Navigating the Grey Zone: A Systematic Review of Ethical Dilemmas and a Decision-Framework for Nurses and Anesthesiologists in Conflict Zones

Background: Military nurses and anesthesiologists stand at the clinical front line of war, where they have a responsibility to uphold the impartial humanitarian standards of medical ethics while also being part of a military institution. This double mandate sets profound and enduring ethical dilemmas that extend beyond standard clinical practice. Aim: This review aims systematically to identify, analyze, and synthesize the most frequent ethical challenges facing military nurses and anesthesiologists practicing in war theaters and present a practical, interdisciplinary model for decision-making to guide their practice. Methods: Peer-reviewed articles were systematically searched using major academic databases (PubMed, Scopus, CINAHL, PsycINFO, and JSTOR) published in 2000-2025. Results: Five core ethical areas identified include: (1) Triage on the battlefield and resource constraints, favoring utilitarianism; (2) Conflict between the obligation to care and potential threats when caring for detainees; (3) Dual loyalty dilemmas between patient welfare and military objectives; (4) Ethical complexities within legal Rules of Engagement; and (5) Risks of moral injury and psychological damage. A synthesized ethical decision-making system is proposed to address these issues.Conclusion: Ethical practice in war medicine extends beyond understanding international law; it necessitates moral resilience and practical resources. This review synthesizes evidence addressing these challenges and offers a structured approach for nurses and anesthesiologists to uphold their ethical integrity, enhancing both patient care and their psychological well-being in the high-stress environment of modern conflict.