In 1987, when Prof. Alexander Aviram was appointed director of Assouta Medical Center, a private hospital in Tel Aviv, he was surprised to discover that, according to arrangements that existed in the institution, physicians who were not on the Assouta staff received payments for referring patients for examinations and treatments at the hospital.

Aviram learned, for example, that physicians were paid for referring patients to imaging examinations and fertility treatments, and that a relative of a senior member on the executive of one of the Kupat Holim health maintenance organizations was paid for referring patients. It was also discovered, around the same time, that two physicians who worked for the Civil Administration in the territories were paid for referring Palestinians to Assouta.

Aviram was concerned that these arrangements were criminal. However, even if they were not criminal, he concluded, they were certainly contrary to the public good and to a basic rule of medical ethics, namely that a physician should not receive brokerage fees for referring people for examinations or treatment.

The ban on brokerage fees in medicine (in contrast to other professions, such as the law) derives from the fact that, because of the distinctiveness of the medical profession, the very act of payment for referral (in contrast to payment for the actual treatment) is liable to push physicians - and with them patients - into an abyss in which the referral is made only in order to get the payment. The result will be that patients will be sent for unnecessary treatments, which could prove harmful to them and even fatal.

Examples are not hard to find. Aviram himself received complaints around this time to the effect that patients had undergone expensive imaging examinations at Assouta needlessly and at risk to their health. Aviram canceled the payback arrangements and also annulled an agreement between a senior member of the management of Ichilov Hospital in Tel Aviv - a municipal-government institution - and Assouta, according to which the senior figure at Ichilov received $2,000 a month (in addition to an annual trip abroad, worth $3,000) for "administrative and financial consultation." It turned out that, in practice, no such consultation was given.

At this time, a larger hospital in the center of the country is at the center of a similar affair. The police are investigating suspicions that the management of Ichilov, headed by Prof. Gabi Barabash, had arrangements of this kind with six government hospitals. The police suspect that under these arrangements, Ichilov makes payments to research funds of senior cardiologists and catheterization specialists in return for the referral of patients to heart surgery in Ichilov, of all places.

The discovery caused a furor and triggered condemnations. Aviram, who has served in senior posts in various health institutions in Israel, including Ichilov, says that apart from the arrangements he discovered at Assouta and then canceled, he was not aware of similar arrangements in the Israeli medical system. Many other senior figures, including Prof. Mordechai Shani, the director of Sheba Medical Center, and Dr. Eran Halperin, who is on the executive of the Clalit HMO, say the same thing.

The police are looking into the possibility that these payments constitute bribes, and are also trying to find out why Prof. Gideon Uretzky, director of cardiac surgery at Ichilov, asked Barabash's office to pay the chief catheter procedure physician at Hillel Yaffeh Medical Center in Hadera - even though the director of Hillel Yaffeh, Dr. Meir Oren, stated that he was appalled by this and demanded that it not be done.

Also under investigation is the question of why Ichilov transferred "consultation fees" totaling tens of thousands of shekels to the private pocket of the chief catheter procedure physician at Barzilai Hospital in Ashkelon, and the connection of these payments to the referral of patients to Ichilov.

These arrangements were discovered in the course of the ramified investigation the police are currently conducting in the case of Uretzky, who denies, like the rest of the people involved in the affair, all the suspicions against him. Uretzky assumed his post in September 2000, when the trial of the former director of the same department, Dr. Vladimir Yakirevich, was still under way.

In January of this year, Yakirevich was convicted on the harshest indictment in the history of Israeli medicine (including manslaughter in the case of two patients, abandoning patients during surgery and bribe taking).

At that time, though, four years ago, serious questions in the trial had not yet been resolved, such as whether, as Yakirevich claimed, Barabash allowed him to ask for payments directly from patients. (The court found that Barabash had not done this, but it was found that he encouraged Yakirevich to transfer to his department private patients from Assouta and arranged with him for extra payments for surgery.) Another question that had not been clarified at that time was how Barabash had behaved in connection with complaints reaching him from physicians who were subordinate to Yakirevich and from patients.

The judgment found that Barabash had behaved "with kid gloves" toward Yakirevich and had not passed on the complaints to the Health Ministry. It was those complaints that led to Yakirevich's conviction on some of the most serious charges - manslaughter, negligence and extortion under threat.

Even if it's decided that Barabash's acts in the Uretzky affair are not criminal, the dark cloud hanging over Barabash in this affair and in the Yakirevich case raises serious questions about his moral fitness, for the good of the public, to serve as director of one of Israel's largest and most important hospitals.