I think what's interesting is that this might also be related to the classist/caste system and general regional discrimination on Cybertron
We know Shockwave's not from Iacon or any of the relatively fancy, upper class polities
How does medical training differ between different city-states on Cybertron?
What supplies or facilities did Shockwave lack when working in a surgical capacity? How strained were the logistics of the healthcare systems in regions like Kaon or Tarn, compared to Iacon?
How many bots in these regions were medics outright, as we know the majority of the population in these areas were manual labourers and otherwise specialised frame types for primarily physical, industrial work? What was the staffing of these health facilities, and what types of health facilities were available?
Shockwave's creativity and engineering prowess may have come in handy when having to carry out surgical procedures with limited tools or materials, in an area that likely did not have robust health services and had a population at greater risk of serious injury or occupational injury.
I think Ratchet would logically understand this on some level; He surely knows he was privileged to work in Iacon, one of the most prestigious health systems on Cybertron, with resources funded by their rich city-state and the best tools, equipment, and facilities possible owing to their patient cohort of Senators and of course, the Prime himself. They were not short of staff, prior to the war. They were a well-funded, well-organised, high capacity health system with world class care provision. Clean and pristine.
Iacon would have been the highest standard, the place all medics with their higher class ranking and greater access to education, training, and opportunities would ultimately want to work. I'm sure many medics were not as morally grounded as Ratchet, and worked in Iacon's medical system for prestige and reputation.
This is a real world problem; Many healthcare professionals end up either forced to seek training in a few specialised centres, almost all of which are in major cities, or they choose to go to prestigious institutions or hospitals/clinics because they want to be "the best among the best".
This contributes to healthcare deserts, where specialists or even basic care services are not able to be provided in rural areas due to lack of staff, because all the staff gravitate towards major cities and specific healthcare institutions that are inaccessible to the patients in greatest need.
Some staff do want to work in rural services, but can't, because certain training or their speciality does not functionally exist in rural areas. So they're forced to go train or work in major cities or healthcare hubs. Some rural areas no longer have the facilities at all, as they've been closed-- Partially due to long term staffing issues, among other reasons.
Some staff work their whole lives solely to work at St Jude's or the Mayo Clinic or Mount Sinai Hospital or other big name healthcare services. In the UK, the equivalent would be all the NHS staff who want to work at Bart's or St Thomas or Great Ormond Street Hospital, which are all London based NHS Trusts. So the people with the best training and most expertise often end up in a select few services.
I can imagine this type of issue would have significantly impacted Kaon, Tarn, and other "lower class" city-states across Cybertron.
Compare Iacon Medical to the makeshift clinics that were built haphazardly next to gladiatorial arenas in Kaon. Ambulance alt-mode may have been common among specialist forged medics in Iacon, but in Kaon, you might only have access to a tow truck alt-mode courtesy of a bot who just does their best to help with whatever they know or have access to, because all the forged medics gravitate towards the bigger, better health centres in other regions.
Ratchet may not have experienced these types of problems himself, but he was likely aware of them. So I think he would understand if Shockwave was likely the best--or only--option to receive care for some people in those areas.
It might be the case that Ratchet would be more disturbed by Shockwave's replacement/modification of his forearm with a brutal weapon. Surely this limits Shockwave's surgical capabilities at least somewhat. Ratchet might struggle with knowing that someone who was gifted in at least some form of medical provision gave that up in order to take lives, rather than repair them.
Sure, to bots who were forged medics, Shockwave's work may look terrifying, unsafe, or highly experimental.
But as far as Shockwave is concerned, there is likely very little medical care available or accessible within Kaon, and it would not make logical sense to allow your comrades to die from a rust infection or protoform laceration.
Logically, repairs are required. Assessing the skills of those present, logically, Shockwave would be the best bot for the job.
I have a sad feeling that many patients in Kaon or Tarn were not accepted as transfer patients by other health services across Cybertron; It's likely the case that many industrial or gladiatorial injuries were too severe and would not have survived the time needed for a patient transfer to occur, anyway.
But class and caste played a role, and inevitably, it's likely that not all medics in other health services were as universally caring as Ratchet.
I'm sure some Kaonite patients who may have otherwise been suitable for transport to another region for treatment were simply denied or could not obtain the means/permissions/etc. to travel.
So I think Ratchet would be fairly understanding of this, even with his tendency to not recognise his own privilege sometimes. He's unavoidably a little skewed from having been a favourite medic of the upper classes and having worked and lived in that environment most of his life, but he would recognise the challenges facing patients in underserved and neglected regions.
So he wouldn't judge Shockwave too hard for having to make repairs in lieu of any actual medical staff being present...
...But as soon as Shockwave's more extreme experimentation efforts take on a medical nature, or if Shockwave taught himself medicine via exploratory procedures on living, vulnerable bots, that is where Ratchet draws the line.
Patients are people, not projects.
And while Ratchet is understanding of the original poor circumstances, he cannot fathom the mindset it would take to go to Shockwave's extremes.
To Shockwave, it is only logical.
To Ratchet, even thinking about such measures is a moral injury in and of itself.
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