The victim or the terrorist: Who gets treated first?
The Jerusalem Ethics Center recently discussed the explosive issue of terrorism and how medical personnel set their priorities.
By JUDY SIEGEL-ITZKOVICHMagen David Adom paramedics evacuate victims from the scene of a stabbing in Kiryat Gat, November 21, 2015(photo credit: MAGEN DAVID ADOM)
In a world stricken by senseless terrorist attacks, it seems that only Israelis – coping for the last five months with a seemingly endless supply of young Palestinian attackers equipped with knives, guns, vehicles and rocks – are debating among themselves the medical ethics of terrorism.If an attacker is seriously wounded by police or soldiers and there is a possibility that his or her life can be saved, do paramedics and medics or hospital doctors treat the attacker before the victims who are less seriously injured? It is very often a theoretical exercise, especially in hospitals, and occasionally realistic in the field. But the subject raised blood pressure levels among the speakers and the nearly 200 people in the audience earlier this month in the Jerusalem Ethics Center at Mishkenot Sha’ananim.“We are seeing a flowering of ethics discussions in all of its aspects,” noted ethics center director Daniel Milo from the outset.“Fifteen years ago, one didn’t hear any of it. We don’t only talk; we try to implement ethical principles. There are organizations that talk but don’t do anything about it,” he continued.“I am optimistic that in the long term, our culture of values will be stronger. We decided to deal with this difficult medical ethics subject that is relevant almost daily.”Some in the audience objected to the illustration specially drawn for the event: a doctor treating a heavily bleeding terrorist on the ground while a mother demands that her son, who has a scrape on his arm, be seen first.They argued that a terrorist attack does not involve such a comparison.PROF. AVINOAM Reches, a veteran Hadassah University Medical Center neurologist, recalled that as a medical student in 1967, he witnessed a wounded Israeli paratrooper giving water to a more seriously wounded Jordanian being treated in the hospital.“Today, however, we are not talking about enemy prisoners of war, but about terrorists,” said Reches, who is a former longtime chairman of the ethics bureau of the Israel Medical Association (IMA) is today in charge of medical ethics at the Jerusalem Ethics Center.”Last year, Reches said, a mock trial was held at Ashkelon’s Sapir Academic College involving actors, doctors and lawyers playing a scenario: a Jew was murdered by a terrorist, who was shot by the police. The physician at the scene saw the terrorist was in serious condition while another Jew was thought to have been moderately wounded. The terrorist was treated first, Unfortunately, the Jew died in the hospital because the medics had not realized he had actually been very seriously hurt.
The student audience voted before the discussion but not after hearing the arguments, Reches added. Seventy-five percent voted that the Jewish victim should have been treated first, while the rest said the decision should have been made according to who had been more seriously wounded.Taking the second position, that the terrorist in serious condition should be treated first – which is the position of the IMA and the national ambulance service Magen David Adom – Reches wrote about the theoretical case in the [left-wing paper] Haaretz.The response of readers was near unanimous against his views, “and that was in Ha’aretz – not in [the right-wing] Yisrael Hayom,” Reches noted.“Philosophers agree that thou shalt not murder; the value of life is universal; one must not hurt one’s fellowman unless he hurt you; an attacker can in many cases be shot in the legs to stop him. Beyond that,” argued the neurologist, a doctor can’t punish. Only the judiciary can do that. The subject is very explosive.”He added that he had invited Israeli Arab directors of hospital emergency rooms to attend the event, but “they felt uncomfortable discussing the issue, and they declined.”PROF. ERAN Dolev, of the department of nutritional sciences at Tel Hai College in the Upper Galilee was the head of the IMA’s ethics bureau before Reches. He also taught the history of military medicine at Tel Aviv University and was chairman of an internal medicine department at Tel Aviv Sourasky Medical Center.“It’s easy to be a philosopher. Using logic, you can reach any conclusion, but you have no accountability. A physician has responsibility and is judged by what he does and the result in his patient. We deal with life and death, health and disease and preventing suffering,” said Dolev.Until the 19th century, there were no mass attacks, said the professor. Armies were small, and weapons did not cause mass destruction.Dominique Jean Larrey, a French surgeon in Napoleon’s Grand Armée and an important innovator in battlefield medicine and triage, established the idea of time in medical treatment, Dolev said, and he is often considered the first modern military surgeon.“He introduced the ‘Golden Hour’ in which injured patients have to be treated. Today, we deal with triage in mass catastrophes. The first people we treat are those in immediate danger of death who can benefit from urgent care.There are sometimes errors – people who are regarded as hopelessly injured, yet walk out of the hospital the next day. It can be a ‘miracle,’ or more likely, a mistaken diagnosis.”Dolev remembered his own “hardest decision."On the first day of the Six Day War, he encountered an Israeli soldier he knew personally who was burnt over 90% of his body. I helped evacuate him under fire, and I gave him morphine, but I was sure that he could not be saved. So instead, I treated three other soldiers who were bleeding. Today, I know that almost 50 years ago, my decision was correct, and I told that to his parents in his kibbutz. But I still feel his eyes on my back.It was my most difficult decision as a doctor.”It is a slippery slope if doctors decide according to irrelevant criteria whom to treat first, said Dolev.“On the fourth day of the Six Day War in Suez, I remember that four of our soldiers were wounded, and one died. Wounded from both sides of the war came to the hospital. The leg of an enemy soldier was detached, and we treated him. I recall a soldier saying: ‘You are treating a man who killed our soldier.’ I said that we all have a role. You soldiers have to fight the enemy. You didn’t succeed, because the Egyptian soldier wasn’t killed. Now it is my role to treat the wounded, including the enemy.”He related that in the war with Egypt, an Israeli fighter pilot was shot down, and an Egyptian saved him from a mob at the site. He took him to the hospital where the soldier’s leg was amputated. They made a effort to get him to Israel via a third country because they knew medicine was better in Israel. The pilot survived, studied medicine and became a specialist in otolaryngology.”Dolev said that the dilemma occurs in nonwar situations as well.“If a man hurts his wife and she’s bleeding, but he is hurt more seriously, their children demanded that their mother be treated first, because he was the attacker. The doctor didn’t listen.”There is a lack of agreement in Israeli society, Dolev concluded. If he Knesset were to decide that a doctor has to treat a Jew first even if he were not the most seriously hurt, I would ignore the law. There are some situations in which it’s worth breaking the law.”Dr. Tami Karni, an Assaf Harofeh Medical Center surgeon and the current head of the IMA’s ethics bureau, remembered when Israel controlled Gaza and there were wounded every day. A Gazan stabbed a soldier in the back and then was hit with a bullet in his neck. Both ended up at Sheba Medical Center.The wounded soldier pulled back the curtain and said: “That is the man who stabbed me in the back!” Karni treated both and stabilized both at the same time. Both survived.I didn’t know then the international code of ethics of the World Medical Association, but I knew then that I had to be concerned about each patient’s personal interest and respect human life.”BUT RABBI Yuval Cherlow of the moderate Orthodox organization Tzohar, who is also head of religious ethics at the Jerusalem Ethics Center, had a different view.“I could have started my talk by saying: ‘You have fallen on your head!’ We are not debating whether the doctor is a judge and if one has to treat a terrorist, but in a situation with limited resources, in which the decision to treat one can harm the other. A person who was attacked, Jew or not, and is at risk of losing a leg but not at risk of death, should be treated before the terrorist who is more seriously injured. If the attacked were at risk of losing a finger, it would not be the same.”Cherlow, who voluntarily served as a member of the “health basket committee” recommending the addition of new medical technologies, recalled an argument that people who got sick because they neglected their own health, as by smoking, had lower priority in getting drugs than people who did not harm themselves.“It was a dilemma. I could argue both sides, but in the end, I voted against any discrimination.In the case of a terrorist, I am not saying the attacker should not get medical treatment, but if the attacked was injured, even not fatally, that party should get care before the attacker.”YEHUDA MESHI-ZAHAV, the ultra-Orthodox chairman of the rescue organization ZAKA (disaster victim identification and rescue) agreed with Cherlow “almost completely.We don’t have to apologize to anyone. The attacked person, whether a Jew or an Arab, should get treatment first, even if that person is less injured than the terrorist.”A few weeks ago, the search-and-rescue group received recognition from the UN Committee on Non-Governmental Organizations and received official observer status.“Representatives from 19 countries discussed us. We were asked whether we treat Jews before non-Jews. I said no; we treat the victim before the murderer. The Iranian representative understood this too, and he voted for our recognition. They all understood this, and it was unanimous. Why should it not be clear to us in Israel? We should stop listening to the phony ethics of the world.”DR. ELI Yaffe, head of MDA’s training division, said that dilemmas here are very complex.“I remember being in the London Underground when a giant fire truck arrived to deal with a lot of smoke. No one went in. They waited for their commander, who checked to make sure their gas masks were all insulated.Here, MDA personnel rush in with the bomb squad; we are endangered and know that terrorists want to kill us, too. Ambulances are sent even before the police arrive, and we often have no protection. No two terrorist attacks are the same. Theoretically, one can say who should get treatment first, but life is not simple. We did a survey, and most MDA volunteers said they would take care of victims and terrorists according to medical urgency. The majority also were willing to risk their own lives to save others.”DR. OFER Merin, a veteran surgeon and head of Shaare Zedek Medical Center’s trauma center (as well as deputy director-general of the Jerusalem hospital) recalled the case of a 20-year-old woman terrorist who was treated in his trauma room. “Priorities are set according to who is most seriously hurt. I was called ‘crazy’ for treating the terrorist first, but she was not treated at another’s expense. Nobody on the staff knew at that point that she was a terrorist; we just took care of her. There is often confusion, and one doesn’t always know for sure if a person is a terrorist or an innocent bystander.”He recalled the recent case of two Palestinian teenage girls who attacked bystanders near Mahaneh Yehuda. One was shot and killed, and the other was brought to his hospital.A surgical nurse arrived late to the operating room and joined the surgery. I was proud that it was carried out as usual, and nobody knew that the girl on the table was the terrorist,” Merin said. “We speak of the ethical issues after almost every terrorist attack.”But Merin, who for a decade has been commander of the IDF’s mobile hospital at mass catastrophes abroad, said priorities can be different abroad.“We couldn’t treat all of those hurt in the Nepal earthquake, and if we learned of an Israeli soldier hurt in a road accident, we would give him priority and treat him.”