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

The death of Mahsa Amini in September 2022 and subsequent protests placed Iranian physicians in an ethical dilemma: comply with state mandates that endangered patients or uphold their duty of care at significant personal risk. This essay examines how Iranian physicians navigated these dual obligations, protecting patients while confronting systemic repression, and situates their struggle within a broader history of medical neutrality under authoritarian regimes. Drawing on core bioethical principles and comparative case studies from Bahrain, Syria and Chile, the essay explores how physicians often assume politicised roles not by choice, but through the inescapable demands of clinical ethics in environments where care itself becomes resistance. In Iran, hospitals were transformed into sites of surveillance, and treating protest-related injuries could lead to arrest or professional sanction. In response, many physicians engaged in quiet resistance-falsifying records, concealing identities and offering covert care-to preserve both ethical integrity and clinical trust. To navigate such challenges, the 'sliding scale of moral obligation' is proposed as an adaptive ethical framework accounting for individual risk, proximity to harm and capacity to act. This model avoids prescribing a universal standard of heroism and instead affirms a baseline duty of non-complicity, offering a flexible yet principled approach to ethical action under duress. By exploring the tension between neutrality and resistance, this essay advocates for a more nuanced understanding of physicians' roles in repressive contexts. For medical students, engaging with these dilemmas deepens ethical literacy, prepares us to navigate moral complexities and equips us to better support colleagues under political duress.