Even the fog of war does not obscure a doctor’s code of ethics  

Evidence continues to point to the fact that Hamas has been able to exploit the protected status of hospitals, granted under international humanitarian law, in order to wage aggression against Israel and hold hostages. It’s been reported some hostages were given ketamine to keep them docile; the knowledge needed to safely give ketamine suggests the possible collaboration of individuals with medical training.  

Article 30 of the Geneva Convention stipulates that prisoners of war must receive adequate medical care, even if imminent repatriation is considered. In the military context, hostages are distinct from prisoners of war, and the taking of hostages is a war crime. The involuntary chemical restraint of a hostage is also a war crime — and never the practice of ethical medicine. 

As a physician concerned with bioethical conduct, I write frequently about my opposition to physician participation in capital punishment. In this way, my view comports with the American Medical Association (AMA) code of medical ethics., which states that a physician should not participate in a legally authorized execution. There is no wiggle room here — or so I contend.  

Despite this, after every opinion piece I write on this subject, I get emails from physicians expressing consternation on why the state simply does not modify its medical or scientific method so as to enable better killing. Counter to the AMA code of medical ethics, these physicians are ready to assist the state in a granular way.  

Everything that a doctor does must pass through an ethics filter because what a doctor knows can be weaponized to kill. A medical license is akin to a concealed carry permit. Bioethics seeks to situate medical practice as separate from changing political winds, but medicine can easily become an arm of state power. For any successful political system, whether it be democratic or otherwise, it must have medical practice under its employ.  

Why many doctors willingly aid the state to facilitate punishment or engage in torture is a question worth unpacking.  

As an extreme example, consider physician participation in Nazi Germany. It is well documented that more than half of all German physicians were early joiners of the Nazi Party. The complicity of the German medical profession exceeded enrollment of all other professions. Nazi doctors carried out unethical human experimentation, practiced involuntary euthanasia, performed forced sterilization, and ultimately facilitated the genocide of Jews on a scale that had never before been achieved.  

The medical profession is ripe for complicity. It is hierarchical by design and values conformity and obedience to authority. This was demonstrated in the famous experiment on the power of authority by Stanley Milgram.  

Nazi medicine drew inspiration from eugenics, an idea attributed to English polymath and behavioral geneticist Sir Francis Galton and taken up with great enthusiasm by American zoologist Charles Davenport. In the early 1900s, America loved eugenics. It received extensive funding from the Carnegie Institution, the Rockefeller Foundation, and the Harriman railroad fortune. Disinfection and sterilization were medical ideas that became entwined with flawed social policy and bad legal reasoning.  

In the notorious case of Buck v. Bell, the brilliant jurist Oliver Wendell Holmes supported a demand to involuntary sterilize “feeble minded” 21-year-old Carrie Buck. She had become pregnant from rape and was herself the offspring of someone deemed feeble-minded. Holmes believed, without evidence, that the child of Buck would be feeble-mined as well and wrote “three generations of imbeciles are enough.” Buck v. Bell is now understood to be deeply flawed. It tramples due process rights and gets flat wrong the heritability of intelligence.  

Eugenics has been widely discredited and is no longer supported by modern medical practice. After WW II, The Doctors Trial charged Nazi physicians with crimes against humanity and focused on the use of experiments as methods of torture. Hippocrates once observed that experiments are treacherous and human trials must at their core involve subject volunteerism Prisoners and hostages lack liberty, and claiming they consent misses the critical element of the necessary mental state of the volunteer.  

Some hostages released by Hamas were reported to be smiling and even expressing gratitude to their former captors. Such scenes were interpreted as proof that the hostages were well treated and even cooperative while in captivity. We know now that such actions were more likely manifestations of psychological trauma and cover for the safety of remaining hostages. The wide experience reported by hostages was terror, starvation and physical, emotional and sexual assault.  

Nazi medicine remains a stain on the practice of medicine, but stains can be washed away, and the lessons learned may not be durable. In more recent history, physicians aided torture in Guantanamo Bay. The war on terror was seen as broad justification to imprison individuals in perpetuity for the safety of society. Torture was seen as morally justified for the greater good, and the medical profession believed it was able to determine the point between cooperation and torture.  

During Hurricane Katrina in New Orleans, the city became inundated with water. Hospitals charged with caring for the sick and wounded became flooded and struggled to function. Memorial was one such hospital. After several days and faced with a deteriorating situation, it made the decision to involuntarily euthanize many patients. Those on the scene later justified these actions as merciful. During that same hurricane, Mercy Hospital also faced the ravages of the storm, seemingly under the same restraints and challenges as Memorial, but no one was euthanized and almost everyone was saved. 

This reasoning, which allows physicians to force-feed hunger strikers and practice torture in the ticking time bomb scenario, may be the same moral calculus used by physicians and hospitals that aid Hamas. In the fog of war, uncertainty confronts the intersection of healthcare delivery and the core principles of ethical medical practice.  

Under questioning by the Israeli Security Agency, the director of a Gaza hospital, Ahmed Kahlot, admitted that he had been recruited by Hamas to help turn Gaza medical centers into military facilities. Dr. Muhammad Abu Salamiyah, chief of Al-Shifa Hospital in Gaza, was questioned after the finding of evidence confirming Hamas had extensively infiltrated that hospital. Further, the multibillion-dollar charity Doctors Without Borders failed its own mission to provide independent and impartial medical humanitarian assistance by remaining silent on the fate of hostages in Gaza.  

Some doctors that help the state during execution rationalize involvement by thinking of the death penalty as a terminal illness. They justify medical involvement as a desire to relieve suffering. If, however, the death penalty is a terminal illness, it is highly treatable. Don’t do it. Hamas-complicit physicians and hospitals may have made a similar moral calculation. They may also reason that being a hostage is a terminal illness. That too is treatable. Set them free.  

Joel Zivot, MD, MA, JM, is associate professor of Anesthesiology and Surgery, Emory School of Medicine; former adjunct professor at the Emory School of Law; and senior fellow in the Emory Center for Ethics.