Saturday, May 21, 2005

How Do Israeli Physicians Deal With Terrorists?

From Normblog:

This is an article by Avraham Rivkind, Professor of Trauma Surgery at Hadassah Hospital in Jerusalem. It was sent to me by email, and as from the journal Care of the Critically Ill. I've been unable to find it online:

It was 3 am on a Saturday morning in April 2002 when my pager went off. 'Trauma call - report to emergency room' was the impersonal message. I struggled out of bed and left the house. The roads were wonderfully empty, a consequence of the early hour and the Sabbath. In Jerusalem, Saturdays still retain that religious aura and most shops remain closed. Buses don't run and by late morning, the streets are usually full of pedestrians on their way to synagogue or just taking a stroll.

It only took me a few minutes to arrive at Hadassah hospital where I work as the lead trauma surgeon. I was met by the senior nurse in the emergency room. 'Hello Professor, we have a 25 year old male, gunshot wound to the abdomen but the wound is 12 days old'. I start to examine my patient whilst thinking '12 days? Who waits 12 days with a wound like this?'

The patient is in a bad way. He is in septic shock and decompensating in front of me. 'Prepare theatre, we need to go now' I say to the resident. 'They are already waiting for us' he replies and with a wry smile he adds, 'do you know who this is Prof?' The patient's face is not familiar and I shrug.

'This is Hassan, from the Church of the Nativity'. Hassan was a member of Hamas and was wanted by Israel for masterminding a double suicide bus bombing in Jerusalem earlier in the year.

A few weeks ago, after a crippling wave of suicide bombings in which hundreds of Israelis had been killed and injured, the Israel Defence Forces had launched attacks on the terrorist infrastructure inside the disputed territories of the West Bank. A group of armed Palestinian terrorists had stormed the Church of the Nativity in Bethlehem, taking the monks there hostage and setting up for a 'last stand'.

The Israeli forces refused to be drawn into a situation which would likely have destroyed the Church and so a stalemate ensued. Hassan had been part of the group storming the Church and had taken a bullet in the initial fracas but his colleagues had refused to allow him out for 12 days. Only now had he been 'released' and here he was in my Emergency department.

I shrugged again, 'let's sort him out now and worry about that later' and off we went.

In theatre we found multiple small bowel lacerations, subcutaneous spread of small bowel contents as well as infestation with maggots. After surgery he was transferred to intensive care where he remained critical and after a short period it was deemed necessary to perform a tracheostomy.

Laws on consent are different in Israel and doctors must take 'all reasonable steps' to ensure that the family agree to any treatment not deemed immediately necessary. With this in mind we embarked on what turned out to be a 10 day quest to gain consent. The Israeli social worker contacted her Palestinian counterpart and much leg work was performed by all involved. This stage of the quest was not without risk and several covert meetings were required in dangerous locations. Full credit to both social workers for the individual risks that they were prepared to take.

Eventually, we received a hand written letter with the appropriate consent and the tracheostomy was carried out. Hassan spent 3 months on ITU, underwent 10 operations and was eventually discharged home after 11 and a half months in hospital. His medical bill was paid by the 'Friends of Hadassah' a Jewish charity group which collects donations from Jews all over the world.

Hassan's case is by no means unique. About a quarter of our patients are Arab and a significant number of these are from the Palestinian areas. Inevitably, we get terrorists brought in as well. We treat everyone as equal and patients are triaged according to clinical need.

Although this approach seems to be the only one that is ethical, there are some unique conundrums thrown up by situations like this. Hassan was on ITU with victims of his bus bombings and some of the relatives found that hard to deal with. (Remarkably, other relatives seemed to harbour no ill feeling at all.)

During his 3 months on the unit, we had many times when we were short of beds, usually due to another suicide bombing. Were we going to deny a victim of terror an ITU bed because that bed already had a terrorist in it? What about after he recovers? Do we arrest him and put him in prison? What happens if he goes back to mastermind another bus bombing?

After Hassan was out of immediate danger, some colleagues used to ask me why we couldn't transfer him back to a Palestinian Authority hospital for further care. The truth is that I really felt that the procedures he had undergone had been so complex and his course so stormy that he would be better served remaining under the care of the team that operated on him during his admission, so he stayed.

Hassan still comes for review at my clinic and is doing very well. The Israeli secret service now feels that he poses a minimal risk to Israeli civilians and as such have dropped the charges against him.

Were we right to put so much effort and resource into one life when that person had murdered so many of our civilians? Would the Palestinians or even the Arab world do the same for a wounded Israeli? Our experience with shootings, kidnappings and lynchings suggests otherwise.

Would other nations, if placed today in a similar state of war, afford such care to their enemies? Let's hope they never have to find out. As far as we are concerned, medicine is about the people who need to be treated regardless of race or religion. As doctors, we must just get on with the job in hand and leave justice to the judges.