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A New Policy Raises a Moral Dilemma

In Israel there is an important organization known as the Israeli Medical Association (IMA), which is the Israeli equivalent of the American Medical Association. The IMA is the official organization representing Israel’s physicians and acts as an independent, apolitical, professional organization, which seeks to advance the cause of physicians and medicine in Israel.

The IMA Ethics Bureau is the only organization in Israel establishing standards of medical ethics for medical professionals.  Accordingly, the standards that it sets out has a significant influence on the medical field in Israel.

In 2008, the Ethics Bureau formulated guidelines for procedures in the aftermath of terrorist attacks that instructed EMTs to treat all the victims of an attack first, before the attacker, in line with the halachic rule of, “The poor of your city come first.”

Recently, as a result of an ongoing effort by the Physicians for Human Rights-Israel (PHR-Israel), a dramatic change has been made in the IMA guidelines. PHR-Israel argued that the 2008 guidelines seriously contradict medical ethics and humanitarian law principles of the international community. After a lengthy debate, the IMA has directed that medical teams must provide medical care to victims at the scene of a terrorist attack, including the terrorist perpetrators, according to the severity of their injury. Such a standard could theoretically include a scenario in which a terrorist could be treated before a victim.

Dr. Tammy Karni, chairman of the IMA Ethics Bureau, explained that “the reason for changing the rule is that doctors are not judges. The meaning of keeping the directive intact was to tell the doctor to investigate who is to blame and punish them by denying care. In a multiple-injury event it’s very easy to make mistakes in identification, and the treating physician clearly can’t do a precise identification of the victims. The doctor must be focused on saving the lives of as many people as possible. It isn’t decent to add to the doctor’s triage task criteria that are unrelated to the health of the casualties.”

In his practical experience, Eli Bein, the general director of Magen David Adom, adds "...the moment you see a wounded person you treat them, we don't check who the victims are. Unfortunately the terrorists are doing awful things to innocent people. At the same time, I don't have the privilege to come and sort out the wounded - the rule of Magen David Adom is to treat the most seriously wounded person who is in life threatening danger."

Understandably, this position has caused quite an uproar.  Rabbi Yuval Cherlow, head of the Religion and Ethics Department at the Jerusalem Center of Ethics, claims, “The problem with the position of the IMA is that they said there should only be one factor that the doctor or medical crew should use when they answer an emergency call, and that factor is the medical situation of all the injured people in an emergency. I think that position is wrong ethically because first of all, medical staff cannot be expected to only use one factor in determining which patient to treat first. But more specifically, the IMA’s standard makes no distinction between the attacker and the innocent people, or the terrorist and the victims. If it’s clear who the terrorist and victim are and there’s only one doctor, the doctor should first take care of the victim and not the terrorist even if the terrorists’ medical situation is worse.”

This debate raises a very serious moral question that could potentially face medical professionals by equating the treatment of the perpetrator to that of his or her victims.  This places doctors, nurses, and EMTs alike in a difficult moral conundrum. Thankfully, Jewish law has built-in parameters that should prevent such a scenario from arising. In a situation where an individual is attempting to kill another person, Jewish law advocates doing whatever is necessary to prevent them from doing so, even if it means taking his or her life. Therefore, in a situation, G-d forbid, where a terrorist is trying to commit an attack, a person can do whatever is necessary in order to stop them. As a result of this halacha and the continued dedicated efforts of security forces to prevent and neutralize such attacks, doctors will hopefully not be forced to address this difficult moral dilemma.