On the abundance of scarcity and the scarcity of ‘politics’

One of the most important motifs within (medical) ethics is scarcity: where essential (health) resources are scarce, urgent ethical questions arise. Over the last decade, at least 250 papers addressing the allocation of scarce health resources have been published in the Journal of Medical Ethics alone.1 In the typical set-up, the authors introduce a situation of scarcity and then review and adjudicate the available or recommended courses of action, sometimes through the lens of a pet normative ethical theory.

It is much less common for (medical) ethicists to focus their enquiries on the origins of scarcity. Why aren’t there sufficient health resources to go around? Who caused the scarcity, and how should they be held responsible? These questions are also firmly within the remit of the discipline.

Discussions of scarcity tend to circumvent these difficult questions by focussing on exceptional cases in Global North settings, where scarcity is relatively rare, and is sometimes defensible or insoluble. For example: it would be wasteful for a hospital to overstock expensive, bulky, energetically intensive, specialist equipment whose supply would only be challenged under the most extreme and unforeseen circumstances (eg, a pandemic), and there may never be sufficient usable donor organs to meet the demand for transplants. Much less attention is given to under-resourced settings, generally in the Global South, where scarcity is common, and is often both indefensible and soluble. The literature appears to favour what is ‘unusual’ and ‘interesting’ in some contexts, rather than what is commonplace, and by that fact more worrying, in others. This division of attention entrenches the idea that scarcity is a fixed feature of certain places and lives.

Why do medical ethicists so often fight shy of these meta-questions? They are, of course, harder and messier. More work and greater care are needed to contextualise the scarcity, and that context inevitably requires the authors to engage with ‘politics’, which is often quietly bypassed in medical ethics. It is much cleaner to excise a problem of scarcity from its political frame and ‘solve’ it as though it were a closed system. The pressure to publish, and the word limits imposed on those publications, surely also plays a part. It might also be the case that medical ethicists are liable to view ethical issues as problems clinicians must grapple with within the walls of the hospital.

What happens when the walls of the hospital are blown away? When neonatal incubators lose power, and premature babies must be kept warm on sheets of aluminium foil?1 What should medical ethicists do when extreme scarcity arises because the entire health infrastructure of a place is being deliberately destroyed?

Israel’s production of health scarcity in Gaza

The attack carried out by Hamas on 7 October 2023 was not the beginning of the story; Gaza’s healthcare system was already dangerously inadequate. The enclave has been under Israeli air, land and sea blockade since 2007, which has obstructed the supply of medical equipment and drugs. Further, Israeli military campaigns, including airstrikes on hospitals, have repeatedly destroyed the existing health infrastructure. As the occupying power in Gaza, Israel is required by international humanitarian law to guarantee that civilians’ basic subsistence needs are met, but has at various points over the last 16 years deliberately blocked access to water, electricity and humanitarian aid.2

In the last 6 months, more than 33 922 people are known to have been killed in Israel, the Occupied West Bank and Gaza, among them 32 783 Palestinians and 1139 Israelis. The bodies of at least 8000 more Palestinians are buried under the extensive rubble. More than 88 124 people have been injured: at least 79 394 Palestinians and 8730 Israelis.3 In April 2024, a representative from Gaza’s morgue monitoring system declared that the system for counting deaths had effectively collapsed.4 1000 children in Gaza have had limbs amputated following shrapnel injuries or after having body parts crushed by collapsing buildings, making them, in the words of trauma surgeon Ghassan Abu-Sittah “the biggest cohort of pediatric amputees in history”.5

In any context, the most basic determinants of health are food, water and sanitation, shelter, and medical infrastructure, each of which requires reliable access to fuel and electricity. All of these are now critically scarce in Gaza.

Doing what we can

‘Whoever stays until the end will tell the story. We did what we could. Remember us.’

Dr Mahmoud Abu Nujaila, who was working with Médecins Sans Frontières at Al-Awda hospital in Gaza, left the above words on the surgical whiteboard on 20 October 2023, anticipating, under heavy bombardment, that he would soon be cut-off from that story.40 Nujaila was killed in an airstrike on 21 November 2023, along with his colleagues, Dr Ahmad Al Sahar and Dr Ziad Al-Tatari.41

‘We did what we could’ are the words of doctors operating under conditions of extreme and devastating scarcity. In the coming months, I hope we will see in these pages careful studies of how medical professionals have endured that scarcity in Gaza’s healthcare facilities, as well as analyses of how this was allowed to happen, and what justice might look like in the wake of such extreme disregard for life and health. In the more immediate term, as medical ethicists, we must oppose and condemn Israel’s deliberate production of health scarcity by every means available to us while we are still able to make some difference to the discourse, if nothing else.

There are, regrettably, many other situations of incursion, occupation and genocide in which healthcare infrastructure is targeted.42 Each of them requires greater attention in this literature. But their neglect is generally the result of ignorance, which requires a different call to arms. When I ask colleagues about their silence on Gaza, more often than ignorance, they confess that they fear wading into something so ‘complicated’ and ‘political’. This is a predictable response to the reprisals that some of those who have spoken out have faced,43 but that is no excuse when the stakes for others are so many orders of magnitude greater. Are we ethicists, or not? A ‘complicated’, ‘uncomfortable’, ‘political’ ethical problem is no less an ethical problem. Will we be able to say: ‘We did what we could’? The medics of Gaza are doing their jobs at risk of death, we need to step up and do ours.