Opinion Editorials, August 2007

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

By Physicians for Human Rights - Israel

PHR, August 25, 2007  

Background

The second week of June 2007 witnessed an escalation of armed clashes between Hamas and Fatah forces in the Gaza Strip. Between the 12^th and the 17^th of 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 14.6 Erez Crossing into Israel was also closed by the Israeli authorities. As a result, access of the sick and wounded to treatment unavailable in Gaza was completely blocked.  

On 19.6 Physicians for Human Rights-Israel (PHR-Israel) and “Gisha” Center submitted a petition to the Israeli High Court of Justice, demanding the opening of the crossings to the sick 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 partial functioning, but a significant tightening of policies was recorded. The State now claims that Israel bears no legal responsibility towards the inhabitants of Gaza , and states that the passage of the sick and wounded will be enabled as a humanitarian gesture only. In addition, for the first time the State has made a pseudo-medical distinction between danger to life and danger to “quality of life”. In practice, this will mean that patients in danger of losing a limb 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 it handled between the 14^th of June and the 4^th of July 2007 .  

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

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

Discussion

According to information given to PHR-Israel by the security authorities, the security apparatus conducts a process of classification based on medical and other criteria before deciding who will be permitted to enter Israel . For this purpose the military consults with medical personnel. Assessment and classification are based on medical documents sent by fax 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 is no permanent assessment process, and that classification, if it is indeed conducted, is conducted in an inconsistent manner, not always by doctors, and not according to ordered medical 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-medical considerations. The analysis below aims to examine the classification procedure, whereby accessibility 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) within the decision-making process at Erez Crossing.  

A. Israeli Policy: Life not Limb

In its response to the High Court of Justice in June 2007, the State of Israel made a distinction 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 be permitted to receive care in Israel , has no medical justification, since the reason for this limitation is not the lack of appropriate medical resources. Accordingly, from a medical ethics perspective, a doctor is not permitted to assist in such a process, which denies access to care. The State, for its part, has no right to oblige doctors to participate in medical triage subject to this unjustified criterion.  

B. Medical Triage

Triage is conducted in emergency medicine in Israel and internationally in cases of overload and bottleneck situations, in order to determine urgency and priority. Whereas the objective of medical triage is to determine priority and urgency rather than the actual eligibility for care and access to care (priority vs. accessibility), in our case, triage, if used, clearly determines eligibility and accessibility.

Triage in extreme cases of shortage, such as multi-casualty crises, natural catastrophes and the like, includes “renouncing” the most severe cases, which have a low prognosis, demand many resources and may block the medical system at the expense of a larger number of casualties who may be saved. Such a decision is made by definition only in extreme cases of shortage, usually during preliminary stages, and with the intention of transferring additional resources 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 of resources.  

It is hard to conclude from the data we have that “stringency-triage” is actually performed in Gaza . 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, if he had a very low prognosis, that is, if his medical condition was so bad that he would probably die even if allowed to receive care in an Israeli hospital. In contrast, PHR-Israel workers succeeded in some cases in reversing a refusal by the authorities at the Crossing, if they could provide a medical opinion by an Israeli expert according to which the patient’s condition was life-endangering, urgent and curable if treated at an Israeli hospital. It would seem, 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 explain the refusal to permit passage to patients with a low prognosis as well as the reversal of 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 hint for this can be seen in the High Court of Justice’s intermediate decision from 20.6: “we have been 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 are not medical and include a political, security-related or image-related agenda, is incompatible with the ethical principles and undertakings a doctor is committed to. The doctor is thus confronted with a clear situation of dual loyalties and ethical conflict.  

C. Reality on the ground: Extra-Medical Decisions

An analysis of the outcomes of the cases shows that medical triage, if was indeed performed, had almost no impact on the decision regarding entry. For example, several patients with leg injuries, apparently not in a life-endangering condition, were allowed to enter Israel , whereas some cancer patients in need of lifesaving care, even if not of immediate urgency, 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 or humanitarian considerations but according to external considerations.  

Conclusion

This analysis suggests that a doctor working on behalf of the military authorities and the civil administration 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 lacks appropriate care, and that the reason for this is not a shortage of resources but external considerations which have nothing to do with the medical profession. Moreover, in a situation in which the professional opinion of the doctor, as expressed through triage, is disregarded in practice 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 International Law 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 healthcare services.   

Irrespective of the status of Gaza, Physicians for Human Rights-Israel states and warns there is no medical-ethical justification for performing medical prioritization within such a system, and that any doctor performing triage in the service of the Erez Crossing Authorities is in transgression of the principles of medical ethics, since s/he is 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 ethical route of action is to demand access to appropriate care for all those who need it.

Opinions expressed in various sections are the sole responsibility of their authors and they may not represent ccun.org.

editor@ccun.org