What's Up Doc? My Slating of Israel's Medical System Was Justified

Following an outpouring of responses to claims she made about the lack of humanity among Israeli doctors, Eva Illouz tries to explain why such generalizations are warranted.

Eva Illouz
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Illustration by Yael Bogen.
Eva Illouz

Months ago, I published a piece in Haaretz telling of the death of my father while in the hands of doctors and a hospital that failed in fulfilling basic ethical rules of their profession, and, more fundamentally, failed in what we commonly call “humanity.” An outpouring of moving responses and disturbing testimonies subsequently reached me, overwhelming by their sheer quantity and force. Many, too many, confirmed my experience.

Others, however, objected to my account and disagreed with the procedure at the heart of the article: namely, the fact that I used my private experience in one hospital to make broad claims about the ways in which medical culture and Israeli society mirror each other, in their blunting of empathy and routinization of indifference. Didn’t I do an injustice to the hard work of many dedicated doctors in making such broad generalizations?

Generalization is a crucial strategy for thinking and making arguments. It is thus important to justify its use. Let me try with examples.

Rape is a crime and we think of rapists as criminals. But feminism has offered a powerful insight: Rape is connected to the normal conduct in heterosexual relationships and to the normal definition of masculinity.

The Israeli movie Shesh Pe’amim (“Six Acts,” 2012) makes exactly that point and presents the (real) story of normal, conventional, upper-middle class adolescents who engage a young girl in a sex that is forced and consensual at the same time, as a matter of routine. None of them, including the girl, understands the meaning of their acts because rape is built into modern heterosexual culture, in the definition of masculinity as sexual power and in the definition of femininity as being sexually available to men.

The rape of a stranger, the rape of one’s wife (dismissed as a possibility by courts until recently), sexual harassment or bullying in the workplace, verbal harassment in the street – all are situated on one single continuum of male violence against women.

If rape is a crime, it is a crime that resonates widely with the conventional norms and models of masculinity which are defined as sexual domination over women. It amplifies certain norms of masculinity rather than deviating from them. This means, then, that rape does not run counter to, but rather reflects, mirrors, perpetuates the models of masculinity available in culture at large.

To generalize in this sense means, then, to understand how cultural definitions that present themselves as normal generate behaviors that are deviant: Normality is haunted from within, by the specter of the monsters it creates.

This does not mean, however, that many men are not good and caring. My claim about doctors is of the same nature: There are many good doctors in the same way there are many good men, but those who fail to be compassionate are left largely unpunished for it, because lack of compassion prolongs and resonates with fundamental features of normal culture propagated by the army – its regular display of force and its routinized indifference to suffering (in training, secret services, military operations, checkpoints, house demolitions, imprisonment, administrative detentions, security operations, torture, etc.).

No combat army I know of promotes values of compassion, vulnerability and softness. On the contrary. There is thus no reason to suspect that the vocation of the Israel Defense Forces is different from that of most armies in the world, which is to kill, and to teach soldiers to be immune to their own and to others’ suffering.

To “generalize,” then, means to ask if behind private and singular experiences there do not lurk widespread and collective patterns of behavior and thought, and whether these collective patterns of thought do not in turn create pathologies whose manifestations in us we want to deny.

Roots of depression

Think of the following examples. Depression is often rooted in the experience of worthlessness and helplessness, which are social, rather than psychological, experiences. This is why depression is experienced more often by women than by men, more by the poor than by the wealthy, more by uneducated people than by educated ones.

Think of how being ashamed about one’s fat body when sitting on the Tel Aviv beach can make one prefer to wear a T-shirt rather than a bathing suit; such shame can be attributed to the dictate of thinness promoted by the media. Or think of how many Mizrahi children in Israel over the years were embarrassed by their parents’ Moroccan accents, surely an effect of ethnic hierarchy.

However private and intimate, these feelings – anxiety, shame with respect to one’s body, embarrassment over one’s ethnic origin – come packed together with social and political structures, with hierarchies (who is high, who is low), with collective definitions of worth (who is worthy, who is unworthy).

When a sociologist generalizes, she does not deny the variety of experiences, and she does not deny the singularity of many experiences. She simply looks for what is general and structural in these singular and variable experiences. Like delicate miniatures that contain whole worlds in a very tiny image, even fleeting emotions contain social worlds, barely seen to the untrained eye.

Normal people do not see the political structure of their lives, because no one can “see” institutions such as patriarchy, ethnic hierarchy or even militarism. What we normally “see” are people, individual units that seem to be the cause of their own actions, will and speech. Not only we do not “see” such abstract concepts, we also lack a language to grasp the invisible chain of causes that lead from the general to the particular and from the particular to the general. This is why our experience feels “private” and “personal,” despite the fact that many – perhaps most – of the indignities of our lives are not, or not only, the fruit of our individual psyches. A good part of the humiliation, failures and despair we experience have their source in the organization of society, not in faulty psyches.

This, however, does not mean that “everyone is the same.” To generalize is not to claim that people behave like robots, in a similar and uniform way. People react to and cope with the indignities of life differently, even when the source of these indignities is social and institutional. To generalize, then, means to uncover the institutional and normative source of a variety of individual experiences. To generalize is nothing but to discover and express the norms that make possible the repeated behavior of many people, despite their individual differences.

To explain how norms shape our thoughts and behavior, let me use a metaphor (borrowed from the great American sociologist Ann Swidler). We know that when they fly, bats use built-in sensors to feel out the physical obstacles of the space in which they move. These sensors enable the bats to fly unhindered in dark grottoes, despite their poor vision. They avoid the walls of the grotto unconsciously.

For human beings, the walls of the “grotto” are the norms of their environment. We behave by feeling non-consciously the walls of the grotto – that is, what is and what is not permissible, what is and what is not a standard of behavior, what is viewed by our environment as moral or immoral.

Endless research in anthropology, sociology, history, economics has proved the powerful presence and influence of norms on human thinking, feeling and behavior. There are countries, for example, in which the use of protektzia (connections) to get jobs, profitable business deals, good medical care, or prestigious awards is considered contemptible. But if there are no norms against such practice, then it is inevitable that the use of protektzia becomes a normal standard to get ahead. An environment that makes it easy to break moral rules and norms creates chaos and disorder, and undermines the very capacity to hold on to the proper criteria for evaluating oneself and others.

The ills of Israeli medicine

The reader who – like me – has benefited from the care of many wonderful doctors, may still be skeptical, and may still feel that my generalization was exaggerated. Let me thus offer further arguments.

Shortly after the piece in Haaretz was published, several prominent figures in the local medical system got in touch with me: Prof. Ari Shamiss, director of the general hospital of the Sheba Medical Center; Prof. Yehoshua Shemer, chairman of Assouta Medical Center; Prof. Avraham Rivkind, head of the shock trauma unit at Hadassah Hospital; and Prof. Dov Chernichovsky, an economist whose expertise is in health care systems.

These four prominent figures expressed unreserved support for my analysis of that system (though not necessarily with the political ramifications), and spoke with me about their struggles with what they called a "very grave" cultural or educational problem of doctors working in Israeli hospitals.

Chernichovsky spoke of “disaster.” Rivkin spoke of a “worrisome collapse of the value of life in hospitals.” Sharmiss and Shemer both spoke of a striking lack of general education among many doctors working in hospitals. They all recognized the problem I evoked in my article – the lack of compassion and humane treatment – as a common one. Even though each spoke with me separately, they remarkably agreed on this: The nature of the problem I described is not financial, but rather one of “education” and “culture” (which does not mean the medical system does not lack money; it simply means the reason doctors behave badly is not financial). They all described an acute lack of patience, courtesy, communicativeness, empathy or kindness as common traits of many (not all) doctors working in Israeli medical institutions. One even spoke of “widespread contempt” for human life.

Readers of Haaretz are free to ignore my opinion, but they cannot ignore or dismiss the opinion of eminent experts in the health-care system.

Another unexpected source confirms my analysis: Prof. Yossi Weiss of Ariel University, in the West Bank. Weiss, whose field is health management, conducted a survey on “Compassion in the Health System” with the Geocartography research institute, and presented the results to the Knesset in 2010. The study, which surveyed a sample of 500 people, found that 40 percent felt that doctors displayed professionalism but no compassion or empathy for their patients.

But the findings are much more interesting and disturbing than that. The same people, when asked if they themselves would be willing to contribute any money to help provide or improve medical care for the following populations, displayed an uncanny lack of compassion: 71 percent would refuse to contribute money to improve the care offered to security prisoners; 65 percent were unwilling to help criminal prisoners; 65 percent refused to help illegal immigrant workers; 60 percent refused to help prostitutes; and 62 percent refused to help refugees who fled their countries of origin.

Since one cannot suspect that an "anti-Zionist" or "post-Zionist" conducted this survey, it is not possible to assume that the results were doctored so as to show Israelis in a negative light. The data suggest a disturbing lack of compassion toward strangers who are sick and in need of help. Most striking, perhaps, is the unwillingness to help prostitutes, immigrants and refugees, who presumably do not do anything to endanger Israelis.

To lack compassion toward strangers is to lack compassion, period. By definition, compassion is geared to the stranger, to the one who does not belong to my group (and even deviates from it). Compassion reserved only for members of my group is not compassion, but self-preservation. The absence of compassion in turn points to the absence of two fundamental moral skills: seeing distant and different Others as full-fledged human beings, fundamentally equal to me; and feeling the urge to relieve the suffering of those who are not members of my group.

Compassion is the feeling that dominates universalist cultures that privilege human rights. Is it surprising then, that it is weak or absent in cultures in which domination, force and power rule the perception of other human beings; ethnic pride is celebrated; religious groups are segregated from each other; and human rights are ignored?

Is it pure chance, for example, that the same person who advocates an unapologetic view of racial and ethnic superiority in Israel, is the same who displays an astonishing lack of compassion? Just before Operation Protective Edge in Gaza last summer, MK Ayelet Shaked of the right-wing religious party Habayit Hayehudi, who is currently Israel’s justice minister, wrote on her Facebook page, after Palestinian militants kidnapped and killed three Israeli teens: “This is a war between two people. Who is the enemy? The Palestinian people an entire people, including its elderly and its women, its cities and its villages, its property and its infrastructure.”

When an Israeli legislator declares publicly that women and the elderly are legitimate targets of war, she turns the sentiments of many into a moral and political norm that dismisses the possibility for compassion and humanity. (If 20 years ago, someone had told me that an Israeli official would declare publicly that it was legitimate to kill old people and women, I would have thought it a vile anti-Semitic demonization of Jews and Israelis).

Let me now make another, and final, point.

The director of the hospital near Tel Aviv in which my father died never contacted me or sent his apologies and condolences in a way that would have clearly shown that he at least regretted the pain inflicted upon me and my family.

What does a human being stand to lose by showing his own humanity to another human being? What does a doctor responsible for an entire and large medical organization stand to lose by demonstrating his sense of responsibility for his doctors?

No accountability

The capacity to apologize derives directly from a crucial feature of properly run institutions: accountability. Accountability is a crucial feature of democratic societies. It is in fact their most essential feature. Governments are “accountable” if citizens can sanction their representatives appropriately, according to performance and moral standards, keeping in office those incumbents who perform well and ousting those who do not. If institutions, politicians and professionals fail to serve the public interest or uphold proper norms of professionalism and morality, they usually at the very least acknowledge that some precious norms have been infringed upon; they often apologize and sometimes even resign.

When caught doing something wrong, however, most Israeli politicians display an astonishing feature: Even if they are convicted of a crime and sent to prison, they deny having ever committed any wrong, never make apologies, and never take responsibility by voluntarily resigning from their post. (We all remember the evasions and denial of wrongdoing by Arye Dery, Yitzhak Mordechai, Moshe Katsav, Avraham Hirschson, Ehud Olmert, and many others.) Indeed, Dery, who went to jail, never acknowledged wrongdoing, nor apologized. Maybe that’s why he can again be the respectable head of a party and serve in the government. This lack of accountability is equivalent to a form of normlessness.

Why is there such an apparent lack of apparent norms and standards with which to hold public figures accountable? Let me offer a hypothesis that involves, again, a work of generalization: When a state controls the lives of an entire population, seizes land illegally and mocks international law, it is compelled to use force continuously. This can only be done by denying its own actions, so therefore the state cannot logically apologize for them. In other words, the use of force is by definition and by necessity a practice that allows a state to deny its own wrongdoing, thus precluding the practice of apology. Moreover, when a state that has committed a wrongdoing is convinced that justice is on its side, it can never properly question itself, and thus can neither apologize nor be held accountable for the injustices it commits.

Is it, then, purely by chance that a close colleague of Ayelet Shaked, Naftali Bennett, the chairman of Habayit Hayehudi and today the education minister, ran an advertising campaign ridiculing the “type” of person who makes apologies. His campaign aimed to restored pride to those who do not apologize. If advertising – political or commercial – employs values that are dear to those it targets, then we may say that the value dear to Bennett and his audience is this: A real man, like a real nation, does not apologize.

Rise of 'civilization'

Jewish German sociologist Norbert Elias defined “civilization” in a very interesting way: not by how many Nobel Prizes a society receives or by how many classical concerts its people attend, but by the fact at some point in its history, a culture starts to become peaceful internally. Sometime during the 15th and 16th centuries, the (French) state took it upon itself to pacify social relations by strictly forbidding the use of violence by individuals and by making itself the sole agent authorized to use violence. To use the language of economists, the state forced its subjects to cooperate with each other. Even more interesting, the enforcement of social peace was accompanied by a change in etiquette and manners.

Elias observed that the pacification of society went hand in hand with new norms of bodily conduct: People were now firmly instructed not to fart, pick their noses, burp, or produce excrements in public (something that had been acceptable until then). The double capacity to control aggressiveness and to feel shame when one’s body lost control, Elias averred, marked the rise of European “civilization.”

Being civilized, then, meant the capacity to acknowledge the presence of others by showing one’s self-restraint. When that other was not properly acknowledged, an apology had to follow to clarify that one accepted the rule that had been broken, and to signal one’s intention to repair the relationship thus broken. In that sense, the capacity to apologize became the mark of a “civilized” person – one who has given up the use of arms as a mode of existence, and one who is ashamed of farting, burping or picking one’s nose in the presence of others.

What is the opposite of this? The human being that Bennett implicitly commends and recommends: someone who engages in those behaviors (literally and metaphorically). Why would a public official of a respectable state mock the civilized practice of apologizing and turn it into his platform for getting elected? Perhaps because many, too many, tie their sense of worth to “strength,” and view the civilized practice of apology as an acknowledgment of weakness and vulnerability, rather than as a display of moral authority and responsibility.

Let me thus deliver a personal message to the heads of Israel’s hospitals and other public institutions: Someone unable to apologize cannot claim the title of moral agent and cannot claim the authority to represent the interests of the public. An apology is an act of moral strength.