Is Israel Its Brother’s Keeper? Responsibility and Solidarity in the Israeli–Palestinian Conflict

Is Israel Its Brother’s Keeper? Responsibility and Solidarity in the Israeli–Palestinian... Abstract This article examines the Israeli government’s role in supporting living conditions conducive to health in the occupied Palestinian territories (OPT). Limiting the discussion to public health, the authors argue that—whether justified in its overall political policy—the Israeli government and people are legally and ethically obligated to care for the well-being of the Palestinian people. The authors first review the current situation in the OPT and compare health statistics with Israel. Next, the authors make three arguments as to why the Israeli government and citizens should assist the Palestinian people: moral responsibility, legal responsibility and solidarity. Based on these, the authors make the case for Israel’s moral duty to ensure that Palestinian people living in the OPT achieve equitable levels of health as compared to Israeli citizens, while minimizing restrictions on Palestinian self-determination. The authors urge the Israeli government and citizens to improve Palestinian’s daily living conditions, tackle inequitable distribution of power and allow international support in these efforts. Hospital Admission must therefore be open to every patient that needs it, irrespective of whether he has money or not, whether he be Jew or heathen. (Virchow, 1879: 26) Introduction In 2007, the Lancet commissioned a steering group on the occupied Palestinian territories (OPT), which since published five reports about health conditions there (Chalmers et al., 2009). The image depicted was grim. In 2005, 70 per cent of the Palestinians reported that their families feared for their personal safety ‘very much or extremely’; 64 per cent feared for their families’ safety ‘very much or extremely’; 68 per cent felt worried over their personal future and the future of their families ‘very much or extremely’ (Giacaman et al., 2009). Undoubtedly, these anxieties at the time were grounded in the collective memory of the Israeli occupation of Gaza, as well as recurrent offensive military excursions elsewhere in the OPT. The Israeli occupation and military excursions still persist. From the first Intifada in December 1987 and August 2013, 8386 Palestinian citizens were killed by Israeli forces. In total, 17,354 Palestinians were injured. Most victims were civilians.1 During the last Israeli military campaign in 2014, 2251 Palestinians were killed, including 1462 Palestinian civilians, 299 women and 551 children. More than 11,000 were injured, with almost 10 per cent suffering permanent disability as a result (Bachmann et al., 2014).2 The economic losses are estimated at over 380 million USD (de Ville de Goyet et al., 2016). More than 70 per cent of the population in the Gaza Strip require humanitarian assistance (InfoGaza—a kit to facilitate understanding of the curfew on the Gaza Strip, 2015). Palestinian anxieties reported potentially reflect the aggressively declining public health infrastructure that was utterly inadequate to provide the most basic needs required for human survival. In what follows, we describe how exactly inadequate it really is, and how much it worsened since 2005. A recent report by Physicians for Human Rights-Israel (PHR-I) examines the public health conditions in Gaza after the 2014 military Operation Protective Edge. The report, particularly focusing on social determinants of health, concludes that the health inequality between the two people is worrisome, and calls upon the Israeli government to act to achieve health equity between the two people. For example, the report found that in 2011, life expectancy among Palestinians was 71 years for men and 73.9 years for women, while in Israel, life expectancy was 79.9 years for men and 83.6 years for women (Efrat, 2015: 15). Similarly, in 2011, infant (<1 year) mortality per 1000 live births was 18.8 in the OPT, compared to 3.7 in Israel (Efrat, 2015: 16).3 In this article, we echo the PHR-I report’s call to action. We argue that the Israeli government should provide appropriate care to the Palestinian people in a way that would bring about health equity between the two people, to the extent possible. We make our case in two steps: first, we review health statistics and the history and current condition of the healthcare infrastructure in the OPT, often comparing specific areas with Israel. Second, we present three arguments in making our case, two stemming from the notion of responsibility and one stemming from the notion of solidarity. This latter argument extends beyond the duty of the Israeli government, however. Using a solidarity argument, we further argue that Israeli citizens, either as individuals or as a collective, have a moral duty to assist the Palestinian people.4 We note two crucial qualifications from the outset: first, although public health and policy are intrinsically tied, this is a public health ethics paper, not a political one. We make no claims as to whether Israel’s political policy toward the Palestinians is justified. Rather, we limit our discussion to public health, arguing that, whether justified in its overall political policy, the Israeli government, being the occupying power, is legally and morally obligated to care for the Palestinian people. Second, we echo the authors of the PHR-I report in claiming that we do not wish to take away the right of the Palestinian people for self-determination and their potential ability to self-govern in an effective way (Efrat, 2015: 40–41). Rather, we simply contend that Israel should assist the Palestinian people until a more stable solution to the conflict is found. This is not a call to enhance Israeli control over the Palestinian people. Health and Healthcare in the OPT The World Health Organization (WHO) 69th World Assembly, convened in May 2016, signaled Israel as a violator of the Palestinian right to health (WHO, 2016).5 The Assembly’s resolution should be understood in its historical context. Historical Context The recent PHR-I report focuses on two geographical areas: Gaza and the West Bank. These areas’ recent history is significant. From the Six-Day War in 1967, Israel, by way of an Israeli military officer (Civil Administration), was actively responsible for the healthcare system in these territories, which operated separately from the Israeli healthcare system. Until 1993, the Civil Administration neglected the development and maintenance of the healthcare system (Giacaman et al., 2009). In total, 85 per cent of the Palestinian healthcare system then was financed through local taxes (Agency of Israeli-Palestinian Physicians for Human Rights, 1993: 5). Complex patients could receive referrals to Israeli hospitals. Until 1974, Palestinian citizens did not have to pay for healthcare services. However, in 1974, a healthcare insurance plan was instituted, becoming a necessary condition for access to health services (Agency of Israeli-Palestinian Physicians for Human Rights, 1993).6 After the first Intifada in 1987, Israel reduced its support to the Palestinian healthcare system, including the number of referrals to Israeli hospitals. In 1991, only 37 per cent of the Palestinian healthcare system was financed by the Civil Administration (Agency of Israeli-Palestinian Physicians for Human Rights, 1993: 5). In 1993, only 25 per cent of the Palestinians were insured (Agency of Israeli-Palestinian Physicians for Human Rights, 1993: 6). As part of the 1993 Oslo Accords, Israel relegated the management of the healthcare system to the Palestine Liberation Organization. As we demonstrate below, this generated the appearance of an independent Palestinian healthcare system, but this independence was merely an illusion (Efrat, 2015: 4–5). An Independent Healthcare System? The Palestinian healthcare system consists of at least four parts: the Palestinian Ministry of Health, the United Nations Relief and Works Agency, non-governmental organizations and the private sector (Giacaman et al., 2009; Horton, 2009; de Ville de Goyet et al., 2016). The total budget of the Palestinian government originates from three sources: taxes collected from Palestinian citizens, funds from donating countries and taxes collected by Israel for products imported into the OPT. The latter constitute 40–70 per cent of the total budget (Giacaman et al., 2009). On various occasions, Israel has held these funds as punishment (Mataria et al., 2009). For example, Israel held the tax money for 3 months following the Palestinian Authority’s application to join the International Criminal Court (Israel and Palestinians ‘Reach Accord’ on Frozen Taxes, 2015). This imposed significant difficulties for the Palestinian healthcare system, as the funding restriction often resulted in Palestinian health workers going without pay (Efrat, 2015: 33–34). Tax money is crucial for a state to increase its domestic product; in turn, citizens require a source of income to be able to pay taxes. In 2011, the total Palestinian growth domestic product (GDP) was 9.3 billion USD, which, for 4.1 million persons, translates into 2250 USD per capita. This number is 93 per cent lower than the Israeli GDP per capita, which in 2011 was 31,200 USD (Efrat, 2015: 7).7 The low Palestinian GDP correlates with, and can be partially explained by, the following: first, the ratio of children under the age of 14 years was 40 per cent in the Palestinian population, while it was 28 per cent in Israel (Efrat, 2015: 8). These children are assumed to be excluded from the workforce, and commonly do not (and should not) contribute to the GDP. Second, the ratio of participation in the workforce among Palestinian was 43 per cent compared to 64 per cent in Israel. While the ratio among Palestinian men was similar to that of Israeli men, only 17 per cent of the Palestinian women were a part of the workforce, compared to 58.1 per cent of the Israeli women (Efrat, 2015: 9). Third, the unemployment rate among Palestinians was 28 per cent, compared to 5.3 per cent in Israel (Efrat, 2015: 9; Unemployment in Israel has Gone Down to 5.3 per cent in February from 5.6 per cent in January, 2015).8 Fourth, in 2013, Palestinians received 8 years of education on average compared to 12 years in Israel (Efrat, 2015: 10). Fifth, 25 per cent of the Palestinian families live below the poverty line, which is 2000 New Shekels (NS) per month (approximately 525 USD), compared to 19.9 per cent of the Israeli families who live below the poverty line, which is 4000 NS (approximately 1050 USD) (Efrat, 2015: 10). Additionally, the Palestinian healthcare system unavoidably depends on Israel for medicines and personnel. Israel blocks the Palestinian import of medicines from neighboring Arab countries, only allowing the import of drugs from Israel. Consequently, Palestinians are forced to pay a higher price for their medicines. The export of medicines is limited as well: Palestinian exporters are only allowed to use small boxes, which raises the expenses. Further, these boxes are often examined by Israel security, thus destroying medicines that require cooling. These restrictions leave the Palestinians with a stock of outdated medicines, which can only be discarded by burying them underground. This in turn damages the environment in different ways, such as pollution of water sources (Efrat, 2015: 34–35). As to personnel, the West Bank hosts two medical universities: Al-Quds University in Abu Dis, and Al-Najah University in Nablus. The clinical training at Al-Quds takes place in East Jerusalem, which is also under Israeli jurisdiction. This means that medical students from the West Bank must apply for passes to cross over to Jerusalem. Each year, roughly 10 per cent of the applicants are denied by Israel authorities. Moreover, at the end of their studies, medical graduates must pass the Israeli Board Exams to be able to practice medicine in East Jerusalem, which hosts six hospitals. Israel, however, does not recognize Al-Quds as an Israeli University, since it is under Palestinian authority, or as a foreign institution.9 Consequently, roughly 300 medical graduates who reside in East Jerusalem are denied the ability to practice medicine there. Israel only allows up to 2000 healthcare professionals to cross over from the West Bank to Jerusalem at any given time. No healthcare professional from Gaza is allowed entry (Efrat, 2015: 35–36).10 To be independent, a healthcare system requires a steady flow of funds and medicines, an educated workforce and stable governance. The Palestinian healthcare system does not benefit from any of the above and—moreover—frequently must recover from continuous warfare and violence. As a result, access to healthcare in the OPT is terribly limited. Access to Healthcare According to the WHO Commission for Social Determinants of Health (henceforth ‘Commission’), health is positively correlated with public spending on healthcare: the higher the public spending, and lower the private, out-of-pocket spending on healthcare, the healthier are the people (Marmot et al., 2008). In the OPT, the national spending per capita is 248 USD compared to 2046 USD in Israel. In total, 16 per cent of the Palestinian GDP is devoted to healthcare compared to 7.7 per cent in Israel. Of this 16 per cent, public spending on healthcare in the OPT amounts to 37 per cent, while another 37 per cent is out of pocket. In Israel, 61 per cent of the GDP devoted to healthcare is public, while only 27 per cent is out of pocket (Efrat, 2015: 32).11 Two examples highlight the significance of these differences. In Israel, the 2013 national vaccination program included vaccines against the following pathogens and diseases: diphtheria, pertussis and tetanus (DPT), polio, measles, mumps and rubella (MMR), varicella, hepatitis B and A, Streptococcus Pneumonia, Rotavirus and human papillomavirus. In 2011, the Palestinian national program only included some of these, namely, DPT, polio, MMR and hepatitis B (Efrat, 2015: 19–20). Similarly, in 2011, there were 3.25 hospital beds per 1000 people in Israel compared to 1.23 beds in the OPT (Efrat, 2015: 29–30). These mean that people in the OPT do not receive good preventive care and lack access to secondary and above care. Because of the dire condition of the Palestinian healthcare system, roughly 200,000 patients or their relatives a year are required to seek medical treatment in Israel. Beyond the economic burden, this creates for the Palestinian healthcare system, roughly 20 per cent are denied access by Israel and are thus exposed to significant health risks (Arisheh, 2015; Efrat, 2015: 37). In 2007, Israel denied entry of all patients (282 cases) who were referred to healthcare facilities in Israel (Mataria et al., 2009). Several patients died while waiting. Occasionally, Israel strip searches and interrogates patients before allowing them entry (Arisheh, 2015). Finally, some patients are not allowed entry, even though they possess permits (Arisheh, 2015; de Ville de Goyet et al., 2016: 9). Further, the movement of ambulances from the West Bank to Jerusalem is limited and requires coordination which often delays crucial transit time of patients. Since Palestinian ambulances are not allowed to drive within Israel, they must transfer their patients to Israeli ambulances for this part of the journey (Efrat, 2015: 37–38; de Ville de Goyet et al., 2016: 9).12 Access to adequate public healthcare merely poses one condition for health. The WHO Commission has determined that healthy places are a necessary condition to cultivate healthy people. The term ‘healthy places’ includes access to clean potable water, basic sanitation, affordable housing, electricity and paved streets. Is the OPT a ‘Healthy Place?’ Palestinian population density in 2011 was 475 people per square kilometer in the West Bank, and 4583 in Gaza. These compare to only 347 people per square kilometer in Israel (Efrat, 2015: 10). Indeed, Gaza is one of the most densely populated places in the world (Finkelstein, 2010: 15). The West Bank possesses two potable water sources: the Jordan River and the Mountain Aquifer. After the Oslo Accords in 1993–1994, the Palestinian Water Authority (PWA) was established with the mandate to provide water to the West Bank. However, the PWA is required to buy water from ‘Mekorot’, its Israeli counterpart, because Israel denies permission to construct the necessary infrastructure, effectively maintaining Israeli control over the West Bank’s water sources. As a result, the average daily water consumption is 73 liter per capita, which is less than the 100 liter minimum recommendation by the WHO. In Israel, the daily water consumption in cities is 242 liter per capita. Gaza only has the beach aquifer as a water source. However, due to pollution and the destruction of infrastructure by Israeli assaults and restriction of import of construction material, only 5–10 per cent of its water is appropriate for drinking (Efrat, 2015: 12; de Ville de Goyet et al., 2016: 13). Importantly, most of the aforementioned statistics referencing Gaza reflect the reality of 2010–2011 and do not incorporate the devastating effects of three later Israeli military operations there: Operation ‘Returning Echo’ in March 2012, Operation ‘Pillar of Defense’ in October 2012 and Operation ‘Protective Edge’ in 2014. During ‘Protective Edge’, of 87 health facilities in Gaza, 25 were severely damaged or destroyed and 52 suffered minor damages. El Rafa Rehabilitation Hospital was specifically targeted and destroyed. Twenty-three healthcare workers lost their lives, 16 of whom while on duty. Eighty-three healthcare workers were injured (de Ville de Goyet et al., 2016: 6). An Ethical Call to Action The Commission has set forth three over-arching recommendations: improve daily living conditions, tackle unequitable distribution of power and resources and measure the problem and assess the intervention impact (Marmot et al., 2008). The problem is measured. Now, we should act to improve the Palestinian’s daily living conditions, tackle unequitable distribution of power and assess the impact of our acts. International support is crucial, but not sufficient, for two main reasons: first, Israel has continually blocked various forms of international support by force. Second, international support is limited by nature, and is unsustainable over time. Therefore, positive action from Israel—as the occupying power and closest neighbor—is fundamental to achieving any significant improvement in the lives of the Palestinians. The Commission has urged governments to adopt social determinants of health framework and strengthen the Ministry of Health’s stewardship role in operating within this framework (Marmot et al., 2008). In the next section, we extend the concept of a government’s stewardship role toward its citizens to any people under the control of that government. Specifically, we claim that Israel, due to its position as an occupying power, has a stewardship role toward the Palestinian people.13 Is Israel Its Brother’s Keeper? We present three arguments in favor of our assertion that Israel is obligated to care for the Palestinian people. The first two arguments rely on moral and legal responsibility, while the third relies on solidarity. Responsibility We understand responsibility as the accountability of actors for an act or omission of an act. Our use and understanding of responsibility rely on deep philosophical grounds. To further elaborate our argument, we distinguish moral from legal responsibility (Raz, 2011: 255; Glover, 1970: 19). Moral responsibility Moral responsibility is classically understood to require the ability of control as a necessary and sufficient condition. If one is in control of one’s acts (or omissions of acts) and therefore of the consequences of these acts, then one is deemed responsible. In other words, if one caused a certain consequence, one is responsible for it (Glover, 1970: 19). However, moral responsibility differs from mere causal responsibility. The former merits praiseworthiness or blameworthiness. When applying moral responsibility, an agent may be blameworthy for an act only if the agent meets the categories of moral responsibility, based on the actor’s level of intention and control. The latter means that to be merely causally responsible means causing a consequence in a way that does not merit blameworthiness. If one caused a car accident because one suffered a heart attack, then one is responsible for the accident but is not blameworthy. Conversely, if one caused an accident because one was text messaging while driving, then one is morally responsible and therefore blameworthy for the accident (Glover, 1970: 52, 56). Various excuses or justifications may relieve one of moral responsibility and blameworthiness, including ignorance, compulsion and—perhaps most importantly to our case—self-defense (Glover, 1970: 19, ch. 3).14 In light of the former two, intentionality often complements control as being sufficient and necessary conditions for responsibility. Only if one both controls one’s acts and intends to bring about specific consequences can one be deemed responsible (Raz, 2011: 228–229, Glover, 1970: 65–66). In contrast, Joseph Raz emphasizes the rationality of the act when assessing accountability. Intention and control of the act and its consequences may be sufficient for responsibility, but are not necessary.15 Instead, Raz posits two necessary conditions for responsibility. First, people may be responsible only if they possess the capacity for rational action, meaning a capacity to act in accordance with one’s reasons. Second, people may be responsible for an act only if this act resulted from an appropriate execution of this capacity for rational action. Importantly, the execution itself may be successful or unsuccessful—what matters is that the capacity is not temporarily blocked or missing. Whenever actions are determined by our rational capacities found within what Raz calls the domain of secure competence, the actor carries responsibility. Raz’s domain of secure competence includes capacities and subsequently acts that do not require reflection or specific intention prior to their execution. Accordingly, individuals can be held morally responsible for any action that is in their power to execute as rational agents, regardless of intent and consequences (Raz, 2011).16 Our argument then is that Israel should be held morally responsible for the grim situation of the Palestinian healthcare system because it controls its acts toward the Palestinians—and thus their consequences, intends to bring about these consequences and acts rationally. As described in Sections 1–2, not only has Israel failed to allow third parties or the Palestinian authorities to better the Palestinian healthcare system, but has also actively contributed to its dire condition (Mataria et al., 2009).17 For example, Israel has actively sabotaged attempts to construct more healthcare facilities in the West Bank, despite available funds and medical approvals (Agency of Israeli-Palestinian Physicians for Human Rights 1993: 7). As forcibly argued by Michael Marmot, ‘Deprived of a clean, safe neighborhood, meaningful work, opportunities for quality children’s education, freedom from police harassment and arrest, and freedom from violence and aggression, it is harder to have control over one’s life or to be a full social participant’ (Marmot, 2006: 1305). Put formally, the argument proceeds thus: Sufficient conditions for moral responsibility include: control of acts and their consequences, intentionality and the rationality of acts. Israel controls its acts toward the Palestinian people and their consequences, intends to inflict these consequences and exercises its ability for rational actions. Given I–II: Israel is morally responsible for the current health condition of the Palestinian people. Moral responsibility entails blameworthiness unless there are valid justifications. Israel does not have any valid justifications. Given III–V: Israel is blameworthy for the current health condition of the Palestinian people. Counter arguments and Responses: Moral Responsibility One immediate objection may be raised against Premise II. We encounter several difficulties in defining what we mean by ‘Israel’ here: is it the Israeli citizens, the Israeli government as a whole or the individuals who constitute the Israeli government? The first understanding is quite implausible: not all Israeli citizens control the acts of the government, intend to bring about the consequences of these acts or have reasons to act in the ways specified in Sections 1–2. The second understanding is also problematic: how can we say about a government that it ‘intends’ to do anything, or that it has an ability for a ‘rational’ action? Arguably, these terms can only be applied to individual agents. Thus, the third understanding is perhaps the closest to what we mean. We acknowledge that not all members of the Israeli government agree with one another, and not all government officials control the acts of the government to the same extent. Perhaps a simple solution to this may be to re-define what we mean here as the majority of the individuals constituting the Israeli government. In any case, we believe that common sense allows a certain degree of vagueness in this case.18 A more formidable objection to our argument may be raised against Premise V. While responsible, Israel is excused of blameworthiness, as it is only defending itself. Since the Palestinian people attacked Israel19 first, and continue attacking, Israel is therefore entitled to defend itself.20 We respond in two ways. First, both sides of the conflict argue that the other side is the initial aggressor, and that the other side is not a real partner for peace. Beyond empirical data, the ‘right’ answer will always remain a matter of interpretation. Second, proportionality determines whether we may accept moral excuses or justifications (Glover, 1970: 20; Mcmahan, 2009: 18–25). The justification of self-defense is plausible up to an extent. Specifically, the quality and probability of risk are vital in determining whether self-defense is a reasonable justification in a certain case. If one kills another for fear of one’s life, then one may be justified. But if one kills another for fear of losing one’s wallet, the justification is arguably much weaker. Based on the comparative data provided in Sections 1–2, we hope to have demonstrated that Israel reacted un-proportionally throughout the history of the conflict, e.g. number of civilian casualties and health disparities due to Israeli action.21 Legal responsibility Legal responsibility renders one legally liable. Liability means subjecting oneself to disadvantages posed by another. Unlawfully causing harm carries a legal duty to compensate the harmed (Raz, 2011: 255). Harms include an action that one should not have performed or a state of affairs that one should not have permitted to exist (Raz, 2011: 257). We argue that Israel should be held legally responsible for the state of affairs of the Palestinian people, as interpreted by existing international law. Notice that this is not an is-ought problem. Put formally, our argument may be described as follows: Countries should obey current international law. Current international law requires that an occupying force should be responsible for the basic needs of the occupied population. Israel is the occupying force in the OPT according to international law. Conclusion: Given I–III, it follows that Israel should be responsible for the basic needs of the Palestinian population. We believe that the first (normative) premise requires no defense. We also assume that the second (descriptive) premise is prima facie accepted, so the following is merely an elaboration. According to international law22, the population in an occupied territory is considered ‘protected persons’, in the language of the 1949 Fourth Geneva Convention (which Israel signed in 1951). According to Article 55 of the Convention, To the fullest extent of the means available to it, the Occupying Power has the duty of ensuring the food and medical supplies of the population; it should, in particular, bring in the necessary foodstuffs, medical stores and other articles if the resources of the occupied territory are inadequate.23 Similarly, Article 56 of the Convention specifies that,24 To the fullest extent of the means available to it, the Occupying Power has the duty of ensuring and maintaining, with the cooperation of national and local authorities, the medical and hospital establishments and services, public health and hygiene in the occupied territory, with particular reference to the adoption and application of the prophylactic and preventive measures necessary to combat the spread of contagious diseases and epidemics. Medical personnel of all categories shall be allowed to carry out their duties. (Convention (IV) relative to the Protection of Civilian Persons in Time of War, 1949)] The Convention emphasizes that the occupying power is obligated to provide for the basic needs of the occupied population, public health being one of the foremost basic needs stressed by the Convention and the many commentaries it received. Counter argument and Responses: Legal Responsibility Perhaps the most common objection to the legal responsibility argument is a rejection of the third premise of our formal argument above, namely, that Israel is still an occupying force in the OPT. If this premise is indeed false, then the argument loses its soundness. Our response to this objection is that Israel fulfills the criteria that define an occupying force. In 2004, the International Court of Justice was asked by the United Nations (UN) General Assembly to provide an advisory opinion on the construction of the ‘Separation Wall’ (see Figure 1, taken from http://www.btselem.org/maps).25 Reiterating a broad and long-standing international and legal consensus, the Court repeated the definitions first declared by the 1907 Fourth Hague Convention: Figure 1. View largeDownload slide Map of the separation wall, November 2014. The yellow line represents the built wall. The red line represents planned construction. Figure 1. View largeDownload slide Map of the separation wall, November 2014. The yellow line represents the built wall. The red line represents planned construction. [T]erritory is considered occupied when it is actually placed under the authority of the hostile army, and the occupation extends only to the territory where such authority has been established and can be exercised. (The International Court of Justice, Legal Consequences of the Construction of a Wall in the Occupied Palestinian Territory, Advisory Opinion, 2004: 35) Based on these definitions, the Court decided that Israel has been the occupying force since 1967, and remained so up to the Court’s decision in 2004. Importantly, Israel has not signed the Hague Convention. However, the Convention’s annexed regulations reflect customary international law, which is universally binding (Report of Detailed Findings of The Independent Commission of Inquiry Established Pursuant to Human Rights Council Resolution S-21/1, 2015: 7). Arguably, nothing has changed as regards Israel’s status as the occupier in the West Bank since the Court’s decision. But this decision applies to the West Bank and East Jerusalem—what about Gaza? (see Figure 2, taken from http://www.btselem.org/maps) Figure 2. View largeDownload slide Map of the West Bank, Gaza, and the Settlements, November 2014. More maps may be found here: http://www.btselem.org/maps. Figure 2. View largeDownload slide Map of the West Bank, Gaza, and the Settlements, November 2014. More maps may be found here: http://www.btselem.org/maps. Israel holds that following its 2005 disengagement from Gaza, it is no longer the occupying force there (Sharvit-Baruch, 2012; Report of Detailed Findings of The Independent Commission of Inquiry Established Pursuant to Human Rights Council Resolution S-21/1, 2015: 7). However, as a variety of international law experts and organizations have concluded (Batniji et al., 2009; Becker et al., 2009; Scale of Control- The Continuing Responsibilty of Israel in The Gaza Strip, 2011; Maurer, 2012), Israel preserves effective control over Gaza, which implies that Israel is still the occupying force in Gaza, according to the established criterion regarding whether the law of occupation applies in a given territory. The Red Cross has recently adopted the ‘functional approach’ to determine whether the extent of control of a foreign territory amounts to effective control and thus to military occupation. In cases in which there is only partial control over a territory, the Red Cross considers any amount of control that meets the criterion as effective control. As the Red Cross report states: Indeed, despite the lack of the physical presence of foreign forces in the territory concerned, the retained authority may amount to effective control for the purposes of the law of occupation and entail the continued application of the relevant provisions of this body of norms. This is referred to as the ‘functional approach’ to the application of occupation law. This test will apply to the extent that the foreign forces still exercise, within all or part of the territory, governmental functions acquired when the occupation was undoubtedly established and ongoing. (The International Committee of the Red Cross, International Humanitarian Law and the Challenges of Contemporary Armed Conflicts: Report for the 32nd International Conference of the Red Cross and Red Crescent 2015: 12) The writers of the report likely had the case of Gaza in mind, since one of the ‘exceptional cases’ where the test of governmental functions has to be applied is ‘when foreign forces withdraw from occupied territory (or parts thereof) but retain key elements of authority…’ (The International Committee of the Red Cross, International Humanitarian Law and the Challenges of Contemporary Armed Conflicts: Report for the 32nd International Conference of the Red Cross and Red Crescent 2015: 12). The report specifies that a state’s territory includes ‘not only its land surface but also… the territorial sea, and the national airspace above this territory’ (The International Committee of the Red Cross, International Humanitarian Law and the Challenges of Contemporary Armed Conflicts: Report for the 32nd International Conference of the Red Cross and Red Crescent 2015: 13). Notably, these areas are components of Gaza’s territory that are incontrovertibly under Israel’s control. Similarly, based on this ‘functional approach’ and the fact that Israel can send troops into Gaza within ‘reasonable time’, the UN Independent Commission of Inquiry, ‘… concludes that Israel has maintained effective control of the Gaza Strip within the meaning of Article 42 of the 1907 Hague Regulations’ (Report of Detailed Findings of The Independent Commission of Inquiry Established Pursuant to Human Rights Council Resolution S-21/1, 2015: 9). Simply put, Israel still exercises functional control in Gaza, albeit not as freely as it did before the 2005 disengagement. To illustrate: Israel limits the entry of construction materials into the Gaza Strip that it considers to be of potential ‘dual use’, meaning for both civilian and military purposes. These include iron and cement. Since the beginning of ‘Protective Edge’ until the end of September 2015, only 9 per cent of the estimated materials needed for repair and re-construction were introduced into Gaza, and only 30 per cent of these serve the private sector. Similarly, during the first half of 2015, Israel allowed a monthly average of 13,832 Palestinians from Gaza to enter Israel, compared to over half a million in 2000. Further, Israel allows fishermen from Gaza to reach only up to 6 nautical miles from the beach, and prevents any entry or exit by both sea and air (InfoGaza- A Kit to Facilitate Understanding of The Curfew on the Gaza Strip, 2015). Perhaps most tellingly, Israel controls the Palestinian population registry common to the West Bank and Gaza. This means that Palestinian identity cards can only be issued with Israeli approval (InfoGaza—A Kit to Facilitate Understanding of The Curfew on the Gaza Strip, 2015; Report of Detailed Findings of The Independent Commission of Inquiry Established Pursuant to Human Rights Council Resolution S-21/1, 2015: 9).26 In sum, former US President Jimmy Carter (2009) wrote about the OPT, ‘[t]here has been no withdrawal from the West Bank and the Palestinians here and in the Gaza Strip have been increasingly strangled’ (Carter: 783). In addition to these two arguments, which are based on responsibility and most plausibly relate to the Israeli government, we wish to present an argument that pertains to the Israeli public. This argument, rather than relying on responsibility, relies on solidarity. Solidarity in Bioethics Explicit considerations of solidarity have been absent from the bioethical literature until recently, but are now receiving greater attention (Prainsack and Buyx, 2011: chap. 3; Dawson and Jennings, 2012; Eckenwiler et al., 2012; Illingworth and Parmet, 2012). We first provide two conceptual accounts of solidarity, and then apply them to our context. Drawing on rich philosophical and sociological scholarship (Prainsack and Buyx, 2011: chap. 1), Barbara Prainsack and Alena Buyx define solidarity as, ‘…shared practices reflecting a collective commitment to carry “costs” (financial, social, emotional) to assist others’ (Prainsack and Buyx, 2011: 46). They apply this definition along three tiers: the interpersonal, the collective and the contractual. According to the first tier, an individual recognizes sameness with, or similarity to another in at least one relevant respect and is willing to carry costs to assist her. Since the definition of solidarity requires action (‘shared practices’), the willingness of the individual must manifest in an act (or omission of an act) to be perceived as solidarity. While the first tier concerns individuals, the second tier concerns collective groups. According to the second tier, solidarity comprises the ‘…manifestation of a collective commitment to carry costs to assist others (who are all linked by means of a shared situation or cause)’.27 Angus Dawson and Bruce Jennings view solidarity as deep-seated in ethical discourse. According to them, solidarity is an essential requirement ‘…for the very possibility of ethical decision making’ (Dawson and Jennings, 2012: 74). They perceive solidarity as a moral practice that is fundamental to mutual relations among persons (Jennings and Dawson, 2015). Solidarity requires a public action, done by a collective rather than individuals. According to Dawson and Jennings, an act of solidarity is considered as such if it is understood by actors and observers as an act of solidarity. Solidarity entails a positive identification with another individual or group, driven by sympathy. ‘The act itself has meaning but also purpose in that it is oriented towards improving or correcting past or present disadvantage or injustice’ (Dawson and Jennings, 2012: 74).28 Dawson and Marcel Verweij similarly mention ‘standing together’ and pursuing shared aims and ideals as key features of solidarity. They distinguish two kinds of solidarity. Rational solidarity is planned and consensual, consciously aimed at achieving a desired goal. Constitutive solidarity reflects shared values and norms, and is less teleological in nature. It engenders actions that may not be rational in the sense of pursing a specific goal.29 Dawson and Jennings (Dawson and Jennings, 2012; Jennings and Dawson, 2015) express three ways in which solidarity may be expressed in relation to the other. First, solidarity means ‘…being open to other ways of thinking and living’ (Dawson and Jennings, 2012: 75); it means ‘standing up with’ another party. Second, solidarity means ‘standing up as’ a collective of creatures with shared biological vulnerabilities, and a shared culture that requires equal respect, civil discourse and tolerance. Third, solidarity means an intention to assist another who is worse off because of one’s behavior. Jennings and Dawson specifically argue that health conditions may be an example for this kind of expression of solidarity (Jennings and Dawson, 2015). Let us now apply these accounts to our context. Solidarity with the Palestinian people Applying Prainsack and Buyx’s first tier, then, we submit that individual Israeli citizens share a similarity with individual Palestinians in more than one relevant respect: they all depend on basic needs such as clean water, reliable sanitation and access to healthcare, etc. They all occupy the same geographic location.30 And they all share a recent history replete with war, occupation and a need for independence. Indeed, perhaps the most important relevant aspect in which individuals in the two groups are similar is that individuals on both sides have lost their loved ones due to actions performed by the other side, and must cope with that loss; for several decades now, individuals on both sides have lived in existential fear. Several of these commonalities translate to Prainsack and Buyx’s second tier of solidarity as well. The Israeli citizens as a collective are linked to the Palestinian people because of their shared situation: both collectives are located in a highly politically and religiously sensitive geographical area, with a rich and bloody history. As socio-economic and political systems, both collectives depend on healthy citizens who in turn depend on access to healthcare and healthy places. Similarly, both collectives are linked because of their shared cause: both seek to exist as free and prosperous societies.31 Perhaps most pertinently, both sides have been engaged in war against one another for decades. Dawson and Jennings’ account of solidarity may also apply to our discussion here. Israelis and Palestinians have disagreed regarding their rights to the land of Israel for many years, with no solution in sight. Some of these disagreements stem from, and may be solved by factual data, but most of them cannot, and will not. Rather, these disagreements stem from national, cultural and psychological biases, and thus will most likely never be solved. Applying the solidarity argument means the Israeli citizens as a collective must consciously decide to be open to differing opinions of their fellow Palestinians; Israeli citizens have to stand up with the Palestinian people. Similarly, Israeli citizens must acknowledge the humanity of their fellow Palestinians. Israeli citizens must recognize that Palestinians are vulnerable biological creatures, constituting part of a modern, post-enlightenment culture that requires equal respect for universal human rights, tolerance and civil discourse. Israeli citizens should stand as Palestinians. Finally, Israeli citizens should realize that their policies play a significant role in the causal chain that led to the current dire condition of the Palestinian healthcare system. Notice that this argument is slightly different from the moral responsibility argument in Section 4.1.1. The argument there is analogous to ‘if you break, you pay’, while here, the argument is analogous to ‘you break, you feel sympathy with the victim (which in turn drives solidarity) and you pay (because of this feeling of solidarity)’. Importantly, we do not commit to any of these accounts. Instead, we suggest that our case is strengthened by the straightforward applicability of both accounts. What is crucial is the plausible identification of the Israeli citizens with the Palestinian people. This identification entails a moral duty to assist the Palestinian people. Both rational and constitutive solidarity may be applied here. Israeli citizens may consensually unite to carry costs versus specific goals to assist the Palestinian people, and they may encourage values of care toward, and empathy with the Palestinian people. In case the two accounts of solidarity do not appeal to the reader, we may understand solidarity minimally as having two necessary components: (i) identification with the other (individual or collective), stemming from some perceived similarity that is relevant in one or more ways, and (ii) the imperative to assist the other. Our argument then may be formally stated thus: An argument based on solidarity is a valid moral argument; it has normative force. Solidarity means identification with another in at least one relevant aspect, which in turn entails the imperative to assist the other. Israeli citizens can identify with the Palestinian people in at least on relevant aspect. Following I–III, Israeli citizens should assist the Palestinian people. Notice that we simply assume that Premise I is true. By ‘valid’ we mean legitimate, justified, or well founded. Solidarity has normative force in that we may expect one to act in a certain way because we judge that one should be compelled by a solidarity argument. This should be similar to the way we commonly accept the moral validity of a responsibility argument. II–IV are formulated as a modus ponens argument, in that wherever the first component applies, the second must follow. Premise II affirms that within the solidarity argument, if one can identify with another in some relevant aspect (relevant to the discussed context), then one should assist the other. If one identifies (P), then one should assist (Q). Our discussion above about the ways in which Israeli citizens may identify with the Palestinian people, both as individuals and as a collective, grounds Premise III, hence P. The conclusion reflects ‘if P then Q’: if Israeli citizens can identify with the Palestinian people in at least one relevant aspect, then they should assist them. Counter arguments and Responses: Solidarity An objection may be raised against our first premise that a solidarity argument has normative force. One may accept a shared basis between the Israeli and the Palestinian people, but nevertheless reject the moral attitude of solidarity and duties stemming from it.32 In other words, one may simply reject solidarity as normatively valid. Similarly to Prainsack and Buyx (Prainsack and Buyx, 2012), we do not argue here for the normative force of solidarity, although we are sympathetic with Jennings and Dawson’ argument, that the world would be a worse place otherwise (Jennings and Dawson, 2015).33 We are also sympathetic with Lisa Eckenwiler et al.’s argument that eventually solidarity is beneficial for the better-off party as well as the worse-off party (Eckenwiler et al., 2012). Prainsack and Buyx allude to another argument for solidarity that is worth exploring further: given that we are relational creatures that depend on our community for the creation of our own identity, we are committed to benefit that community (Prainsack and Buyx, 2012).34 This is to say that we do not offer our own defense of solidarity as a valid moral argument, but rather simply assume that it is based on said arguments and deeper philosophical justifications.35 Granted its validity and normative force, what does solidarity mean? That if a person agrees that there are relevant similarities between her and another who is worse off36, she should assist the other. The same goes for a collective. Thus, if an Israeli accepts solidarity as a valid moral argument—and indeed, many Israeli ethicists seem to (Gross, 2004; Glick, 1997)—and agrees that there are relevant similarities between the Israeli and Palestinian people, then she should assist the Palestinians. Our second premise may also encounter resistance. Even if a solidarity argument is accepted as a valid normative argument, not every kind of identification entails an obligation to assist. Humans and vampires may share the need and desire to feed, but this does not mean that humans would be morally obligated to provide blood meals to vampires.37 This is when ‘relevant aspect’ would factor into the argument’s reasoning. Indeed, not every kind of identification entails an obligation to assist. Rather, one has to identify with another in at least one relevant aspect. The identification has to be relevant to the specific context, and thus a case-by-case discussion must take place to determine whether the identification is relevant and what exactly it should mean. At this point, one may disagree with our third premise—that Israeli citizens can identify with the Palestinian people—negating any relevant aspect of identification between the Israeli and Palestinian people. If this premise falls, then the argument becomes unsound. Our brief response involves both a historical–empirical and interpretative–conceptual components. First, historians and social scientists may determine whether there are important and fundamental similarities between the two people. However, whether these similarities are relevant enough to fulfill the first component of solidarity is of course a matter of interpretation. So second, we believe that at least some of the similarities we mentioned involve such basic needs for the lives of individuals (e.g. clean water, having a family) or for the formation of a national collective (e.g. history, the search for independence) that negating them as relevant similarities practically annuls the very possibility of ever using solidarity in any normative capacity. If solidarity is to have any normative force, we should accept some similarities as commonsensically relevant.38 General Counterarguments and Responses A general objection against our three arguments may be that governments (and collectives) have responsibilities only toward their own people, and not to other peoples; similarly, solidarity, if at all applicable, can only extend within national borders (Eckenwiler et al., 2012). This claim pertains to a much more general debate regarding global justice and cosmopolitanism upon which we wish not to elaborate here (Nagel, 2005; Pogge, 2005; Singer, 2011: chap. 8; Prainsack and Buyx, 2011, Section 7.4). However, this response misses our point. We do not argue for cosmopolitanism or global solidarity in this article. Rather, we make a narrower case for why Israeli citizens should assist another people—the Palestinian people. Even if the ethical case for cosmopolitanism fails—and global solidarity with it— our three arguments still hold. Israel has a moral responsibility to assist the Palestinian people because of its causal role in their dire condition. Israel also has a legal responsibility to assist the Palestinian people, as an occupying power. Finally, Israeli citizens (as individuals or as a collective) can identify with the Palestinian people in morally relevant ways, and therefore should assist them. A second general objection is asking why Israel should care about the Palestinian people in effect. In other words, Israel may be ethically responsible for the health of the Palestinian people, but on a practical level, it should not. This argument can appear in various forms, some more sophisticated than others. For instance, one can argue that very few countries in the world actually take responsibility for the people they occupied in the past or occupy in the present, e.g. the USA/Canada and Native Americans, Guatemala and native Mayans or the European colonies in Africa. The answer here is straightforward: the fact that this is indeed the current situation does not mean it should be, and the fact that other countries do it, does not mean that Israel is justified in doing it as well. If our case so far is compelling, then Israel should assist the Palestinian people. However, how should we determine the appropriate extent of this assistance? How Much to Assist? Specific recommendations as to the role of Israel in bettering the health conditions of the Palestinian people have existed for more than two decades (Agency of Israeli-Palestinian Physicians for Human Rights 1993; Mataria et al., 2009; de Ville de Goyet et al., 2016). In light of the current status quo, some of these seem more realistic than others. We are content with merely suggesting that the specifics should be determined jointly by the various stakeholders involved, particularly the true representative of the Palestinian people. Concluding Remarks In this article, we first presented recent data on the health conditions in the OPT. We then articulated and defended three arguments as to why Israel should assist the Palestinian people: moral responsibility, legal responsibility and solidarity. A Lancet editorial states: ‘The Pursuit of health as a political objective and the creation of a strong health system for Palestinians could be one fruitful diplomatic path to reconciliation, peace, and justice’ (Horton, 2009: 784). We concur. This article is our own modest attempt at solidarity with the Palestinian people, mainly in Gaza (Manduca et al., 2014; Stall et al., 2014). Our discussion, in fact, implements and contextualizes the peace-through-health framework [otherwise known as ‘Health as a Bridge for Peace’ (de Ville de Goyet et al., 2016)]. Specifically, it calls for tertiary prevention in the OPT, with the objective of restoring capacities for peaceful social processes such as healthcare (Barbara and Macqueen, 2004). Armed conflicts usually engender suffering and poor health conditions in one or more of the participating factions. Whenever that happens, public health ethicists should be there, at least in writing, defending the sick and vulnerable and protesting injustices. Political, ethnic and religious differences should be left aside. Notes Footnotes 1. In comparison, 1433 Israelis were killed and 1834 were injured in this period. Most of the victims were soldiers. 2. WHO provides slightly different numbers: 2260 casualties, including 612 children and 230 women, 12,625 injured, including 3827 children and 1773 women. In total, 899 Palestinians are permanently disabled (de Ville de Goyet et al., 2016). During this operation, 72 Israelis were killed, and over 800 were injured. Most of the victims were soldiers (Hartman, 2014). 3. In Gaza alone, infant mortality rate in 2011 was 22.4 per 1000 live births (van den Berg et al., 2015). 4. We believe that in light of their expertise, specifically Israeli healthcare professionals and students carry this duty (Horton, 2009; de Ville de Goyet et al., 2016: 17), but we do not pursue this point further. We also believe that this duty could be easily extended to the global community, but again, do not pursue this further here. 5. The Assembly commissioned a WHO delegation for the following mission: ‘to report and make practical recommendations on the health conditions in the OPT, including east Jerusalem, and in the occupied Syrian Golan, to the Seventieth World Health Assembly, through a field assessment…’ (WHO, 2016). 6. According to Mataria et al., currently only public employees must pay insurance premiums (Mataria et al., 2009). There are also differences between Gaza and the West Bank governances. For example, in Gaza there is no co-payment for primary healthcare except medicines (de Ville de Goyet et al., 2016). 7. GDP, both total and per capita, is known positively to correlate with health. Life expectancy, a common measure for health, was found to be higher in countries with higher GDP compared with countries with lower GDP. Conversely, GDP was found to be higher in countries with higher life expectancy compared to countries with lower life expectancy (Swift, 2011). 8. Currently, unemployment in the Gaza strip is at 41.5 per cent (InfoGaza- A Kit to Facilitate Understanding of The Curfew on the Gaza Strip, 2015). 9. Normally, foreign medical graduates who have completed their studies in European countries such as Hungary and Italy are allowed to take the Israeli board exams. 10. Indeed, Israel has been hampering healthcare training for decades now. A report from 1993 already lamented that Israel does not allow Palestinian residents to finish their training periods in Israel (Agency of Israeli-Palestinian Physicians for Human Rights, 1993: 7–8). 11. The Palestinian GDP devoted to healthcare is actually relatively high, for various reasons. These include low overall GDP, the need to rehabilitate a healthcare system that was neglected for many years and inefficient spending, e.g. over-prescription of drugs (Mataria et al., 2009). 12. As an emergency medical technician, one of the authors (Z. L.) has transported patients to and from the Palestinian territories. As a medical intern in a hospital in Israel, Z. L. cared for pediatric patients from Gaza. 13. The UK-based Nuffield Council on Bioethics (henceforth, the Council) espoused the Stewardship model for public health governance. According to this model, liberal states are obliged to provide certain conditions for their people, both as individuals and as collectives. Importantly, the Council asserts that states are responsible not only for their citizens but for their populations as a whole, including non-citizens (Hepple et al., 2007: 25–26). 14. Glover distinguishes excuses from justifications but points to the difficulty of clearly differentiating them (Glover, 1970: 55). We agree, and will therefore treat them as synonymous. 15. Raz in fact proposes the guidance principle as successfully uniting the requirements of control and intention (Raz, 2011: 229). However, since this is not a common understanding of responsibility, and since Raz himself does not accept this principle, we may ignore it here. 16. Raz is aware of the problems inherent in this account, for example, how people may develop this domain of competence, and replies to them (Raz, 2011: 247). 17. But this is not to exempt other countries and international organizations from bearing the blame, as well as elements internal to the Palestinian politics. Other causes invariably include internal governance failures, actions and inactions of the international community and a rapid epidemiological transition (Giacaman et al., 2009; Horton, 2009; Mataria et al., 2009). 18. In fact, this vagueness applies to the whole text. After many deliberations and for consistency sake, we opted to use the term ‘Israeli citizens’. However, does it mean that all of the citizens of Israel are obligated to assist the Palestinian people? What about the very young, or the very poor or the Arab–Israeli and other minorities who are Israeli citizens? Even referring to Israeli citizens as a collective would not be satisfying here, considering the latter group. 19. Again, by ‘Israel’ here we must allow some flexibility in the possible meaning. It may mean its land, citizens or even government’s interests. 20. Perhaps a modified version of this counterargument may be that Israel is absolved from moral responsibility because the Palestinian Authority is the one to blame for the current situation of the Palestinian people, due to corruption, etc. Regardless of whether this claim is empirically true, we think it is conceptually mistaken. Two agents can be morally responsible for the same effect, and thus be blameworthy. The argument about Israel’s responsibility is one argument while the responsibility of the Palestinian Authority is quite another. It very well may be that the Palestinian Authority could have made things better, and is blameworthy, but this does not absolve Israel from its responsibility. 21. A longer, more comprehensive response will lead us deep into the political realm, which we explicitly wish to avoid. 22. A 1993 report by Physicians for Human Rights Israel makes the same argument as our first premise here. In addition to the Geneva Convention, the report also cites the UN Convention on the Rights of a Child, ratified by Israel in 1991, the UN Convention on the Elimination of All Forms of Racial Discrimination, signed by Israel in 1979, and the International Convent on Economic, Social and Cultural Rights (Agency of Israeli-Palestinian Physicians for Human Rights, 1993). 23. Commentary to this article elaborates as follows: ‘The rule that the Occupying Power is responsible for the provision of supplies for the population places that Power under a definite obligation to maintain at a reasonable level the material conditions under which the population of the occupied territory lives. The inclusion of the phrase “to the fullest extent of the means available to it” shows, however, that the authors of the Convention did not wish to disregard the material difficulties with which the Occupying Power might be faced in wartime (financial and transport problems, etc.); but the Occupying Power is nevertheless under an obligation to utilize all the means at its disposal. Supplies for the population are not limited to food, but include medical supplies and any article necessary to support life.’. 24. See commentary: ‘In most cases, however, the invading forces will be occupying a country suffering… severely from the effects of war; hospitals and medical services will be disorganized, without the necessary supplies and quite unable to meet the needs of the population. The Occupying Power must then, with the co-operation of the authorities and to the fullest extent of the means available to it, ensure that hospital and medical services can work properly and continue to do so.The Article refers in particular to the prophylactic measures necessary to combat the spread of contagious diseases and epidemics. Such measures include, for example, supervision of public health, education of the general public, the distribution of medicines, the organization of medical examinations and disinfection, the establishment of stocks of medical supplies, the dispatch of medical teams to areas where epidemics are raging, the isolation and accommodation in hospital of people suffering from communicable diseases, and the opening of new hospitals and medical centres’. 25. The Separation- or Annexation Wall meant in reality the confiscation of more than 34,000 acres of privately owned Palestinian land by Israel (Blumenthal, 2013: 357). 26. See also a report by the International Criminal Court, which states the following: ‘Israel maintains that following the 2005 disengagement, it is no longer an occupying power in Gaza as it does not exercise effective control over the area. However, the prevalent view within the international community is that Israel remains an occupying power in Gaza despite the 2005 disengagement. In general, this view is based on the scope and degree of control that Israel has retained over the territory of Gaza following the 2005 disengagement – including, inter alia, Israel’s exercise of control over border crossings, the territorial sea adjacent to the Gaza Strip, and the airspace of Gaza; its periodic military incursions within Gaza; its enforcement of no-go areas within Gaza near the border where Israeli settlements used to be; and its regulation of the local monetary market based on the Israeli currency and control of taxes and customs duties. The retention of such competences by Israel over the territory of Gaza even after the 2005 disengagement overall supports the conclusion that the authority retained by Israel amounts to effective control’ (The Office of The Prosecutor. Situation on Registered Vessels of Comoros, Greece and Cambodia. Article 53(1) Report, 2014: 16–17). Of course, not all agree. See, for instance, one international law expert who not only denies that Israel is occupying Gaza but also suggests (ironically, we hope) that Gaza is occupying Israel (Kontorovitch, 2014). 27. At the third tier, solidarity is manifested in contractual or legal norms. We do not discuss this tier further because we are not clear as to whether Prainsack and Buyx would define Israel’s duty as grounded in responsibility or third-tier solidarity. They argue that the key difference between responsibility and solidarity is the possibility of consequences attached to the former, but qualify it with the condition that solidarity is not perceived according to the third tier (Prainsack and Buyx, 2011: 40). We wish not to argue over semantics and therefore ground Israel’s duty in responsibility, with the price of neglecting the third tier of solidarity. 28. Angus Dawson and Bruce Jennings are not convinced that the first-tier solidarity as defined by Prainsack and Buyx cannot be defined rather as beneficence or altruism. They also doubt that solidarity indeed requires carrying costs. Instead, they argue that what is foundational of solidarity is the willingness to carry costs (Dawson and Jennings, 2012; Jennings and Dawson, 2015). Their critique has merits, but addressing it here goes beyond the scope of this article. We also agree with Dawson and Marcel Verweij that Prainsack and Buyx’s report lacks normative work, and that it is wrong in divorcing solidarity from pandemic responses (Dawson and Verweij, 2012). Like them, we focus on Prainsack and Buyx’s report because it provides substantial descriptive and conceptual analysis of solidarity and related terms. Prainsack and Buyx do respond to Dawson and Jennings’ criticism (Prainsack and Buyx, 2012). 29. For a plausible critique of this classification, see (Prainsack and Buyx, 2012). 30. No pun intended. 31. A 2012 editorial hints at the possibility of extending solidarity to animals (Illingworth and Parmet, 2012). More recently, Melanie Rock and Chris Degeling argued for the extension of human-solidarity to ‘more-than-human’ solidarity to include non-human animals, plants and ecosystems (Rock and Degeling, 2015). Jennings and Dawson also suggest that one can ‘stand up’ for other species or an ecosystem (Jennings and Dawson, 2015). In light of recurrent outbreaks of avian flu occurring in the West Bank and threatening both animals and humans in Israel and the OPT, we point to the relevance of that term to our discussion. However, space limitations do not allow us to elaborate further. In any case, we agree with Dawson and Jennings that while solidarity may stem in part from mutual self-interest, it is not a necessary condition (Dawson and Jennings, 2012). 32. We thank an anonymous reviewer for raising this objection. 33. Jennings and Dawson are probably responding to Prainsack and Buyx’s (Prainsack and Buyx, 2012) critique that their own (Dawson and Jennings’) account of solidarity lacks justification. 34. Prainsack and Buyx do not clearly explain why this is the case. Zohar Lederman has recently made a similar relational argument to justify family-centered care: since one’s autonomy phenomenologically depends on one’s social family and friends, involving them in one’s medical care actually conceptually enhances one’s autonomy (Lederman, under review). Clearly, this argument raises the plausible objection that the said community in this case is confined to a few people; how can one’s autonomy possibly depend on a larger community of hundreds, thousands or millions of people? This objection hinders the applicability of this kind of relational argument to national or international solidarity. 35. Communitarians have offered compelling and rigorous arguments to justify their position, and the same arguments may justify solidarity (Raz, 1986; Taylor, 2003). 36. We do not necessarily think that the other being worse off is a necessary condition for a solidarity argument, but suspect that in most cases where solidarity is discussed and applied, the other will be worse off. 37. We thank Voo Teck Chuan for raising this objection. 38. Of course, with this response, we open the door again to the vampire charge above—blood meals are also a basic need for vampires. Addressing this charge to the fullest will take us to places we wish not reach here. However, the most immediate plausible response is that vampires would fundamentally be different from us, humans. Therefore, no relevant identification is possible. A second plausible response is to concede that we may indeed be obligated by solidarity to assist the vampires. However, this obligation does not mean providing them with blood meals, necessarily. Rather, we should find alternative ways to assist them. 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Solidarity: Reflections on an Emerging Concept in Bioethics . Wiltshire, UK. Prainsack B., Buyx A. ( 2012). Understanding Solidarity (With a Little Help from Your Friends): Response to Dawson and Verweij. Public Health Ethics , 5, 206– 210. Google Scholar CrossRef Search ADS   Raz J. ( 1986). The Morality of Freedom . Oxford, UK: Oxford University Press. Raz J. ( 2011). From Normativity to Responsibility . Oxford, New York, NY, Oxford University Press. Google Scholar CrossRef Search ADS   Report of Detailed Findings of The Independent Commission of Inquiry Established Pursuant to Human Rights Council Resolution S-21/1. ( 2015). United Nations Human Rights Council. Rock M. J., Degeling C. ( 2015). Public Health Ethics and More-Than-Human Solidarity. Social Medicine & Medicine , 129, 61– 67. Google Scholar CrossRef Search ADS   Scale of Control- The Continuing Responsibilty of Israel in The Gaza Strip. ( 2011). Israel: Gisha-Legal Center for Freedom of Movement. Sharvit-Baruch P. ( 2012). Is the Gaza Strip Still Occupied by Israel? Opinio Juris. Singer P. ( 2011). Practical Ethics . Cambridge: Cambridge University Press. Google Scholar CrossRef Search ADS   Stall N. M., Berger P. B., Ray J. G., Bogler T., Bell C. M. ( 2014). Open Letter for The People in Gaza-More Than A Military Conflict. Lancet , 384, 398– 399. Google Scholar CrossRef Search ADS PubMed  Swift R. ( 2011). The Relationship Between Health and GDP in OECD Countries in The Very Long Run. Health Economics , 20, 306– 322. Google Scholar CrossRef Search ADS PubMed  Taylor C. ( 2003). The Ethics of Authenticity . Cambridge, MA, Harvard University Press. The International Committee of the Red Cross. ( 2015). International Humanitarian Law and the Challenges of Contemporary Armed Conflicts: Report for the 32nd International Conference of the Red Cross and Red Crescent. The International Court of Justice. ( 2004). Legal Consequences of the Construction of a Wall in the Occupied Palestinian Territory, Advisory Opinion. The Office of The Prosecutor. ( 2014).Situation on Registered Vessels of Comoros, Greece and Cambodia. Article 53(1) Report. International Criminal Court. Unemployment in Israel has Gone Down to 5.3% in February from 5.6% in January. ( 2015). Available from: http://www.globes.co.il/news/article.aspx?did=1001022566 [accessed August 2015. van den Berg M. M., Madi H. H., Khader A., Hababeh M., Zeidan W. A., Wesley H., El-Kader M. A., Maqadma M., Seita A. ( 2015). Increasing Neonatal Mortality among Palestine Refugees in the Gaza Strip. PLoS One , 10, e0135092. Google Scholar CrossRef Search ADS PubMed  Virchow R. ( 1879). Public Health Services. In Rather L. J. (ed.), Collected Essays on Public Health and Epidemiology . Canton, MA: Science History Publication. World Health Organization ( 2016). Health Conditions in The Occupied Palestinian Territory, Including East Jerusalem, and in The Occupied Syrian Golan. Sixty- Ninth World Health Assembly. World Health Organization. © The Author 2017. Published by Oxford University Press. Available online at www.phe.oxfordjournals.org http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Public Health Ethics Oxford University Press

Is Israel Its Brother’s Keeper? Responsibility and Solidarity in the Israeli–Palestinian Conflict

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Oxford University Press
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© The Author 2017. Published by Oxford University Press. Available online at www.phe.oxfordjournals.org
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1754-9973
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1754-9981
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10.1093/phe/phx004
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Abstract

Abstract This article examines the Israeli government’s role in supporting living conditions conducive to health in the occupied Palestinian territories (OPT). Limiting the discussion to public health, the authors argue that—whether justified in its overall political policy—the Israeli government and people are legally and ethically obligated to care for the well-being of the Palestinian people. The authors first review the current situation in the OPT and compare health statistics with Israel. Next, the authors make three arguments as to why the Israeli government and citizens should assist the Palestinian people: moral responsibility, legal responsibility and solidarity. Based on these, the authors make the case for Israel’s moral duty to ensure that Palestinian people living in the OPT achieve equitable levels of health as compared to Israeli citizens, while minimizing restrictions on Palestinian self-determination. The authors urge the Israeli government and citizens to improve Palestinian’s daily living conditions, tackle inequitable distribution of power and allow international support in these efforts. Hospital Admission must therefore be open to every patient that needs it, irrespective of whether he has money or not, whether he be Jew or heathen. (Virchow, 1879: 26) Introduction In 2007, the Lancet commissioned a steering group on the occupied Palestinian territories (OPT), which since published five reports about health conditions there (Chalmers et al., 2009). The image depicted was grim. In 2005, 70 per cent of the Palestinians reported that their families feared for their personal safety ‘very much or extremely’; 64 per cent feared for their families’ safety ‘very much or extremely’; 68 per cent felt worried over their personal future and the future of their families ‘very much or extremely’ (Giacaman et al., 2009). Undoubtedly, these anxieties at the time were grounded in the collective memory of the Israeli occupation of Gaza, as well as recurrent offensive military excursions elsewhere in the OPT. The Israeli occupation and military excursions still persist. From the first Intifada in December 1987 and August 2013, 8386 Palestinian citizens were killed by Israeli forces. In total, 17,354 Palestinians were injured. Most victims were civilians.1 During the last Israeli military campaign in 2014, 2251 Palestinians were killed, including 1462 Palestinian civilians, 299 women and 551 children. More than 11,000 were injured, with almost 10 per cent suffering permanent disability as a result (Bachmann et al., 2014).2 The economic losses are estimated at over 380 million USD (de Ville de Goyet et al., 2016). More than 70 per cent of the population in the Gaza Strip require humanitarian assistance (InfoGaza—a kit to facilitate understanding of the curfew on the Gaza Strip, 2015). Palestinian anxieties reported potentially reflect the aggressively declining public health infrastructure that was utterly inadequate to provide the most basic needs required for human survival. In what follows, we describe how exactly inadequate it really is, and how much it worsened since 2005. A recent report by Physicians for Human Rights-Israel (PHR-I) examines the public health conditions in Gaza after the 2014 military Operation Protective Edge. The report, particularly focusing on social determinants of health, concludes that the health inequality between the two people is worrisome, and calls upon the Israeli government to act to achieve health equity between the two people. For example, the report found that in 2011, life expectancy among Palestinians was 71 years for men and 73.9 years for women, while in Israel, life expectancy was 79.9 years for men and 83.6 years for women (Efrat, 2015: 15). Similarly, in 2011, infant (<1 year) mortality per 1000 live births was 18.8 in the OPT, compared to 3.7 in Israel (Efrat, 2015: 16).3 In this article, we echo the PHR-I report’s call to action. We argue that the Israeli government should provide appropriate care to the Palestinian people in a way that would bring about health equity between the two people, to the extent possible. We make our case in two steps: first, we review health statistics and the history and current condition of the healthcare infrastructure in the OPT, often comparing specific areas with Israel. Second, we present three arguments in making our case, two stemming from the notion of responsibility and one stemming from the notion of solidarity. This latter argument extends beyond the duty of the Israeli government, however. Using a solidarity argument, we further argue that Israeli citizens, either as individuals or as a collective, have a moral duty to assist the Palestinian people.4 We note two crucial qualifications from the outset: first, although public health and policy are intrinsically tied, this is a public health ethics paper, not a political one. We make no claims as to whether Israel’s political policy toward the Palestinians is justified. Rather, we limit our discussion to public health, arguing that, whether justified in its overall political policy, the Israeli government, being the occupying power, is legally and morally obligated to care for the Palestinian people. Second, we echo the authors of the PHR-I report in claiming that we do not wish to take away the right of the Palestinian people for self-determination and their potential ability to self-govern in an effective way (Efrat, 2015: 40–41). Rather, we simply contend that Israel should assist the Palestinian people until a more stable solution to the conflict is found. This is not a call to enhance Israeli control over the Palestinian people. Health and Healthcare in the OPT The World Health Organization (WHO) 69th World Assembly, convened in May 2016, signaled Israel as a violator of the Palestinian right to health (WHO, 2016).5 The Assembly’s resolution should be understood in its historical context. Historical Context The recent PHR-I report focuses on two geographical areas: Gaza and the West Bank. These areas’ recent history is significant. From the Six-Day War in 1967, Israel, by way of an Israeli military officer (Civil Administration), was actively responsible for the healthcare system in these territories, which operated separately from the Israeli healthcare system. Until 1993, the Civil Administration neglected the development and maintenance of the healthcare system (Giacaman et al., 2009). In total, 85 per cent of the Palestinian healthcare system then was financed through local taxes (Agency of Israeli-Palestinian Physicians for Human Rights, 1993: 5). Complex patients could receive referrals to Israeli hospitals. Until 1974, Palestinian citizens did not have to pay for healthcare services. However, in 1974, a healthcare insurance plan was instituted, becoming a necessary condition for access to health services (Agency of Israeli-Palestinian Physicians for Human Rights, 1993).6 After the first Intifada in 1987, Israel reduced its support to the Palestinian healthcare system, including the number of referrals to Israeli hospitals. In 1991, only 37 per cent of the Palestinian healthcare system was financed by the Civil Administration (Agency of Israeli-Palestinian Physicians for Human Rights, 1993: 5). In 1993, only 25 per cent of the Palestinians were insured (Agency of Israeli-Palestinian Physicians for Human Rights, 1993: 6). As part of the 1993 Oslo Accords, Israel relegated the management of the healthcare system to the Palestine Liberation Organization. As we demonstrate below, this generated the appearance of an independent Palestinian healthcare system, but this independence was merely an illusion (Efrat, 2015: 4–5). An Independent Healthcare System? The Palestinian healthcare system consists of at least four parts: the Palestinian Ministry of Health, the United Nations Relief and Works Agency, non-governmental organizations and the private sector (Giacaman et al., 2009; Horton, 2009; de Ville de Goyet et al., 2016). The total budget of the Palestinian government originates from three sources: taxes collected from Palestinian citizens, funds from donating countries and taxes collected by Israel for products imported into the OPT. The latter constitute 40–70 per cent of the total budget (Giacaman et al., 2009). On various occasions, Israel has held these funds as punishment (Mataria et al., 2009). For example, Israel held the tax money for 3 months following the Palestinian Authority’s application to join the International Criminal Court (Israel and Palestinians ‘Reach Accord’ on Frozen Taxes, 2015). This imposed significant difficulties for the Palestinian healthcare system, as the funding restriction often resulted in Palestinian health workers going without pay (Efrat, 2015: 33–34). Tax money is crucial for a state to increase its domestic product; in turn, citizens require a source of income to be able to pay taxes. In 2011, the total Palestinian growth domestic product (GDP) was 9.3 billion USD, which, for 4.1 million persons, translates into 2250 USD per capita. This number is 93 per cent lower than the Israeli GDP per capita, which in 2011 was 31,200 USD (Efrat, 2015: 7).7 The low Palestinian GDP correlates with, and can be partially explained by, the following: first, the ratio of children under the age of 14 years was 40 per cent in the Palestinian population, while it was 28 per cent in Israel (Efrat, 2015: 8). These children are assumed to be excluded from the workforce, and commonly do not (and should not) contribute to the GDP. Second, the ratio of participation in the workforce among Palestinian was 43 per cent compared to 64 per cent in Israel. While the ratio among Palestinian men was similar to that of Israeli men, only 17 per cent of the Palestinian women were a part of the workforce, compared to 58.1 per cent of the Israeli women (Efrat, 2015: 9). Third, the unemployment rate among Palestinians was 28 per cent, compared to 5.3 per cent in Israel (Efrat, 2015: 9; Unemployment in Israel has Gone Down to 5.3 per cent in February from 5.6 per cent in January, 2015).8 Fourth, in 2013, Palestinians received 8 years of education on average compared to 12 years in Israel (Efrat, 2015: 10). Fifth, 25 per cent of the Palestinian families live below the poverty line, which is 2000 New Shekels (NS) per month (approximately 525 USD), compared to 19.9 per cent of the Israeli families who live below the poverty line, which is 4000 NS (approximately 1050 USD) (Efrat, 2015: 10). Additionally, the Palestinian healthcare system unavoidably depends on Israel for medicines and personnel. Israel blocks the Palestinian import of medicines from neighboring Arab countries, only allowing the import of drugs from Israel. Consequently, Palestinians are forced to pay a higher price for their medicines. The export of medicines is limited as well: Palestinian exporters are only allowed to use small boxes, which raises the expenses. Further, these boxes are often examined by Israel security, thus destroying medicines that require cooling. These restrictions leave the Palestinians with a stock of outdated medicines, which can only be discarded by burying them underground. This in turn damages the environment in different ways, such as pollution of water sources (Efrat, 2015: 34–35). As to personnel, the West Bank hosts two medical universities: Al-Quds University in Abu Dis, and Al-Najah University in Nablus. The clinical training at Al-Quds takes place in East Jerusalem, which is also under Israeli jurisdiction. This means that medical students from the West Bank must apply for passes to cross over to Jerusalem. Each year, roughly 10 per cent of the applicants are denied by Israel authorities. Moreover, at the end of their studies, medical graduates must pass the Israeli Board Exams to be able to practice medicine in East Jerusalem, which hosts six hospitals. Israel, however, does not recognize Al-Quds as an Israeli University, since it is under Palestinian authority, or as a foreign institution.9 Consequently, roughly 300 medical graduates who reside in East Jerusalem are denied the ability to practice medicine there. Israel only allows up to 2000 healthcare professionals to cross over from the West Bank to Jerusalem at any given time. No healthcare professional from Gaza is allowed entry (Efrat, 2015: 35–36).10 To be independent, a healthcare system requires a steady flow of funds and medicines, an educated workforce and stable governance. The Palestinian healthcare system does not benefit from any of the above and—moreover—frequently must recover from continuous warfare and violence. As a result, access to healthcare in the OPT is terribly limited. Access to Healthcare According to the WHO Commission for Social Determinants of Health (henceforth ‘Commission’), health is positively correlated with public spending on healthcare: the higher the public spending, and lower the private, out-of-pocket spending on healthcare, the healthier are the people (Marmot et al., 2008). In the OPT, the national spending per capita is 248 USD compared to 2046 USD in Israel. In total, 16 per cent of the Palestinian GDP is devoted to healthcare compared to 7.7 per cent in Israel. Of this 16 per cent, public spending on healthcare in the OPT amounts to 37 per cent, while another 37 per cent is out of pocket. In Israel, 61 per cent of the GDP devoted to healthcare is public, while only 27 per cent is out of pocket (Efrat, 2015: 32).11 Two examples highlight the significance of these differences. In Israel, the 2013 national vaccination program included vaccines against the following pathogens and diseases: diphtheria, pertussis and tetanus (DPT), polio, measles, mumps and rubella (MMR), varicella, hepatitis B and A, Streptococcus Pneumonia, Rotavirus and human papillomavirus. In 2011, the Palestinian national program only included some of these, namely, DPT, polio, MMR and hepatitis B (Efrat, 2015: 19–20). Similarly, in 2011, there were 3.25 hospital beds per 1000 people in Israel compared to 1.23 beds in the OPT (Efrat, 2015: 29–30). These mean that people in the OPT do not receive good preventive care and lack access to secondary and above care. Because of the dire condition of the Palestinian healthcare system, roughly 200,000 patients or their relatives a year are required to seek medical treatment in Israel. Beyond the economic burden, this creates for the Palestinian healthcare system, roughly 20 per cent are denied access by Israel and are thus exposed to significant health risks (Arisheh, 2015; Efrat, 2015: 37). In 2007, Israel denied entry of all patients (282 cases) who were referred to healthcare facilities in Israel (Mataria et al., 2009). Several patients died while waiting. Occasionally, Israel strip searches and interrogates patients before allowing them entry (Arisheh, 2015). Finally, some patients are not allowed entry, even though they possess permits (Arisheh, 2015; de Ville de Goyet et al., 2016: 9). Further, the movement of ambulances from the West Bank to Jerusalem is limited and requires coordination which often delays crucial transit time of patients. Since Palestinian ambulances are not allowed to drive within Israel, they must transfer their patients to Israeli ambulances for this part of the journey (Efrat, 2015: 37–38; de Ville de Goyet et al., 2016: 9).12 Access to adequate public healthcare merely poses one condition for health. The WHO Commission has determined that healthy places are a necessary condition to cultivate healthy people. The term ‘healthy places’ includes access to clean potable water, basic sanitation, affordable housing, electricity and paved streets. Is the OPT a ‘Healthy Place?’ Palestinian population density in 2011 was 475 people per square kilometer in the West Bank, and 4583 in Gaza. These compare to only 347 people per square kilometer in Israel (Efrat, 2015: 10). Indeed, Gaza is one of the most densely populated places in the world (Finkelstein, 2010: 15). The West Bank possesses two potable water sources: the Jordan River and the Mountain Aquifer. After the Oslo Accords in 1993–1994, the Palestinian Water Authority (PWA) was established with the mandate to provide water to the West Bank. However, the PWA is required to buy water from ‘Mekorot’, its Israeli counterpart, because Israel denies permission to construct the necessary infrastructure, effectively maintaining Israeli control over the West Bank’s water sources. As a result, the average daily water consumption is 73 liter per capita, which is less than the 100 liter minimum recommendation by the WHO. In Israel, the daily water consumption in cities is 242 liter per capita. Gaza only has the beach aquifer as a water source. However, due to pollution and the destruction of infrastructure by Israeli assaults and restriction of import of construction material, only 5–10 per cent of its water is appropriate for drinking (Efrat, 2015: 12; de Ville de Goyet et al., 2016: 13). Importantly, most of the aforementioned statistics referencing Gaza reflect the reality of 2010–2011 and do not incorporate the devastating effects of three later Israeli military operations there: Operation ‘Returning Echo’ in March 2012, Operation ‘Pillar of Defense’ in October 2012 and Operation ‘Protective Edge’ in 2014. During ‘Protective Edge’, of 87 health facilities in Gaza, 25 were severely damaged or destroyed and 52 suffered minor damages. El Rafa Rehabilitation Hospital was specifically targeted and destroyed. Twenty-three healthcare workers lost their lives, 16 of whom while on duty. Eighty-three healthcare workers were injured (de Ville de Goyet et al., 2016: 6). An Ethical Call to Action The Commission has set forth three over-arching recommendations: improve daily living conditions, tackle unequitable distribution of power and resources and measure the problem and assess the intervention impact (Marmot et al., 2008). The problem is measured. Now, we should act to improve the Palestinian’s daily living conditions, tackle unequitable distribution of power and assess the impact of our acts. International support is crucial, but not sufficient, for two main reasons: first, Israel has continually blocked various forms of international support by force. Second, international support is limited by nature, and is unsustainable over time. Therefore, positive action from Israel—as the occupying power and closest neighbor—is fundamental to achieving any significant improvement in the lives of the Palestinians. The Commission has urged governments to adopt social determinants of health framework and strengthen the Ministry of Health’s stewardship role in operating within this framework (Marmot et al., 2008). In the next section, we extend the concept of a government’s stewardship role toward its citizens to any people under the control of that government. Specifically, we claim that Israel, due to its position as an occupying power, has a stewardship role toward the Palestinian people.13 Is Israel Its Brother’s Keeper? We present three arguments in favor of our assertion that Israel is obligated to care for the Palestinian people. The first two arguments rely on moral and legal responsibility, while the third relies on solidarity. Responsibility We understand responsibility as the accountability of actors for an act or omission of an act. Our use and understanding of responsibility rely on deep philosophical grounds. To further elaborate our argument, we distinguish moral from legal responsibility (Raz, 2011: 255; Glover, 1970: 19). Moral responsibility Moral responsibility is classically understood to require the ability of control as a necessary and sufficient condition. If one is in control of one’s acts (or omissions of acts) and therefore of the consequences of these acts, then one is deemed responsible. In other words, if one caused a certain consequence, one is responsible for it (Glover, 1970: 19). However, moral responsibility differs from mere causal responsibility. The former merits praiseworthiness or blameworthiness. When applying moral responsibility, an agent may be blameworthy for an act only if the agent meets the categories of moral responsibility, based on the actor’s level of intention and control. The latter means that to be merely causally responsible means causing a consequence in a way that does not merit blameworthiness. If one caused a car accident because one suffered a heart attack, then one is responsible for the accident but is not blameworthy. Conversely, if one caused an accident because one was text messaging while driving, then one is morally responsible and therefore blameworthy for the accident (Glover, 1970: 52, 56). Various excuses or justifications may relieve one of moral responsibility and blameworthiness, including ignorance, compulsion and—perhaps most importantly to our case—self-defense (Glover, 1970: 19, ch. 3).14 In light of the former two, intentionality often complements control as being sufficient and necessary conditions for responsibility. Only if one both controls one’s acts and intends to bring about specific consequences can one be deemed responsible (Raz, 2011: 228–229, Glover, 1970: 65–66). In contrast, Joseph Raz emphasizes the rationality of the act when assessing accountability. Intention and control of the act and its consequences may be sufficient for responsibility, but are not necessary.15 Instead, Raz posits two necessary conditions for responsibility. First, people may be responsible only if they possess the capacity for rational action, meaning a capacity to act in accordance with one’s reasons. Second, people may be responsible for an act only if this act resulted from an appropriate execution of this capacity for rational action. Importantly, the execution itself may be successful or unsuccessful—what matters is that the capacity is not temporarily blocked or missing. Whenever actions are determined by our rational capacities found within what Raz calls the domain of secure competence, the actor carries responsibility. Raz’s domain of secure competence includes capacities and subsequently acts that do not require reflection or specific intention prior to their execution. Accordingly, individuals can be held morally responsible for any action that is in their power to execute as rational agents, regardless of intent and consequences (Raz, 2011).16 Our argument then is that Israel should be held morally responsible for the grim situation of the Palestinian healthcare system because it controls its acts toward the Palestinians—and thus their consequences, intends to bring about these consequences and acts rationally. As described in Sections 1–2, not only has Israel failed to allow third parties or the Palestinian authorities to better the Palestinian healthcare system, but has also actively contributed to its dire condition (Mataria et al., 2009).17 For example, Israel has actively sabotaged attempts to construct more healthcare facilities in the West Bank, despite available funds and medical approvals (Agency of Israeli-Palestinian Physicians for Human Rights 1993: 7). As forcibly argued by Michael Marmot, ‘Deprived of a clean, safe neighborhood, meaningful work, opportunities for quality children’s education, freedom from police harassment and arrest, and freedom from violence and aggression, it is harder to have control over one’s life or to be a full social participant’ (Marmot, 2006: 1305). Put formally, the argument proceeds thus: Sufficient conditions for moral responsibility include: control of acts and their consequences, intentionality and the rationality of acts. Israel controls its acts toward the Palestinian people and their consequences, intends to inflict these consequences and exercises its ability for rational actions. Given I–II: Israel is morally responsible for the current health condition of the Palestinian people. Moral responsibility entails blameworthiness unless there are valid justifications. Israel does not have any valid justifications. Given III–V: Israel is blameworthy for the current health condition of the Palestinian people. Counter arguments and Responses: Moral Responsibility One immediate objection may be raised against Premise II. We encounter several difficulties in defining what we mean by ‘Israel’ here: is it the Israeli citizens, the Israeli government as a whole or the individuals who constitute the Israeli government? The first understanding is quite implausible: not all Israeli citizens control the acts of the government, intend to bring about the consequences of these acts or have reasons to act in the ways specified in Sections 1–2. The second understanding is also problematic: how can we say about a government that it ‘intends’ to do anything, or that it has an ability for a ‘rational’ action? Arguably, these terms can only be applied to individual agents. Thus, the third understanding is perhaps the closest to what we mean. We acknowledge that not all members of the Israeli government agree with one another, and not all government officials control the acts of the government to the same extent. Perhaps a simple solution to this may be to re-define what we mean here as the majority of the individuals constituting the Israeli government. In any case, we believe that common sense allows a certain degree of vagueness in this case.18 A more formidable objection to our argument may be raised against Premise V. While responsible, Israel is excused of blameworthiness, as it is only defending itself. Since the Palestinian people attacked Israel19 first, and continue attacking, Israel is therefore entitled to defend itself.20 We respond in two ways. First, both sides of the conflict argue that the other side is the initial aggressor, and that the other side is not a real partner for peace. Beyond empirical data, the ‘right’ answer will always remain a matter of interpretation. Second, proportionality determines whether we may accept moral excuses or justifications (Glover, 1970: 20; Mcmahan, 2009: 18–25). The justification of self-defense is plausible up to an extent. Specifically, the quality and probability of risk are vital in determining whether self-defense is a reasonable justification in a certain case. If one kills another for fear of one’s life, then one may be justified. But if one kills another for fear of losing one’s wallet, the justification is arguably much weaker. Based on the comparative data provided in Sections 1–2, we hope to have demonstrated that Israel reacted un-proportionally throughout the history of the conflict, e.g. number of civilian casualties and health disparities due to Israeli action.21 Legal responsibility Legal responsibility renders one legally liable. Liability means subjecting oneself to disadvantages posed by another. Unlawfully causing harm carries a legal duty to compensate the harmed (Raz, 2011: 255). Harms include an action that one should not have performed or a state of affairs that one should not have permitted to exist (Raz, 2011: 257). We argue that Israel should be held legally responsible for the state of affairs of the Palestinian people, as interpreted by existing international law. Notice that this is not an is-ought problem. Put formally, our argument may be described as follows: Countries should obey current international law. Current international law requires that an occupying force should be responsible for the basic needs of the occupied population. Israel is the occupying force in the OPT according to international law. Conclusion: Given I–III, it follows that Israel should be responsible for the basic needs of the Palestinian population. We believe that the first (normative) premise requires no defense. We also assume that the second (descriptive) premise is prima facie accepted, so the following is merely an elaboration. According to international law22, the population in an occupied territory is considered ‘protected persons’, in the language of the 1949 Fourth Geneva Convention (which Israel signed in 1951). According to Article 55 of the Convention, To the fullest extent of the means available to it, the Occupying Power has the duty of ensuring the food and medical supplies of the population; it should, in particular, bring in the necessary foodstuffs, medical stores and other articles if the resources of the occupied territory are inadequate.23 Similarly, Article 56 of the Convention specifies that,24 To the fullest extent of the means available to it, the Occupying Power has the duty of ensuring and maintaining, with the cooperation of national and local authorities, the medical and hospital establishments and services, public health and hygiene in the occupied territory, with particular reference to the adoption and application of the prophylactic and preventive measures necessary to combat the spread of contagious diseases and epidemics. Medical personnel of all categories shall be allowed to carry out their duties. (Convention (IV) relative to the Protection of Civilian Persons in Time of War, 1949)] The Convention emphasizes that the occupying power is obligated to provide for the basic needs of the occupied population, public health being one of the foremost basic needs stressed by the Convention and the many commentaries it received. Counter argument and Responses: Legal Responsibility Perhaps the most common objection to the legal responsibility argument is a rejection of the third premise of our formal argument above, namely, that Israel is still an occupying force in the OPT. If this premise is indeed false, then the argument loses its soundness. Our response to this objection is that Israel fulfills the criteria that define an occupying force. In 2004, the International Court of Justice was asked by the United Nations (UN) General Assembly to provide an advisory opinion on the construction of the ‘Separation Wall’ (see Figure 1, taken from http://www.btselem.org/maps).25 Reiterating a broad and long-standing international and legal consensus, the Court repeated the definitions first declared by the 1907 Fourth Hague Convention: Figure 1. View largeDownload slide Map of the separation wall, November 2014. The yellow line represents the built wall. The red line represents planned construction. Figure 1. View largeDownload slide Map of the separation wall, November 2014. The yellow line represents the built wall. The red line represents planned construction. [T]erritory is considered occupied when it is actually placed under the authority of the hostile army, and the occupation extends only to the territory where such authority has been established and can be exercised. (The International Court of Justice, Legal Consequences of the Construction of a Wall in the Occupied Palestinian Territory, Advisory Opinion, 2004: 35) Based on these definitions, the Court decided that Israel has been the occupying force since 1967, and remained so up to the Court’s decision in 2004. Importantly, Israel has not signed the Hague Convention. However, the Convention’s annexed regulations reflect customary international law, which is universally binding (Report of Detailed Findings of The Independent Commission of Inquiry Established Pursuant to Human Rights Council Resolution S-21/1, 2015: 7). Arguably, nothing has changed as regards Israel’s status as the occupier in the West Bank since the Court’s decision. But this decision applies to the West Bank and East Jerusalem—what about Gaza? (see Figure 2, taken from http://www.btselem.org/maps) Figure 2. View largeDownload slide Map of the West Bank, Gaza, and the Settlements, November 2014. More maps may be found here: http://www.btselem.org/maps. Figure 2. View largeDownload slide Map of the West Bank, Gaza, and the Settlements, November 2014. More maps may be found here: http://www.btselem.org/maps. Israel holds that following its 2005 disengagement from Gaza, it is no longer the occupying force there (Sharvit-Baruch, 2012; Report of Detailed Findings of The Independent Commission of Inquiry Established Pursuant to Human Rights Council Resolution S-21/1, 2015: 7). However, as a variety of international law experts and organizations have concluded (Batniji et al., 2009; Becker et al., 2009; Scale of Control- The Continuing Responsibilty of Israel in The Gaza Strip, 2011; Maurer, 2012), Israel preserves effective control over Gaza, which implies that Israel is still the occupying force in Gaza, according to the established criterion regarding whether the law of occupation applies in a given territory. The Red Cross has recently adopted the ‘functional approach’ to determine whether the extent of control of a foreign territory amounts to effective control and thus to military occupation. In cases in which there is only partial control over a territory, the Red Cross considers any amount of control that meets the criterion as effective control. As the Red Cross report states: Indeed, despite the lack of the physical presence of foreign forces in the territory concerned, the retained authority may amount to effective control for the purposes of the law of occupation and entail the continued application of the relevant provisions of this body of norms. This is referred to as the ‘functional approach’ to the application of occupation law. This test will apply to the extent that the foreign forces still exercise, within all or part of the territory, governmental functions acquired when the occupation was undoubtedly established and ongoing. (The International Committee of the Red Cross, International Humanitarian Law and the Challenges of Contemporary Armed Conflicts: Report for the 32nd International Conference of the Red Cross and Red Crescent 2015: 12) The writers of the report likely had the case of Gaza in mind, since one of the ‘exceptional cases’ where the test of governmental functions has to be applied is ‘when foreign forces withdraw from occupied territory (or parts thereof) but retain key elements of authority…’ (The International Committee of the Red Cross, International Humanitarian Law and the Challenges of Contemporary Armed Conflicts: Report for the 32nd International Conference of the Red Cross and Red Crescent 2015: 12). The report specifies that a state’s territory includes ‘not only its land surface but also… the territorial sea, and the national airspace above this territory’ (The International Committee of the Red Cross, International Humanitarian Law and the Challenges of Contemporary Armed Conflicts: Report for the 32nd International Conference of the Red Cross and Red Crescent 2015: 13). Notably, these areas are components of Gaza’s territory that are incontrovertibly under Israel’s control. Similarly, based on this ‘functional approach’ and the fact that Israel can send troops into Gaza within ‘reasonable time’, the UN Independent Commission of Inquiry, ‘… concludes that Israel has maintained effective control of the Gaza Strip within the meaning of Article 42 of the 1907 Hague Regulations’ (Report of Detailed Findings of The Independent Commission of Inquiry Established Pursuant to Human Rights Council Resolution S-21/1, 2015: 9). Simply put, Israel still exercises functional control in Gaza, albeit not as freely as it did before the 2005 disengagement. To illustrate: Israel limits the entry of construction materials into the Gaza Strip that it considers to be of potential ‘dual use’, meaning for both civilian and military purposes. These include iron and cement. Since the beginning of ‘Protective Edge’ until the end of September 2015, only 9 per cent of the estimated materials needed for repair and re-construction were introduced into Gaza, and only 30 per cent of these serve the private sector. Similarly, during the first half of 2015, Israel allowed a monthly average of 13,832 Palestinians from Gaza to enter Israel, compared to over half a million in 2000. Further, Israel allows fishermen from Gaza to reach only up to 6 nautical miles from the beach, and prevents any entry or exit by both sea and air (InfoGaza- A Kit to Facilitate Understanding of The Curfew on the Gaza Strip, 2015). Perhaps most tellingly, Israel controls the Palestinian population registry common to the West Bank and Gaza. This means that Palestinian identity cards can only be issued with Israeli approval (InfoGaza—A Kit to Facilitate Understanding of The Curfew on the Gaza Strip, 2015; Report of Detailed Findings of The Independent Commission of Inquiry Established Pursuant to Human Rights Council Resolution S-21/1, 2015: 9).26 In sum, former US President Jimmy Carter (2009) wrote about the OPT, ‘[t]here has been no withdrawal from the West Bank and the Palestinians here and in the Gaza Strip have been increasingly strangled’ (Carter: 783). In addition to these two arguments, which are based on responsibility and most plausibly relate to the Israeli government, we wish to present an argument that pertains to the Israeli public. This argument, rather than relying on responsibility, relies on solidarity. Solidarity in Bioethics Explicit considerations of solidarity have been absent from the bioethical literature until recently, but are now receiving greater attention (Prainsack and Buyx, 2011: chap. 3; Dawson and Jennings, 2012; Eckenwiler et al., 2012; Illingworth and Parmet, 2012). We first provide two conceptual accounts of solidarity, and then apply them to our context. Drawing on rich philosophical and sociological scholarship (Prainsack and Buyx, 2011: chap. 1), Barbara Prainsack and Alena Buyx define solidarity as, ‘…shared practices reflecting a collective commitment to carry “costs” (financial, social, emotional) to assist others’ (Prainsack and Buyx, 2011: 46). They apply this definition along three tiers: the interpersonal, the collective and the contractual. According to the first tier, an individual recognizes sameness with, or similarity to another in at least one relevant respect and is willing to carry costs to assist her. Since the definition of solidarity requires action (‘shared practices’), the willingness of the individual must manifest in an act (or omission of an act) to be perceived as solidarity. While the first tier concerns individuals, the second tier concerns collective groups. According to the second tier, solidarity comprises the ‘…manifestation of a collective commitment to carry costs to assist others (who are all linked by means of a shared situation or cause)’.27 Angus Dawson and Bruce Jennings view solidarity as deep-seated in ethical discourse. According to them, solidarity is an essential requirement ‘…for the very possibility of ethical decision making’ (Dawson and Jennings, 2012: 74). They perceive solidarity as a moral practice that is fundamental to mutual relations among persons (Jennings and Dawson, 2015). Solidarity requires a public action, done by a collective rather than individuals. According to Dawson and Jennings, an act of solidarity is considered as such if it is understood by actors and observers as an act of solidarity. Solidarity entails a positive identification with another individual or group, driven by sympathy. ‘The act itself has meaning but also purpose in that it is oriented towards improving or correcting past or present disadvantage or injustice’ (Dawson and Jennings, 2012: 74).28 Dawson and Marcel Verweij similarly mention ‘standing together’ and pursuing shared aims and ideals as key features of solidarity. They distinguish two kinds of solidarity. Rational solidarity is planned and consensual, consciously aimed at achieving a desired goal. Constitutive solidarity reflects shared values and norms, and is less teleological in nature. It engenders actions that may not be rational in the sense of pursing a specific goal.29 Dawson and Jennings (Dawson and Jennings, 2012; Jennings and Dawson, 2015) express three ways in which solidarity may be expressed in relation to the other. First, solidarity means ‘…being open to other ways of thinking and living’ (Dawson and Jennings, 2012: 75); it means ‘standing up with’ another party. Second, solidarity means ‘standing up as’ a collective of creatures with shared biological vulnerabilities, and a shared culture that requires equal respect, civil discourse and tolerance. Third, solidarity means an intention to assist another who is worse off because of one’s behavior. Jennings and Dawson specifically argue that health conditions may be an example for this kind of expression of solidarity (Jennings and Dawson, 2015). Let us now apply these accounts to our context. Solidarity with the Palestinian people Applying Prainsack and Buyx’s first tier, then, we submit that individual Israeli citizens share a similarity with individual Palestinians in more than one relevant respect: they all depend on basic needs such as clean water, reliable sanitation and access to healthcare, etc. They all occupy the same geographic location.30 And they all share a recent history replete with war, occupation and a need for independence. Indeed, perhaps the most important relevant aspect in which individuals in the two groups are similar is that individuals on both sides have lost their loved ones due to actions performed by the other side, and must cope with that loss; for several decades now, individuals on both sides have lived in existential fear. Several of these commonalities translate to Prainsack and Buyx’s second tier of solidarity as well. The Israeli citizens as a collective are linked to the Palestinian people because of their shared situation: both collectives are located in a highly politically and religiously sensitive geographical area, with a rich and bloody history. As socio-economic and political systems, both collectives depend on healthy citizens who in turn depend on access to healthcare and healthy places. Similarly, both collectives are linked because of their shared cause: both seek to exist as free and prosperous societies.31 Perhaps most pertinently, both sides have been engaged in war against one another for decades. Dawson and Jennings’ account of solidarity may also apply to our discussion here. Israelis and Palestinians have disagreed regarding their rights to the land of Israel for many years, with no solution in sight. Some of these disagreements stem from, and may be solved by factual data, but most of them cannot, and will not. Rather, these disagreements stem from national, cultural and psychological biases, and thus will most likely never be solved. Applying the solidarity argument means the Israeli citizens as a collective must consciously decide to be open to differing opinions of their fellow Palestinians; Israeli citizens have to stand up with the Palestinian people. Similarly, Israeli citizens must acknowledge the humanity of their fellow Palestinians. Israeli citizens must recognize that Palestinians are vulnerable biological creatures, constituting part of a modern, post-enlightenment culture that requires equal respect for universal human rights, tolerance and civil discourse. Israeli citizens should stand as Palestinians. Finally, Israeli citizens should realize that their policies play a significant role in the causal chain that led to the current dire condition of the Palestinian healthcare system. Notice that this argument is slightly different from the moral responsibility argument in Section 4.1.1. The argument there is analogous to ‘if you break, you pay’, while here, the argument is analogous to ‘you break, you feel sympathy with the victim (which in turn drives solidarity) and you pay (because of this feeling of solidarity)’. Importantly, we do not commit to any of these accounts. Instead, we suggest that our case is strengthened by the straightforward applicability of both accounts. What is crucial is the plausible identification of the Israeli citizens with the Palestinian people. This identification entails a moral duty to assist the Palestinian people. Both rational and constitutive solidarity may be applied here. Israeli citizens may consensually unite to carry costs versus specific goals to assist the Palestinian people, and they may encourage values of care toward, and empathy with the Palestinian people. In case the two accounts of solidarity do not appeal to the reader, we may understand solidarity minimally as having two necessary components: (i) identification with the other (individual or collective), stemming from some perceived similarity that is relevant in one or more ways, and (ii) the imperative to assist the other. Our argument then may be formally stated thus: An argument based on solidarity is a valid moral argument; it has normative force. Solidarity means identification with another in at least one relevant aspect, which in turn entails the imperative to assist the other. Israeli citizens can identify with the Palestinian people in at least on relevant aspect. Following I–III, Israeli citizens should assist the Palestinian people. Notice that we simply assume that Premise I is true. By ‘valid’ we mean legitimate, justified, or well founded. Solidarity has normative force in that we may expect one to act in a certain way because we judge that one should be compelled by a solidarity argument. This should be similar to the way we commonly accept the moral validity of a responsibility argument. II–IV are formulated as a modus ponens argument, in that wherever the first component applies, the second must follow. Premise II affirms that within the solidarity argument, if one can identify with another in some relevant aspect (relevant to the discussed context), then one should assist the other. If one identifies (P), then one should assist (Q). Our discussion above about the ways in which Israeli citizens may identify with the Palestinian people, both as individuals and as a collective, grounds Premise III, hence P. The conclusion reflects ‘if P then Q’: if Israeli citizens can identify with the Palestinian people in at least one relevant aspect, then they should assist them. Counter arguments and Responses: Solidarity An objection may be raised against our first premise that a solidarity argument has normative force. One may accept a shared basis between the Israeli and the Palestinian people, but nevertheless reject the moral attitude of solidarity and duties stemming from it.32 In other words, one may simply reject solidarity as normatively valid. Similarly to Prainsack and Buyx (Prainsack and Buyx, 2012), we do not argue here for the normative force of solidarity, although we are sympathetic with Jennings and Dawson’ argument, that the world would be a worse place otherwise (Jennings and Dawson, 2015).33 We are also sympathetic with Lisa Eckenwiler et al.’s argument that eventually solidarity is beneficial for the better-off party as well as the worse-off party (Eckenwiler et al., 2012). Prainsack and Buyx allude to another argument for solidarity that is worth exploring further: given that we are relational creatures that depend on our community for the creation of our own identity, we are committed to benefit that community (Prainsack and Buyx, 2012).34 This is to say that we do not offer our own defense of solidarity as a valid moral argument, but rather simply assume that it is based on said arguments and deeper philosophical justifications.35 Granted its validity and normative force, what does solidarity mean? That if a person agrees that there are relevant similarities between her and another who is worse off36, she should assist the other. The same goes for a collective. Thus, if an Israeli accepts solidarity as a valid moral argument—and indeed, many Israeli ethicists seem to (Gross, 2004; Glick, 1997)—and agrees that there are relevant similarities between the Israeli and Palestinian people, then she should assist the Palestinians. Our second premise may also encounter resistance. Even if a solidarity argument is accepted as a valid normative argument, not every kind of identification entails an obligation to assist. Humans and vampires may share the need and desire to feed, but this does not mean that humans would be morally obligated to provide blood meals to vampires.37 This is when ‘relevant aspect’ would factor into the argument’s reasoning. Indeed, not every kind of identification entails an obligation to assist. Rather, one has to identify with another in at least one relevant aspect. The identification has to be relevant to the specific context, and thus a case-by-case discussion must take place to determine whether the identification is relevant and what exactly it should mean. At this point, one may disagree with our third premise—that Israeli citizens can identify with the Palestinian people—negating any relevant aspect of identification between the Israeli and Palestinian people. If this premise falls, then the argument becomes unsound. Our brief response involves both a historical–empirical and interpretative–conceptual components. First, historians and social scientists may determine whether there are important and fundamental similarities between the two people. However, whether these similarities are relevant enough to fulfill the first component of solidarity is of course a matter of interpretation. So second, we believe that at least some of the similarities we mentioned involve such basic needs for the lives of individuals (e.g. clean water, having a family) or for the formation of a national collective (e.g. history, the search for independence) that negating them as relevant similarities practically annuls the very possibility of ever using solidarity in any normative capacity. If solidarity is to have any normative force, we should accept some similarities as commonsensically relevant.38 General Counterarguments and Responses A general objection against our three arguments may be that governments (and collectives) have responsibilities only toward their own people, and not to other peoples; similarly, solidarity, if at all applicable, can only extend within national borders (Eckenwiler et al., 2012). This claim pertains to a much more general debate regarding global justice and cosmopolitanism upon which we wish not to elaborate here (Nagel, 2005; Pogge, 2005; Singer, 2011: chap. 8; Prainsack and Buyx, 2011, Section 7.4). However, this response misses our point. We do not argue for cosmopolitanism or global solidarity in this article. Rather, we make a narrower case for why Israeli citizens should assist another people—the Palestinian people. Even if the ethical case for cosmopolitanism fails—and global solidarity with it— our three arguments still hold. Israel has a moral responsibility to assist the Palestinian people because of its causal role in their dire condition. Israel also has a legal responsibility to assist the Palestinian people, as an occupying power. Finally, Israeli citizens (as individuals or as a collective) can identify with the Palestinian people in morally relevant ways, and therefore should assist them. A second general objection is asking why Israel should care about the Palestinian people in effect. In other words, Israel may be ethically responsible for the health of the Palestinian people, but on a practical level, it should not. This argument can appear in various forms, some more sophisticated than others. For instance, one can argue that very few countries in the world actually take responsibility for the people they occupied in the past or occupy in the present, e.g. the USA/Canada and Native Americans, Guatemala and native Mayans or the European colonies in Africa. The answer here is straightforward: the fact that this is indeed the current situation does not mean it should be, and the fact that other countries do it, does not mean that Israel is justified in doing it as well. If our case so far is compelling, then Israel should assist the Palestinian people. However, how should we determine the appropriate extent of this assistance? How Much to Assist? Specific recommendations as to the role of Israel in bettering the health conditions of the Palestinian people have existed for more than two decades (Agency of Israeli-Palestinian Physicians for Human Rights 1993; Mataria et al., 2009; de Ville de Goyet et al., 2016). In light of the current status quo, some of these seem more realistic than others. We are content with merely suggesting that the specifics should be determined jointly by the various stakeholders involved, particularly the true representative of the Palestinian people. Concluding Remarks In this article, we first presented recent data on the health conditions in the OPT. We then articulated and defended three arguments as to why Israel should assist the Palestinian people: moral responsibility, legal responsibility and solidarity. A Lancet editorial states: ‘The Pursuit of health as a political objective and the creation of a strong health system for Palestinians could be one fruitful diplomatic path to reconciliation, peace, and justice’ (Horton, 2009: 784). We concur. This article is our own modest attempt at solidarity with the Palestinian people, mainly in Gaza (Manduca et al., 2014; Stall et al., 2014). Our discussion, in fact, implements and contextualizes the peace-through-health framework [otherwise known as ‘Health as a Bridge for Peace’ (de Ville de Goyet et al., 2016)]. Specifically, it calls for tertiary prevention in the OPT, with the objective of restoring capacities for peaceful social processes such as healthcare (Barbara and Macqueen, 2004). Armed conflicts usually engender suffering and poor health conditions in one or more of the participating factions. Whenever that happens, public health ethicists should be there, at least in writing, defending the sick and vulnerable and protesting injustices. Political, ethnic and religious differences should be left aside. Notes Footnotes 1. In comparison, 1433 Israelis were killed and 1834 were injured in this period. Most of the victims were soldiers. 2. WHO provides slightly different numbers: 2260 casualties, including 612 children and 230 women, 12,625 injured, including 3827 children and 1773 women. In total, 899 Palestinians are permanently disabled (de Ville de Goyet et al., 2016). During this operation, 72 Israelis were killed, and over 800 were injured. Most of the victims were soldiers (Hartman, 2014). 3. In Gaza alone, infant mortality rate in 2011 was 22.4 per 1000 live births (van den Berg et al., 2015). 4. We believe that in light of their expertise, specifically Israeli healthcare professionals and students carry this duty (Horton, 2009; de Ville de Goyet et al., 2016: 17), but we do not pursue this point further. We also believe that this duty could be easily extended to the global community, but again, do not pursue this further here. 5. The Assembly commissioned a WHO delegation for the following mission: ‘to report and make practical recommendations on the health conditions in the OPT, including east Jerusalem, and in the occupied Syrian Golan, to the Seventieth World Health Assembly, through a field assessment…’ (WHO, 2016). 6. According to Mataria et al., currently only public employees must pay insurance premiums (Mataria et al., 2009). There are also differences between Gaza and the West Bank governances. For example, in Gaza there is no co-payment for primary healthcare except medicines (de Ville de Goyet et al., 2016). 7. GDP, both total and per capita, is known positively to correlate with health. Life expectancy, a common measure for health, was found to be higher in countries with higher GDP compared with countries with lower GDP. Conversely, GDP was found to be higher in countries with higher life expectancy compared to countries with lower life expectancy (Swift, 2011). 8. Currently, unemployment in the Gaza strip is at 41.5 per cent (InfoGaza- A Kit to Facilitate Understanding of The Curfew on the Gaza Strip, 2015). 9. Normally, foreign medical graduates who have completed their studies in European countries such as Hungary and Italy are allowed to take the Israeli board exams. 10. Indeed, Israel has been hampering healthcare training for decades now. A report from 1993 already lamented that Israel does not allow Palestinian residents to finish their training periods in Israel (Agency of Israeli-Palestinian Physicians for Human Rights, 1993: 7–8). 11. The Palestinian GDP devoted to healthcare is actually relatively high, for various reasons. These include low overall GDP, the need to rehabilitate a healthcare system that was neglected for many years and inefficient spending, e.g. over-prescription of drugs (Mataria et al., 2009). 12. As an emergency medical technician, one of the authors (Z. L.) has transported patients to and from the Palestinian territories. As a medical intern in a hospital in Israel, Z. L. cared for pediatric patients from Gaza. 13. The UK-based Nuffield Council on Bioethics (henceforth, the Council) espoused the Stewardship model for public health governance. According to this model, liberal states are obliged to provide certain conditions for their people, both as individuals and as collectives. Importantly, the Council asserts that states are responsible not only for their citizens but for their populations as a whole, including non-citizens (Hepple et al., 2007: 25–26). 14. Glover distinguishes excuses from justifications but points to the difficulty of clearly differentiating them (Glover, 1970: 55). We agree, and will therefore treat them as synonymous. 15. Raz in fact proposes the guidance principle as successfully uniting the requirements of control and intention (Raz, 2011: 229). However, since this is not a common understanding of responsibility, and since Raz himself does not accept this principle, we may ignore it here. 16. Raz is aware of the problems inherent in this account, for example, how people may develop this domain of competence, and replies to them (Raz, 2011: 247). 17. But this is not to exempt other countries and international organizations from bearing the blame, as well as elements internal to the Palestinian politics. Other causes invariably include internal governance failures, actions and inactions of the international community and a rapid epidemiological transition (Giacaman et al., 2009; Horton, 2009; Mataria et al., 2009). 18. In fact, this vagueness applies to the whole text. After many deliberations and for consistency sake, we opted to use the term ‘Israeli citizens’. However, does it mean that all of the citizens of Israel are obligated to assist the Palestinian people? What about the very young, or the very poor or the Arab–Israeli and other minorities who are Israeli citizens? Even referring to Israeli citizens as a collective would not be satisfying here, considering the latter group. 19. Again, by ‘Israel’ here we must allow some flexibility in the possible meaning. It may mean its land, citizens or even government’s interests. 20. Perhaps a modified version of this counterargument may be that Israel is absolved from moral responsibility because the Palestinian Authority is the one to blame for the current situation of the Palestinian people, due to corruption, etc. Regardless of whether this claim is empirically true, we think it is conceptually mistaken. Two agents can be morally responsible for the same effect, and thus be blameworthy. The argument about Israel’s responsibility is one argument while the responsibility of the Palestinian Authority is quite another. It very well may be that the Palestinian Authority could have made things better, and is blameworthy, but this does not absolve Israel from its responsibility. 21. A longer, more comprehensive response will lead us deep into the political realm, which we explicitly wish to avoid. 22. A 1993 report by Physicians for Human Rights Israel makes the same argument as our first premise here. In addition to the Geneva Convention, the report also cites the UN Convention on the Rights of a Child, ratified by Israel in 1991, the UN Convention on the Elimination of All Forms of Racial Discrimination, signed by Israel in 1979, and the International Convent on Economic, Social and Cultural Rights (Agency of Israeli-Palestinian Physicians for Human Rights, 1993). 23. Commentary to this article elaborates as follows: ‘The rule that the Occupying Power is responsible for the provision of supplies for the population places that Power under a definite obligation to maintain at a reasonable level the material conditions under which the population of the occupied territory lives. The inclusion of the phrase “to the fullest extent of the means available to it” shows, however, that the authors of the Convention did not wish to disregard the material difficulties with which the Occupying Power might be faced in wartime (financial and transport problems, etc.); but the Occupying Power is nevertheless under an obligation to utilize all the means at its disposal. Supplies for the population are not limited to food, but include medical supplies and any article necessary to support life.’. 24. See commentary: ‘In most cases, however, the invading forces will be occupying a country suffering… severely from the effects of war; hospitals and medical services will be disorganized, without the necessary supplies and quite unable to meet the needs of the population. The Occupying Power must then, with the co-operation of the authorities and to the fullest extent of the means available to it, ensure that hospital and medical services can work properly and continue to do so.The Article refers in particular to the prophylactic measures necessary to combat the spread of contagious diseases and epidemics. Such measures include, for example, supervision of public health, education of the general public, the distribution of medicines, the organization of medical examinations and disinfection, the establishment of stocks of medical supplies, the dispatch of medical teams to areas where epidemics are raging, the isolation and accommodation in hospital of people suffering from communicable diseases, and the opening of new hospitals and medical centres’. 25. The Separation- or Annexation Wall meant in reality the confiscation of more than 34,000 acres of privately owned Palestinian land by Israel (Blumenthal, 2013: 357). 26. See also a report by the International Criminal Court, which states the following: ‘Israel maintains that following the 2005 disengagement, it is no longer an occupying power in Gaza as it does not exercise effective control over the area. However, the prevalent view within the international community is that Israel remains an occupying power in Gaza despite the 2005 disengagement. In general, this view is based on the scope and degree of control that Israel has retained over the territory of Gaza following the 2005 disengagement – including, inter alia, Israel’s exercise of control over border crossings, the territorial sea adjacent to the Gaza Strip, and the airspace of Gaza; its periodic military incursions within Gaza; its enforcement of no-go areas within Gaza near the border where Israeli settlements used to be; and its regulation of the local monetary market based on the Israeli currency and control of taxes and customs duties. The retention of such competences by Israel over the territory of Gaza even after the 2005 disengagement overall supports the conclusion that the authority retained by Israel amounts to effective control’ (The Office of The Prosecutor. Situation on Registered Vessels of Comoros, Greece and Cambodia. Article 53(1) Report, 2014: 16–17). Of course, not all agree. See, for instance, one international law expert who not only denies that Israel is occupying Gaza but also suggests (ironically, we hope) that Gaza is occupying Israel (Kontorovitch, 2014). 27. At the third tier, solidarity is manifested in contractual or legal norms. We do not discuss this tier further because we are not clear as to whether Prainsack and Buyx would define Israel’s duty as grounded in responsibility or third-tier solidarity. They argue that the key difference between responsibility and solidarity is the possibility of consequences attached to the former, but qualify it with the condition that solidarity is not perceived according to the third tier (Prainsack and Buyx, 2011: 40). We wish not to argue over semantics and therefore ground Israel’s duty in responsibility, with the price of neglecting the third tier of solidarity. 28. Angus Dawson and Bruce Jennings are not convinced that the first-tier solidarity as defined by Prainsack and Buyx cannot be defined rather as beneficence or altruism. They also doubt that solidarity indeed requires carrying costs. Instead, they argue that what is foundational of solidarity is the willingness to carry costs (Dawson and Jennings, 2012; Jennings and Dawson, 2015). Their critique has merits, but addressing it here goes beyond the scope of this article. We also agree with Dawson and Marcel Verweij that Prainsack and Buyx’s report lacks normative work, and that it is wrong in divorcing solidarity from pandemic responses (Dawson and Verweij, 2012). Like them, we focus on Prainsack and Buyx’s report because it provides substantial descriptive and conceptual analysis of solidarity and related terms. Prainsack and Buyx do respond to Dawson and Jennings’ criticism (Prainsack and Buyx, 2012). 29. For a plausible critique of this classification, see (Prainsack and Buyx, 2012). 30. No pun intended. 31. A 2012 editorial hints at the possibility of extending solidarity to animals (Illingworth and Parmet, 2012). More recently, Melanie Rock and Chris Degeling argued for the extension of human-solidarity to ‘more-than-human’ solidarity to include non-human animals, plants and ecosystems (Rock and Degeling, 2015). Jennings and Dawson also suggest that one can ‘stand up’ for other species or an ecosystem (Jennings and Dawson, 2015). In light of recurrent outbreaks of avian flu occurring in the West Bank and threatening both animals and humans in Israel and the OPT, we point to the relevance of that term to our discussion. However, space limitations do not allow us to elaborate further. In any case, we agree with Dawson and Jennings that while solidarity may stem in part from mutual self-interest, it is not a necessary condition (Dawson and Jennings, 2012). 32. We thank an anonymous reviewer for raising this objection. 33. Jennings and Dawson are probably responding to Prainsack and Buyx’s (Prainsack and Buyx, 2012) critique that their own (Dawson and Jennings’) account of solidarity lacks justification. 34. Prainsack and Buyx do not clearly explain why this is the case. Zohar Lederman has recently made a similar relational argument to justify family-centered care: since one’s autonomy phenomenologically depends on one’s social family and friends, involving them in one’s medical care actually conceptually enhances one’s autonomy (Lederman, under review). Clearly, this argument raises the plausible objection that the said community in this case is confined to a few people; how can one’s autonomy possibly depend on a larger community of hundreds, thousands or millions of people? This objection hinders the applicability of this kind of relational argument to national or international solidarity. 35. Communitarians have offered compelling and rigorous arguments to justify their position, and the same arguments may justify solidarity (Raz, 1986; Taylor, 2003). 36. We do not necessarily think that the other being worse off is a necessary condition for a solidarity argument, but suspect that in most cases where solidarity is discussed and applied, the other will be worse off. 37. We thank Voo Teck Chuan for raising this objection. 38. Of course, with this response, we open the door again to the vampire charge above—blood meals are also a basic need for vampires. Addressing this charge to the fullest will take us to places we wish not reach here. However, the most immediate plausible response is that vampires would fundamentally be different from us, humans. Therefore, no relevant identification is possible. A second plausible response is to concede that we may indeed be obligated by solidarity to assist the vampires. However, this obligation does not mean providing them with blood meals, necessarily. Rather, we should find alternative ways to assist them. 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Public Health EthicsOxford University Press

Published: Apr 1, 2018

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