Navigating Risk Without Protection: Defensive Medicine Among General Practitioners in a Fragile Afghan Health System

Background: Defensive medicine refers to clinical practices driven primarily by physicians’ concerns about potential complaints or accusations rather than patient benefit. While extensively studied in high-income countries, little is known about defensive medicine in fragile and low-resource health systems. This study aimed to examine the prevalence, perceived causes, and potential mitigation strategies of defensive medicine among general practitioners working in hospitals in Herat, Afghanistan. Methods: A cross-sectional survey was conducted in 2023 among general practitioners employed in four major hospitals in Herat. Of 318 eligible physicians, 104 completed a researcher-designed and validated questionnaire (response rate: 32.7%). Content validity was confirmed using the content validity ratio (0.56) and content validity index (0.79), and reliability was assessed through test–retest procedures (Cronbach’s α = 0.77). Descriptive statistics and Chi-square tests were used for data analysis. Results: Although only 35.3% of physicians reported full familiarity with defensive medicine, 46.2% indicated high levels of defensive practice. Common behaviors included unnecessary inpatient admissions (58.8%), avoidance of high-risk procedures (80.4%), and avoidance of high-risk patients (41.2%). Low clinical confidence and limited specialized knowledge were identified as the leading perceived causes. Legal protection for physicians was the most strongly supported mitigation strategy. Years of work experience were significantly associated with defensive practice (p = 0.02). Conclusion: Defensive medicine is prevalent among general practitioners in Herat despite limited conceptual awareness. These practices appear to be driven more by systemic vulnerabilities and clinical uncertainty than by litigation pressure. Strengthening legal protections, improving access to evidence-based guidelines, and enhancing professional training may help reduce unnecessary defensive behaviors in fragile health systems. Trial registration: Not applicable.