There are two major ethical issues described by healthcare professionals providing end of life support in the Palestinian Authority. The first is the problem of health service provision when working in an area riven by conflict, and with no home care support. The organisation Physicians for Human Rights-Israel recently published a report outlining these problems of access, which leads to considerable suffering for people undergoing treatment or when they are at the end of life. ^56,57

The second is the problem of disclosure of the diagnosis and prognosis to cancer patients. Dr Fouad Sabatin discusses these two ethical problems:

‘Sometimes the families also can ask us not to tell the patient he or she has cancer and we end up having to deal with the situation because the patient doesn’t know if he has a tumour. Eventually they will know they have a terminal illness, but for the families the pressure is so hard not to tell the patient. So the families they take that role, they try to take decisions for the patient. I try my best to avoid that. I love it when I get to the patient first before a family member comes to me and says, “Oh please, don’t tell him that he has so-and-so.” And in certain situations that has happened, so that’s number one. Number two, these families, most families they don’t have support; for example, although we have a social worker on the staff, but we don’t have enough support and resources for these people and because the insurance system is not great, once these patients go home they don’t have the luxury of having like a visiting nurse or sometimes having physiotherapy at home or home care or for example home equipment and so on. So sometimes the families get overwhelmed But this is probably different from the Western countries, most of the families here are committed, so they really take care of the patients very well, but it’s a hard job.’⁵⁸

Carol El Jabari suggests that much of the problem relating to disclosure is due to lack of training for doctors. She also feels that the lack of access to care is a major issue:

‘A major ethical issue is that the doctors are not frank with the patient; they don’t tell them they have cancer. It is a major obstacle we as caregivers have to try and overcome when trying to give palliative care or any kind of care.

Usually the family will know, and the family tells the doctor, “please don’t tell, don’t tell them.” Most of the patients know.- won’t they figure out when they go for chemotherapy or radiotherapy? .While most people don’t want to say or hear the word ‘cancer’ we have found in our experience it is best to tell the patients, so they can get on with the rest of their lives.. Most of the doctors have never been trained to discuss such a major health issue so they need skills and sensitivity training to better deal with patients and families. We’ve have some workshops with nurses. The nurses we’ve been teaching are great, but they’re all very frustrated because they’re dealing with patients the doctors haven’t told.

Another ethical problem is that the access to care, whether it be for diagnosis, chemotherapy, radiotherapy or psychosocial support, depends on the individual being well enough to go obtain a permit, have it accepted at the barriers and eventually get to their treatment. This is all very traumatic, disheartening and exhausting.’⁵⁹