physicians for human rights-israel: position paper israeli policies at erez crossing - gaza...

8/8/2019 Physicians for Human Rights-Israel: Position Paper Israeli Policies at Erez Crossing - Gaza Medical-Ethical - August 2

1/3

August 2007

Israeli Policies at Erez Crossing, Gaza: Medical-Ethical Position Paper1

BackgroundThe second week of June 2007 witnessed an escalation of armed clashes between Hamasand Fatah forces in the Gaza Strip. Between the 12

thand the 17

thof June some 170 people

were killed and many hundreds were injured by gunfire.

On 9.6 Rafah Crossing, the only access to Egypt, was closed, and on the morning of 14.6Erez Crossing into Israel was also closed by the Israeli authorities. As a result, access of thesick and wounded to treatment unavailable in Gaza was completely blocked.

On 19.6 Physicians for Human Rights-Israel (PHR-Israel) and Gisha Center submitted apetition to the Israeli High Court of Justice, demanding the opening of the crossings to thesick and wounded and entry permits for 26 patients in urgent need of medical care in Israel.The court rejected the petition, making no decision with regard to the individual cases, and

avoiding discussion of the status of Gaza and Israeli responsibility towards its inhabitants.

Following the High Court decision, Erez Crossing permit mechanisms returned to partialfunctioning, but a significant tightening of policies was recorded. The State now claims thatIsrael bears no legal responsibility towards the inhabitants of Gaza, and states that thepassage of the sick and wounded will be enabled as a humanitarian gesture only. Inaddition, for the first time the State has made a pseudo-medical distinction between danger tolife and danger to quality of life. In practice, this will mean that patients in danger of losing alimb will not be considered in a condition necessitating passage to medical centers in Israel.

For the purposes of the discussion below, PHR-Israel made a detailed review of the cases ithandled between the 14

thof June and the 4

thof July 2007.

Below is a breakdown of requests and rejections according to categories of urgency andseverity of the cases:

Medical condition Permitsrequested

Permits rejected Comments

Emergency life-threateningconditions

9 3 One death

Life-threatening conditions(e.g., cancer)

12 6 Two deaths

Urgent, non-life-threatening conditions(e.g. limbs in danger ofamputation)

18 6 Loss of limb in 4cases

Non-urgent conditions 5 1

Total 44 16

In addition to these rejections, delays were recorded in almost all cases.

1This position paper was written by Miri Weingarten. The ethical analysis was formulated by Prof.

Michael Weingarten and Dr. Kobi Arad. Detailed medical analysis of the cases was conducted byvolunteer doctors of PHR-Israel. The data in the report are based on correspondence with the militaryauthorities held by PHR-Israel Staff member Ran Yaron. Mistakes in content or understanding are theresponsibility of the author.


2/3

2

DiscussionAccording to information given to PHR-Israel by the security authorities, the securityapparatus conducts a process of classification based on medical and other criteria beforedeciding who will be permitted to enter Israel. For this purpose the military consults withmedical personnel. Assessment and classification are based on medical documents sent byfax to the military authorities at Erez Crossing. All our attempts to discover who these doctors

are have so far failed. Preliminary correspondence has led us to the conclusion that there isno permanent assessment process, and that classification, if it is indeed conducted, isconducted in an inconsistent manner, not always by doctors, and not according to orderedmedical regulations.

The data above relates to the period immediately following the closing of the Gaza crossings,in the course of which the security apparatus employed a medically inconsistent entry policy(see table above). Today, the permits mechanism has returned to more regular functioning,but it is still clear that the decision-making process is conducted according to extra-medicalconsiderations. The analysis below aims to examine the classification procedure, wherebyaccessibility of appropriate medical care is determined.

Pseudo-medical classification by non-medical personnel is problematic in itself, but the

discussion below will relate to the place of doctors and of medical classification (triage) withinthe decision-making process at Erez Crossing.

A. Israeli Policy: Life not LimbIn its response to the High Court of Justice in June 2007, the State of Israel made adistinction between life-endangering conditions and conditions endangering quality of life(i.e., loss of a limb), and claimed that entry would be permitted only to life-endangering cases.This distinction, which means that anyone defined as in danger of quality of life will not bepermitted to receive care in Israel, has no medical justification, since the reason for thislimitation is not the lack of appropriate medical resources. Accordingly, from a medical ethicsperspective, a doctor is not permitted to assist in such a process, which denies access tocare. The State, for its part, has no right to oblige doctors to participate in medical triagesubject to this unjustified criterion.

B. Medical TriageTriage is conducted in emergency medicine in Israel and internationally in cases of overloadand bottleneck situations, in order to determine urgency and priority. Whereas the objective ofmedical triage is to determine priority and urgency rather than the actual eligibility for care andaccess to care (priority vs. accessibility), in our case, triage, if used, clearly determineseligibility and accessibility.Triage in extreme cases of shortage, such as multi-casualty crises, natural catastrophes andthe like, includes renouncing the most severe cases, which have a low prognosis, demandmany resources and may block the medical system at the expense of a larger number ofcasualties who may be saved. Such a decision is made by definition only in extreme cases ofshortage, usually during preliminary stages, and with the intention of transferring additionalresources to the area of shortage. Clearly, the situation in Gaza does not fit this definition. For

this reason such stringency-triage is evidently not legitimate, as it is not a case of lack ofresources.

It is hard to conclude from the data we have that stringency-triage is actually performed inGaza. Rather, the data point to a medically inconsistent or even arbitrary policy. Nonetheless,it is possible to discern a certain pattern of decision-making: According to the data collected,in some cases the entry of a patient was denied, even if the patient was in danger of his life, ifhe had a very low prognosis, that is, if his medical condition was so bad that he wouldprobably die even if allowed to receive care in an Israeli hospital. In contrast, PHR-Israelworkers succeeded in some cases in reversing a refusal by the authorities at the Crossing, ifthey could provide a medical opinion by an Israeli expert according to which the patientscondition was life-endangering, urgent and curable if treated at an Israeli hospital. It wouldseem, then, that if medical triage was performed, an important criterion for this triage would

be avoiding death caused directly by prevention of passage into Israel. Such a criterion could


3/3

3

explain the refusal to permit passage to patients with a low prognosis as well as the reversalof refusal in the case of a serious but salvageable condition.

It seems that the reason for this criterion is not medical but political and image-related. A hintfor this can be seen in the High Court of Justices intermediate decision from 20.6: we havebeen informed, first, that the policy is to avoid causing a humanitarian crisis, and therefore,

among other things, to treat patients in dangerous conditions.

The need of the State to present a humane image, coupled with selection principles which arenot medical and include a political, security-related or image-related agenda, is incompatiblewith the ethical principles and undertakings a doctor is committed to. The doctor is thusconfronted with a clear situation of dual loyalties and ethical conflict.

C. Reality on the Ground: Extra-Medical DecisionsAn analysis of the outcomes of the cases shows that medical triage, if it was indeedperformed, had almost no impact on the decision regarding entry. For example, severalpatients with leg injuries, apparently not in a life-endangering condition, were allowed to enterIsrael, whereas some cancer patients in need of lifesaving care, even if not of immediateurgency, were not allowed to pass. Other cases, which were neither urgent nor dangerous,

were permitted to enter. It seems that the final decision was made not according to medical orhumanitarian considerations but according to external considerations.

ConclusionThis analysis suggests that a doctor working on behalf of the military authorities and the civiladministration is not permitted to conduct or cooperate with triage performed by the military,since s/he knows that those not afforded a high priority will remain in Gaza, which lacksappropriate care, and that the reason for this is not a shortage of resources but externalconsiderations which have nothing to do with the medical profession. Moreover, in a situationin which the professional opinion of the doctor, as expressed through triage, is disregarded inpractice by the system, it is clear that the doctor may not cooperate in triage for that system.

PHR-Israel has expressed its position regarding the status of Gaza and Israeli responsibility

toward its inhabitants countless times. It has repeatedly stated that according to InternationalLaw the occupation of Gaza has not ended, and for this reason Israel bears full responsibility,as the Occupying Power, for the welfare of its residents, including the provision of healthcareservices.

Irrespective of the status of Gaza, Physicians for Human Rights-Israel states and warnsthat there is no medical-ethical justification for performing medical prioritization withinsuch a system, and that any doctor performing triage in the service of the ErezCrossing Authorities is in transgression of the principles of medical ethics, since s/heis conducting a pseudo-medical procedure out of non-medical motives, for extra-medical purposes and against the benefit of some of the patients. The only ethicalroute of action is to demand access to appropriate care for all those who need it.

physicians for human rights-israel: position paper israeli policies at erez crossing - gaza...

Documents