What Iranian physicians under the Mahsa Amini crackdown reveal about medicine, complicity, and conscience.

By Amir Davoodi

In September 2022, a 22-year-old woman named Mahsa Amini died in police custody in Tehran, three days after being arrested by Iran’s morality police for wearing her hijab improperly. What followed was one of the largest protest movements in Iran’s modern history.

I watched it from a distance, and not just geographically.

I was born in Iran, and much of my family still lives there. During those weeks, I split my days between clinical responsibilities and a constant, quiet urgency: refreshing for updates, waiting for fragmented messages, trying to confirm that people I love were safe. I could speak freely. I could post, share, and advocate. Yet, after a while, even that began to feel insufficient. That unease deepened when I started reading accounts from inside Iran’s healthcare system.

Physicians were being detained, beaten, and dismissed, not for protesting, but for doing their jobs: treating the injured. The earliest challenges to the state’s official narrative of Amini’s death came from physicians involved in her autopsy who chose to speak despite knowing the consequences.

Hospitals had become sites of surveillance. Patients were taken directly from their beds.

Physicians were pressured to document protest-related injuries in ways that exposed patients to immediate arrest. Treating someone, the most basic act of medicine, had become a risky political decision, a line you had to decide whether to cross.

That is where neutrality begins to fracture.

Medicine, at its core, depends on a fundamental social contract. The state shields the clinical space from political interference, and in return, physicians treat anyone who walks through the door, impartially and without fear.

But when the system not only fails to honor that agreement but becomes the very threat it promised to protect against, neutrality ceases to exist. Remaining passive is no longer a neutral act. It is a choice.

Because at that point, you are no longer prescribing an antidote. You are administering the poison.

What struck me most, though, was not only the coercion. It was the response.

Many physicians quietly resisted. They omitted identifying details from charts, advised patients to use false names, and guided the wounded toward covert care networks outside official channels. Others assumed greater risks: speaking publicly, organizing and documenting abuses. More than 800 physicians signed an open letter condemning state violence, a collective act that diluted the risk of retaliation that would have crushed any single doctor acting alone.

This was not heroism as spectacle. It was conscience made clinical.

In thinking through what these physicians faced, I found the ethical frameworks we are taught in medicine to be necessary but insufficient. I’m fairly sure there was no lecture in medical school titled “What to do when the government starts kidnapping your patients.” That one didn’t make the curriculum.

Standard bioethical principles — beneficence, non-maleficence, autonomy, justice — assume a stable baseline: that the institutions around you are, however imperfectly, oriented toward patient welfare. When that assumption collapses, the question changes. It is no longer simply: what is the right thing to do? It becomes: what is the right thing to do, given what it might cost you, your patients, and those around you?

That tension led me to think about ethical responsibility as something adaptive rather than fixed. In my paper in the Journal of Medical Ethics, I propose a “sliding scale” of moral obligation. A framework that holds one non-negotiable baseline: physicians must not become complicit in harm, while acknowledging that how one acts beyond that will depend on individual risk, proximity, and capacity to act.

Not all resistance looks the same, because not all physicians are operating in equal conditions.

For some, ethical action may mean miscoding a bullet wound to prevent an arrest. For others, it may mean organizing care outside formal systems or speaking to international bodies. For diaspora physicians advocating from safer positions abroad, it means leveraging that protection to organize and amplify voices from the ground to reach across borders.

This raises a question that extends far beyond Iran: when we are more protected, do we carry a greater responsibility to act?

The answer, I think, is yes, and it applies more broadly than we might realize. We see versions of this tension in conflict zones, in under-resourced health systems, and in policies that restrict access to care. The contexts change, but the central question does not.

How do we act with integrity when the systems we work within pull us away from it?

There is no framework that answers this cleanly. What I hope the sliding scale offers is not a prescription, but a kind of ethical compass — a way for physicians to find their bearings when the terrain beneath them shifts. One that holds them accountable without demanding sainthood, and that recognizes the moral weight of even the quietest acts of resistance.

Because if these events clarify anything, it is this: neutrality is not always neutral. Refusing to harm your patient, even when a government demands it, is never a political act.

It is simply medicine.

 

Article: Between regime and responsibility: scaling physician ethics in times of crisis

Author: Amir Davoodi

Affiliation: Cooper Medical School of Rowan University

Competing interests: None

Social media: Amir Davoodi LinkedIn