The Health Ministry is discussing implementing procedures to govern cases where people with physical ailments refuse to be taken to the hospital. The issue came into the public eye in August 2012 when the actor Doron Nesher, who had suffered a stroke, refused the advice of the Magen David Adom ambulance team called to his home that he go with them to the hospital. Nesher’s family subsequently brought him to the hospital by themselves, rolled in a rug.

A Health Ministry committee determined that the ambulance team had acted properly and that it could not force Nesher to go to the hospital after they had determined he was lucid. However, the family argued that because Nesher had suffered a severe stroke, he was unaware of his actions.

In light of the incident, and of the fact that clear procedures have never been formulated in Israel for dealing with physically ill people who refuse to be taken to the hospital, the Health Ministry asked the National Council on Bioethics to discuss the matter. The 17-member council serves as an independent advisory body funded by the ministries of health and of science and technology.

According to Dr. Rafi Strugo, head of Magen David Adom’s medical division, since the incident with Nesher the organization’s ambulance teams have begun to ask for directives from headquarters in any case where a patient refuses to go to the hospital. Strugo told the committee that MDA’s headquarters receives two or three calls a day over such cases − a total of between 800 to 900 cases a year.

Data the first-aid service has collected in recent months show that out of 400,000 calls a year, patients are not taken to the hospital for various reasons in about 10 percent of calls. According to international medical literature, some 30 percent of delirious patients who refuse to be taken to the hospital die within days. These are mainly patients under the influence of drugs or alcohol, or suffering from meningitis.

Magen David Adom began formulating procedures for such cases two years ago and sent a draft to the Health Ministry, but following the Nesher case, the Bioethics Committee was asked to weigh in on the matter. The model under discussion is to be based on a clause of the 1996 Patients’ Rights Law that in emergencies allows hospitals to treat patients even if they have refused treatment, after an ethics committee consisting of three physicians has deliberated on the case. Since there is no time to call together a committee in the cases under discussion, the possibility is being explored to poll a committee by phone; the panel would consist of two physicians and the paramedic at the scene.

Strugo said that until permanent procedures are in place, he has instructed that when a patient for whom a regular ambulance has been called refuses to go to the hospital, the paramedic at the scene will call an intensive care ambulance, whose teams are more experienced. All of Magen David Adom’s 75 intensive care ambulances are staffed by paramedics and 10 of them are staffed by doctors. The latter would be the field representative in the poll by telephone over whether a patient should be forced to go to the hospital.

Magen David Adom has proposed that of two physicians who will be phoned, one will at the ambulance service’s national headquarters in Kiryat Ono and the other will be a Magen David Adom physician on call.

The new procedures will also cover administering tranquilizers to patients who refuse to be taken to the hospital, following the decision of the ethics committee.

Other countries have various procedures for dealing with the situation in cases where three conditions are met: the patient’s life is in danger, the patient’s mental state prevents him or her from understanding the situation, and active opposition to evacuation. In some countries a doctor must come to the scene to determine whether the conditions are met; others allow non-physicians to decide.

The Health Ministry confirmed that it had begun working with Magen David Adom on the procedures and that the Bioethics Committee had been consulted. “We are waiting for the committee’s position before issuing the directives,” the ministry said.