response to 'First, Do No Harm' - A matter of medical ethics alone

To the Editor

Defenders of the Israeli Medical Association and Dr Yoram Blachar may be quick to claim that “cynical manipulation characterizes the broader campaign against Blachar” but there is no evidence that it the case. I signed the petition because I believe there is a simple question to be answered - Is the professional leadership of a global medical body an appropriate position for Dr Blachar? I believe not, and I outline the reasons below. There is no sinister agenda, no anti-semitism at play, no hatred for Jews and no cyncism – only medical ethics at stake. It is important that readers of Forward realise that, and not be led astray by unfounded and often inflammatory allegations to the contrary.

Dr Blachar has been in a leadership position in the IMA since 1995, during which period the IMA has failed to act against reports of medical complicity in torture. Instead of initiating their own inquiries, the IMA and Dr Blachar have repeatedly asked for others to present ‘evidence.’ And, even when presented with such evidence by various human rights groups, the IMA and Dr Blachar have not taken proactive steps to investigate or remediate the situation. Ironically, it is human rights NGO’s in Israel, such as Physicians for Human Rights-Israel that have had to take on this responsibility, with far less power and access to resources than the IMA. PHR-Israel, I am informed, in its recent efforts to investigate cases, is typically given partial files with no registrations from the period of investigation by the authorities.

The IMA has not used its standing in Israel and relative power to gain access to the information that is critical for investigating and preventing cases of torture and medical complicity. Yet, this is exactly what many human rights groups and professional bodies expect of national professional associations and it is exactly the standard that was applied in criticising medical bodies in South Africa who refused to investigate allegations of torture and human rights violations under apartheid. Having lived through a period in South Africa where black peoples’ lives were dispensable because medical professional organizations did not have enough ‘evidence’ to act, I am convinced it is not enough to stand back and wait. It is this leadership upon which Dr Blachar should be judged, since he is now assuming global leadership of the medical profession.

A lot is made about Dr Blachar and the IMA writing letters to Israeli military authorities to restate what are existing international ethical guidelines, which have been cited as evidence of the IMA’s compliance with international norms. This is the most passive form of action and it is easy to understand why such actions are ignored by the security forces and have had little effect. In South Africa under apartheid, the then Medical Association of South African (MASA) established medical panels for detainees in response to allegations of torture by security forces and made much of these panels in national and international counterpropaganda to combat criticisms of apartheid. But, as confirmed at the Truth and Reconciliation hearings in 1997, these were token structures set up to deflect criticism of the MASA when human rights bodies in South Africa were begging them to take more proactive steps. By its own admission, such steps were designed to protect the Association from criticism rather than the victims of human rights violations of security forces.



Why do I say that it is not enough to simply pronounce yourself opposed to torture? In the late 1980s, I was working as a doctor in a rural part of South Africa and attended to a black activist who had been most horribly tortured under interrogation during his detention some months previously. He told me how, in a semi-conscious state, he overhead a medical doctor advising the police how to cover up evidence of his torture if he died. However, he lived to tell his story about his torture and the collusion of the doctor a decade later to a Truth and Reconciliation hearing in 1997. The doctor involved was interviewed the next day by the media, denied the claim and stated that (translated from Afrikaans) “…such behaviour is absolutely contrary to my ethical beliefs as a doctor. But most of all it is directly against my deepest values as a person.” I tell this story because I know that the detainee’s story was entirely consistent with the evidence presented to me. Although Dr Blachar can claim that his “position as well as the position of the leadership of the IMA is firmly and unequivocally against torture of any kind,” it is easy to say you are against torture. What matters, particularly when you are in a position to give leadership to other doctors vulnerable to state pressure, is what you actually do to prevent it and to hold accountable those who allow torture to take place.



A lot has been said about Dr Blachar’s comments published in the Lancet on ‘moderate physical pressure’ being legal. On the one hand, it is claimed he never indicated his support for ‘moderate physical pressure.’ On the other hand, critics cite it as evidence that he tolerated torture. This argument is to miss the point. When, in 1998, the IMA was approached by PHR-Israel, together with prison and police doctors, to clarify its stance on this question of moderate physical pressure, so as to give guidance to prison doctors, it avoided taking any position, and only did so after the Israeli High Court made a legal pronouncement that moderate physical pressure did, indeed, constitute a form of torture. Rather than adopt an independent and critical analysis of the situation, the IMA, under Dr Blachar’s leadership, deferred an ethical judgment to a legal one.

This is exactly what the MASA and the then-South African Medical and Dental Council did in South Africa in the late 1980’s, in trying to avoid disciplining the doctors who were complicit in the notorious and tragic torture and death of Mr Steve Biko. Mr Biko was a political detainee who suffered a head injury whilst being assaulted during interrogation and whose medical care was subjugated to the interests of the security forces, resulting in his death. The medical authorities constantly resorted to a legal fiction to avoid taking action against the doctors concerned, a case which medical students worldwide continue to hear about in their ethics teaching. This approach of hiding behind the law is not the leadership I want at the head of the global organization of doctors today. I want a leader who is able to separate the law from ethics, who is able to stand up for what is the right principle and who will not hide behind legal niceties. It is not a matter of casting “guilt by association” to hold the head of the IMA responsible for not displaying firm leadership. It is his actions and lack of action, when they were most needed, which matter.

So, to call for Dr Yoram Blachar to step down has nothing to do with his ethnicity or my ethnicity, which is also Jewish, or one’s views about the political resolution of the Israeli-Palestinian conflict. It is simply a matter of medical ethics. To say that it is not appropriate for Dr Blachar to preside over the World Medical Association is to say that international standards of medical ethics deserve better.

Professor Leslie London, University of Cape Town, South Africa





Professor Leslie London

Health and Human Rights programme

School of Public Health and Family Medicine

Health Sciences Faculty

University of Cape Town

Anzio Road

Observatory

7925

South Africa

Response letter to IMA letter from Prof Yudkin

An Open Letter to Israeli Doctors who are Members of Physicians for Human Rights-Israel


Dear Colleagues

I have seen, and had translated for me, the letter of 21st July 2009 from Dr Yoram Blachar, President of the Israeli Medical Association addressed to doctors who are members of PHR-I. He explains that he feels that the actions of PHR-I in publicising internationally their concerns about medical complicity in torture is responsible for feeding ‘anti-Israeli and anti-Zionist anti-Semitism.’ He describes the petition of 725 doctors calling for his expulsion from the post of President of the World Medical Association, and the questioning to which he was subjected at the British Medical Association annual conference, implying that the attacks are coming from ‘Moslem and anti-Semitic and anti-Israeli doctors.’ I would like to challenge some of these assertions, suggesting not only that Dr Blachar and the IMA still have issues which require answers, but also that the challenges are coming from a position of human rights, and not anti-semitism.

I do not regard myself as anti-semitic: I am Jewish, have many relatives who live in Israel, and had a Jewish National Fund collection box by our telephone throughout my childhood. Yet I have raised with Dr Blachar a series of questions, about torture, about access to medical care for patients from Gaza, and about attacks on health care facilities during Operation Cast Lead, in the form of an article in the Lancet in April (attached). I contrasted the powerful position statement on torture on the IMA website with the failure of that body to respond adequately to the PCATI report, published in May 2007, in which detailed testimonies of 9 torture victims included names of medical personnel involved in their management, 6 of these being IMA members. The reasons for medical involvement varied, but included a 29-year-old man with a sacral ulcer and consequent permanent foot drop following interrogation. During this time, over a 4 day period he was intermittently tied by 4 limbs arched back over a chair with a sharp edge to the seat. In response to concerted pressure, the Chairman of the IMA Ethics Committee reported having contacted and spoken to ‘most of those listed,’ all of whom denied either any connection with the prison services or, for the 3 who were so employed, any involvement in interrogations, torture, or medical approval for this. What is missing is any evidence that the inquiry went further than these conversations, as might be expected in such circumstances. For example, was there contact with the hospitals where the prisoners were treated, or were the medical records examined?

The question which needs considering by the IMA President, its Ethics Committee, and its members, is whether the security risks facing Israel can be allowed to override human rights. Are members of PHR-I, or of the IMA, willing to accept that one in three patients being referred from Gaza for medical care is being denied entry to Israel on ‘security grounds,’ this seemingly comprising in several instances the names and telephone numbers of relatives or friends who may be Hamas sympathizers? In particular, I would contend that as the President of the WMA, Dr Blachar needs to re-examine the role of the medical profession in defending human rights. Failure to investigate to the level of accepted international norms could imply an anxiety that there is veracity in the claims. To imply that such calls are no more than a concerted anti-Israeli, or even anti-semitic, campaign is to attempt to silence critics.

The events of the last 9 months have seen a marked shift in world opinion regarding Israel. While the causes of these changes may relate, in part, to changes in policy with new governments in Israel and the US, and in part to the events surrounding Operation Cast Lead, there is undoubtedly a rising tide of anti-Israeli sentiment in many countries. But to dismiss all criticisms as the consequence of anti-semitism is naïve, particularly if this is used as an excuse for inaction, or even for failing to listen to the criticism.

Like Dr Blachar, I hope you will act in accordance with your conscience. But I have nothing but praise for an organization, like PHR-I, which is acting as a powerful tool for the national conscience, despite all the brickbats thrown in its way.

Yours sincerely
Professor John S Yudkin MD FRCP
Emeritus Professor of Medicine,
University College London

Open letter from IMA to PHR-I doctors

Translation from the Hebrew by PHR-Israel. All emphases are in the original.

IMA website (Hebrew): About IMA > IMA activities > International relations > to doctors who are members of PHR-Israel

To doctors who are members of PHR-Israel

21 July 2009: IMA Chair, Dr. Yoram Blachar, publishes a letter in which he explains to doctors who are members of PHR-Israel, why IMA has decided to sever all contacts with the association.

To doctors who are members of the PHR-Israel association

I appeal to you first of all as Israeli doctors who are members of IMA and additionally as members of PHR-Israel. I want to share with you my hard feelings following recent developments.

For some 14 years IMA, and myself at its head, have served as a defensive barrier between international anti-Israeli bodies and the doctors of the State of Israel, against baseless attacks, according to which, inter alia, the doctors of the State of Israel are allegedly actively involved in the torture of Palestinian prisoners, and/or are accused of allegedly ignoring such phenomena.

These are baseless accusations that are expressed, for instance, in medical journals such as the Lancet, the BMJ and the Journal of the Royal College of Medicine.

Unfortunately, various organizations, and particularly PHR-Israel are contributing to the international offensive against us. For years we have appealed to PHR-Israel to give us the personal details of those who were allegedly involved in torture so that we could relate to each case individually – but we received no such details from PHR-Israel.

On one single occasion, about 13 names were transferred to us, of doctors who were allegedly involved in torture or degradation of Palestinian detainees, by the organization PCATI (Public Committee Against Torture in Israel) and not by PHR-Israel. An investigation into the subject, held by Prof. Reches, the head of IMA's Ethics Board, showed that among the doctors accused, some had never worked in those facilities, and three who had worked there, categorically denied any connection to the accusations. Of course the accusations are "based" on one-sided testimonies with no supporting evidence. By the way, since participation in torture is a criminal offence, the accusers are free to submit a complaint to the police or to the Attorney General.

I would like to state that we are open to criticism and in several meetings that the leadership of IMA held with the Board of PHR-Israel we clarified our position. Nonetheless, we objected strongly to criticism when it was expressed in international fora. Time and again, we begged PHR's Board to avoid using the international arena, blackening names and slinging mud at the doctors of Israel and at IMA, but in vain. The infuriating reality is that the activities of PHR-Israel constitute fertile ground for anti-Israeli and anti-Zionist anti-Semitism.

It would seem that this issue reached a new climax when about one month ago a petition signed by 725 doctors was published, calling for my expulsion from my position as the president of the World Medical Association (WMA). Dr. Ruchama Marton, President of PHR-Israel, also signed this petition!!!

It is important for me to emphasize that in any case I am about to end my role at WMA in October, so that the personal issue is marginal. The issue is much more problematic, and it involves the harnessing of the world medical community to a struggle against us, the doctors in Israel, and against the Israeli medical system, supposedly as part of the regional political system, and by blackening our names and slinging mud at us doctors.

Matters have gone so far, that in one of the discussions held this week in the annual conference of the British Medical Association (BMA) (to which I was invited as president of the WMA), a stormy discussion was held in which very hard and baseless accusations were directed at IMA and the State of Israel. The discussion was polarized and reached a point where the situation in the State of Israel was compared in the same breath to the situation in Darfur and Sri Lanka, states in which, as is known, genocide and blood baths are taking place!

The speakers at the conference stated several times that they had drawn the information that they were basing their claims on from PHR-Israel and that if an organization of Israeli doctors makes such a claim, who are we, the Moslem and anti-Semitic and anti-Israeli doctors, to doubt the credibility of information from PHR-Israel?!!.

What was absurd was that it was our friends at the BMA who prevented the members of the conference from adopting hard resolutions at the end of the discussion, and they were the ones who assisted us in withstanding the rising wave of Israel-haters.

The damage caused by this activity of PHR-Israel against IMA is great and it hurts each of us – it is an expression of a clear position against the medical community in the State of Israel and against the organization that you are members of!

I do not thing that there are differences in our worldview with regard to torture and involvement of doctors [in torture]. In order that there should be no doubt about it, although I feel that in the light of the position we have voiced repeatedly, it is superfluous to emphasize that IMA and myself as its leader are strictly opposed to torture and to degrading treatment of Palestinian or other prisoners and detainees. We demand that a doctor who was witness to torture or to its consequences report it – all according to the international conventions of the WMA of which we are signatories.

The leadership of PHR-Israel directs accusations against us in the international arena in a manner that is very difficult to erase, in the face of growing tendencies of waves of anti-Semitism. I wish to stress that IMA is not a political body and any attempt of PHR-Israel to tie the policies of the government to the policies of IMA is irrelevant.

I deliberated for a long time about whether I should appeal to you, since IMA has always been open to criticism, but from the feelings I get on the ground, I think not all of you are aware of this activity of PHR-Israel and of the damage it is causing to the doctors of the State of Israel and to IMA.

In the light of the above, IMA has decided to sever all ties with PHR-Israel and I hope that you will act in this regard in accordance with your conscience.

Regards,

Dr. Yoram Blachar

Chair, IMA

Report from Breaking the silence

From the content:
(...) Several months have passed since the end of Operation Cast Lead in Gaza, and many Israelis are still not aware of what really happened there. For lack of basic facts, we are forced to accept unconditionally the positions of the official bodies, whichassure us that in spite of any doubts, the IDF’s conduct was faultless and publicaccountability is uncalled for. This publication includes the testimonies of aroundthirty combatants who took part in the operation in early 2009. The testimonies that appear here were gathered over the past few months from soldiers who served in all sectors of the operation. The majority of the soldiers who spoke with us are still serving in their regular military units and turned to us in deep distress at the moral deterioration of the IDF. Although this publication does not claim to provide a broad, comprehensive review of all the soldiers and the units who carried out the operation, these narratives are enough to bring into question the credibility of the official IDF versions. (...)

Is everyone who critses Israel antisemitic? - One story with some moral conclusions

A little bird was flying south for the winter. It was so cold the bird froze and fell to the ground into a large field. While he was lying there, a cow came by and dropped some dung on him. As the frozen bird lay there in the pile of cow dung, he began to realize how warm he was. The dung was actually thawing him out! He lay there all warm and happy, and soon began to sing for joy. A passing cat heard the bird singing and came to investigate. Following the sound, the cat discovered the bird under the pile of cow dung, promptly dug him out and ate him.

Moral of the story:

(1) Not everyone who shits on you is your enemy.

(2) Not everyone who gets you out of shit is your friend.

(3) And when you're in deep shit, it's smart to keep your mouth shut!