**8. Legal and ethical aspects of the Israeli medical assistance programme for Syrians**

One of the important points to study with regard to this programme was the legal and ethical framework in which it took place. The patients who came to Israel came for different reasons. At the start many were unconscious when they crossed the border so that one could not talk about voluntary or consensual transfer. Once in Israel, the individuals were the legal responsibility of the IDF and military law, yet their status was ill-defined. Unlike prisoners of war or refugees, groups that are covered by clear frameworks of international convention and law, the Syrian patients were not defined as either nor were they tourists. They came or were brought usually without documentation of any kind. This meant that these patients had no defined legal standing nor, therefore, defined protection. It is certainly my belief backed by extensive experience and exposure that the human and medical rights of these patients were rigorously safeguarded at all times by the dedicated medical and hospital staff that treated them, yet nevertheless the theoretical possibility of a breach of rights existed, and if this had occurred in practice, the patients would have had little legal or other recourse beyond the unsure solution of military law. This must certainly be a source of concern for any similar scenario whether in Israel or in any other country faced with a similar situation. An example of this nonoptimal situation was the restriction on transferring patients to other medical facilities in Israel in the case of need. The limitation on this was enforced and backed by a decision of the Israel Supreme Court. In one prime example, a paediatric patient requiring a bone marrow transplant could not be treated in Israel (for medical and social reasons) and needed transfer to an academic centre in an Arab country. This could not be done via the safe and direct route through Israel but rather via a return to Syria. Although in this case the transfer was completed without incident, it was certainly arguable that the patient's best interests could have been better served.

Another area of ethical concern relates to the area of research. There is no doubt that the huge amount of experience gained and the complexity of the medical challenges faced required documentation and reporting. In many cases clinical protocols and techniques required modification and alteration, and the results of the study of these constitute a form of clinical research as defined by the Israel Ministry of Health. Clinical research in Israel is governed by the principles of the World Health Association's Declarations of Helsinki and other international standards, as given expression by the regulations and laws extant in Israel. Principal among the tenets of ethical clinical research is the requirement for for full explanation to be given to the participant and also for his or her voluntarily given free, informed consent to be recorded on a signed, approved consent form (or in the case of minors or others unable to give legal consent, the agreement of their legal custodian). Putting aside the legal complexities of compliance with these requirements in the case of noncitizens with undefined status, there is the ethical issue of consent from someone who is completely dependent on the medical institution in which he finds himself or herself. Even assuming that the participant can be fully informed, how free can his/her decision be? On the public stage, it is also highly problematic to what extent these dependent noncitizens can be included in clinical research. The settlement of these weighty issues required a high degree of professional and ethical wisdom yet remained in the last resort a kind of ad hoc approach.
