Recently, medical workers at Israeli hospitals told BBC News that Palestinian detainees from Gaza were “shackled and blindfolded” while they received treatment. Physicians owe a duty to their patients based on well-established ethical principles. In truth, the doctor-patient relationship is aspirational, and at the bedside, circumstance reveals a much more complex exchange. At the core of the doctor-patient relationship, two assumptions are needed. The patient must be at liberty, and the patient must want to live. Sometimes a patient wants to die, or at least rejects treatment to allow natural death. Discourse around doctor-assisted death is important, but such requests are currently under much debate internationally and not specific to Palestinian detainees. When the patient is also a prisoner, the traditional doctor-patient dynamic really starts to fall apart.

As a physician, I have worked extensively with prisoners on death row in the US. My work concerns post-conviction death penalty defense. I have been to death rows in eight states. As an ICU doctor, I may never hear the voice of my patient owing to illness. I learn about them through friends and families. We improperly call these proxy decision-makers “loved ones.” This is a poor assumption as we cannot know the nature of these relationships. I cannot know if my patient is the abuser or the abused. Sometimes, patients can advocate for themselves and make decisions about care that are clearly not in what I imagine would be in their best interest. In best interest discourse, I hew to the middle of the road and imagine the theoretically reasonable person with normal aspirations and desires.

Sometimes, a patient demands to be released during treatment. Patients have different reasons for such demands, some tragic, some nefarious. Sometimes I let them go “against medical advice,” sometimes I double down and prevent them from leaving. My argument is that as an advocate of their best interest, they would make a different decision if they were rational. To do this, I sometimes use physical and chemical restraints to hold a patient in the bed. Such practices are common in the ICU. Laws govern the use of such restraints, but the physician is granted extraordinary power in the name of patient advocacy.

I am particularly troubled in these moments of conflict because the right to make terrible choices is at the heart of liberty, and I recognize I might be accused of projecting my beliefs when I want them to choose differently. Sometimes, my patient has done terrible things or may do terrible things to others in the future. It is not the doctor’s job to police such actions when the patient is at liberty. When I confront a morally objectionable person, I am challenged. My experience has taught me that I still owe a duty to the patient in these moments, but this might be configured as the classic example of loving humanity but hating man. The kind of patient I like the most might be the one I like the least as a person. Under these circumstances, the medical work is pure.

As difficult as the theoretical doctor-patient relationship is, the complexity rises sharply when the patient is a prisoner. In the US, Estele v. Gamble enshrines a constitutional right to healthcare, and the upholding of this right is particularly vexing when the state tries to kill the prisoner as a lawful but controversial punishment. When a prisoner becomes sick before execution, they must have their health restored, but once healthy, they can then be killed. Is it reasonable to assume a prisoner would consent to treatment so they may be executed? Physicians have also found themselves maintaining the health of prisoners so they may be further interrogated. The blurry line of physician duty to the prisoner-patient on one hand and the state on the other confounds bioethical practice as ethical adjudication can justify seemingly conflicting positions.

Modern military medicine involves physicians on the battlefield, and international humanitarian law protects them in accordance with the rules of war. The military doctor owes a duty to the soldier and civilian patient but also to the mission. In extreme circumstances, a military physician might use a weapon to defend a soldier, civilian patient, or themselves. As a relatively benign comparison, physicians may be hired by a sports team to protect the health of players but also to keep the player in the game. The player wants to play, and the physician advocates for their desire even if playing would compromise their health.

Physicians not under the employ of state corrections can be tasked with caring for prisoners as can non-military physicians be utilized to care for injured prisoners in war. An enemy combatant is owed specific protection when they fight within a recognized state army. When individuals fight as non-state combatants, as in the case of Hamas, they are not afforded the traditional protections of prisoners of war. The legal consensus on how to manage these actions remains under debate. Captured non-state combatants may be guilty of crimes and fall under the legal system’s jurisdiction for adjudicating such actions. Prisoners in Israel are entitled to medical care in a fashion like in the US. In both instances, because the prisoner is not at liberty and can present an ongoing danger to others, they are guarded and always restrained when they are receiving care in a civilian hospital that lacks the sort of security that might be present in a prison. Exceptions to physical restraint may occur when such actions directly interfere with patient care, but in that circumstance, a guard is present to guarantee the safety of the medical staff.

The physician-prisoner relationship is not a fiduciary one. From a legal perspective, it most closely resembles the relationship between a public health physician and a patient. In both cases, the physician’s duty is primarily to the health and safety of the community and not to the patient. Such a relationship does not permit subjecting the prisoner to cruelty but threading the needle of what we consider cruelty beyond incarceration is problematic. Restraint may need to be physical. The prisoner patient might not be permitted to use bathroom facilities and instead be required to use a diaper. They may be fed through a straw or a tube. Not only prisoners but sick ICU patients may also be restrained, be fed through a tube inserted via the nose or mouth into the stomach, and be required to relieve bladder and bowel functions directly into the hospital bed. Such circumstance is not advanced as desirable but is advanced and done as necessary. No one likes this. Not the doctor, not the nurse, not the patient, not the courts, not the public.

In discussion, qualitative words like “dignity” might be raised. Dignity can be many things, and even defecation into a bed can be dignified when properly understood. In the Israel-Hamas war, emotions are high, and doctors are subject to a complex and seemingly competing set of demands. Doctors are people, guided by an ethical principle to do right, but the additional danger faced by civilian doctors caring for Palestinian prisoners is the risk of being too close to the narrative. We teach doctors to utilize empathy when dealing with patients. This is poor advice. Empathy is easily weaponized against oneself or against others. The good torturer lacks empathy, but the excellent torturer is very empathic – if you want to make it hurt for someone else, you need to understand what the pain feels like to yourself. In place of empathy, the well-trained and practiced physician utilizes compassion. We have compassion for the patients we do not like as people, and we guard their interests but recognize in the case of a prisoner, the lack of liberty sets them into a different category of duty because the physician owes a vital and higher community duty. Such a duty does not set medical ethics aside. On the contrary, it upholds medical ethics. In these terrible circumstances, we place adherence to our values as our highest priority.

Joel Zivot is a practicing physician in anesthesiology and intensive care medicine and a senior fellow in ethics at Emory University in Atlanta, Georgia. Zivot is a recognized expert who advocates against the use of lethal injection in the death penalty and is against the use of the tools of medicine as an arm of state power. Follow him on “X”/Twitter @joel_zivot