The Israel-Hamas war is an ongoing mass casualty event and will require a complex medical effort to save as many lives as possible. Physicians are involved in this conflict, some on the front lines. Bioethicist Edmund Pellegrino, MD, stated in the practice of medicine, ethics must be the same for civilian and military physicians “except in the most extreme contingencies.” In the current moment of hostilities between Israel and Hamas, some might wonder, is this that extreme moment? The answer to this is no.
Since the mid-1800s, physicians have been considered non-combatants so they may provide clinical care based on need alone. A doctor contributes to the mission by affirming the primacy of the patient. That is the doctor’s job.
I completed some of my medical training at Rambam Hospital in Haifa, Israel. Rambam Hospital is on the beach, and house staff would sometimes leave their windsurfing boards there in case time opened for a break. I was there first on a medical student rotation and later for part of my critical care fellowship. During my fellowship training, the department head was Belgian, and the assistant director was German. The house staff consisted of an ethnic mix of health professionals, including Italian, American, Canadian, Israeli, and a couple of Arab doctors from the West Bank. The Arab doctors had gone to medical school in Israel. This was no small feat as acceptance to medical school, particularly for Arab applicants, was very competitive. I recall them to be very smart and capable. Rounds were a back-and-forth cacophony of language. We spoke French, German, Italian, English, Hebrew, and Arabic. After rounds, the chief would invite us all into the inner sanctum of his office. There, he would provide delicious pastries and teach us some magical medical topic as he smoked his Gitanes cigarettes. In my time there, I learned many things about critical care medicine, including an outsized knowledge about chemical warfare and Scud missiles. I loved it, and the international flavor of collaboration as we cared for the sick is among the best memories of my life as a physician.
I was in Israel during a relatively peaceful time, and when a mass casualty event occurs outside of a war zone, the bioethical reply informing triage is cleaner. However, the intensity of the recent attack by Hamas, the immense Israeli response, and the barrage of social media disinformation present challenges for physicians who must remain clear-headed and impartial in the provision of care. Physicians may find themselves in uniform at the front line. In modern war, triage and the role of the medic and medical care run the risk of becoming mired in the conflict. In circumstances where a physician must triage, there is pressure to sort patients for reasons other than medical considerations (e.g. political reasons or beliefs). Such pressure should be resisted. Medical practice has always been an arm of state power, and the use of power to advance a political agenda that departs from bioethics is the end of medical professionalism. In Vom Kriege (On War), Prussian general Carl von Clausewitz saw war as a continuation of politics by other means. Now, more than ever, we must strive to keep the apolitical nature of medical practice at the forefront of our actions.
It’s possible to imagine certain battlefield conditions that might lead a military commander to order the suspension of patient-centered medical ethics. Under the international law of armed conflict, medical personnel are deemed non-combatants and therefore afforded some protection. While physicians may defend themselves and their patients, they are not permitted to engage in offensive military action. The motto of the U.S. army medical corps is “To Conserve Fighting Strength” and the Israeli Defense Force directs all soldiers to “preserve human dignity…regardless of race, faith, nationality, gender, or status.” Regardless of combatant status, military medical personnel are part of a fighting force and receive combat training. When sorting the wounded, the enemy combatant may also be a patient.
Soldiers in uniform enjoy protection according to the Geneva Convention. Such protection is not afforded to the combatant not in uniform. Notably, Hamas is a non-state actor, including its military wing, the Izz al-Din al-Qassam Brigades, meaning they fight in civilian clothing. This can complicate matters. While it is not the job of the physician to punish by withholding medical care, the current emotional state among Israeli and Palestinian medical personnel is tense. Providing care to the enemy, or simply to people we do not like, might naturally generate feelings of enmity. However, I have long recognized in myself that the patient I like the most is more often the one I like the least as a person. In that circumstance, the work is pure. Physicians are discouraged from caring for close friends and family because the positive emotional connection impedes the necessary cool-headed thinking sometimes needed to make tough treatment decisions. Certainly, the reverse is true, but I do not need a tragic story to do my best. I do not need to be petitioned to try.
In this current conflict, one must also consider the safety of physicians providing care — not only physicians, but the hospitals where care occurs. Article 18 of the Geneva Convention stipulates that under no circumstances can a civilian hospital organized to give care to the wounded or sick be the object of attack. A military target, on the other hand, is any location for attack that through its nature, content, or use, makes it an effective component of the military actions of the other side. In this Israel-Hamas war, and in the wider war, a blurred line now exists between civilian and combatant, between the front line and any other place, and between legitimate military targets and safe places.
In war, physicians are presented with divided duties and potentially complex loyalties. The Israel-Hamas war has put neighbors against each other, and the fight is not only ideological but personal. Pellegrino wondered if certain wars would provide the contingency needed to set aside bioethical practice. I repeat that in the Israel-Hamas war, my answer is no.