There are several issues identified as ethical dilemmas in palliative care in Israel; issues around disclosure of prognosis, the impact of genetic testing on discussions of prognosis with patients, decisions around stopping treatment when a patient is at the end of life, children and bereavement, the new law of the dying patient, and inequalities and difficulties around shared responsibilities when managing of service provision. There is also a continuing problem of opioid phobia, which affects access to pain relief and symptom control.

In Israel the patient has a right to full disclosure of prognosis from their physician. However, there are many problems that continue to arise with families requesting that the doctor does not tell the patient, as Professor Shvartzman explains:

‘The main issue that arises all the time is getting into the house and people telling you, family members telling you, ‘Psst, don’t tell anything to the patient.’ I think that’s the most problem, ‘Don’t tell him anything at all, if he finds out he’ll commit suicide.’ And it’s a very complicated issue because, first of all, we are visitors, so you go to their house; you have to be polite, you cannot say, ‘Hey, I’ll tell you what I’ll tell you.’ But still you have to do what you have to do, so I think that’s the most common issue....What happens is the son says ‘Don’t tell Dad that he has cancer, or he’ll be upset.’ Dad says to his son, ‘Joseph, go in the kitchen, make a cup of tea for me, a cup of coffee for the doctor, get the cake from the larder and do something else ...’ and as the son’s going out, ‘Don’t tell Joseph that I have cancer, he’ll be devastated if he finds out.’  That’s what usually happens.’¹⁵⁷

This situation is changing as there is more awareness through the media. Although as Amitai Oberman explains, physicians still withhold information:

‘They tend not to tell, on the whole. Nathan always says the physician is the first liar, and, which is true. Usually, in many cases it is up to us, or the oncologist will say, ‘You don’t have to come any more. If you want you can come again.’ In many situations we don’t directly speak to the patients, but it varies from culture to culture and sometimes theoretically you would think that you would [discuss this less] with more orthodox people, but we’ve found that we will discuss death with the rabbis and imams and sheikhs. It varies: it’s not based on a socio-economic or education level or anything like that, it’s very personal, I think. But compared to America where I trained, we’re still more paternalistic in Israel but the system is changing fairly rapidly and people are getting orders to tell patients and getting, ‘if you don’t tell patients, you may be liable, they can sue you.’ But still, there are problems, there are problems.’¹⁵⁸

Shlomith Perry, who has specialized in research on the impact of genetic testing for women with breast cancer, is very aware of the ethical dilemma this poses for families of people who may have the test and then have to be told about a poor prognosis:

‘[I feel that] people should learn how to deal withthis issue, all the genetic issues, all the medical genetics which become very important, to change the attitude to what is ill, to who is ill and who is not ill.  Is a carrier ill or not ill, because few of them have preventive mastectomies? How do you divide the division from illness and health? So I think that theissue of the family is very important in this, in the genetics because DNA is a family affair, and also at the end. So I think that in the medical continuum, there are a few areas where the family becomes very important: palliative care, genetics, donating [organs].

Shlomith Perry notes other ethical issues she has identified, around decisions by physicians and patients whether to continue (or begin treatment) or when to stop treatment:

‘It starts from the beginning, and here it will be more important. Palliative care will be well established here; and part of the thinking in palliative care will be the influence on all the care of the patient. In Israel we don’t know when to stop [treatment], the patient wants more and more drugs and doesn’t know when to stop.  I think it’s a problem in Israel, a society’s not well educated to decide when to stop; they need all the time to continue. They all need education, how to be more conscious, more aware of the decision, not to take more chemotherapy and more chemotherapy because you can stop chemotherapy. I think we don’t know it.  I think that it in Israel we take the most and expensive drugs, because then people want more and more and more. This environment is that you must treat, you know, I think this is a Jewish cultural [thing] that you have to save people.’¹⁵⁹

Ruth Gassner at Hadassah agrees that this is a problem at the very last stages of life and describes how they deal with the issue in the hospice:

‘The way forward is to talk with patient and family. I think they look at every case from a start at the zero point all over again. We haven’t made decisions like: we don’t give blood, or we don’t give feeding tubes, or we don’t do this. Every case is an individual case and we start depending on who the patient is, what the family wants. We are very open, talking to them.’¹⁶⁰

There are many ethical concerns about how to support children in bereavement prior to their relative’s death. Social worker Malka Yehezhel explains:

'Sometimes I feel when there are small children, that we won’t let them come and visit parents or grandfather or grandmother; the patient doesn’t want the visit, so what do we do? Usually, of course, first I try to explain and to work with the patient and to explain how important it is and that we can find a situation that will be OK for him, also not too difficult, not to let him feel he has to be nice and ... even if he is sleeping just to let this child come and do his separation. This is one of the things when it’s children that I know for everyone, and for me too, is more difficult with the years, but I am so sure how important it is to help these children because I know how families try to protect them and try to avoid from them pain, so before death comes they try not to talk about, and I really do a lot of work with the family to help them understand how important it is to remember the children; to help them understand what’s happening, see what’s happening and feel what’s happening, so they need support, they need to feel they can talk about what is happening. If the family thinks he is too small, he doesn’t understand; it’s a mistake. Of course it’s a lot of work because I have to show them how they don’t protect them and they don’t help them, and it’s very, very vulnerable really work, but I do it even if it’s difficult. And all the staff is very happy that I’m doing, but they help me when I need, Dr Azoulay comes and sit with the children, they have questions, they want to ask questions and he is wonderful, really wonderful, and the nurses also. The children become very frightened to see the parent, to see this place, and they get this beautiful hug, yes, it helps a lot: it helps me of course to continue to work with them. They are happy to come to here, even if it’s difficult, but it’s a nice place, it’s ... they feel the parents is taken care very nicely, they feel they are wanted here, and it’s so important.’¹⁶¹

There is an active debate in Israel about palliative care, euthanasia and assisted suicide which, in 2005, culminated in the passing of a new law of the
dying patient. ^162,163 
Professor Abraham Steinberg who chaired the committee on this debate explains the kinds of ethical dilemmas they have attempted to address by passing a law that will attend to the needs of the majority of patients:

‘I feel that it won’t be fair not to provide the best palliative care to those who are suffering, who want to die, but if we provide them with palliative care they may still want to live, or at least have some reason to continue to live. And therefore we included as part of the law, which I understand there are very few countries, if any, that the law provides for the government to be responsible to give palliative care. Which means that the law says that every dying patient, obviously we can extend it to the non-dying, but the law talks about the dying, so we talk about the dying, every dying patient should get the best palliative care according to the standard at that time/…

 It should include finding for the accessories, for medications, for anything that palliative care demands, which nowadays is not available on a governmental level. And also we suggest that, not in the law but it comes out from this paragraph, that palliative care should be recognised as a field of medicine in the way that it should be studied, it should be recognised as a sub-specialty, there should be experts in the field - in other words it should be part of medicine like any other part of medicine, which I think is something new from a legal point of view, certainly in Israel but I think worldwide as well./

On a philosophical level there might be differences on how we interpret palliative care: does it include always food and fluid and only no resuscitation, or does it include medication, routine medic-, I mean they are debates there are debates that are ongoing. So the standards of palliative care obviously will be presented by the experts and then there may be some variations on what is acceptable or not. Now whether it should be an acute care facility or in a hospice or in a home hospice or whatever, I mean, these are things that have to be worked out, I assume on individual levels, I mean, that has not to be decided on the legal, on a law level. Because I think that certainly the hospices know how to work with such patients, that’s their job, but the problem I think is in acute care facilities where patients of this kind are admitted, they’re being treated like anyone else, no-one knows how to take care of the aspect of suffering of pain, and that’s where she should put more emphasis. Now whether to move them out or not is a very individual decision, but as long as they are here or in an old age home or even at home, they should get the best palliative care - that’s the concept. … I know some people say that part of palliation is hastening death because he is suffering and, let’s say the Dutch, their view of palliative care is active euthanasia, it’s a way of palliative care - that obviously is unacceptable from a Jewish point of view, I think from a true palliative care perspective as well. But if it involves medication and support and family and the social and psychological, that is very positively viewed even if medication occasionally may hasten death; that is taken into account. In fact from a Jewish point of view pain and suffering is viewed as any other illness - let’s say someone has a brain tumour, what do you do for him? You take him to the operating room, you operate him, and a few die on the table, so it doesn’t mean that you don’t operate because somebody died. So the same here, if you, if you equate pain to a brain tumour, the same way that there you give a treatment which is called operation and some die, you give a treatment which is called morphine or whatever and some die, so that really does not take away from the legitimacy, unless you purposely give such amounts that will kill because you think that this is the way to help the patient, that is not a help from the Jewish point of view. … If the patient wants to live, to continue living, even though from a medical point of view it doesn’t make sense, it’s futile - whatever futile means - you must provide him whatever needed for him to continue living, including palliative care. Now if the patient doesn’t want to continue to live, then it depends what he wants. If he just wants to withhold treatment that is fine: if he wants to withdraw treatment it’s also fine as long as the withdrawal is not causing instant death. So for instance if he’s on dialysis treatment and he got ten rounds and now he doesn’t want any more, so you don’t give the next one because it’ll take days before he’ll die because of his decision, so that’s a withholding process from the law.’¹⁶⁴

The ethics the Professor Steinberg is working to resolve are closely allied to the inequalities of access to adequate and appropriate service provision. Palliative care consultant Dr Ora Rosengarten discusses some aspects of this dilemma she and other colleagues face in home hospice care:

‘First there’s always the problem of keeping the patient at home or not. One of the problems encountered is the question of whether to go on with the home hospitalisation or not because, if the family and the patient is able to manage with all this, sometimes we do have the feeling that - this is not a majority - but sometimes we have patients who call other doctors who are involved in the treatment. In that case we have a real medical problem in managing and taking the responsibility for the treatment.

We do have a problem sometimes when a patient is alone, he doesn’t have a family to support him, and the dilemma is whether to get in there and give him what we can, but we know that it’s not optimal because there’s nobody there to take the responsibility. Or [can we] leave him like this, because if you’re not there then nothing will be done? But if you are there you know you cannot do your job properly.’¹⁶⁵

Inspite of the increase in education and training, several palliative care specialists noted that opioid phobia and fear of sedation continues to be a problem, both among health professionals and the public.¹⁶⁶ Amitai Oberman and Jim Shalom in the north of Israel note, they still encounter physicians who are afraid to prescribe opioids. Amitai Oberman describes the practice of pharmacists who still put ‘poison’ on an opioid prescription:

‘I give a couple of lectures to pharmacists. It’s fascinating to talk to them because they have their own perspective, and stories. I can give them a call and say, ‘Look ... please help us with this,’ and it’s usually fine. They’ve got their own laws and rules; they’re not allowed to be flexible - you can’t give this, and this has to be written down - and still when a patient gets a script of MCR , they put on the back sometimes a notice saying ‘poison’ on it. We’re working on them to try and convince them it’s not really clever to put ‘poison’. But there’s still this thing about narcotics in Israel. But it is changing. Some of the old pharmacists keep putting, just out of habit, I think, ‘poison’ and during my talks about, I have these slides showing them what are the obstacles to perception of opioid and then I show them, and I say to them, ‘Who wants to take a drug which is poisonous?’¹⁶⁷

At Hadassah, director Ruth Gassner and social worker Malka Yehezhel discuss the difficulties they find where patients ask for sedation, although the family maybe afraid to see their relative sedated:

‘That’s a dilemma that we have; the whole issue of sedating, when the patient is awake and asks us to sedate him and it comes from the patient. …. When we deal with the dilemma, first we have to feel we know what we feel and what we think we are ready to start to do, and then we come to the family, because we don’t want to let them feel the responsibility is [just theirs] or the patients - we want to help, we want to be there really as helpers.’¹⁶⁸