” is any area on land where the forward elements of opposing forces are in contact with each other, especially where they are exposed to direct fire from the ground.
Areas controlled by an adverse party
Prior agreement
12.112. Medical aircraft continue to be protected whilst flying over land or sea areas physically controlled by an adverse party so long as there are prior agreements to that effect. Parties to the conflict are encouraged to notify such flights and to conclude such agreements, particularly in areas where control is not clearly established. Agreements should specify the altitudes, times and routes for safe operation and should include means of identification and communications.
12.112.1. A medical aircraft which flies over an area physically controlled by an adverse party either without prior agreement or in breach of the terms of an agreement, either through navigational error or because of an emergency affecting the safety of the flight, must make every effort to identify itself and to inform the adverse party of the circumstances. As soon as a medical aircraft has been recognized by an adverse party, that party is to make all reasonable efforts to give the order to land or to alight on water for inspection, or to take other measures to safeguard its own interests. In any case, the aircraft concerned must be allowed time for compliance before it is attacked. It is likely that any such agreement would be for a specific flight or series of flights rather than a general agreement lasting for a period of time. The necessity for having an agreement and adhering rigidly to its terms cannot be over-stressed. A medical aircraft, no matter how well-marked and in how many ways it indicates its status, which enters enemy airspace without agreement or in breach of the terms of an agreement is at risk of attack even if it has been recognized as claiming medical status. Before attacking, an adverse party must make all reasonable efforts to give the order to land or alight on water for inspection. This obligation arises only where there has been navigational error or an emergency affecting the safety of the flight and the circumstances have been communicated to the adverse party.
Absence of prior agreement
12.113. Whether a belligerent orders a medical aircraft to land for inspection or takes other measures to safeguard its interests, for example, ordering a change of route, an increase in altitude or requesting more information about the nature of the medical aircraft’s difficulties, it must allow that aircraft time for compliance before attacking. The degree of deviation from an agreement or from instructions that an enemy may claim as justification for an attack might be very slight. The captain of a medical aircraft must take great care to ensure that his aircraft does not enter enemy airspace without prior agreement and that, when it does enter by agreement, that the terms of the agreement are closely adhered to. The captain of a medical aircraft who finds that his aircraft has strayed into enemy airspace must make every effort to identify his aircraft to the enemy and to indicate his submission to that adverse party’s air traffic instructions. If, owing to an emergency, it is necessary to enter enemy airspace without prior agreement or contrary to the terms of an agreement, contact should, if possible, be made with the enemy in order to obtain agreement to the proposed course of action.
Medical aircraft in neutral airspace
12.114. Belligerent medical aircraft shall not enter neutral airspace except by prior agreement. When within neutral airspace pursuant to agreement, medical aircraft shall comply with the terms of the agreement. The terms of the agreement may require the aircraft to land for inspection at a designated airport within the neutral state. Should the agreement so require, the inspection and follow-on action shall be conducted in accordance with paragraphs 12.115 to 12.116.
12.115. Should a medical aircraft, in the absence of an agreement or in deviation from the terms of an agreement, enter neutral airspace, either through navigational error or because of an emergency affecting the safety of the flight, it shall make every effort to give notice and to identify itself. Once the aircraft is recognised as a medical aircraft by the neutral state, it shall not be attacked but may be required to land for inspection. Once it has been inspected, and if it is determined in fact to be a medical aircraft, it shall be allowed to resume its flight.
12.116. If the inspection reveals that the aircraft is not a medical aircraft, it may be captured, and the occupants shall, unless agreed otherwise between the neutral State and the parties to the conflict, be detained in the neutral State where so required by the rules of international law applicable in armed conflict, in such a manner that they cannot again take part in the hostilities.
Summary of rules
12.117. The rules that must be observed by the captain of a medical aircraft in relation to overflight of the territory of an adverse party may be summarized as follows:
a. no overflying without agreement;
b. where there is an agreement, its terms must be adhered to strictly;
c. there must be no deviation from the terms of an agreement for any reason other than an emergency affecting the safety of the flight;
d. if there is accidental overflight, in the absence of an agreement, every effort must be made to contact the adverse party, to identify the aircraft, its status and the circumstances of its flight and to submit to the adverse party’s air traffic instructions;
e. if an emergency affecting the safety of a flight necessitates overflying without agreement or in breach of an agreement, every attempt must be made to inform the adverse party and to seek its agreement. If times does not permit this course of action, a medical aircraft may proceed but must identify itself and its status to the adverse party and must immediately notify the adverse party of the circumstances and proposed course of action; and
f. the adverse party’s instructions, including instructions to land, must be obeyed.
Interception of enemy medical aircraft
12.118. If there is no agreement concerning the operation of an apparent enemy medical aircraft and it fails to respond to instructions then, if it constitutes an immediate military threat and other methods of control are impracticable, it may be attacked. Similarly, an apparent medical aircraft may be attacked if it is beyond reasonable doubt that its claim to protection is unjustified or indeed if it initiates an attack.
12.118.1. Any attack on an enemy aircraft recognized as claiming medical status should be instituted only as a last resort. If a purported medical aircraft is not known to be engaged in any activity inconsistent with medical status and obeys the instructions of its interceptor, it must not be attacked even if there has been no prior agreement as to its activity. 
United Kingdom, The Manual of the Law of Armed Conflict, Ministry of Defence, 1 July 2004, §§ 12.110–12.118.1.
Regarding restrictions on the use of medical aircraft, the manual states:
12.119. Parties to an armed conflict must not use medical aircraft in an attempt to acquire a military advantage. Their presence must not be used in an attempt to render military objectives immune from attack.
12.119.1. For example, areas where medical aircraft are loaded or unloaded, including helicopter pads, should be as far away as practicable from areas of normal military operations. Medical aircraft should not be parked adjacent to buildings or other installations which themselves are not entitled to protection.
Intelligence
12.120. Medical aircraft must not be used to collect or transmit intelligence data or carry any equipment intended for such purposes. The persons and cargo that may be carried by medical aircraft are restricted to the wounded, sick, shipwrecked, medical and religious personnel and medical supplies. Personal effects and equipment intended solely to facilitate navigation, communication or identification are permissible.
12.120.1. The presence of communications and encryption equipment in an aircraft operating as a medical aircraft is not precluded. Nor is the use of such equipment wholly to facilitate navigation, identification and communication in support of the operation of medical aircraft. Neither such presence nor such use negates the protection to which the medical aircraft is entitled.
Arms
12.121. Medical aircraft must not carry any armament. However, small arms and ammunition collected from the wounded, sick and shipwrecked on board and not yet handed over to the proper service authority, together with such light individual weapons as may be necessary to enable medical personnel on the aircraft to defend themselves and the wounded, sick and shipwrecked in their charge, are permissible.
Search and rescue
12.122. Whilst flying over contact or similar zones or over areas controlled by an adverse party, medical aircraft must not, without prior agreement with the adverse party, be used to search for the wounded, sick and shipwrecked.
12.122.1. This restriction does not relate to the use of medical aircraft for such search purposes in areas controlled by friendly forces or not physically controlled by an adverse party. In these circumstances, the medical aircraft is, when recognized, entitled to protection.
12.122.2. An agreement to operate medical aircraft in a search and rescue role will be more readily achieved following a specific engagement when search and rescue is considered necessary. A speculative search and rescue operation when there are no known casualties is more likely to be construed as a reconnaissance exercise and an agreement is thus less likely to be achieved. 
United Kingdom, The Manual of the Law of Armed Conflict, Ministry of Defence, 1 July 2004, §§ 12.119–12.122.2.
[emphasis in original]
In a footnote to paragraph 12.120.1, the manual states:
On ratification of [the 1977 Additional Protocol I], the UK made the following statement: “given the practical need to make use of non-dedicated aircraft for medical evacuation purposes, the UK does not interpret this paragraph as precluding the presence on board of communications equipment and encryption materials or the use thereof solely to facilitate navigation, identification or communication in support of medical transportation”. 
United Kingdom, The Manual of the Law of Armed Conflict, Ministry of Defence, 1 July 2004, § 12.120.1, footnote 162.
Regarding the landing and inspection of medical aircraft, the manual states:
12.125. A medical aircraft flying over areas which are either physically controlled by an adverse party or over which physical control has not been clearly established may be ordered to land for inspection. Medical aircraft must obey such an order.
12.125.1. Whether a medical aircraft has landed in response to such an order or whether it has landed for other reasons, an inspection must be commenced without delay and must be conducted expeditiously. The party carrying out the inspection may not order the removal of the wounded and sick from the aircraft unless their removal is essential for the inspection. It must, in any event, ensure that the condition of the wounded and sick is not adversely affected by the inspection or the removal. Although there is no provision prohibiting the removal of crews, the medical attendants or medical supplies from the aircraft during the inspection, the inspection should be carried out as expeditiously as possible and with the minimum of inconvenience and should be carried out in a reasonable and unprovocative manner always bearing in mind the humanitarian mission of the aircraft involved.
Medical status confirmed
12.126. If the inspection discloses that an aircraft:
a. is a medical aircraft as defined in paragraph 12.104;
b. has not violated any of the restrictions set out in paragraphs 12.119–12.121 [relating to military advantage, intelligence, arms, and search and rescue]; and
c. has not flown without, or in breach of, a prior agreement where such an agreement is required …
the aircraft and those of its occupants who belong to the adverse party operating the aircraft or to a neutral state or other state which is not a party to the conflict must be allowed to continue the flight without further delay.
Medical status not confirmed
12.127. If, however, an inspection discloses that an aircraft:
a. is not a medical aircraft as defined in paragraph 12.104;
b. has violated any of the restrictions set out in paragraphs 12.119–12.121 [relating to military advantage, intelligence, arms, and search and rescue]; or
c. has flown without, or in breach of, a prior agreement where such an agreement is required …
the aircraft may be seized. A seized aircraft that has been assigned as a permanent medical aircraft may be used thereafter by the capturing power as, and only as, a medical aircraft. Each occupant of the aircraft is treated according to his status. 
United Kingdom, The Manual of the Law of Armed Conflict, Ministry of Defence, 1 July 2004, §§ 12.125–12.127.
United States of America
The US Field Manual (1956) restates Article 36 of the 1949 Geneva Convention I and adds:
It is not necessary that the aircraft should have been specially built and equipped for medical purposes. There is no objection to converting ordinary aircraft into medical aircraft or to using former medical aircraft for other purposes, provided the distinctive markings are removed. 
United States, Field Manual 27-10, The Law of Land Warfare, US Department of the Army, 18 July 1956, as modified by Change No. 1, 15 July 1976, § 237.
United States of America
The US Air Force Pamphlet (1976) states:
Generally, a medical aircraft (identified as such) should not be attacked unless under the circumstances at the time it represents an immediate military threat and other methods of control are not available. For example, this might occur when it approaches enemy territory or a combat zone without permission and disregards instructions, or initiates an attack. Attacks might also occur when the aircraft is not identified as a medical aircraft because of lack of agreement as to the height, time and route. 
United States, Air Force Pamphlet 110-31, International Law – The Conduct of Armed Conflict and Air Operations, US Department of the Air Force, 1976, § 4-2(f).
The Pamphlet further provides: “In addition to grave breaches of the Geneva Conventions of 1949, the following acts are representative of situations involving individual criminal responsibility: (1) deliberate attack on protected medical aircraft”. 
United States, Air Force Pamphlet 110-31, International Law – The Conduct of Armed Conflict and Air Operations, US Department of the Air Force, 1976, § 15-3(c)(1).
United States of America
The US Air Force Commander’s Handbook (1980) provides:
Medical aircraft, recognized as such, should not be deliberately attacked or fired on. Medical aircraft are not permitted to fly over territory controlled by the enemy, without the enemy’s prior agreement. Medical aircraft must comply with requests to land for inspection. Medical aircraft complying with such a request must be allowed to continue their flight, with all personnel on board, if inspection does not reveal that the aircraft has engaged in acts harmful to the enemy or otherwise violated the Geneva Conventions of 1949. 
United States, Air Force Pamphlet 110-34, Commander’s Handbook on the Law of Armed Conflict, Judge Advocate General, US Department of the Air Force, 25 July 1980, § 3-2(c).
United States of America
The US Naval Handbook (1995) qualifies “deliberate attack upon … medical aircraft” as a war crime. 
United States, The Commander’s Handbook on the Law of Naval Operations, NWP 1-14M/MCWP 5-2.1/COMDTPUB P5800.7, issued by the Department of the Navy, Office of the Chief of Naval Operations and Headquarters, US Marine Corps, and Department of Transportation, US Coast Guard, October 1995 (formerly NWP 9 (Rev. A)/FMFM 1-10, October 1989), § 6.2.5.
United States of America
The US Naval Handbook (2007) states that examples of war crimes that could be considered as grave breaches of the 1949 Geneva Conventions include: “Deliberate attacks upon … medical aircraft.” 
United States, The Commander’s Handbook on the Law of Naval Operations, NWP 1-14M/MCWP 5-12.1/COMDTPUB P5800.7, issued by the Department of the Navy, Office of the Chief of Naval Operations and Headquarters, US Marine Corps, and Department of Homeland Security, US Coast Guard, July 2007, § 6.2.6(7).
Yugoslavia, Socialist Federal Republic of
The Socialist Federal Republic of Yugoslavia’s Military Manual (1988) restates the rules on medical aircraft set out in Articles 25–28 of the 1977 Additional Protocol I. 
Yugoslavia, Socialist Federal Republic of, Propisi o Primeri Pravila Medjunarodnog Ratnog Prava u Oruzanim Snagama SFRJ, PrU-2, Savezni Sekretarijat za Narodnu Odbranu (Pravna Uprava), 1988, §§ 317–321.
Zimbabwe
Zimbabwe’s Code of Conduct for Combatants (1993) states: “Respect … medical aircrafts marked with Red Cross/Red Crescent/Red Crystal emblems.” 
Zimbabwe, Code of Conduct for Combatants, Joint publication of the Zimbabwe Defence Forces and the International Committee of the Red Cross Regional Delegation in Harare, 1993, p. 7.
Bangladesh
Bangladesh’s International Crimes (Tribunal) Act (1973) states that the “violation of any humanitarian rules applicable in armed conflicts laid down in the Geneva Conventions of 1949” is a crime. 
Bangladesh, International Crimes (Tribunal) Act, 1973, Section 3(2)(e).
Denmark
Denmark’s Military Criminal Code (1973), as amended in 1978, provides:
Any person who uses war instruments or procedures the application of which violates an international agreement entered into by Denmark or the general rules of international law, shall be liable to the same penalty [i.e. a fine, lenient imprisonment or up to 12 years’ imprisonment]. 
Denmark, Military Criminal Code, 1973, as amended in 1978, § 25(1).
Denmark’s Military Criminal Code (2005) provides:
Any person who deliberately uses war means [“krigsmiddel”] or procedures the application of which violates an international agreement entered into by Denmark or international customary law, shall be liable to the same penalty [i.e. imprisonment up to life imprisonment]. 
Denmark, Military Criminal Code, 2005, § 36(2).
Estonia
Under Estonia’s Penal Code (2001), “an attack against … a medical aircraft” is a war crime. 
Estonia, Penal Code, 2001, § 106.
Greece
Greece’s Military Penal Code (1995) provides for the protection of medical aircraft. 
Greece, Military Penal Code, 1995, Article 156.
Ireland
Ireland’s Geneva Conventions Act (1962), as amended in 1998, provides that any “minor breach” of the 1949 Geneva Conventions, including violations of Article 36 of the Geneva Convention I, and of the 1977 Additional Protocol I, including violations of Articles 25–27, is a punishable offence. 
Ireland, Geneva Conventions Act, 1962, as amended in 1998, Section 4(1) and (4).
Norway
Norway’s Military Penal Code (1902), as amended in 1981, provides:
Anyone who contravenes or is accessory to the contravention of provisions relating to the protection of persons or property laid down in … the Geneva Conventions of 12 August 1949 … [and in] the two additional protocols to these Conventions … is liable to imprisonment. 
Norway, Military Penal Code, 1902, as amended in 1981, § 108.
Somalia
Somalia’s Military Criminal Code (1963) states:
363. Where a commander fails to adopt measures to protect buildings, places or objects that must be respected. – 1. A penalty of military confinement for up to three years shall be imposed on a commander of attacking forces who fails to adopt the measures prescribed by law and by international agreements to ensure respect for:
(a) … medical aircraft that have been assigned to military use … where they are not at the same time being used for military purposes and have been designated by the distinctive signs specified in the international conventions, or have in some way been indicated in advance to the enemy, and are easily visible even from a great distance and at a high altitude;
375. Use of weapons against … medical … aircraft … Anyone who uses weapons against … medical aircraft assigned to military use … when, in accordance with the law and international agreements, they must be regarded as respected and protected, shall, unless the act constitutes a more serious offence, be punished by military confinement for not less than 10 years. 
Somalia, Military Criminal Code, 1963, Articles 363(1)(a) and 375.
South Africa
In 1987, in the Petane case, the Cape Provincial Division of South Africa’s Supreme Court dismissed the accused’s claim that the 1977 Additional Protocol I reflected customary international law. The Court stated:
The accused has been indicted before this Court on three counts of terrorism, that is to say, contraventions of s 54(1) of the Internal Security Act 74 of 1982. He has also been indicted on three counts of attempted murder.
The accused’s position is stated to be that this Court has no jurisdiction to try him.
… The point in its early formulation was this. By the terms of [the 1977 Additional] Protocol I to the [1949] Geneva Conventions the accused was entitled to be treated as a prisoner-of-war. A prisoner-of-war is entitled to have notice of an impending prosecution for an alleged offence given to the so-called “protecting power” appointed to watch over prisoners-of-war. Since, if such a notice were necessary, the trial could not proceed without it, Mr Donen suggested that the necessity or otherwise for giving such a notice should be determined before evidence was led. …
On 12 August 1949 there were concluded at Geneva in Switzerland four treaties known as the Geneva Conventions. …
South Africa was among the nations which concluded the treaties. … Except for the common art 3, which binds parties to observe a limited number of fundamental humanitarian principles in armed conflicts not of an international character, they apply to wars between States.
After the Second World War many conflicts arose which could not be characterised as international. It was therefore considered desirable by some States to extend and augment the provisions of the Geneva Conventions, so as to afford protection to victims of and combatants in conflicts which fell outside the ambit of these Conventions. The result of these endeavours was Protocol I and Protocol II to the Geneva Conventions, both of which came into force on 7 December 1978.
Protocol II relates to the protection of victims of non-international armed conflicts. Since the State of affairs which exists in South Africa has by Protocol I been characterised as an international armed conflict, Protocol II does not concern me at all.
The extension of the scope of art 2 of the Geneva Conventions was, at the time of its adoption, controversial. …
The article has remained controversial. More debate has raged about its field of operation than about any other articles in Protocol I. …
South Africa is one of the countries which has not acceded to Protocol I. Nevertheless, I am asked to decide, as I indicated earlier, as a preliminary point, whether Protocol I has become part of customary international law. If so, it is argued that it would have been incorporated into South African law. If it has been so incorporated it would have to be proved by one or other of the parties that the turmoil which existed at the time when the accused is alleged to have committed his offences was such that it could properly be described as an “armed conflict” conducted by “peoples” against a “ra[c]ist regime” in the exercise of their “right of self-determination”. Once all this has been shown it would have to be demonstrated to the Court that the accused conducted himself in such a manner as to become entitled to the benefits conferred by Protocol I on combatants, for example that, broadly speaking, he had, while he was launching an attack, distinguished himself from civilians and had not attacked civilian targets. …
… I am prepared to accept that where a rule of customary international law is recognised as such by international law it will be so recognised by our law.
To my way of thinking, the trouble with the first Protocol giving rise to State practice is that its terms have not been capable of being observed by all that many States. At the end of 1977 when the treaty first lay open for ratification there were few States which were involved in colonial domination or the occupation of other States and there were only two, South Africa and Israel, which were considered to fall within the third category of ra[c]ist regimes. Accordingly, the situation sought to be regulated by the first Protocol was one faced by few countries; too few countries in my view, to permit any general usage in dealing with armed conflicts of the kind envisaged by the Protocol to develop.
Mr Donen contended that the provisions of multilateral treaties can become customary international law under certain circumstances. I accept that this is so. There seems in principle to be no reason why treaty rules cannot acquire wider application than among the parties to the treaty.
Brownlie Principles of International Law 3rd ed at 13 agrees that non-parties to a treaty may by their conduct accept the provisions of a multilateral convention as representing general international law. …
I incline to the view that non-ratification of a treaty is strong evidence of non-acceptance.
It is interesting to note that the first Protocol makes extensive provision for the protection of civilians in armed conflict. …
In this sense, Protocol I may be described as an enlightened humanitarian document. If the strife in South Africa should deteriorate into an armed conflict we may all one day find it a cause for regret that the ideologically provocative tone of s 1(4) has made it impossible for the Government to accept its terms.
To my mind it can hardly be said that Protocol I has been greeted with acclaim by the States of the world. Their lack of enthusiasm must be due to the bizarre mixture of political and humanitarian objects sought to be realised by the Protocol. …
According to the International Review of the Red Cross (January/February 1987) No 256, as at December 1986, 66 States were parties to Protocol I and 60 to Protocol II, which, it will be remembered, deals with internal non-international armed conflicts. With the exception of France, which acceded only to Protocol II, not one of the world’s major powers has acceded to or ratified either of the Protocols. This position should be compared to the 165 States which are parties to the Geneva Conventions.
This approach of the world community to Protocol I is, on principle, far too half-hearted to justify an inference that its principles have been so widely accepted as to qualify them as rules of customary international law. The reasons for this are, I imagine, not far to seek. For those States which are contending with “peoples[’]” struggles for self-determination, adoption of the Protocol may prove awkward. For liberation movements who rely on strategies of urban terror for achieving their aims the terms of the Protocol, with its emphasis on the protection of civilians, may prove disastrously restrictive. I therefore do not find it altogether surprising that Mr Donen was unable to refer me to any statement in the published literature that Protocol I has attained the status o[f] customary international [law].
I have not been persuaded by the arguments which I have heard on behalf of the accused that the assessment of Professor Dugard, writing in the Annual Survey of South African Law (1983) at 66, that “it is argued with growing conviction that under contemporary international law members of SWAPO [South-West Africa People’s Organisation] and the ANC [African National Congress] are members of liberation movements entitled to prisoner-of-war status, in terms of a new customary rule spawned by the 1977 Protocols”, is correct. On what I have heard in argument I disagree with his assessment that there is growing support for the view that the Protocols reflect a new rule of customary international law. No writer has been cited who supports this proposition. Here and there someone says that it may one day come about. I am not sure that the provisions relating to the field of application of Protocol I are capable of ever becoming a rule of customary international law, but I need not decide that point today.
For the reasons which I have given I have concluded that the provisions of Protocol I have not been accepted in customary international law. They accordingly form no part of South African law.
This conclusion has made it unnecessary for me to give a decision on the question of whether rules of customary international law which conflict with the statutory or common law of this country will be enforced by its courts.
In the result, the preliminary point is dismissed. The trial must proceed. 
South Africa, Supreme Court, Petane case, Judgment, 3 November 1987, pp. 2–8.
South Africa
In 2010, in the Boeremag case, South Africa’s North Gauteng High Court stated:
In Petane, … Conradie J found that the provisions of [the 1977 Additional] Protocol I are not part of customary international law, and therefore are also not part of South African law.
Referring to the fact that in December 1986 only 66 of the 165 States party to the Geneva Conventions had ratified Protocol I, the Court [in Petane] stated:
This approach of the world community to Protocol I is, on principle, far too half-hearted to justify an inference that its principles have been so widely accepted as to qualify them as rules of customary international law. The reasons for this are, I imagine, not far to seek. For those States which are contending with “peoples[’]” struggles for self-determination, adoption of the Protocol may prove awkward. For liberation movements who rely on strategies of urban terror for achieving their aims the terms of the Protocol, with its emphasis on the protection of civilians, may prove disastrously restrictive. I therefore do not find it altogether surprising that Mr Donen was unable to refer me to any statement in the published literature that Protocol I has attained the status of customary international law.
Important changes with respect to certain aspects applicable at the time of Petane have taken place. The ANC [African National Congress] has become South Africa’s ruling party and in 1995 ratified Protocol I. The total number of States that have ratified it, is now … 162.
This last aspect forms the basis on which the First Respondent [the State] and the applicants agree that Protocol I forms part of customary international law as well as of South African law. As requested, this position is accepted for the purposes of the decision, without deciding on the matter.
Despite these changes, it remains debatable whether the provisions of Protocol I have become a part of South African law in this way.
The consensus of both parties to the conflict is required. See Petane … and Article 96 of Protocol I. …
Parliament’s failure to incorporate Protocol I into legislation in accordance with Article 231(4) of the Constitution in fact points to the contrary, and is indicative that the requirements of usus and/or opinio juris have not been met. See Petane. 
South Africa, North Gauteng High Court, Boeremag case, Judgment, 26 August 2010, pp. 21–22.
[footnotes in original omitted]
The Court also held:
If the [1977 Additional Protocol I] applies in South Africa as customary international law, the two requirements that form the basis of customary law must be met. It is arguable that the requirement of usus has been met by the vast number of States that have acceded or ratified it. By ratifying Protocol I the Republic of South Africa has indicated its intention to apply the Protocol, thereby fulfilling the requirement of opinio juris. 
South Africa, North Gauteng High Court, Boeremag case, Judgment, 26 August 2010, p. 66.
Egypt
At the CDDH, during a debate in Committee II on Article 32 of the draft Additional Protocol I (“Neutral or other States not parties to the conflict”), Egypt stated: “To attack a medical aircraft is a serious matter and it would be better to take all other possible action first.” 
Egypt, Statement at the CDDH, Official Records, Vol. XII, CDDH/II/SR. 58, 27 April 1976, p. 34, § 30.
Egypt
At the CDDH, commenting on Article 27 of the draft Additional Protocol I, Egypt stated: “For the protection of medical aircraft, prior agreement is absolutely necessary for aircraft to fly over contact or similar zones.” 
Egypt, Statement at the CDDH, Official Records, Vol. VI, CDDH/SR.39, 25 May 1977, p. 114.
France
The instructions given to the French armed forces for the conduct of Opération Mistral, simulating a military operation under the right of self-defence or a mandate of the UN Security Council, refer to Articles 25 and 27 of the 1977 Additional Protocol I. 
France, Etat-major de la Force d’Action Rapide, Ordres pour l’Opération Mistral, 1995, Section 6, § 62.
France
Upon ratification of the 1977 Additional Protocol I, France stated:
Given the practical need to use non-dedicated aircraft for medical evacuation missions, the Government of the Republic of France does not interpret paragraph 2 of Article 28 as precluding the presence on board of communication equipment and encryption material or the use thereof solely to facilitate navigation, identification or communication in support of a medical transportation mission as defined in Article 8. 
France, Reservations and declarations made upon ratification of the 1977 Additional Protocol I, 11 April 2001, § 5.
Japan
At the CDDH, Japan stated: “Flying over enemy occupied areas was still prohibited … if [it] occurred by force of urgent necessity, in the absence of an agreement, that constituted a violation of the Protocol.” 
Japan, Statement at the CDDH, Official Records, Vol. XI, CDDH/II/SR.47, 5 April 1975, pp. 528–529, § 22.
United Kingdom of Great Britain and Northern Ireland
Upon ratification of the 1977 Additional Protocol I, the United Kingdom declared with respect to Article 28(2):
Given the practical need to make use of non-dedicated aircraft for medical evacuation purposes, the United Kingdom does not interpret this paragraph as precluding the presence on board of communication equipment and encryption materials or the use thereof solely to facilitate navigation, identification or communication in support of medical transportation as defined in Article 8 (f). 
United Kingdom, Reservations and declarations made upon ratification of the 1977 Additional Protocol I, 28 January 1998, § (e).
United States of America
It is reported that in the Vietnam War, US army medical evacuation helicopters marked with the red cross emblem suffered a high loss rate from enemy fire, with the result that some medical evacuation units armed their helicopters with machine guns. 
Peter Dorland and James Nanney, Dust Off: Army Aeromedical Evacuation in Vietnam, Center of Military History, United States Army, Washington D.C., 1982, p. 85.
United States of America
In 1987, the Deputy Legal Adviser of the US Department of State affirmed: “We support the principle that known medical aircraft be respected and protected when performing their humanitarian functions.” He added: “That is a rather general statement of what is reflected in many, but not all, aspects of the detailed rules in Articles 24 through 31, which include some of the more useful innovations in the Protocol.” 
United States, Remarks of Michael J. Matheson, Deputy Legal Adviser, US Department of State, The Sixth Annual American Red Cross-Washington College of Law Conference on International Humanitarian Law: A Workshop on Customary International Law and the 1977 Protocols Additional to the 1949 Geneva Conventions, American University Journal of International Law and Policy, Vol. 2, 1987, p. 423–424.
United States of America
The Report on US Practice notes that US practice suggests that if enemy forces do not respect the protected status of medical units, the right of self-defence may justify the use of force. 
Report on US Practice, 1997, Chapter 2.7.
Yugoslavia, Socialist Federal Republic of
In 1991, in a document entitled “Examples of violations of the rules of international law committed by the so-called armed forces of Slovenia”, the Ministry of Defence of the Socialist Federal Republic of Yugoslavia included the following example: “Fire has been opened on medical helicopters and planes in spite of their Red Cross signs.” 
Yugoslavia, Socialist Federal Republic of, Minister of Defence, Examples of violations of the rules of international law committed by the so-called Armed Forces of Slovenia, 10 July 1991, § 1(iii).
UN Commission on Human Rights (Special Rapporteur)
In 1996, in a report on the situation of human rights in the Sudan, in a section entitled “Human rights violations – Abuses by parties to the conflict other than the Government of Sudan”, the Special Rapporteur of the UN Commission on Human Rights reported that an ICRC plane was shot at and hit when preparing for landing. Following the incident, the ICRC delegation was advised by its headquarters not to fly to certain areas. 
UN Commission on Human Rights, Special Rapporteur on the Situation of Human Rights in the Sudan, Report, UN Doc. E/CN.4/1996/62, 20 February 1996, § 78.
No data.
No data.
No data.
ICRC
To fulfil its task of disseminating IHL, the ICRC has delegates around the world teaching armed and security forces the rules set out in Articles 25–28 of the 1977 Additional Protocol I. 
Frédéric de Mulinen, Handbook on the Law of War for Armed Forces, ICRC, Geneva, 1987, §§ 628–632.
ICRC
In a press release issued in 1993 in the context of the conflict in Angola, the ICRC denounced the destruction of one of its planes at Uige airport while waiting to evacuate 21 foreigners held by the União Nacional para Independência Total de Angola (UNITA). It called on the parties to comply with IHL and regarded the attack as a serious breach of the principles of IHL concerning respect for the red cross emblem. 
ICRC, Press Release No. 1737, Angola: Solemn ICRC Appeal, 10 February 1993.
No data.
Geneva Convention I
Article 35 of the 1949 Geneva Convention I provides:
Transports of wounded and sick or of medical equipment shall be respected and protected in the same way as mobile medical units.
Should such transports or vehicles fall into the hands of the adverse Party, they shall be subject to the laws of war, on condition that the Party to the conflict who captures them shall in all cases ensure the care of the wounded and sick they contain.
The civilian personnel and all means of transport obtained by requisition shall be subject to the general rules of international law. 
Convention (I) for the Amelioration of the Condition of the Wounded and Sick in Armed Forces in the Field, Geneva, 12 August 1949, Article 35.
Article 20 of the Convention provides:
Hospital ships entitled to the protection of the Geneva Convention for the Amelioration of the Condition of Wounded, Sick and Shipwrecked Members of Armed Forces at Sea of August 12, 1949, shall not be attacked from the land. 
Convention (I) for the Amelioration of the Condition of the Wounded and Sick in Armed Forces in the Field, Geneva, 12 August 1949, Article 20.
Geneva Convention II
Article 22 of the 1949 Geneva Convention II provides:
Military hospital ships, that is to say, ships built or equipped by the Powers specially and solely with a view to assisting the wounded, sick and shipwrecked, to treating them and to transporting them, may in no circumstances be attacked or captured, but shall at all times be respected and protected, on condition that their names and descriptions have been notified to the Parties to the conflict ten days before those ships are employed.
The characteristics which must appear in the notification shall include registered gross tonnage, the length from stem to stern and the number of masts and funnels. 
Convention (II) for the Amelioration of the Condition of the Wounded, Sick and Shipwrecked Members of Armed Forces at Sea, Geneva, 12 August 1949, Article 22.
Article 24 of the Convention provides:
Hospital ships utilized by National Red Cross Societies, by officially recognized relief societies or by private persons shall have the same protection as military hospital ships and shall be exempt from capture, if the Party to the conflict on which they depend has given them an official commission and in so far as the provisions of Article 22 concerning notification have been complied with.
These ships must be provided with certificates from the responsible authorities, stating that the vessels have been under their control while fitting out and on departure. 
Convention (II) for the Amelioration of the Condition of the Wounded, Sick and Shipwrecked Members of Armed Forces at Sea, Geneva, 12 August 1949, Article 24.
Article 25 of the Convention provides:
Hospital ships utilized by National Red Cross Societies, officially recognized relief societies, or private persons of neutral countries shall have the same protection as military hospital ships and shall be exempt from capture, on condition that they have placed themselves under the control of one of the Parties to the conflict, with the previous consent of their own governments and with the authorization of the Party to the conflict concerned, in so far as the provisions of Article 22 concerning notification have been complied with. 
Convention (II) for the Amelioration of the Condition of the Wounded, Sick and Shipwrecked Members of Armed Forces at Sea, Geneva, 12 August 1949, Article 25.
Article 26 of the Convention provides:
The protection mentioned in Articles 22, 24 and 25 shall apply to hospital ships of any tonnage and to their lifeboats, wherever they are operating. Nevertheless, to ensure the maximum comfort and security, the Parties to the conflict shall endeavour to utilize, for the transport of wounded, sick and shipwrecked over long distances and on the high seas, only hospital ships of over 2,000 tons gross. 
Convention (II) for the Amelioration of the Condition of the Wounded, Sick and Shipwrecked Members of Armed Forces at Sea, Geneva, 12 August 1949, Article 26.
Article 27 of the Convention provides:
Under the same conditions as those provided for in Articles 22 and 24, small craft employed by the State or by the officially recognized lifeboat institutions for coastal rescue operations, shall also be respected and protected, so far as operational requirements permit.
The same shall apply so far as possible to fixed coastal installations used exclusively by these craft for their humanitarian missions. 
Convention (II) for the Amelioration of the Condition of the Wounded, Sick and Shipwrecked Members of Armed Forces at Sea, Geneva, 12 August 1949, Article 27.
Article 28 of the Convention provides:
Should fighting occur on board a warship, the sick-bays shall be respected and spared as far as possible. Sick-bays and their equipment shall remain subject to the laws of warfare, but may not be diverted from their purpose so long as they are required for the wounded and sick. Nevertheless, the commander into whose power they have fallen may, after ensuring the proper care of the wounded and sick who are accommodated therein, apply them to other purposes in case of urgent military necessity. 
Convention (II) for the Amelioration of the Condition of the Wounded, Sick and Shipwrecked Members of Armed Forces at Sea, Geneva, 12 August 1949, Article 28.
Article 29 of the Convention provides: “Any hospital ship in a port which falls into the hands of the enemy shall be authorized to leave the said port.” 
Convention (II) for the Amelioration of the Condition of the Wounded, Sick and Shipwrecked Members of Armed Forces at Sea, Geneva, 12 August 1949, Article 29.
Article 30 of the Convention provides:
The vessels described in Articles 22, 24, 25and 27 shall afford relief and assistance to the wounded, sick and shipwrecked without distinction of nationality.
The High Contracting Parties undertake not to use these vessels for any military purpose.
Such vessels shall in no wise hamper the movements of the combatants.
During and after an engagement, they will act at their own risk. 
Convention (II) for the Amelioration of the Condition of the Wounded, Sick and Shipwrecked Members of Armed Forces at Sea, Geneva, 12 August 1949, Article 30.
Article 31 of the Convention provides:
The Parties to the conflict shall have the right to control and search the vessels mentioned in Articles 22, 24, 25 and 27. They can refuse assistance from these vessels, order them off, make them take a certain course, control the use of their wireless and other means of communication, and even detain them for a period not exceeding seven days from the time of interception, if the gravity of the circumstances so requires.
They may put a commissioner temporarily on board whose sole task shall be to see that orders given in virtue of the provisions of the preceding paragraph are carried out.
As far as possible, the Parties to the conflict shall enter in the log of the hospital ship, in a language he can understand, the orders they have given the captain of the vessel.
Parties to the conflict may, either unilaterally or by particular agreements, put on board their ships neutral observers who shall verify the strict observation of the provisions contained in the present Convention. 
Convention (II) for the Amelioration of the Condition of the Wounded, Sick and Shipwrecked Members of Armed Forces at Sea, Geneva, 12 August 1949, Article 31.
Article 32 of the Convention provides: “Vessels described in Articles 22, 24, 25 and 27 are not classed as warships as regards their stay in a neutral port.” 
Convention (II) for the Amelioration of the Condition of the Wounded, Sick and Shipwrecked Members of Armed Forces at Sea, Geneva, 12 August 1949, Article 32.
Article 33 of the Convention provides: “Merchant vessels which have been transformed into hospital ships cannot be put to any other use throughout the duration of hostilities.” 
Convention (II) for the Amelioration of the Condition of the Wounded, Sick and Shipwrecked Members of Armed Forces at Sea, Geneva, 12 August 1949, Article 33.
Article 34 of the Convention provides:
The protection to which hospital ships and sick-bays are entitled shall not cease unless they are used to commit, outside their humanitarian duties, acts harmful to the enemy. Protection may, however, cease only after due warning has been given, naming in all appropriate cases a reasonable time limit, and after such warning has remained unheeded.
In particular, hospital ships may not possess or use a secret code for their wireless or other means of communication. 
Convention (II) for the Amelioration of the Condition of the Wounded, Sick and Shipwrecked Members of Armed Forces at Sea, Geneva, 12 August 1949, Article 34.
Article 35 of the Convention provides:
The following conditions shall not be considered as depriving hospital ships or sick-bays of vessels of the protection due to them:
(1) The fact that the crews of ships or sick-bays are armed for the maintenance of order, for their own defence or that of the sick and wounded.
(2) The presence on board of apparatus exclusively intended to facilitate navigation or communication.
(3) The discovery on board hospital ships or in sick-bays of portable arms and ammunition taken from the wounded, sick and shipwrecked and not yet handed to the proper service.
(4) The fact that the humanitarian activities of hospital ships and sick-bays of vessels or of the crews extend to the care of wounded, sick or shipwrecked civilians.
(5) The transport of equipment and of personnel intended exclusively for medical duties, over and above the normal requirements. 
Convention (II) for the Amelioration of the Condition of the Wounded, Sick and Shipwrecked Members of Armed Forces at Sea, Geneva, 12 August 1949, Article 35.
Article 38 of the Convention provides:
Ships chartered for that purpose shall be authorized to transport equipment exclusively intended for the treatment of wounded and sick members of armed forces or for the prevention of disease, provided that the particulars regarding their voyage have been notified to the adverse Power and approved by the latter. The adverse Power shall preserve the right to board the carrier ships, but not to capture them or seize the equipment carried.
By agreement amongst the Parties to the conflict, neutral observers may be placed on board such ships to verify the equipment carried. For this purpose, free access to the equipment shall be given. 
Convention (II) for the Amelioration of the Condition of the Wounded, Sick and Shipwrecked Members of Armed Forces at Sea, Geneva, 12 August 1949, Article 38.
Geneva Convention IV
Article 21 of the 1949 Geneva Convention IV provides:
Convoys of vehicles or hospital trains on land or specially provided vessels on sea, conveying wounded and sick civilians, the infirm and maternity cases, shall be respected and protected in the same manner as the hospitals provided for in Article 18, and shall be marked, with the consent of the State, by the display of the distinctive emblem provided for in Article 38 of the Geneva Convention for the Amelioration of the Condition of the Wounded and Sick in Armed Forces in the Field of August 12, 1949. 
Convention (IV) relative to the Protection of Civilian Persons in Time of War, Geneva, 12 August 1949, Article 21.
Additional Protocol I
Article 8 of Additional Protocol I provides: “For the purposes of this Protocol: … i) ‘medical ships and craft’ means any medical transports by water.” 
Protocol Additional to the Geneva Conventions of 12 August 1949, and relating to the Protection of Victims of International Armed Conflicts (Protocol I), Geneva, 8 June 1977, Article 8(i).
Article 22 of the Protocol provides:
1. The provisions of the Conventions relating to:
a) vessels described in Articles 22, 24, 25 and 27 of the [1949 Geneva Convention II],
b) their lifeboats and small craft,
c) their personnel and crews, and
d) the wounded, sick and shipwrecked on board,
shall also apply where these vessels carry civilian wounded, sick and shipwrecked who do not belong to any of the categories mentioned in Article 13 of the [1949 Geneva Convention II]. Such civilians shall not, however, be subject to surrender to any Party which is not their own, or to capture at sea. If they find themselves in the power of a Party to the conflict other than their own, they shall be covered by the Fourth Convention [1949 Geneva Convention IV] and by this Protocol.
2. The protection provided by the Conventions to vessels described in Article 25 of the [1949 Geneva Convention II] shall extend to hospital ships made available for humanitarian purposes to a Party to the conflict:
a) by a neutral or other State which is not a Party to that conflict; or
b) by an impartial international humanitarian organization,
provided that, in either case, the requirements set out in that Article are complied with. 
Protocol Additional to the Geneva Conventions of 12 August 1949, and relating to the Protection of Victims of International Armed Conflicts (Protocol I), Geneva, 8 June 1977, Article 22.
Article 23 of the Protocol provides:
1. Medical ships and craft other than those referred to in Article 22 of this Protocol and Article 38 of the [1949 Geneva Convention II] shall, whether at sea or in other waters, be respected and protected in the same way as mobile medical units under the [1949 Geneva] Conventions and this Protocol. Since this protection can only be effective if they can be identified and recognized as medical ships or craft, such vessels should be marked with the distinctive emblem and as far as possible comply with the second paragraph of Article 43 of the [1949 Geneva Convention II].
2. The ships and craft referred to in paragraph 1 shall remain subject to the laws of war. Any warship on the surface able immediately to enforce its command may order them to stop, order them off, or make them take a certain course, and they shall obey every such command. Such ships and craft may not in any other way be diverted from their medical mission so long as they are needed for the wounded, sick and shipwrecked on board.
3. The protection provided in paragraph 1 shall cease only under the conditions set out in Articles 34 and 35 of the [1949 Geneva Convention II]. A clear refusal to obey a command given in accordance with paragraph 2 shall be an act harmful to the enemy under Article 34 of the [1949 Geneva Convention II].
4. A Party to the conflict may notify any adverse Party as far in advance of sailing as possible of the name, description, expected time of sailing, course and estimated speed of the medical ship or craft, particularly in the case of ships of over 2,000 gross tons, and may provide any other information which would facilitate identification and recognition. The adverse Party shall acknowledge receipt of such information. 
Protocol Additional to the Geneva Conventions of 12 August 1949, and relating to the Protection of Victims of International Armed Conflicts (Protocol I), Geneva, 8 June 1977, Article 23.
Report of the Commission on Responsibility
Based on several documents supplying evidence of outrages committed during the First World War, the 1919 Report of the Commission on Responsibility lists violations of the laws and customs of war which should be subject to criminal prosecution, including “attack on and destruction of hospital ships”.  
Report submitted to the Preliminary Conference of Versailles by the Commission on Responsibility of the Authors of the War and on Enforcement of Penalties, Versailles, 29 March 1919.
Hague Rules of Air Warfare
Article 25 of the 1923 Hague Rules of Air Warfare provides: “In bombardment by aircraft, all necessary steps must be taken by the commander to spare as far as possible … hospital ships … provided [they] are not at the time used for military purposes.” 
Rules concerning the Control of Wireless Telegraphy in Time of War and Air Warfare, Part II, drafted by a Commission of Jurists, The Hague, December 1922–February 1923, Article 25.
San Remo Manual
Paragraph 47(a), (b) and (c)(ii) of the 1994 San Remo Manual includes hospital ships, small craft used for coastal rescue operations and other medical transports, as well as vessels engaged in humanitarian missions, among the classes of enemy vessels exempt from attack. Paragraph 48 of the manual lists the conditions of exemption as follows: such vessels must be “innocently employed in their normal role”; they must “submit to identification and inspection when required”; and they must not “intentionally hamper the movement of combatants and obey orders to stop or move out of the way when required”. 
Louise Doswald-Beck (ed.), San Remo Manual on International Law Applicable to Armed Conflicts at Sea, 12 June 1994, Prepared by international lawyers and naval experts convened by the International Institute of Humanitarian Law, Cambridge University Press, Cambridge, 1995, §§ 47(a), (b) and (c)(ii) and 48.
Australia
Australia’s LOAC Manual (2006) states:
6.44 Classes of vessels exempt from attack. The following classes of enemy vessels are exempt from attack:
• hospital ships;
• small craft used for coastal rescue operations and other medical transports;
6.45 [Such] vessels are exempt from attack only if they:
• are innocently employed in their normal role,
• submit to identification and inspection when required, and
• do not intentionally hamper the movement of combatants and obey orders to stop or move out of the way when required.
9.78 … [H]ospital ships … must be respected and protected at all times and must not be attacked. …
13.30 Among other war crimes generally recognised as forming part of the customary LOAC are:
• attacking a properly marked hospital ship. 
Australia, The Manual of the Law of Armed Conflict, Australian Defence Doctrine Publication 06.4, Australian Defence Headquarters, 11 May 2006, §§ 6.44–6.45, 9.78 and 13.30; see also § 5.41.
The LOAC Manual (2006) replaces both the Defence Force Manual (1994) and the Commanders’ Guide (1994).
Cameroon
Cameroon’s Instructor’s Manual (2006) states:
352.2 – Special protection: (persons and objects specially protected.)
Certain categories of persons and objects benefit from special protection under the law of armed conflict and international humanitarian law both in the civilian domain and in the military domain.
352.20 Military medical services
Hospital ships (measuring more than 2000 gross tonnes) are charged with providing assistance to the victims of war [and are specially protected]. 
Cameroon, Droit des conflits armés et droit international humanitaire, Manuel de l’instructeur en vigueur dans les forces de défense, Ministère de la Défense, Présidence de la République, Etat-major des Armées, 2006, p. 92, § 352.2 and p. 93, § 352.20; see also p. 135, § 412.20.
The manual also states: “The medical personnel on hospital ships (as well as their equipment) must not be captured during the entire time that they are in service on these ships.” 
Cameroon, Droit des conflits armés et droit international humanitaire, Manuel de l’instructeur en vigueur dans les forces de défense, Ministère de la Défense, Présidence de la République, Etat-major des Armées, 2006, p. 122, § 403; see also p. 123, § 403 and p. 165, § 463.
Canada
Canada’s LOAC Manual (1999) states: “Medical transports of all types (land, sea, air) are protected and must not be attacked.”. 
Canada, The Law of Armed Conflict at the Operational and Tactical Level, Office of the Judge Advocate General, 1999, p. 4-9, §§ 92; see also p. 9-4, §§ 35–36.
The manual qualifies “attacking a properly marked hospital ship” as a war crime. 
Canada, The Law of Armed Conflict at the Operational and Tactical Level, Office of the Judge Advocate General, 1999, p. 16-4, § 21(e).
Canada
Canada’s LOAC Manual (2001) states in its chapter on targeting:
1. Medical transports of all types (land, sea and air) are protected and must not be attacked.
2. Medical transports should not be armed (i.e., crew-served weapons) because of the danger that they may be mistaken as fighting vehicles. Medical personnel in the medical transports can, however, retain their personal weapons. 
Canada, The Law of Armed Conflict at the Operational and Tactical Levels, Office of the Judge Advocate General, 13 August 2001, § 448.1–2.
In its chapter on the treatment of the wounded, sick and shipwrecked, the manual states:
918. Protection of medical establishments, transport, aircraft and hospital ships
1. Medical establishments on land, hospital ships, medical aircraft, and medical transports must be respected and protected at all times and must not be attacked. If they are used for purposes hostile to the adverse party and outside their humanitarian purpose, protection may cease. Protection will only cease, however, following a clear warning which has remained unheeded.
920. Sick bays and hospital ships
1. The sick bay on a warship must, in case of combat on board, be respected and protected as far as this is possible. A captor may, however, use the sick bay for other purposes if this is militarily necessary, provided proper care is taken of the wounded and sick.
2. Hospital ships and other craft employed on medical duties are subject to control and search. They may be required to follow a particular course and their radios and other means of communication may be controlled. The medical services may be controlled or even rejected. Depending on the circumstances, they may be detained for up to seven days. Neutral observers may also be put on board to ensure that the provisions of the Convention are strictly obeyed.
3. Hospital ships found in a port at the time of its occupation by an adverse party must be allowed to leave. Hospital ships do not rank as warships with regard to their stay in neutral ports. 
Canada, The Law of Armed Conflict at the Operational and Tactical Levels, Office of the Judge Advocate General, 13 August 2001, §§ 918 and 920.
In its chapter entitled “Treatment of civilians in the hands of a party to the conflict or an occupying power”, the manual provides:
Convoys of vehicles or hospital trains on land, and specially provided vessels at sea, conveying wounded and sick civilians, must be protected and respected in the same way as civilian hospitals. Subject to the consent of the State they must bear the distinctive Red Cross or Red Crescent emblem provided for hospitals. 
Canada, The Law of Armed Conflict at the Operational and Tactical Levels, Office of the Judge Advocate General, 13 August 2001, § 1112.1.
In its chapter on “War crimes, individual criminal liability and command responsibility”, the manual qualifies “attacking a properly marked hospital ship or medical aircraft” as a war crime. 
Canada, The Law of Armed Conflict at the Operational and Tactical Levels, Office of the Judge Advocate General, 13 August 2001, § 1609.3.e.
In its chapter on non-international armed conflicts, the manual states:
Medical units and transports are to be respected at all times and not be made the object of attack. This protection shall only cease if they commit hostile acts outside their humanitarian function. In such circumstances, a warning must be given, and protection only ceases if such warning remains unheeded. 
Canada, The Law of Armed Conflict at the Operational and Tactical Levels, Office of the Judge Advocate General, 13 August 2001, § 1719.2.
In its glossary, the manual defines hospital ships as:
a. vessels built or equipped by a party to the conflict specially and solely with a view to assisting either military and/or civilian wounded, sick or shipwrecked;
b. vessels of the same nature used by national Red Cross or Red Crescent societies, officially recognized relief societies or by private persons, provided that the party to the conflict on which they depend has given them an official commission; and
c. vessels of the same nature used by neutral states, their national Red Cross or Red Crescent societies, officially recognized relief societies, private persons of neutral states or impartial international humanitarian organizations, provided that they have placed themselves under the control of one of the parties to the conflict with the authorization of that party and with the previous consent of their own government. 
Canada, The Law of Armed Conflict at the Operational and Tactical Levels, Office of the Judge Advocate General, 13 August 2001, Glossary, p. GL-7.
Central African Republic
The Central African Republic’s Instructor’s Manual (1999) states in Volume 2 (Instruction for group and patrol leaders): “Hospital ships … may not be captured or attacked. They must never hamper the movement of combatants. During an engagement they act at their own risk.” 
Central African Republic, Le Droit de la Guerre, Fascicule No. 2: Formation pour l’obtention du certificat technique No. 2 (Chef de Groupe), du certificat Inter-Armé (CIA), du certificat d’aptitude de Chef de Patrouille (CACP), Ministère de la Défense, Forces Armées Centrafricaines, 1999, Chapter II, Section II, § 2.1.
Also in Volume 2, the manual states that “in case of doubt a ship can reasonably be stopped and searched to ascertain its status. If it refuses to stop or resists being visited and searched it may be destroyed after a warning to this effect has been given.” 
Central African Republic, Le Droit de la Guerre, Fascicule No. 2: Formation pour l’obtention du certificat technique No. 2 (Chef de Groupe), du certificat Inter-Armé (CIA), du certificat d’aptitude de Chef de Patrouille (CACP), Ministère de la Défense, Forces Armées Centrafricaines, 1999, Chapter II, Section I, § 1.2.
In Volume 3 (Instruction for non-commissioned officers studying for the level 1 and 2 certificates and for future officers of the criminal police), the manual states: “Hospital ships (including their rescue boats and small craft) … may not be captured or attacked.” 
Central African Republic, Le Droit de la Guerre, Fascicule No. 3: Formation pour l’obtention du Brevet d’Armes No. 1, du Brevet d’Armes No. 2 et le stage d’Officier de Police Judiciaire (OPJ), Ministère de la Défense, Forces Armées Centrafricaines, 1999, Chapter III, Section 4.
Chad
Chad’s Instructor’s Manual (2006) states that “a hospital ship may not be attacked or captured”. 
Chad, Droit international humanitaire, Manuel de l’instructeur en vigueur dans les forces armées et de sécurité, Ministère de la Défense, Présidence de la République, Etat-major des Armées, 2006, p. 65.
Côte d’Ivoire
Côte d’Ivoire’s Teaching Manual (2007) provides in Book III, Volume 2 (Instruction of second-year trainee officers):
II.2.1. Protection of hospitals and material used by medical personnel
Hospitals must not be attacked and medical personnel must be spared. As long as they have to fulfil their special task, they must not be used for a different purpose. This equally applies to medical transports.
Medical transport means any means of transportation assigned exclusively to the conveyance by land, water or air of the wounded, sick, shipwrecked, medical and religious personnel or medical material.
A hospital ship means a ship built or equipped specially and exclusively with a view to assisting the wounded, sick and shipwrecked, to caring for them and to transporting them. 
Côte d’Ivoire, Droit de la guerre, Manuel d’instruction, Livre III, Tome 2: Instruction de l’élève officier d’active de 2ème année, Manuel de l’instructeur, Ministère de la Défense, Forces Armées Nationales, November 2007, pp. 29–30.
In Book IV (Instruction of heads of division and company commanders), the Teaching Manual provides:
II.2.6. Means of medical transportation
Means of medical transportation of all kinds (land, sea and air) are protected and must not be made the object of attack. …
Medical transportation should not be armed (i.e. by collective weapons) because of the risk that they are considered as combat vehicles. The medical personnel of medical transportations can, however, keep their individual weapons. …
II.2.7. Ships
The following ships of an adverse Party must not be attacked:
- hospital ships;
- boats used for coastal rescue operations or medical transport operations. 
Côte d’Ivoire, Droit de la guerre, Manuel d’instruction, Livre IV: Instruction du chef de section et du commandant de compagnie, Manuel de l’élève, Ministère de la Défense, Forces Armées Nationales, November 2007, p. 39.
Croatia
Croatia’s Soldiers’ Manual (1992) instructs soldiers to respect hospital ships displaying the distinctive emblem. 
Croatia, Rules of Conduct for Soldiers, Republic of Croatia, Ministry of Defence, 1992, pp. 2 and 3.
Ecuador
Ecuador’s Naval Manual (1989) qualifies “deliberate attack upon hospitals ships … [and] medical vehicles” as a war crime. 
Ecuador, Aspectos Importantes del Derecho Internacional Marítimo que Deben Tener Presente los Comandantes de los Buques, Academia de Guerra Naval, 1989, § 6.2.5.
France
France’s LOAC Manual (2001) provides:
Convention II adopted in Geneva on 12 August 1949 protects hospital ships against armed attacks and capture. Considered as a hospital ship is a ship built or equipped specially and solely with a view to assisting the wounded. It must be the object of special marking, i.e. be painted white and covered with a red cross, so that its identification is possible. A hospital ship must not be equipped with weapons: it can, however, possess portable arms for self-defence. Ships chartered by a party to the conflict for the transport of medical equipment and lifeboats benefit from the same protections.
Furthermore, the warships of parties to a conflict can carry out support missions in the health domain; these ships are not considered as hospital ships. 
France, Manuel de droit des conflits armés, Ministère de la Défense, Direction des Affaires Juridiques, Sous-Direction du droit international humanitaire et du droit européen, Bureau du droit des conflits armés, 2001, p. 57.
Greece
The Hellenic Navy’s International Law Manual (1995) provides:
The need to protect non-combatants during naval warfare, as in any other kind of warfare, is indispensable. This is why art. 22 of the Ist Add. Protocol to the Geneva Conventions extend the protection afforded by the provisions of the IInd Geneva Convention to hospital vessels and lifeboats of any type, their personnel and generally to all non-combatants who are wounded, sick or shipwrecked even when they are aboard any kind of vessel. As a consequence, these persons should not be captured by the enemy and in cases where they are found in enemy hands, there is an obligation to be assisted and protected, according to the relevant conventional provisions. 
Greece, International Law Manual, Hellenic Navy General Staff, Directorate A2, Division IV, 1995, Chapter 7, Part I, § 5.
Guinea
Guinea’s Soldier’s Manual (2010), under the heading “Distinctive signs”, displays an image of a ship with a red cross on a white ground and states: “Let these … ships … move around and do not enter them.” 
Guinea, Soldier’s Manual, Ministry of National Defence, 2010, p. 14.
Hungary
Hungary’s Military Manual (1992) instructs soldiers to respect and protect medical transports, whether by land, sea or air. 
Hungary, A Hadijog, Jegyzet a Katonai, Föiskolák Hallgatói Részére, Magyar Honvédség Szolnoki Repülötiszti Föiskola, 1992, p. 19.
Mexico
Mexico’s Army and Air Force Manual (2009), in a section on the 1949 Geneva Convention II, states:
121. Military hospital ships may not be attacked or captured under any circumstances and must be respected and protected at all times, provided that their names and descriptions have been notified to the parties to the conflict ten days before they are employed.
122. Hospital ships utilized by National Red Cross Societies, by officially recognized relief societies or by private persons are entitled to the same protection as military hospital ships.
123. Establishments ashore entitled to the protection of the Geneva Convention for the Amelioration of the Condition of the Wounded and Sick in Armed Forces in the Field must be protected from bombardment or attack from the sea.
128. Ships chartered to transport medical equipment and materials are authorized to transport supplies intended exclusively for the treatment of wounded and sick members of armed forces or for the prevention of disease. The adverse power reserves the right to board such ships, but not to capture them or seize the supplies that they are carrying. 
Mexico, Manual de Derecho Internacional Humanitario para el Ejército y la Fuerza Área Mexicanos, Ministry of National Defence, June 2009, §§ 121–123 and 128.
Netherlands
The Military Manual (1993) of the Netherlands states: “Medical transport and medical means of transportation (vehicles, ships and aircraft) must be respected and protected.” 
Netherlands, Toepassing Humanitair Oorlogsrecht, Voorschift No. 27-412/1, Koninklijke Landmacht, Ministerie van Defensie, 1993, p. VI-6.
The manual repeats this rule with respect to non-international armed conflicts. 
Netherlands, Toepassing Humanitair Oorlogsrecht, Voorschift No. 27-412/1, Koninklijke Landmacht, Ministerie van Defensie, 1993, p. XI-6.
Netherlands
The Military Handbook (1995) of the Netherlands provides: “Medical transports may not be attacked … Medical transports, whether on water, on land or in the air, must also be respected. Such transport may not, however, be used as normal military transport.” 
Netherlands, Handboek Militair, Ministerie van Defensie, 1995, pp. 7-40 and 7-41.
New Zealand
New Zealand’s Military Manual (1992) states:
Hospital ships … must be respected and protected at all times and must not be attacked …
Convoys of vehicles or hospital trains on land, and specially provided vessels at sea, conveying wounded and sick civilians, the infirm, and maternity cases must be protected and respected in the same way as civilian hospitals. 
New Zealand, Interim Law of Armed Conflict Manual, DM 112, New Zealand Defence Force, Headquarters, Directorate of Legal Services, Wellington, November 1992, §§ 1007(1) and (2) and 1110(1).
The manual further states that “attacking a properly marked hospital ship” constitutes a war crime recognized by the customary law of armed conflict. 
New Zealand, Interim Law of Armed Conflict Manual, DM 112, New Zealand Defence Force, Headquarters, Directorate of Legal Services, Wellington, November 1992, § 1704(5).
With respect to non-international armed conflicts in particular, it states that “medical … transports are to be respected at all times and not made the object of attack”. 
New Zealand, Interim Law of Armed Conflict Manual, DM 112, New Zealand Defence Force, Headquarters, Directorate of Legal Services, Wellington, November 1992, § 1818(2).
Nicaragua
Nicaragua’s Military Manual (1996) states, with respect to international armed conflicts, that assistance to the wounded, sick and shipwrecked includes a requirement of “respect for and protection of transportation over … sea of civilian wounded and sick”. 
Nicaragua, Manual de Comportamiento y Proceder de las Unidades Militares y de los Miembros del Ejército de Nicaragua en Tiempo de Paz, Conflictos Armados, Situaciones Irregulares o Desastres Naturales, Ejército de Nicaragua, Estado Mayor General, Asesoría Jurídica del Nicaragua, 1996, Article 14(38).
Peru
Peru’s IHL Manual (2004) states:
Military hospital ships, that is to say, ships built or equipped by the Powers specially and solely with a view to assisting the wounded, sick and shipwrecked, to treating them and to transporting them, may in no circumstances be attacked or captured, but shall at all times be respected and protected, on condition that their names and descriptions have been notified to the parties to the conflict ten days before those ships are employed. 
Peru, Manual de Derecho Internacional Humanitario para las Fuerzas Armadas, Resolución Ministerial Nº 1394-2004-DE/CCFFAA/CDIH-FFAA, Lima, 1 December 2004, § 157.f; see also §§ 87.a and b, 129.a.(1) and 172.h.
The manual further states:
(1) The exemption from attack of a hospital ship may cease only by reason of a breach of a condition of exemption and, in such a case, only after due warning has been given naming in all appropriate cases a reasonable time limit to discharge itself of the cause endangering its exemption, and after such warning has remained unheeded.
(2) If after due warning a hospital ship persists in breaking a condition of its exemption, it renders itself liable to capture and other necessary measures to enforce compliance.
(3) A hospital ship may only be attacked as a last resort if:
(a) diversion or capture is not feasible;
(b) no other method is available for exercising military control;
(c) the circumstances of non-compliance are sufficiently grave that the hospital ship has become, or may be reasonably assumed to be, a military objective;
(d) the collateral casualties or damage will not be disproportionate to the military advantage gained or expected. 
Peru, Manual de Derecho Internacional Humanitario para las Fuerzas Armadas, Resolución Ministerial Nº 1394-2004-DE/CCFFAA/CDIH-FFAA, Lima, 1 December 2004, § 129.c.
The manual also states: “The names and descriptions of hospital ships must be notified to the parties to the conflict. Hospital ships and coastal rescue craft can be ordered to stop, move away or follow a certain route.” 
Peru, Manual de Derecho Internacional Humanitario para las Fuerzas Armadas, Resolución Ministerial Nº 1394-2004-DE/CCFFAA/CDIH-FFAA, Lima, 1 December 2004, § 110.c.
Peru
Peru’s IHL and Human Rights Manual (2010) states:
Military hospital ships, that is to say, ships built or equipped by the powers specially and solely with a view to assisting the wounded, sick and shipwrecked, to treating them and to transporting them, may in no circumstances be attacked or captured, but shall at all times be respected and protected, on condition that their names and descriptions have been notified to the parties to the conflict ten days before those ships are employed. 
Peru, Manual de Derecho Internacional Humanitario y Derechos Humanos para las Fuerzas Armadas, Resolución Ministerial No. 049-2010/DE/VPD, Lima, 21 May 2010, § 148(f), p. 335; see also pp. 396–397.
The manual also states:
The following categories of enemy ships may not be attacked:
(1) Hospital ships.
(2) Coastal rescue craft and other means of medical transport. 
Peru, Manual de Derecho Internacional Humanitario y Derechos Humanos para las Fuerzas Armadas, Resolución Ministerial No. 049-2010/DE/VPD, Lima, 21 May 2010, § 120(a)(1)–(2), p. 310.
The manual further states:
b. Conditions for immunity
… [Hospital ships] only enjoy immunity from attack if:
(1) They act in a way consistent with their usual activities.
(2) They submit to identification and inspection as requested.
(3) They do not intentionally obstruct the movement of combatants and obey orders to stop or move away as requested.
c. Loss of immunity
(1) The immunity of a hospital ship from attacks may only cease if it does not comply with any of the conditions for immunity and, if this is the case, it shall not cease until after due warning has been given, naming, in all appropriate cases, a reasonable time limit to discharge itself of the cause endangering its immunity [from attack], and after such warning has remained unheeded. 
Peru, Manual de Derecho Internacional Humanitario y Derechos Humanos para las Fuerzas Armadas, Resolución Ministerial No. 049-2010/DE/VPD, Lima, 21 May 2010, § 120(b)–(c)(1), p. 310.
Russian Federation
The Russian Federation’s Regulations on the Application of IHL (2001) states:
117. The following vessels shall not be attacked:
- military hospital ships;
- hospital ships;
- small craft used for coastal rescue operations and medical transports;
The above vessels shall not be attacked or captured if they:
- are innocently employed in their normal role;
- do not commit actions falling under Paragraph 116 [i.e., make an effective contribution to military action];
- do not intentionally hamper the movement of combatants and obey orders to stop or move out of the way when required.
118. Ships that belong to any class of vessels mentioned in Paragraph 117 may only be attacked as a last resort if:
- diversion is not feasible;
- no other method is available for exercising military control;
- the acts it commits give reasons to consider it as a military objective;
- the collateral casualties or damage will not be disproportionate to the military advantage gained or anticipated.
119. Military hospital ships shall not be attacked or captured and shall enjoy respect and protection, on condition that their names and descriptions have been notified to the parties to the conflict ten days before those ships are employed.
Hospital ships shall have the same protection as military hospital ships on condition that they observe the provision concerning notification with regard to the latter; they must also be provided with certificates from responsible authorities stating that the vessels have been under their control while fitting out and on departure.
The medical and religious personnel of hospital ships and their crews may not be captured, whether or not there are wounded and sick on board.
122. The ships described in Paragraph 119 shall not be exempt from protection provided by international humanitarian law if:
- the crews of ships are armed for the maintenance of order, for their own defence or that of the sick and wounded;
- apparatus exclusively intended to facilitate navigation or communication is present on board;
- portable arms and ammunition taken from the wounded, sick and shipwrecked is discovered on board;
- equipment and personnel intended exclusively for medical duties are transported, over and above the normal requirements. 
Russian Federation, Regulations on the Application of International Humanitarian Law by the Armed Forces of the Russian Federation, Ministry of Defence of the Russian Federation, Moscow, 8 August 2001, §§ 117–119 and 122.
Sierra Leone
Sierra Leone’s Instructor Manual (2007) states:
Any means of transportation, whether military or civilian, permanent or temporary, assigned exclusively for the transportation of medical personnel, wounded and sick and other facilities are referred to as medical transport. These may include aircraft, vehicles, ships etc.
Before any transport for medical purpose, it must be marked with the protective emblem which is the Red Cross on a white background.
Medical transport is not to be attacked but may lose its [protected] status if, for example, it carries arms or military equipment or the vehicle is used to gather intelligence about the location or deployment of the enemy.
It is a crime to attack a clearly marked medical transport or to use them for a non-medical purpose.
Medical transport, if captured, should be used to provide medical services to the wounded and sick. 
Sierra Leone, The Law of Armed Conflict. Instructor Manual for the Republic of Sierra Leone Armed Forces (RSLAF), Armed Forces Education Centre, September 2007, pp. 60–61.
South Africa
South Africa’s Revised Civic Education Manual (2004) states:
67. Medical Transportation. The following definitions are relevant under this heading:
a. “Medical transportation” means the conveyance by land, water or air of wounded, sick or shipwrecked persons, medical and religious personnel and medical material.
b. “Medical transports” cover any means of transport, military or civilian, permanent or temporary, assigned exclusively to medical transportation and under the control of a competent authority of a Party to a conflict.
68. All means of medical transport, whether permanent or temporary, must be assigned exclusively to medical purposes in order to be entitled to protection. A convoy carrying both wounded and able-bodied soldiers or arms would lose the right to protection to the detriment of the wounded. (Note: the presence of light arms which have just been taken from the wounded and not yet turned over to the proper authority is permitted).
69. The term “respect” for the means of medical transport indicates that they may not be attacked or damaged, nor may their passage be obstructed. They must be permitted to carry out their assigned tasks. Medical transports by land and medical ships and craft must be respected and protected in the same way as mobile medical units. 
South Africa, Revised Civic Education Manual, South African National Defence Force, 2004, Chapter 4, §§ 67–69.
South Africa
South Africa’s LOAC Teaching Manual (2008) states:
Enemy Vessel and Aircraft that may not be attacked
- The following classes of enemy vessels may not be attacked:
- Hospital ships.
- Small crafts used for coastal rescue operations and other medical transports.
- The protected vessels listed above are exempt from attack only if they
- Are innocently employed in their normal role;
- Submit to identification and inspection when required; or
- Do not intentionally hamper the movement of combatants and obey orders to stop or move out the way when required.
Loss of Exemption
- Hospital Ships
- The exemption from attack of a hospital ship may cease only by reason of a breach of a condition of exemption in the previous subparagraph and, in such a case, only after due warning has been given naming in all appropriate cases a reasonable time limit to discharge itself of the cause endangering its exemption, and after such warning has remained unheeded.
- If after due warning a hospital ship persists in breaking a condition of exemption, it renders itself liable to capture or other necessary measures to enforce compliance.
- A hospital ship may only be attacked as a last resort if:
- Diversion or capture is not feasible;
- No other method is available for exercising military control;
- The circumstances of non-compliance are sufficiently grave that the hospital ship has become, or may be reasonably assumed to be, a military objective; and
- The collateral casualties or damage will not be disproportionate to the military advantage gained or expected.
- If any other class of vessel that is exempted from attack breaches any of the conditions of its exemption, it may be attacked. But only if
- Diversion or capture is not feasible;
- No other method is available for exercising military control under the circumstances;
- The non-compliance is so grave that the vessel has become, or may be reasonably assumed to have become a military objective; and
- The collateral casualties or damage will not be disproportionate to the military advantage expected or to be gained. 
South Africa, Advanced Law of Armed Conflict Teaching Manual, School of Military Justice, 1 April 2008, as amended to 25 October 2013, Learning Unit 4, pp. 201–203.
[emphasis in original]
The manual also states:
Measures Short of Attack: Interception, Visit, Search, Diversion and Capture
- Capture
- Enemy Vessels and Goods
- Protected vessels may not be captured (hospital ships and small craft used for coastal rescue operations, other medical transports, so long as they are needed for the wounded, sick and shipwrecked on board, etc). These vessels are only exempted from capture if they:
- Are innocently employed in their normal role.
- Do not commit acts harmful to the enemy.
- Immediately submit to identification and inspection when required.
- Do not intentionally hamper the movement of combatants and obey orders to stop or move out of the way when required. 
South Africa, Advanced Law of Armed Conflict Teaching Manual, School of Military Justice, 1 April 2008, as amended to 25 October 2013, Learning Unit 4, pp. 207 and 208–209.
Ukraine
Ukraine’s IHL Manual (2004) states: “‘Means of medical transportation’ means any transport used for medical (sanitary) transportation by land, sea or air … [M]eans of medical transportation may be escorted by guard or convoy.” 
Ukraine, Manual on the Application of IHL Rules, Ministry of Defence, 11 September 2004, § 1.2.35.
The manual further states: “Objects protected by international humanitarian law [include] means of medical transportation … Attacks against such objects shall be prohibited.” 
Ukraine, Manual on the Application of IHL Rules, Ministry of Defence, 11 September 2004, § 1.2.51.
The capture of hospital ships, if not justified by military necessity, is considered to be a “serious violation” of international humanitarian law. 
Ukraine, Manual on the Application of IHL Rules, Ministry of Defence, 11 September 2004, § 1.8.6.
United Kingdom of Great Britain and Northern Ireland
The UK Military Manual (1958) states: “Convoys of vehicles or hospital trains on land, and specially provided vessels at sea, conveying wounded and sick civilians, the infirm, and maternity cases must be protected and respected in the same way as civilian hospitals.” 
United Kingdom, The Law of War on Land being Part III of the Manual of Military Law, The War Office, HMSO, 1958, § 33.
United Kingdom of Great Britain and Northern Ireland
The UK LOAC Manual (2004) states:
7.12. Medical transport means any means of transportation, whether military or civilian, permanent or temporary, assigned exclusively to the conveyance by land, water or air of the wounded, sick, shipwrecked, medical or religious personnel, medical equipment or medical supplies protected by the Geneva Conventions and Additional Protocol I and under the control of a competent authority of a party to the conflict. In Additional Protocol I, reference to “medical vehicles” expressly means “any medical transports by land”. Similarly, “medical ships and craft” means “any medical transports by water” and “medical aircraft” means “any medical transports by air”.
7.12.1. The assignment to medical purposes must be exclusive, although it may be permanent or temporary. The word “exclusive” is intended to restrict the definition of medical transport and its use so that the essential protection will not be eroded by abuses. “Permanent” means for an indeterminate period; “temporary” means limited periods but devoted exclusively to medical tasks during the whole of such periods.
Protection
7.20. The general rule is that medical transport is entitled to similar respect and protection as is given to medical units. However, there remain some practical difficulties especially in the case of medical ships and craft and medical aircraft. These categories are dealt with below.
Hospital ships
7.21. Ships that are built, converted or equipped specially and solely with a view to assisting the wounded, sick and shipwrecked and to treating them and transporting them are regarded as hospital ships. 
United Kingdom, The Manual of the Law of Armed Conflict, Ministry of Defence, 1 July 2004, §§ 7.12–7.13.1 and 7.20–7.21.
In its chapter on maritime warfare, the manual provides that “hospital ships” and “small craft used for coastal rescue operations and other medical transports” are exempt from attack and from capture. 
United Kingdom, The Manual of the Law of Armed Conflict, Ministry of Defence, 1 July 2004, §§ 13.33 and 13.100.
Lastly, in its chapter on enforcement of the law of armed conflict, the manual refers to “attacking a properly marked hospital ship or medical aircraft” as a war crime “traditionally recognized by the customary law of armed conflict”. 
United Kingdom, The Manual of the Law of Armed Conflict, Ministry of Defence, 1 July 2004, § 16.29.
United States of America
The US Air Force Pamphlet (1976) states: “In addition to grave breaches of the Geneva Conventions of 1949, the following acts are representative of situations involving individual criminal responsibility: (1) deliberate attack on … hospital ships”. 
United States, Air Force Pamphlet 110-31, International Law – The Conduct of Armed Conflict and Air Operations, US Department of the Air Force, 1976, § 15-3(c)(1).
United States of America
The US Air Force Commander’s Handbook (1980) provides that ambulances and hospital ships “should not be deliberately attacked, fired upon, or unnecessarily prevented from performing their medical duties”. 
United States, Air Force Pamphlet 110-34, Commander’s Handbook on the Law of Armed Conflict, Judge Advocate General, US Department of the Air Force, 25 July 1980, § 3-2.
United States of America
The US Naval Handbook (1995) qualifies “deliberate attack upon hospital ships” as a war crime. 
United States, The Commander’s Handbook on the Law of Naval Operations, NWP 1-14M/MCWP 5-2.1/COMDTPUB P5800.7, issued by the Department of the Navy, Office of the Chief of Naval Operations and Headquarters, US Marine Corps, and Department of Transportation, US Coast Guard, October 1995 (formerly NWP 9 (Rev. A)/FMFM 1-10, October 1989), § 6.2.5.
United States of America
The US Naval Handbook (2007) states that examples of war crimes that could be considered as grave breaches of the 1949 Geneva Conventions include: “Deliberate attacks upon … hospital ships.” 
United States, The Commander’s Handbook on the Law of Naval Operations, NWP 1-14M/MCWP 5-12.1/COMDTPUB P5800.7, issued by the Department of the Navy, Office of the Chief of Naval Operations and Headquarters, US Marine Corps, and Department of Homeland Security, US Coast Guard, July 2007, § 6.2.6.
United States of America
The US Manual on Detainee Operations (2008) states:
Legal Considerations
a. As a subset of military operations, detainee operations must comply with the law of war during all armed conflicts, however such conflicts are characterized, and in all other military operations …
c. The four Geneva Conventions of 1949 are fully applicable as a matter of international law to all military operations that qualify as international armed conflicts … The principles reflected in these treaties are considered customary international law, binding on all nations during international armed conflict. Although often referred to collectively as the “Geneva Conventions,” the specific treaties are:
(2) [1949] Geneva Convention [II] … This convention … protects hospital ships. 
United States, Manual on Detainee Operations, Joint Chiefs of Staff, 30 May 2008, pp. I-2–I-3.
Zimbabwe
Zimbabwe’s Code of Conduct for Combatants (1993) states: “Respect hospitals ships … marked with Red Cross/Red Crescent/Red Crystal emblems.” 
Zimbabwe, Code of Conduct for Combatants, Joint publication of the Zimbabwe Defence Forces and the International Committee of the Red Cross Regional Delegation in Harare, 1993, p. 7.
Denmark
Denmark’s Military Criminal Code (1973), as amended in 1978, provides:
Any person who uses war instruments or procedures the application of which violates an international agreement entered into by Denmark or the general rules of international law, shall be liable to the same penalty [i.e. a fine, lenient imprisonment or up to 12 years’ imprisonment]. 
Denmark, Military Criminal Code, 1973, as amended in 1978, § 25(1).
Denmark’s Military Criminal Code (2005) provides:
Any person who deliberately uses war means [“krigsmiddel”] or procedures the application of which violates an international agreement entered into by Denmark or international customary law, shall be liable to the same penalty [i.e. imprisonment up to life imprisonment]. 
Denmark, Military Criminal Code, 2005, § 36(2).
Estonia
Under Estonia’s Penal Code (2001), “an attack against … a hospital ship or aircraft, or any other means of transport used for transportation of non-combatants” is a war crime. 
Estonia, Penal Code, 2001, § 106.
Ireland
Ireland’s Geneva Conventions Act (1962), as amended in 1998, provides that any “minor breach” of the 1949 Geneva Conventions, including violations of Article 35 of the Geneva Convention I and Article 21 of the Geneva Convention IV, and of the 1977 Additional Protocol I, including violations of Article 21, as well as any “contravention” of the 1977 Additional Protocol II, including violations of Article 11, are punishable offences. 
Ireland, Geneva Conventions Act, 1962, as amended in 1998, Section 4(1) and (4).
Norway
Norway’s Military Penal Code (1902), as amended in 1981, provides:
Anyone who contravenes or is accessory to the contravention of provisions relating to the protection of persons or property laid down in … the Geneva Conventions of 12 August 1949 … [and in] the two additional protocols to these Conventions … is liable to imprisonment. 
Norway, Military Penal Code, 1902, as amended in 1981, § 108.
Romania
Romania’s Penal Code (1968) provides for the punishment of:
The total or partial destruction of objects marked with the regular distinctive emblem, such as:
a) … hospital ships … 
Romania, Penal Code, 1968, Article 359.
Somalia
Somalia’s Military Criminal Code (1963) states:
363. Where a commander fails to adopt measures to protect buildings, places or objects that must be respected. – 1. A penalty of military confinement for up to three years shall be imposed on a commander of attacking forces who fails to adopt the measures prescribed by law and by international agreements to ensure respect for:
(a) … hospital ships [and] ambulance ships, … where they are not at the same time being used for military purposes and have been designated by the distinctive signs specified in the international conventions, or have in some way been indicated in advance to the enemy, and are easily visible even from a great distance and at a high altitude.
375. Use of weapons against … medical ships … – Anyone who uses weapons against … hospital ships, ambulance ships or their vessels … when, in accordance with the law and international agreements, they must be regarded as respected and protected, shall, unless the act constitutes a more serious offence, be punished by military confinement for not less than 10 years. 
Somalia, Military Criminal Code, 1963, Articles 363(1)(a) and 375.
Germany
In the Dover Castle case in 1921, a German court acquitted the commander of a German submarine of sinking a hospital ship and killing six members of its crew in violation of the customs and laws of war. The Court found that the commander had sunk the ship in execution of orders and could not, therefore, be held responsible for the ensuing violations of the law. 
Germany, Reichsgericht, Dover Castle case, Judgment, 4 June 1921, p. 429.
South Africa
In 1987, in the Petane case, the Cape Provincial Division of South Africa’s Supreme Court dismissed the accused’s claim that the 1977 Additional Protocol I reflected customary international law. The Court stated:
The accused has been indicted before this Court on three counts of terrorism, that is to say, contraventions of s 54(1) of the Internal Security Act 74 of 1982. He has also been indicted on three counts of attempted murder.
The accused’s position is stated to be that this Court has no jurisdiction to try him.
… The point in its early formulation was this. By the terms of [the 1977 Additional] Protocol I to the [1949] Geneva Conventions the accused was entitled to be treated as a prisoner-of-war. A prisoner-of-war is entitled to have notice of an impending prosecution for an alleged offence given to the so-called “protecting power” appointed to watch over prisoners-of-war. Since, if such a notice were necessary, the trial could not proceed without it, Mr Donen suggested that the necessity or otherwise for giving such a notice should be determined before evidence was led. …
On 12 August 1949 there were concluded at Geneva in Switzerland four treaties known as the Geneva Conventions. …
South Africa was among the nations which concluded the treaties. … Except for the common art 3, which binds parties to observe a limited number of fundamental humanitarian principles in armed conflicts not of an international character, they apply to wars between States.
After the Second World War many conflicts arose which could not be characterised as international. It was therefore considered desirable by some States to extend and augment the provisions of the Geneva Conventions, so as to afford protection to victims of and combatants in conflicts which fell outside the ambit of these Conventions. The result of these endeavours was Protocol I and Protocol II to the Geneva Conventions, both of which came into force on 7 December 1978.
Protocol II relates to the protection of victims of non-international armed conflicts. Since the State of affairs which exists in South Africa has by Protocol I been characterised as an international armed conflict, Protocol II does not concern me at all.
The extension of the scope of art 2 of the Geneva Conventions was, at the time of its adoption, controversial. …
The article has remained controversial. More debate has raged about its field of operation than about any other articles in Protocol I. …
South Africa is one of the countries which has not acceded to Protocol I. Nevertheless, I am asked to decide, as I indicated earlier, as a preliminary point, whether Protocol I has become part of customary international law. If so, it is argued that it would have been incorporated into South African law. If it has been so incorporated it would have to be proved by one or other of the parties that the turmoil which existed at the time when the accused is alleged to have committed his offences was such that it could properly be described as an “armed conflict” conducted by “peoples” against a “ra[c]ist regime” in the exercise of their “right of self-determination”. Once all this has been shown it would have to be demonstrated to the Court that the accused conducted himself in such a manner as to become entitled to the benefits conferred by Protocol I on combatants, for example that, broadly speaking, he had, while he was launching an attack, distinguished himself from civilians and had not attacked civilian targets. …
… I am prepared to accept that where a rule of customary international law is recognised as such by international law it will be so recognised by our law.
To my way of thinking, the trouble with the first Protocol giving rise to State practice is that its terms have not been capable of being observed by all that many States. At the end of 1977 when the treaty first lay open for ratification there were few States which were involved in colonial domination or the occupation of other States and there were only two, South Africa and Israel, which were considered to fall within the third category of ra[c]ist regimes. Accordingly, the situation sought to be regulated by the first Protocol was one faced by few countries; too few countries in my view, to permit any general usage in dealing with armed conflicts of the kind envisaged by the Protocol to develop.
Mr Donen contended that the provisions of multilateral treaties can become customary international law under certain circumstances. I accept that this is so. There seems in principle to be no reason why treaty rules cannot acquire wider application than among the parties to the treaty.
Brownlie Principles of International Law 3rd ed at 13 agrees that non-parties to a treaty may by their conduct accept the provisions of a multilateral convention as representing general international law. …
I incline to the view that non-ratification of a treaty is strong evidence of non-acceptance.
It is interesting to note that the first Protocol makes extensive provision for the protection of civilians in armed conflict. …
In this sense, Protocol I may be described as an enlightened humanitarian document. If the strife in South Africa should deteriorate into an armed conflict we may all one day find it a cause for regret that the ideologically provocative tone of s 1(4) has made it impossible for the Government to accept its terms.
To my mind it can hardly be said that Protocol I has been greeted with acclaim by the States of the world. Their lack of enthusiasm must be due to the bizarre mixture of political and humanitarian objects sought to be realised by the Protocol. …
According to the International Review of the Red Cross (January/February 1987) No 256, as at December 1986, 66 States were parties to Protocol I and 60 to Protocol II, which, it will be remembered, deals with internal non-international armed conflicts. With the exception of France, which acceded only to Protocol II, not one of the world’s major powers has acceded to or ratified either of the Protocols. This position should be compared to the 165 States which are parties to the Geneva Conventions.
This approach of the world community to Protocol I is, on principle, far too half-hearted to justify an inference that its principles have been so widely accepted as to qualify them as rules of customary international law. The reasons for this are, I imagine, not far to seek. For those States which are contending with “peoples[’]” struggles for self-determination, adoption of the Protocol may prove awkward. For liberation movements who rely on strategies of urban terror for achieving their aims the terms of the Protocol, with its emphasis on the protection of civilians, may prove disastrously restrictive. I therefore do not find it altogether surprising that Mr Donen was unable to refer me to any statement in the published literature that Protocol I has attained the status o[f] customary international [law].
I have not been persuaded by the arguments which I have heard on behalf of the accused that the assessment of Professor Dugard, writing in the Annual Survey of South African Law (1983) at 66, that “it is argued with growing conviction that under contemporary international law members of SWAPO [South-West Africa People’s Organisation] and the ANC [African National Congress] are members of liberation movements entitled to prisoner-of-war status, in terms of a new customary rule spawned by the 1977 Protocols”, is correct. On what I have heard in argument I disagree with his assessment that there is growing support for the view that the Protocols reflect a new rule of customary international law. No writer has been cited who supports this proposition. Here and there someone says that it may one day come about. I am not sure that the provisions relating to the field of application of Protocol I are capable of ever becoming a rule of customary international law, but I need not decide that point today.
For the reasons which I have given I have concluded that the provisions of Protocol I have not been accepted in customary international law. They accordingly form no part of South African law.
This conclusion has made it unnecessary for me to give a decision on the question of whether rules of customary international law which conflict with the statutory or common law of this country will be enforced by its courts.
In the result, the preliminary point is dismissed. The trial must proceed. 
South Africa, Supreme Court, Petane case, Judgment, 3 November 1987, pp. 2–8.
South Africa
In 2010, in the Boeremag case, South Africa’s North Gauteng High Court stated:
In Petane, … Conradie J found that the provisions of [the 1977 Additional] Protocol I are not part of customary international law, and therefore are also not part of South African law.
Referring to the fact that in December 1986 only 66 of the 165 States party to the Geneva Conventions had ratified Protocol I, the Court [in Petane] stated:
This approach of the world community to Protocol I is, on principle, far too half-hearted to justify an inference that its principles have been so widely accepted as to qualify them as rules of customary international law. The reasons for this are, I imagine, not far to seek. For those States which are contending with “peoples[’]” struggles for self-determination, adoption of the Protocol may prove awkward. For liberation movements who rely on strategies of urban terror for achieving their aims the terms of the Protocol, with its emphasis on the protection of civilians, may prove disastrously restrictive. I therefore do not find it altogether surprising that Mr Donen was unable to refer me to any statement in the published literature that Protocol I has attained the status of customary international law.
Important changes with respect to certain aspects applicable at the time of Petane have taken place. The ANC [African National Congress] has become South Africa’s ruling party and in 1995 ratified Protocol I. The total number of States that have ratified it, is now … 162.
This last aspect forms the basis on which the First Respondent [the State] and the applicants agree that Protocol I forms part of customary international law as well as of South African law. As requested, this position is accepted for the purposes of the decision, without deciding on the matter.
Despite these changes, it remains debatable whether the provisions of Protocol I have become a part of South African law in this way.
The consensus of both parties to the conflict is required. See Petane … and Article 96 of Protocol I. …
Parliament’s failure to incorporate Protocol I into legislation in accordance with Article 231(4) of the Constitution in fact points to the contrary, and is indicative that the requirements of usus and/or opinio juris have not been met. See Petane. 
South Africa, North Gauteng High Court, Boeremag case, Judgment, 26 August 2010, pp. 21–22.
[footnotes in original omitted]
The Court also held:
If the [1977 Additional Protocol I] applies in South Africa as customary international law, the two requirements that form the basis of customary law must be met. It is arguable that the requirement of usus has been met by the vast number of States that have acceded or ratified it. By ratifying Protocol I the Republic of South Africa has indicated its intention to apply the Protocol, thereby fulfilling the requirement of opinio juris. 
South Africa, North Gauteng High Court, Boeremag case, Judgment, 26 August 2010, p. 66.
Egypt
In its written comments submitted to the ICJ in the Nuclear Weapons case in 1995, Egypt stated that it was “prohibited to attack convoys of vehicles, hospital trains, hospital ships, aircraft exclusively employed for the removal of wounded and sick civilians, or the transport of medical personnel and equipment”. 
Egypt, Written comments on other written statements before the ICJ, Nuclear Weapons case, September 1995, p. 21, § 50.
Germany
In 1944, the German hospital ship the Tübingen was bombed and sunk by the British air force. Following the sinking, the German Government issued the following official protest:
On 18 November 1944 at 0745 hours near Pola the German hospital ship Tübingen was attacked by two double-engine British bombers with machine guns and bombs so that it sank, although the course of the hospital ship had been communicated to the British government well in advance of its voyage to Saloniki and back for the purpose of transporting wounded German soldiers. Numerous members of the crew were thereby killed and wounded. The German government emphatically protests the serious violations of international law committed by the sinking of the hospital ship Tübingen. 
Germany, as cited by Alfred M. de Zayas, The Wehrmacht War Crimes Bureau, 1939–1945, University of Nebraska Press, Lincoln, 1989, pp. 261–266.
United Kingdom of Great Britain and Northern Ireland
The United Kingdom reacted to the sinking of the Tübingen during the Second World War by ordering an inquiry, in the course of which it was determined that, through a chain of errors on the part of the UK pilots and a misunderstanding in the wireless transmission, the order was actually given to attack the hospital ship. The UK Government expressed its regret at the sinking of the ship, stating:
In the circumstances described, they cannot refrain from remarking that had the Tübingen been properly illuminated at the time of sighting in accordance with international practice, the leader of the section would have had no difficulty in identifying her as a hospital ship and the incident would thus have been avoided. 
United Kingdom, as cited by Alfred M. de Zayas, The Wehrmacht War Crimes Bureau, 1939–1945, University of Nebraska Press, Lincoln, 1989, pp. 261–266.
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ICRC
To fulfil its task of disseminating IHL, the ICRC has delegates around the world teaching armed and security forces that:
“Medical transport” means any means of transportation assigned exclusively to conveyance by land, water or air of the wounded, sick, shipwrecked, of medical and religious personnel, or of medical material. 
Frédéric de Mulinen, Handbook on the Law of War for Armed Forces, ICRC, Geneva, 1987, § 67.
Delegates also teach that “specifically protected … transports recognized as such must be respected”. 
Frédéric de Mulinen, Handbook on the Law of War for Armed Forces, ICRC, Geneva, 1987, § 474.
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