In times of war, said Cicero, the law falls silent. Afghanistan. Iraq. Syria. Yemen. Somalia. Ukraine. Libya. Chad. An irregular patchwork of violent conflict lies across great swathes of the globe. Many of these are new kinds of conflict. The clash of opposing armies has given way. Splinter groups, proxies, irregular forces, insurgents, paramilitaries. It is the language of indistinctness and blurred identity. The theatres of war have also shifted. They are increasingly urban and densely populated—places of deep human settlement. Here the force of modern weaponry is unleashed to catastrophic and indiscriminate effect. The unrestrained savagery of so much of this conflict, its blindness to any moral restraint, recall Thucydides and the Athenian generals on Melos. Their words are still cited by those who hold that there is no place for morality in war. “There is no justice between the weak and the strong: the strong take what they can, and the weak bear what they must.” Every playground bully and every one of his—or her—victims knows the part of truth in this.

At some point between 02.08 and 03.15 on the night of the 3rd of October 2015 a US AC-130 gunship opened fire on the MSF trauma facility in Kunduz. At least 42 people are reported to have been killed and over 30 injured. MSF had relayed the hospital’s co-ordinates to the Americans. MSF shared an account of the attack and its immediate aftermath by an MSF nurse, Lajos Zoltan Jecs.

“We tried to take a look into one of the burning buildings. I cannot describe what was inside. There are no words for how terrible it was. In the Intensive Care Unit six patients were burning in their beds.”

The American investigations into the attacks on Kunduz have yet to report. MSF have understandably called for an independent investigation. Accident, negligence, or malice are yet to be established. We will wait for the reports. But Amnesty International for one is in no doubt about more recent attacks on medical facilities. “Hospitals”, they say in a recent press release, “have become the new front line.” Underneath a photograph of the rubble and twisted reinforcing rods of another former MSF-supported hospital Amnesty International accuse Syrian and Russian forces of the deliberate targeting of six hospitals and clinics to pave the way for ground interventions in northern Aleppo.

There is an awkward moral fact that Thucydidean realists need to confront when they speak of the necessary immorality of war: injustice tends to invoke its opposite. The unrestrained use of force brings down moral judgement. War may serve—or seek to serve—the interests of states or other combatants, but morality is among our deepest interests. A parallel history, stretching equally as far back as realism, calls for justice and restraint in the waging of war. Its most recent and systematic embodiment are the Geneva Conventions and the other instruments of International Humanitarian Law (IHL). This history—a liberal or idealistic history—says that even in the extremity of wars our actions are open to moral judgement and the demands of justice.

At the end of 2015 the 32nd International Conference of the Red Cross and Red Crescent was held in Geneva. Behind it lay years of increasing contempt by belligerents for IHL. On the table were proposals, hammered out after four years of consultation by the International Committee of the Red Cross (ICRC) and the Swiss government, for a new mechanism to strengthen compliance with the rules of law. No agreement was reached. I was not there, but a quick internet scan suggests that realpolitik had its hand in that failure. A compromise position, put forward by a group of Arab states involving continuing consultation, was adopted. The realists may have won out on this occasion.

The deliberate targeting of hospital facilities presents an existential threat to humanitarian interventions during wartime. Without a respect for the neutrality of medical personnel and facilities, few health professionals will venture into conflict zones. Many more, countless many more, will suffer and die. Although only a fool would underestimate the scope of the challenge, it is imperative that we find new ways of strengthening medical neutrality.

Julian Sheather is specialist adviser (ethics and human rights), professionalism and guidance, policy directorate, BMA. The views he expresses in his blog posts are entirely his own.