In October 2023, the Hamas terrorist organization carried out a murderous attack on Israeli civilians and soldiers. Approximately one thousand and two hundred people were murdered. Among the victims were hundreds of young people who attended a music festival, while others were killed in their homes. Thousands were injured and over two hundred were abducted. 

These horrendous acts triggered an all-out military conflict that affected all the parties involved: Israelis and Palestinians, as well as both soldiers and civilians. In addition, the attack caused the Israeli health system to face a wide array of dilemmas in medical ethics. 

While solutions to peacetime ethical dilemmas are generally regulated by legislation and addressed by both professional organizations as well as Ministry of Health guidelines, wartime ethical dilemmas remain unaddressed and certainly not thoroughly thought through.

Accordingly, the ethical dilemmas that emerged on the Israeli home front were initially addressed by ad-hoc solutions, some of which were influenced by public opinion. It was only later that solutions conceived with medical ethics in mind were sought and adopted.

In what follows, we highlight several of the more unique of these dilemmas. 

Medical Treatment for Suspected Terrorists in Civilian Hospitals

In the aftermath of the October 7th attack, many people required medical care. The majority of these were victims of the attack, but some of the terrorists who perpetrated the massacre were also among those requiring treatment.

Caring for these terrorists in the same hospitals as victims provoked unprecedented public opposition. For example, after a rumor spread that terrorists were being treated at the Sheba Medical Center, hundreds of people rioted and scuffled with police and the hospital’s security personnel.

Protests held against the hospitals that treated suspected terrorists highlighted a series of ethical dilemmas: Can publicly funded Israeli hospitals refuse to provide treatment to suspected terrorists alongside victims? Where else can the suspected terrorists be treated? Who is responsible for treating suspected terrorists? Is it the Israel Defense Forces? The Ministry of Health? The Israel Prison Service? 

Initially, and following public pressure,The Minister of Health issued a directive to the effect that suspected terrorists were not to be treated in public hospitals.

It was only on 19 December 2023 that the Ministry of Health published official guidelines which stated that detainees suspected of being terrorists would receive medical care at a field hospital, staffed by military medical personnel. Under the new guidelines, the suspected terrorists can nonetheless still be transferred to civilian hospitals if their life is in danger, or if a physician determines they would suffer an irreversible disability.

Assignment of healthcare providers by ethnicity

After over 50 days of being held captive by Hamas in harsh conditions, 110 hostages were liberated (136 hostages are still in captivity). The liberated hostages were returned to Israel during a lull in the fighting and admitted to Israeli medical centers. Most of them were women and children who were severely traumatized by their captors, who were invariably men of Arab ethnicity. 

The Israeli public healthcare system routinely employs caregivers of different ethnicities, and many of these are Arab-Israelis. 

A unique ethical dilemma arose regarding the provision of medical care to liberated hostages: should they be treated solely by non-Arab-Israeli therapists in order to minimize trauma and make them feel protected? 

The Israeli healthcare system is committed to the principle of equality and denounces racism in routine practice[AB1] [SKF2] . Accordingly, Israeli public medical centers do not allow patients to choose their healthcare providers, and certainly not by ethnicity. 

The Ministry of Health, however, issued special guidelines for the treatment of liberated hostages on 25 October 2023.

More specifically, all hospitals were instructed to prepare a separate treatment facility, which was to be closed to all visitors and medical personnel except for appointed caregivers. There was no formal directive to avoid assigning Arab-Israeli medical staff to liberated hostages, but the ethnic origin of caregivers was considered in some cases in order to avoid exacerbating trauma and hindering recovery.

Posthumous Sperm Extraction for Fertilization Purposes

The large number of deaths of men of reproductive age, and specifically those who did not have a spouse at the time of death, sharpened the longstanding Israeli ethical and legal debate on posthumous sperm extraction and use.

The desire of relatives, parents, or spouses to preserve the memory of the deceased through the conception and birth of their descendants, is human and understandable, and all the more so in the pro-natalist Israeli culture.

However, this desire also raises concerns regarding the deceased’s dignity, autonomy, and wishes:was this the deceased’s wish, or are his relatives acting of their own accord? which of the deceased’s relatives is the most qualified to assess his wishes?

Furthermore, and with respect to the future child’s welfare, is it healthy for a child to be born into such a familial and social context, where she or he is an orphan without a father and may serve as a living shrine to a father she or he never knew?

In the aftermath of the Hamas attack, it rapidly became apparent that the Israeli healthcare system was facing an unusually high number of sperm extraction requests[AB5] [SKF6] . Indeed, dozens of inquiries concerning sperm extraction were received by Israel’s medical centers in the first week after the attack alone.

In order to alleviate the families’ stress – echoed by both the attending personnel and the media – the Attorney General of Israel issued a temporary order on 10 October 2023, which states that parents’ requests for sperm extraction will be granted without requiring prospective court approval. This arrangement was previously applied to spouses’ requests alone.

Since sperm extraction must be carried out within a limited time window, waiving court approval allowed the procedure to be completed more rapidly and thus in more cases. Nonetheless, the order precluded the attempt to establish the deceased’s wishes. 

Subsequently, a law to regulate this issue is presently being deliberated in the Israeli parliament.

War Exacerbates Dilemmas

The scope of the right to medical treatment, the right to autonomy, and the commitment to beneficence and equality all present dilemmas during routine times. War, however, exacerbated these dilemmas.

Specifically, the right to medical treatment is challenged when victim and attacker cannot be treated near each other; autonomy in posthumous sperm extraction is challenged when invasive intervention is required urgently on a high number of deceased with no known explicit desires, and the obligation to denounce racism is challenged when sensitivity is required in the treatment of victims of violence.

As there was no policy governing such issues in the Israeli civilian health care system during wartime, ad hoc decisions were made that sometimes deviated from law and medical ethics. There was a violation of the commitment to beneficence when public hospitals refused to treat terrorists; there was a violation of the principle of autonomy when no attempt was made to find out the wishes of the deceased with regard to posthumous sperm extraction, and appointing non-Arab practitioners to treat hostages who returned to Israel could be perceived as racism.

In times of war, law and ethics are still binding, and preventing their violation requires advance thinking about solutions to ethical dilemmas that may arise.

These ethical dilemmas should not be resolved by creating new ethical guidelines, but by adapting existing guidelines proactively while taking public concerns into account.

Dr. Shelly Kamin-Friedman, Department of Health Policy and Management, School of Public Health, Faculty of Health Sciences, Ben-Gurion University of the Negev, Israel 

Dr. Maya Peled Raz, Department of Bioethics, The School of Public Health, Faculty of Social Welfare and Health Sciences, University of Haifa, Israel  

Dr. Nili Karako-Eyal,The Haim Striks School of Law, The College of Management (Academic Studies), Israel

*We declare no conflict of interest.