OPINION

 

When silence kills

 

 

'Every man is a social and political animal', Aristotle, the father of politics, tells us.^[1] It may not be immediately apparent to us why medicine and politics intersect and hold profound implications for humanity. Physicians are on the frontline of healthcare, bearing witness to the hardships and the many challenges in everyday life that their patients face.

 

The physician's role in society

Physicians are regarded as trusted experts in healthcare and are thus in a unique position to influence and direct policy decisions within the healthcare system. It is through engaging in politics that we can advocate for our patients in areas such as healthcare infrastructure, accessing treatment options, equitable distribution of resources and ensuring that human rights abuses are exposed and stopped.

Physicians also have specialised knowledge of medical ethics, and the intricacies of healthcare structures and policies. We are in a unique position to champion the causes of the poor, to reduce disparities in our society, regardless of socioeconomic status, race, or geographic location. We are also trained in evidence-based medicine, thus ensuring that policymaking decisions are grounded in scientific research and empirical data, rather than political expediency.

Physicians also have a role to play in a public health crisis, ensuring the safeguarding of the principles of autonomy, beneficence, non-maleficence and justice. Physicians have a social contract with society, with an understanding that policies that prioritise patient care are advocated for.

In order for us to fully embody ethical, sound moral judgements, we need to integrate our feelings, thoughts and actions in addressing bioethical dilemmas.^[2] English philosopher David Hume argues that to make ethical decisions, emotions and reason are important, providing a 'corrective role' in order to validate facts, side-stepping any prejudice in the choices we make.^[3] When our emotions are roused they can become 'upheavals of thoughts' and there can be no 'adequate ethical theory without an adequate theory of emotions'.^[4] Hume felt that reason alone was not enough to guide our actions, but the uncomfortable feelings of dissaproval or virtuous character traits give us a sense of what is morally good or bad.

 

Complicity in silence

So why have the medical community and academia been largely 'quiet' in regard to the war in Gaza? Why have we not protested en masse? Daily, we watch in horror as healthcare workers are targeted, as doctors work without essential medicines and resources, risking their lives for the population they serve. The lack of resources in Gaza has been documented as far back as 2014 in a report to UNRWA.^[5] Currently, the health sector in Gaza is at breaking point.^[6,7] There is a public health crisis!

Simultaneously, a vulnerable population has become collateral damage for political purposes, evident in the deliberate targeting of women, children and the elderly. The healthcare of an entire population is on the verge of complete public health collapse, with starvation and the spread of communicable diseases imminent.^[6] Aside from the obvious physical trauma, there exists a population that will be devastated by the long-term psychological trauma.^[8] I believe we have reached a critical point where it is beyond doubt; what the morally right thing is - it is just the right thing to do! It no longer is about being a virtuous person that requires an outcry, it is our duty and obligation.

The psychological scars will be challenging to heal,[9] on both sides.

In a correspondence article in one of our most distinguished journals, The Lancet ('The conflict in Gaza: a view from Israel') the authors, all doctors in Israel, tried to justify and provide 'the facts' for Israel's atrocities^[10] after a rehabilitation pain doctor in Gaza described the catastrophe that he witnessed.^[11] After a global call for healthcare professionals to sign an online petition, an open letter of this petition was submitted for publication^[12] but was rescinded at the last minute, and subsequently published in Social Medicine.^[13]

The silence is not only evident in relation to overt trauma but also in the lack of academic colleagues speaking out against these horrors. When they do, fear of being labelled 'racist' or 'antisemitic' for speaking out against apartheid-like policies persists.^[14] Academic censorship is evident in medical journals when certain topics are raised.^[14] Prestigious journals capitulate to powerful external lobby and political interests, overriding editorial and publishing policies. Academic meetings run by senior colleagues shy away from allowing anyone the opportunity to raise their outrage. The censorship of academics, researchers and clinicians has significant effects on patient care, suppressing evidence-based data and ultimately preventing the advancement of medicine that is just for all.^[15] Academic censorship fosters isolation in a rapidly changing society and impoverishes academic pursuits.

Where are the morality and ethics in medicine? Are we at a crossroads? Have we seen this type of bias before?

 

Nazi Germany and the Holocaust

It was during Nazi Germany, that the German medical fraternity overtly committed genocide, with many others complicit in their silence on the crimes committed by their leaders.^[16] The rest of the world was too. In fact, after the end of the war, scientists such as Herbatus Strughold were invited to continue their work in the United States, the USA conveniently ignoring his involvement in Nazi Germany in Operation Paperclip.^[15]

At what point in the face of tremendous trauma, suffering and death can we as physicians call out a nation's 'right to defend itself' a serious violation of human rights and a breach of humanitarian law?^[15,16]

Can we use the horror of the Holocaust in the context of the Israeli-Palestinian conflict? Is it comparable? The Holocaust helps us to gain further understanding. Avishai Margalit and Gabriel Motzkin (contemporary thinkers and Israeli philosophers) have provided arguments on what made the Holocaust unique: 'What is unique about the Holocaust is its particular fusion of collective humiliation and mass destruction. (...) Since the Nazis had a unique racial conception of their Jewish enemies as questionably human, they devised a unique fusion of humiliation and death in order to destroy them'. According to Margalit and Motzkin, 'the Jews were much less unique than the Germans,' and the theory and practice of the National Socialist genocide against the Jews combined to create a unique situation by which the Germans, 'more radically than anyone else in the last several millennia, (... ) denied the idea of a common humanity.'[17] It is signifcant that Margalit and Motzkin insist on the uniqueness of the Holocaust, while others construe it as inherently comparable with other events throughout history.^[18]

Can we ethically compare the Holocaust to the genocide of civilians in Gaza? There has been a de-emphasis on the uniqueness of the holocaust with its ongoing historicisation. Jean Amery, an Austrian essayist[19] profoundly affected by his experiences during WWII, views the Holocaust as part of a 'century of barbarism' and that with time, it will become indistinguishable from any other 'genocide'.^[20] As Gavriel Rosenfeld discusses, this ongoing scholarly debate is vital.[20] Are we doomed to repeat history? We may become desensitized to the extreme trauma. Indeed a 'century of barbarism'.

 

Is there genocide being committed in Gaza?

Genocide is defined as acts of crime against particular groups with an established 'intent' ('dolus specialis' ) to inflict harm on both the mental and physical wellbeing of a group, whether it be national, ethnical, racial or religious.^[20]

Gregory Stanton, a humanitarian rights lawyer, identified eight stages of genocide including classification, symbolisation, organisation, polarisation, dehumanisation, preparation, extermination and denial.^[21] By examining the policies pertaining to Palestine, and looking at the most recent attempts by Israel to dehumanise Palestinians, and to infringe on their rights of free movement and speech, in addition to the denial of other rights over the last 75 years, we can draw our own conclusions.^[22]

What is concerning is that, as the political rhetoric gains momentum, and we fail to speak out as a collective and unified medical body, we become complicit in further heinous crimes being committed. It has become acceptable, in full view of the global media, for Israeli ministers to label people as animals.^[23] By invoking religious sentiments and 'legitimising' a 'Holy War', the ethical boundaries in people's minds have become blurred and difficult to navigate.^[24,25] As physicians we need to ask ourselves if Palestinians deserve to enjoy the same access to water, sanitation, food, electricity and medical care. Is a Palestinian child a 'lesser' human being than any other child? Are our Palestinian medical colleagues a 'lesser' type of physician?^[26]

 

Apartheid in South Africa

South Africa's society was profoundly affected by its segregation policies, creating division and fear in all communities. Resistance fighters, in particular, Umkhonto we Sizwe, a paramilitary wing of the ANC, were responsible for increased levels of violence during the 1960s, against a vicious and oppressive government.^[27] The casualties during Apartheid, however, do not come close to the level of brutality in Gaza. It was with increasing sanctions and pressure from the rest of the world that a divided nation was forced to transform. After the end of Apartheid, South African society has been left with indelible psychological scars that will take generations to work through.^[27]

As South Africans, we know the hardships that we have experienced. We wish for no nation to go through the same struggles. It is hard. We had physicians complicit in crimes against our fellow black citizens during this dark period in our history.^[28]

We cannot remain silent as we witness the daily horrors that the people of Palestine are going through. Hospitals are bombed. Pregnant women undergo caesarian sections with minimal anaesthesia. A public health crisis emerges as children develop diarrhoea due to the lack of available drinking water. Gaza has never had potable water.^[29]

Our ethical obligation is to speak out, as much as possible. It is our collective responsibility, irrespective of our religious affiliations, philosophical views and political allegiance. We need to take an ethical stand against a brutal and vengeful state that has little regard for the most vulnerable in our society: the sick, the infirm, those with disabilities, the environment and the animals - all those that cannot speak out for themselves, who have no voice. During times of violence, not speaking up for the victim is the same as standing with the oppressor. Being neutral does not solve any issue but only ensures that the loud voices of the majority on both opposing sides are heard above everyone else.

 

A traumatised region

Approximately 80% of the population in the Middle East have been exposed to high levels of violence and trauma.

Kant claims that the authority of morality is always in conflict with duty and inclination, but our moral duty based on deontological rules should take precedence.^[29] Simply put - we all need to follow moral rules, regardless of any extenuating circumstance or desire. The categorical imperative is to treat people with respect, as an end of itself and not as a means to an end.

In a democracy, it is essential to have a robust discourse and that within medical academia we allow ourselves to feel, think, reflect and do what is morally right. My alma mater's oath is:

As a graduant of the University of the Witwatersrand, Johannesburg, I do solemnly declare:

That I will exercise my profession to the best of my knowledge and ability for the safety and welfare of all persons entrusted to my care and for the health and well-being of the community.

That I will not knowingly or intentionally do anything or administer anything to them to their hurt or prejudice.

That I will not permit consideration of religion, nationality, race, politics, or social standing to intervene between my duty and my patient.

That I will not improperly divulge anything I have learned in my professional capacity.

That I will endeavour at all times to defend my professional independence against improper interference.

That I will not employ any secret method of treatment, nor keep secret from my colleagues any method of treatment that I may consider beneficial.

That in my relations with patients and colleagues, I will conduct myself as becomes a member of an honourable profession.

I make this declaration upon my honour'

 

Empirical data

As discussed initially, a physician's role is to advocate for the poor, sick and vulnerable. It is the doctor's role to ensure that the basic provisions of medical care are advocated for and that justice prevails.^[30] It is our duty to expose the injustices that affect all people, using empirical data that does not lie.

The facts are that a terrible crime was committed against the Israeli people where 1 200 people were murdered and 250 people were kidnapped.^[31]

It is a fact that Israel is traumatised by the heinous acts of a few.^[32]

It is a fact that the Palestinian people have been subjected to horrendous living conditions, kept isolated and apart from the majority in Israel for the past 75 years.^[33]

It is a fact that Palestinians have been prevented from free movement and have had their land occupied illegally, for 75 years.^[34]

It is a fact that every Israeli lives with fear and anxiety because of the political tensions in the country.^[35]

It is a fact that Palestinians have high rates of depression, anxiety and PTSD in comparison with Israelis.^[8,9,36]

It is a fact that to date, Israel has bombed Palestine daily, killing over 30 000 people, with the majority being children, women and the elderly within a 4 month period.^[37]

It is a fact that hospitals, ambulances, journalists and first responders are being targeted and killed daily.^[38]

It is a fact that Gaza has run out of water, food, fuel and basic supplies after its supplies were cut off by Israel.^[39]

It is a fact that doctors are performing medical procedures with little anaesthesia and analgesics.^[40]

It is a fact that there is no safe place in Gaza.

The list continues...

Aristotle believed that abstract knowledge of ethics and politics is useless. Practical knowledge is only useful if we act on it. We must act appropriately if we are to be moral. He says in Ethics: 'The purpose of the present study (of morality) is not, as it is in other inquiries, the attainment of theoretical knowledge: we are not conducting this inquiry in order to know what virtue is, but in order to become good, else there would be no advantage in studying it.'^[41]

Is it ethical to keep quiet as physicians? Are we witnesses and accomplices to a genocide?

You be the judge.

S Fernandes

Divisional Head of Neuropsychiatry, Department of Psychiatry, University of the Witwatersrand, Johannesburg, South Africa

Sandra.fernandes@wits.ac.za

 

References

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