Each war revives the clash between the safety of a country’s own citizens and that of its soldiers. The recent Operation Protective Edge, taken by Israel with the objective of restoring calm to its citizens, should be examined by the same standard. Was the presumed political gain worth the soldiers’ loss of lives? Was the blow to Hamas’s infrastructure a reasonable compensation for the death of sixty four young combatants? And, more broadly, are we willing to sacrifice the innocent lives of soldiers in order to temporarily decrease the number of rockets targeting our neighborhoods?
There are arguments in both directions, and a universally-correct answer probably does not exist. Nevertheless, it is safe to say that the political calculus informing war-related decisions is based on a risk-benefit ratio. Whether to embark on ground invasion or massively mobilize troops to the fire zone relies on a meticulous estimation of the hazards versus the gains. The troops endanger their lives for geopolitical purposes that may or may not be justified. Their actions may bring the desirable relief—to their country and communities—but may also inflict some unwanted adverse effects. Potential detriment exists alongside the hope for betterment, but what are we to make of the summated result?
I ask these questions because in our profession, medicine, we are faced with similar conundrums. When we, as physicians, offer any medical intervention to a patient, we always assess the likelihood of a positive outcome in relation to the potential harm. We like to say that the single most important factor, when deciding whether to utilize a given treatment option, is its possible deleterious effect. Even if a treatment regimen promises to alter the natural course of a devastating neurological condition or to eradicate a dangerous infectious organism, we always evaluate its safety and toxicity first. Other factors may matter—the benefit to society, well-being of family members, burden on healthcare system—but the decision eventually rests upon a careful estimation of the risks and the benefits.
Take the case of mental illness. A person may suffer from intractable depression or schizophrenia but, because of significant side effects or financial constraints, chooses not to take any medication. Such drug non-compliance may negatively affect the lives of family relatives and, you may argue, society as a whole. Still, we will honor the patient’s wishes. Why? Because the decision (to be or) not to be treated lies exclusively within the hands of the individual in question (that is, unless he or she is deemed to have the potential to harm either himself/herself or other people, in which case involuntary admission to mental facility may be required). We call that autonomy, the patient’s right to make decisions for herself. I further stipulate that, as much as bystanders are influenced, the sole entity responsible for making medical decisions should be the one with the greatest potential harm, namely the patient herself.
How does this relate to soldiers and civilians at times of war? The players may be different but the rationale is similar. Israeli civilians have lived in fear of rockets for several weeks already (and in the case of southern cities, several years). True, the mental capacity and courage displayed by Israelis are admirable. Leading a live routinely jeopardized by missiles and bombs is emotionally exhausting. It is a source of anxiety for some and a traumatic stress for most. However, the most vulnerable entity in the bloody Israeli-Hamas conflict is—and that may be hard for some to admit—the army’s combatants. These are the men and women who literally stand a hair’s breadth away from grave injuries, abduction, and, God forbid, death. They engage in intensely complex procedures that require extreme sophistication and precision. Failure of a single step and the game is over.
The troops’ safety profile must occupy a more central location in the strategic equation. Doctors balance the expected hazards against the gains when considering medical procedures—and politicians should do exactly the same in the military setting. While all agree that no nation can afford its citizens to live under the constant threat of rockets, no country can tolerate exceedingly high numbers of soldiers to be maimed and killed either, the way Israel has just sustained in Operation Protective Edge. As much as we Israelis want peaceful and sane sunrises and sunsets for our children—we must first prioritize the safety of our troops, those at highest risk of harm.
To me, our soldiers are the nation’s patients. We want to minimize their exposure to unsafe circumstances and we want to preserve their lives. Therefore, each intervention must first overcome the “troop safety” test. If it is determined that the threat to combatants’ lives trumps the short and long term benefits to national security, then it is probably better to withhold more aggressive operations, even if rockets keep reaching our cities. In medicine, no physician will ever dream of exposing a patient to an unsafe regimen without his or her explicit consent. It is the patient’s judgment call—and that is how it should be, given that the patient is going to be affected by the treatment. Although combatants cannot technically give their consent to every military procedure (no army can serve as a soldiers’ ballot cast), decision makers must recognize that our troops, and nobody else, are the most high risk entity during a full scale military operation. The Israeli government must acknowledge this fact and treat our soldiers the way in which doctors treat their patients.
Ohad Oren is a graduate of the Ruth and Bruce Rappaport Faculty of Medicine, Technion – Israel Institute of Technology, Haifa, Israel.