The following scenario isn't even imaginary. These days, it could happen at any time. Picture this: An Israeli doctor arrives at the scene of a multi-casualty terrorist attack. There's a shortage of medical personnel, and not too much equipment. What should he do? Treat the wounded strictly according to the severity of their injuries, meaning that the most seriously hurt is treated before anyone else? And what if that happens to be the terrorist who carried out the attack? Should the doctor treat him (or her) first, too? Or should the doctor first care for the victims of the attack, and only thereafter treat the attacker? The Ethics Board of the Israeli Medical Association formulated a guideline that was supposed to answer these dicey questions, and that was in place until very recently. The regulation stipulated that "charity begins at home" -- that is, in a case where personnel or equipment are in short supply in a multi-casualty terrorist attack, the victims should be treated before the terrorists. But a week ago, a change was made to the medical ethics regulations, and it was decided to eliminate that instruction. The only rule that remains in place is the one that decrees that the wounded must be treated according to the severity of their condition and ability to survive, and no other criteria. The announcement about the revocation of the previous rule appeared on the IMA website, but without any voluntary publicity among the general public. The IMA was apparently concerned about widespread political and ethical criticism of its decision, which was made right in the middle of the wave of terrorism that started in September of this year, in which 22 Israelis have been killed and 347 have been wounded, including victims of shock, according to figures from Magen David Adom. The decision, which was reported this week for the first time in Israel Hayom, caused controversy, as expected, and sparked harsh responses. One such came from Rabbi Yuval Cherlow, who heads the ethics division of the Tzohar rabbinical organization. Cherlow knows the issue of medical ethics first-hand; he is a member of the Supreme Helsinki Committee on Medical and Genetic Experiments Involving Human Subjects, and formerly served as the public's representative on the National Conference to Expand the Medical Basket. "The dramatic new instructions are a serious mistake," Cherlow says. "The wounded at the scene of a terrorist attack should always be treated first, and only then the attacker. Only in special cases, in which it can't be determined who the terrorist is and who the victims are, should medical treatment be given to the most seriously wounded first." According to Professor Asa Kasher, a renowned philosopher and ethicist who wrote the Israel Defense Forces' code of conduct, "The immediate example that comes to mind is the difference in battlefield triage, which has to account for things beyond pure medical considerations, like sending soldiers back to their units as quickly as possible. "The same goes for the scene of a terrorist attack. You can't run it according to pure medical considerations -- that's just out of the question. Say you have two people seriously wounded, the terrorist and a victim. The terrorist's wounds are slightly more serious than the victim's. Would you treat the terrorist before the victim? That's unthinkable. There is more to the scene of a terrorist attack than pure medical considerations -- as there should be. What are we supposed to tell a victim's family if he dies because we treated the terrorist first? That we're sorry, but we had no choice but to treat the terrorist first? That's absurd." The rule of providing treatment "beginning at home" in a terrorist attack, which was retracted this week, was part of the instructions for a multi-casualty attack the IMA Ethics Board issued in 2008. The instructions were compiled by a group of doctors that included Professor Pini Halpern, head of the emergency room at Tel Aviv Sourasky Medical Center and one of Israel's leading experts in emergency medicine. And indeed, according to Halpern, it is a mistake to drop it. Instead, he argues, a discussion should have been held that would have led to detailed guidelines for the treatment of the enemy. "In the situation of a multi-casualty incident, where there is also an extreme lack of personnel or medical equipment, of course it would never occur to me not to treat the terrorist attacker or to give substandard treatment. But in a situation where a decision has to be made about whether one of the wounded lives or dies, it's right to treat "your own" first -- that is, the victim of terrorism, whether [they are] Jewish or Arab -- and only then the enemy who carried out the terrorist act. The Ethics Committee should have outlined the duties derived from the 'charity begins at home' principle rather than revoke it completely and leave the issue of treating the enemy during a mass-casualty event unaddressed," Halpern says. Most, not best The Ethics Board of the Israeli Medical Association is the place to turn to with dilemmas like these. It is the only entity in Israel charged with setting ethical standards for the nation's doctors and paramedical personnel, including paramedics, medics, nurses, etc. The standards for medical ethics are determined by the Ethics Board according to field and subject, and in 2008, the binding guidelines for multi-casualty scenarios were coalesced by a team of doctors led by Halpern and Professor Pierre Singer, head of the Intensive Care Unit at Rabin Medical Center in Petach Tikva. The 2008 regulations define a multi-casualty scenario as a catastrophic event that wounds a large number of people in a time of war, armed struggle, terrorism, or civilian disaster. A multi-casualty scenario is characterized by doctors' lack of ability or resources to do the utmost to save the lives of all the wounded. The professional guiding principle is "do the most possible for the most wounded," not "the best for everyone." In such a situation, doctors perform triage for treatment and evacuation, something that necessarily carries the potential that not all of the wounded will receive the best possible treatment, and could lead to some dying or being disabled. The event also involves non-medical actors such as family members, onlookers and members of the police and the media, "whose contribution to the mission of saving lives is minor, and sometimes even negative or interferes." The regulations also determine that in a multi-casualty scenario the doctor performing triage decides on the triage policy according to the circumstances. The first priority is to treat the wounded who are in immediate mortal danger but can apparently be saved; the second priority is the wounded who need immediate treatment, even if it is not life-saving; the third priority is to care for the wounded whose treatment can be put off for a time without causing harm; and the fourth priority is to care for the wounded deemed have the lowest chance of being saved given their injuries, the place and conditions. The regulations make specific reference to a multi-casualty incident related to terrorism: "In cases of human violence that causes wounded among the perpetrators of that violence [the enemy], obligations toward those perpetrators should be determined explicitly. Here, the principle of 'charity begins at home' should be applied." This regulation was accepted and ratified by the Ethics Board, but since 2008 it has not provided detailed recommendations about how to implement it toward terrorists who are wounded in an attack they themselves commit. The danger of devolution In October, a change took place after members of Physicians for Human Rights contacted IMA Chairman Dr. Leonid Edelman and IMA Ethics Board Chairwoman Dr. Tami Karni. Their demand: Cancel the "charity begins at home" clause in the regulations on treating terrorism victims. Physicians for Human Rights argued in a letter that they were convinced that the principle went against the ethical principles that have guided the medical community until now. The authors also noted that their examination of international humanitarian law prohibited giving priority when providing treatment other than that mandated by medical need, and that the group to which the person needing treatment belongs is irrelevant. They said the code of the World Medical Association orders doctors to provide treatment without discrimination even against an enemy, and determines that doctors are required to refrain from acts of retribution against wounded and patients. The authors also note that they had not found anywhere in the world regulations similar to the "charity begins at home" principle of the IMA Ethics Board. "It is not part of the medical team's job to be investigators, judges and bailiffs," the letter argued. "Principle notwithstanding, the horrible results of the murder of asylum seeker Haftom Zarhum [in the terrorist attack at the Beersheba central bus station in October] are enough to show the risks of such devolution. The eroding of the principles of medical ethics and bending them to political voices and public sentiment -- as hard as it might be -- are the beginning of the end of medicine as we would like to see it, a place where anyone needing treatment is merely a patient. Given all this, we would thank you if you would re-examine your position. Leaving the position paper as it is currently phrased is a serious violation of medical ethics, a contradiction that has concrete, fateful ramifications. We ask that you publish your corrected stance for all the doctors in the country to sharpen professional conduct in light of the current challenges we face today." An unfair obligation Following the appeal by members of Physicians for Human Rights, the Ethics Board held a discussion on Dec. 1. At its conclusion, a decision was taken to accede to the organization's request and cancel the "care for your own" clause entirely. According to Ethics Board members, most members agreed with the decision. One was Dr. Yisrael Eiling, chairman of the doctors' committee at Soroka Medical Center in Beersheba and a senior anesthesiologist at the hospital. "There was a mistake in the ethical regulations, because all our lives we've operated according to medical priority. So we decided to change the ethical guidelines, and there was agreement," Eiling said. During the discussion, Eiling described the treatment Haftom Zarhum, an Eritrean national, received at Soroka after he was lynched. He said he found that even after the patient was in the operating room, the police still believed he had carried out the terror attack. Considerable time passed before he was positively identified. "Even when we thought he was the terrorist, we treated him at Soroka with love and all our hearts, just like we treat anyone. When you're treating [a patient], you try to ignore your feelings or leave them until later," Eiling said. Did you really treat someone you thought was a terrorist with love and all your heart? "Yes. At Soroka we treat wounded people who come in from all over the region, including residents of Gaza, employment seekers from Sinai, smugglers, drug dealers, car thieves, and other violent people. And all this alongside a population that has no criminal or negative background. We treat them all with love and give them the best we can," Eiling says. Karni, a senior surgeon at Assaf Harofeh Medical Center and chairwoman of the Ethics Board, also justifies the decision. "The quote 'care for your own first' isn't appropriate here," she told Israel Hayom on Tuesday. "If we look it up in the [biblical] source, we understand that prioritizing requires clarifying a person's place of residence and his economic situation before starting treatment. "That's one more task for doctors in an already busy situation. Doctors aren't judges. Leaving the directive as it is means doctors have to determine guilt and penalize the guilty party by withholding medical care." According to Karni, "It's very easy to make mistakes when dealing with a mass-casualty event, and a doctor at the scene cannot be expected to pinpoint victims' identity -- he has to focus on saving as many lives as possible. It's unfair to burden doctors with additional triage criteria that have nothing to do with patients' welfare." Besides, she says, "international conventions -- such as the Geneva Convention -- address situations of war, in which it's clear which army or state people belong to. But in situations of terrorists, or lone wolf terrorists from a population in the same country, there are no conventions. The role of every citizen, and doctors too, is to bring the person to a police investigation and to trial, not to violate the law or judge him themselves." The story might be over, but it's not done with. As a result of the Israel Hayom report, there have been calls for the IMA to reverse its decision, and reopen the discussion in light of the ongoing wave of terrorism.
