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The ‘P’ Word: Hospital Ethics Committees and Palestinian National Identity

Anthropologists like to tell their stories of ‘entering the field,’ whether they are left alone on a tropical beach as their dinghy sails away (Malinowski 1922) or run away from the police into a local’s courtyard (Geertz 1973). These stories are often told to show us, their readers, the distance anthropologists must travel from their own worlds into those of their research subjects. If stories traditionally fall within the thriller or adventure genres, my own is rather more Kafkaesque. And much like the stories from The Trial and The Castle, it is more about the system in which my interlocutors and I live than our own personal stories.

It took me more than six months to get my research with Palestinian physicians approved in two large Israeli hospitals. In a third hospital my access was denied. My ‘entry story’ is thus about my repeated attempts to obtain the approval of three Helsinki Committees (HCs, Israeli hospitals’ research ethics committees) to conduct ethnographic research with Palestinian physicians in Israeli public hospitals. While my research was eventually approved in two of these institutions, correspondence with HC representatives, as well as evidence of their informal moves with institutions’ management, reflect their perceptions of the risk my study posed.

I had already passed the University of North Carolina’s meticulous ethical approval process, and so the very different response of Israeli committees left me bewildered. Had the UNC’s committee overlooked important risks? In fact, the discrepancies between these committees calls into question the very idea of a universal ethical code of research conduct, as the 1964 Declaration of Helsinki aimed to establish. This post-World War II cornerstone declaration was meant to set ethical standards for human experimentation. It has since undergone seven revisions but remains a universal guideline for research ethics. The worldwide emergence of Institutional Review Boards (IRBs) is a result of the 1975 Helsinki Declaration II affirmed in Tokyo[i].

But pointing, once again, to the non-universality of self-proclaimed universal values (cf. Heimer and Petty 2010) is not what is interesting about this story. It is the specificity of local ethical standards, enforced by local commissars who draw on the idea of the universal, to promote local political agendas. In Israel, the Helsinki Declaration’s ethical standards became legally instantiated in the 1980 Takanot Briut Ha’am – the People’s (or Nation’s) Health Regulations. Traveling from Finland to Japan to Israel, research ethics thus turned from a human issue into a national concern. The informal and formal feedback I received on my research topic, as well as the numerous revisions the Israeli committees required to approve my research proposal, show that it was not the safety of research subjects that was at stake for the Israeli HCs. It was the integrity of the ideals of medical neutrality and Jewish ethnocracy.

Consider the following short anecdotes from my experiences in the three institutions:

Hospital X:

After six months of submissions and resubmissions of my research proposal to Hospital X’s HC, I was desperate and ready to rethink my whole dissertation project. I called the secretary on the phone. Maybe she noticed my dismayed tone and felt sorry for me; perhaps she just could not bring herself to process my resubmissions endlessly. This is how the phone conversation went:

Secretary: Do you remember that we changed the title so it will be Arab physicians and not Palestinian physicians?

Guy: Yes…

S: So… that word is still there… many times in the research protocol…

G: What do you mean that word?

S: You know… just make sure your research proposal stays in line with the new title…

I then used the word processor’s ‘find and replace’ function to replace all references to ‘Palestinians’ with ‘Arabs,’ quite literally erasing my interlocutors’ national identity.

It was less than two weeks later that I received the long-awaited approval.

Hospital Y:

I was sitting in the chief physician’s office, hoping to get my research approved on his ward. On Professor H’s office wall hung a ‘thank you’ plaque given to him for his military service in the occupied Gaza Strip. The hospital’s deputy CEO was the one who recommended that I do my research in Professor H’s ward. The question of my military service in the IDF was an issue of concern in my earlier meeting with the deputy CEO and once again with Professor H. They both had long military careers, and were suspicious about the national loyalty of an anthropologist coming to study Palestinian physicians. Social scientists have a reputation of being ‘lefties’ and this was a test I clearly had to pass before I was granted access.

After the ritualized brief exchange about the timing, location, and nature of military service by which Israeli men size each other up, the chief physician wanted to know more about my research. I told him that I am interested in the experience of Arab physicians in the Israeli public health system. He immediately shared some anecdotes and amateurish social analysis about “our cousins” (Bnei Dodenu, “euphemism” for Arabs). The conversation was very open and friendly. He then said that he approves of my request to conduct research in this department; I will only need the “Helsinki approval.” He then called the head of the hospital’s Helsinki Committee:

“Hi, how are you? I have here a PhD student who wants to conduct research on minorities…” (Bnei Miutim, yet another “euphemism” for Arabs).

His friendly face immediately became serious and worrisome.

“I see… well he is right here… I’ll ask him straight to his face …”

He hung up and said: “The person who heads the Helsinki Committee… well… he is a religious person… but also very experienced… I don’t have a problem telling you what he said… well… he said: ‘Read my lips [in English] – nothing good is going to come out of this! If you ask me… don’t do it. They’ll just say that we are racists. And if they find that we aren’t, then they’ll not publish it.’”

I faced six months of politically whitewashing “revisions” before successfully meeting with Hospital Y’s HC approval.

Hospital Z:

At first, entering the field in Hospital Z was the smoothest of all. I interviewed a few physicians from the hospital and found Professor A, the chief physician of the ward I chose as the site for participant observation, to be friendly and welcoming. He approved my research and even appointed a research administrator to help with my Helsinki application to expedite the process.

I then received an email, notifying me that the HC finds my proposed research “not included in the committee’s jurisdiction” and that if I wish to proceed with my study, I will have to get “the management’s approval.” Trying to probe with the HC chair what sort of approval it was that I needed to obtain, and what, precisely, was the managerial unit that could grant it, I was rebuffed rather rudely, and referred to the chief physician who sponsored my research for answers. Quite disappointed and upset, I contacted Professor A, recalling his friendly attitude to my project. This time, he responded with a very short and cutting message, stating that he “will not be able to handle this project” and referring me to Professor R, the hospital’s deputy CEO, whom he also copied on the message. More than a year after this correspondence, I ran into Professor A at a conference. I asked him about these events and he said that the HC contacted the executive management “over his head” and that it was taken “out of his hands.”

But most telling was the communication with Professor R that followed. In his first response to my request to conduct the research in the hospital he said: “We have only 13 Palestinian physicians (all from the West Bank) and to the best of my knowledge they are outstandingly integrated.” At length, I explained that my research is with Palestinian citizens, what he would call “Israeli Arabs,[ii]” and that there are hundreds of them employed in the hospital. To that he interestingly replied “we treat all our Israeli citizen physicians as totally equal without regard to their religion” – as if being Palestinian is a religion. After further explanations on my part, he wrote: “I have to admit that I have a principled disagreement with the definitions in your research proposal. According to my world view, physicians with Israeli citizenship, from the Arab nation, of any religion, are Israeli physicians for all purposes.” He continued: “I will share this dilemma with senior members of management here in hospital Z and will get back to you.” The following day, it seems that “the dilemma” was solved and he wrote “after consultations with a number of management members we prefer that the research not be conducted in hospital Z.” He later agreed to meet me but in that meeting he stood fast in his opinion, saying: “I am proud to be blind in these matters and see everyone as equal Israelis.”

Protecting the (Jewish) Nation’s Health

Palestinian citizens of Israel, approximately one fifth of Israel’s population of eight million, are an ethnic and national minority within the “Jewish State,” but also part of yet another national body, the Palestinian people struggling for their own independent state – in the West Bank under Israeli occupation, in the besieged Gaza Strip, and in the diaspora. These communities that remained under Israel’s rule following the Israeli independence and the Palestinian Nakba (catastrophe) of 1948 were put first under military rule and have since been treated as second class citizens, holding what has been termed a “hollow citizenship,” devoid of national-cultural recognition (Jamal 2007). Palestinian citizens’ marginality in Israeli political, economic and social reality is the outcome of processes of Judaization which has turned the Israeli state, under a democratic façade, into a Jewish ethnocracy (Yiftachel 2006). While Palestinian citizens struggle for equal civil rights as Israeli citizens, they see themselves as Palestinian nationals. This stance, in the context of a prolonged bloody national conflict, is often viewed by Jewish Israeli hegemony as straightforward treachery (Kimmerling and Migdal 2003).

Nevertheless, asserting Palestinian national identity has become more prevalent among Palestinian citizens in the past decades (Rabinowitz and Abu-Baker 2005). In the recent 2015 national elections, a vast majority (more than 80%)[iii] of Palestinian citizens voted for the non-Zionist, outspokenly Palestinian Joint List, gaining some 11% of the seats and becoming the third largest party in the Israeli Parliament. Hence, there was yet another source of anxiety that made these administrators and ethics committee censors find my research ‘risky.’ That is the risk it posed to ideals of political neutrality within the medical sphere.

While educational, residential and occupational segregation draw physical as well as social boundaries between Palestinian and Jewish citizens of Israel (Khattab and Miaari 2013), with Palestinian citizens comprising about 12% of physicians working in Israel (Reznik 2011), the country’s public health system is one of the few arenas in which Arab and Jewish citizens work side-by-side. Many Palestinians and Israelis frequently depict Israel’s predominantly public healthcare system as a “world unto itself, transcending the two worlds” (Abuelaish 2011:91). Anthropologist Dan Rabinowitz (1997:137) asserts that “where personal wellbeing is at stake, distrust of Palestinians’ intentions is subordinated to the basic faith in the professional integrity of physicians, whatever their national affiliation.” Such views render the health sphere as an exceptional space of professional integration and opportunity for Palestinians (Reznik 2011). This allegedly successful integration is often presented as evidence of the potential for coexistence, as the late Israeli president Shimon Peres noted: “Given all the discomfort that could arise among Jews due to having an Arab doctor, it’s noteworthy that it has succeeded. And if this happens with people who are ill, why not when they’re healthy?”

Making the case for a neutral medical sphere is a staple of Jewish-Israeli hegemony, and in particular, for health administrators and professionals (Shalev 2016). Although overt expressions of ethnic hostility are rare in medical settings, Palestinian doctors frequently encounter assertions of difference, social exclusion and tacit hostility by Jewish patients and professionals that challenge the frail façade of political neutrality.

Most Palestinian physicians I have been talking to during fieldwork make it clear that talking about national politics in the hospital or clinic is not recommended and they make a great effort to avoid such discussions. Many of them acknowledge the fact that, as Palestinians, their politics are just too radical for mainstream Jewish-Israelis and best be kept private, lest personal conflicts erupt. In these contexts, the basic stance of not being a Zionist is enough for one to be considered a radical and for some, even an extremist. Thus, Palestinians who cannot accept the Zionist core principle of Israel as a Jewish state (therefore accepting their own status as second class citizens), are immediately considered as holding illegitimate political positions. Like other public spaces in Israel (and in somewhat contrast to US public spaces), the health sphere is very much an appropriate setting for political discussions, debates and sometimes even heated arguments. But only among Jews. As one physician told me in an interview: “sometimes I join [my colleagues’] table in the cafeteria and there is silence. I know they were talking about politics. But that’s fine with me.”

The sort of medical neutrality that is manifested in the Israeli health system is thus, in a sense, ‘selective neutrality.’ It is an ideal selectively enforced on Palestinians, acting to neutralize their national belonging and political dissent. Facing my proposal to do research with Palestinian physicians in the hospital, HCs were confronted with a double risk: acknowledging Palestinian nationalism and breaching their institution’s political neutrality, which they consider very real and pragmatically crucial. None of these risks was, however, posed to the research subjects whose wellbeing they are appointed to protect. While HCs cannot deny research altogether, but request revisions and resubmissions, the committees in hospitals X and Y were using everything in their power to postpone and, one might guess, dissuade me from conducting it in their institutions. Hospital Z’s HC, however, made the extra effort of directly involving the institutions’ executive management, getting it to explicitly deny my access.

Thus, a secretary’s suggestion that I erase the “P word,” a professor’s rich use of “euphemisms” referring to Palestinians as “cousins” or “minorities,” and a senior manager’s ‘voluntary blindness’ are all practices of national erasure, assertions that only one national identity is possible within the Israeli state. But being Palestinian in the hospital is considered a double offense. It risks the hegemony of Jewish nationalism and contaminates the allegedly neutral, politically sterilized medical sphere. While HCs’ mandate is to monitor and enforce ethical standards in research with human subjects, all three committees were practicing political gatekeeping. Through endless requests for revisions, an insistent warning to a professor colleague that “nothing good is going to come out of this,” the outright overriding of a chief physician’s authority and having the research refused by the institution’s senior management, HCs acted as political censors. Ostensibly mechanisms for the protection of human rights, these committees are embedded in local social hierarchies and power struggles. More importantly, when ethics committees practice such erasure and political gatekeeping, they not only limit academic inquiry but also redefine, in political terms, the realm of the moral. In practice, this amounts to defining counter-hegemonic narratives as ‘unethical.’ In this sense, they are, quite literally, fulfilling the Israeli state’s interpretation of the Helsinki declaration, and its local aim to protect the (Jewish) nation’s health.

 

Guy Shalev is a PhD candidate at The University of North Carolina at Chapel Hill. His research with Palestinian physicians in the Israeli public health system was funded by the NSF (#BCS-1424100). Guy’s dissertation examines how ideals of ‘medical neutrality’ (re)produce social hierarchies and exclusion, but also how they serve as a ground for social mobility and political action for Palestinian citizens of Israel. His article A Doctor’s Testimony: Medical Neutrality and the Visibility of Palestinian Grievances in Jewish-Israeli Publics was recently published in Culture, Medicine, and Psychiatry.

 

References

Abuelaish, Izzeldin. 2011. I Shall Not Hate: A Gaza Doctor’s Journey on the Road to Peace and Human Dignity. New York: Walker and Company.

Geertz, Clifford. 1973. The Interpretation of Cultures: Selected Essays. Basic Books.

Heimer, Carol A., and JuLeigh Petty. 2010. Bureaucratic Ethics: IRBs and the Legal Regulation of Human Subjects Research. Annual Review of Law and Social Science 6: 601-626.

Jamal, Amal. 2007. Nationalizing States and the Constitution of ‘Hollow Citizenship’: Israel and its Palestinian Citizens. Ethnopolitics 6.4: 471-493

Khattab, Nabil, and Sami Miaari, eds. 2013. Palestinians in the Israeli Labor Market: A Multi-Disciplinary Approach. Palgrave Macmillan.

Kimmerling, Baruch S., and Joel Samuel Migdal. 2003. The Palestinian People: A History. Harvard University Press.

Malinowski, Bronislaw. 2002 [1932]. Argonauts of the Western Pacific: An Account of Native Enterprise and Adventure in the Archipelagoes of Melanesian New Guinea. Routledge.

Rabinowitz, Dan. 1997. Overlooking Nazareth: The Ethnography of Exclusion in Galilee. Cambridge University Press.

Rabinowitz, Dan, and Khawla Abu-Baker. 2005. Coffins on our Shoulders: The Experience of the Palestinian Citizens of Israel. Berkeley: University of California Press.

Reznik, Ran. 2011. The Integration of Arab Citizens of Israel in the Health System. The Abraham Fund Initiatives, Accessed October 19, 2016.

Shalev, Guy. 2016. A Doctor’s Testimony: Medical Neutrality and the Visibility of Palestinian Grievances in Jewish-Israeli Publics. Culture, Medicine, and Psychiatry 40.2: 242-262.

Yiftachel, Oren. 2006. Ethnocracy: Land and Identity Politics in Israel/Palestine. University of Pennsylvania Press.

Notes

[i] In the US it was the infamous Tuskegee Syphilis Study (1932–1972) on black rural communities in Alabama that brought about the National Research Act, which set federal regulation of human subjects research.

[ii] See Rabinowitz and Abu-Baker 2005:43-44 for more about the politics of this terminology.

[iii] Israeli Official election results do not include sector-based voting patterns, but post-election analyses claim that 80-86 percent of Arab citizens voted for the Joint List.


One Response to The ‘P’ Word: Hospital Ethics Committees and Palestinian National Identity

  1. The author seems to be totally blind to both, security and hygiene issues and anti-Semitism.
    Israeli hospitals had been targets of terrorism ever since, just because the Israeli health system denies war and conflict maybe more than in any other country. Functionaries of Hamas seek treatment in Israeli hospitals as well as Syrian Jihadis were treated in the Golan sanctuaries. Suicide attacks on hospitals occured. Any researcher should ask himself if there are not many other (but less convenient) places to do research: Ghanaian hospitals, Sudanese health institutions, Hungarian hospitals and Roma and refugees, the field is endless. Israel seems to be the most convenient “conflict”-region for so many journalists and researchers. At the same time, vast shares of the AAA calls out for a boycott of Israeli researchers (with 49% approval rate, and the support of the AAA-executive board). It is outright cynical to have US-researchers doing anthropology in Israel at the moment, while Israeli researchers are openly denigrated by the slightly modified AAA-resolution – which has “passed” or rather slipped through so many “ethic”-awareness experts, or rather was the effect of a deeply blotched research ethic in itself: the urge of intervening without having a clue and so doing harm.
    In short: anyone knows that an anthropologist from the US doing research about “Palestinians” in Israel might do exactly what this article is about: raising resentments even when there is nothing to report.

    The entire article seems to be built around repeating the nationalist narrative of a harrassed palestinian entity (the “besieged Gaza”), of the “Nakba”, telling not even half of the story and especially not the story of the expulsion of about 1 million jews from the arab states. It simply complains about Israel being a “jewish state”, not discussing the necessity of one in an anti-Semitic world.
    The article has a deep problem with Israel being a jewish state, a refuge for jews in the world. But is has no problem with repeating the “palestinian” mythology, with belittling the anti-Semitism meted out on Israelis from both, the anthropology in the US as well as from nationalist “palestinians”.

    “Palestinians” as a deeply problematic ethnic construct is not questioned by the author as could be expected from anthropologists in other cases (e.g. see Lentz about ethnicity in Ghana). In general, the article seems to be positive with ethnic identity.

    But the word “palestinians” has not existed until Arafat branded it. It is in itself anti-Semitic: Palestine was the name given by jews to their land. By calling disorganized arab groups “palestinians”, Arafat sucessfully turned the attacking anti-Semitic fundamentalists on the arab side into the ancient “jewish” position. The word “Palestine” is in itself a symptom and strategy of what research in anti-Semitism has pointed out as the victim-aggressor-reversal. The anti-Semitic aggressor poses as “the victim”, even to the extent of faking jewish ancestors, and then lashes out against the “bad jews” or “the nazis of today”.

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