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BMJ editorial on the Lancet open leter on Gaza and some responses

Politics, medical journals, the medical profession and the Israel lobby

Criticism of the Israeli government does not necessarily equate with antisemitism

John S Yudkin and Jennifer Leaning

In April, Reed Elsevier, publishers of the Lancet, received a complaint written by Professor Mark Pepys and signed by 396 physicians and scientists, including five Nobel Laureates.1 They protested that the Lancet was being used for political purposes and for “publication of deliberately false material which deepens polarization between Israelis and Palestinians.”

The most recent example of what was termed this “political vendetta” was the July publication, during the latest Israeli assault on Gaza, of an “Open letter for the people in Gaza.”2 They wrote that the letter “contains false assertions and unverifiable dishonest ‘facts,’ many of them libellous,” and that its authors had failed to declare possible conflicts of interest. The complaint insisted that the July letter be retracted (disagreeing with the Lancet ombudsman’s decision3) and that it contravened the code of the Committee on Publication Ethics (disagreeing with a former chair of the committee4). It asked for the support of all scientists and clinicians “on whom they [Reed Elsevier] depend for their business,” adding “none of us is under any obligation to submit and review material for publication in their journals or to serve on their editorial or advisory boards.”

An email chain soliciting support for this complaint was more explicit.5 In it Pepys accused the July letter of “viciously attacking Israel with blood libels echoing those used for a thousand years to create anti-Semitic pogroms” and being “written by dedicated Jew haters.” He suggested that the letter “would have made Goebbels proud” and that “anybody who was not a committed anti-Semite would firstly not have published Manduca [lead author of the July letter] and secondly would have retracted instantly when her long track record of blatant anti-Semitism were [sic] exposed.” Two days before the complaint, the title of the email chain was modified to read “DO NOT CITE The Lancet in your work—Their content includes fraudulent data.”6

The July letter included a UN estimate of the number of Gazan children killed up to that date during the Israeli bombardment,7 which the Pepys email implied was exaggerated. The UN Office for the Coordination of Humanitarian Affairs (OCHA) has estimated the cumulative number of Palestinian children killed during the conflict as 5518; the estimate of Defence for Children International Palestine is 547, around two thirds of whom were aged 12 years or younger.9 A report cited by the Telegraph recorded that 137 children were killed during 15-22 July 2014, including 59 on 20 July, two days before the letter was published.10 Reports on the conflict from OCHA,7 Physicians for Human Rights—Israel,11 B’Tselem,12 and Amnesty International13 all concur that the July letter’s allegations of disproportionality in civilian deaths and injuries and of targeting residential areas, schools, power and water treatment plants, and medical facilities and staff were probably not overstated. None of these humanitarian or human rights organisations imputes a motive regarding these findings. Certainly the outcomes raise issues of adherence to principles of international law and norms of humanity.

Medicine cannot avoid politics

These events raise two issues. The first is the appropriateness of medical journals discussing political issues that have bearing on health, including civilian mortality and morbidity. The Gaza letter in the Lancet provoked a statement from senior editors and presidents of diabetes and endocrinology associations saying that their “journals will refrain from publishing articles addressing political issues that are outside of either research funding or health care delivery.”14 In response, an editorial in the European Journal of Public Health referred to the upstream determinants of patterns of nutrition and physical activity that are driving the diabetes epidemic, quoting Virchow, who taught that “Medicine is a social science and politics is nothing else but medicine on a large scale.”15 The Lancet’s editor, Richard Horton, has transformed it into the leading journal in global health, with politics being intrinsic to many issues that the journal covers. If medical journals are fearful of entering the debate where medicine, politics, and ethics intersect, it is hardly surprising that professional associations are even more reluctant to do so.16 Yet to avoid such debate is to remain obdurately silent in the face of important trends and events that impact negatively on the wellbeing of individuals and groups. Inevitably, controversy will ensue, but this is a healthy aspect of public discourse on political matters.

The second issue is the similarity between this complaint’s attempt to stifle coverage of the conflict in Gaza and previous examples of writing campaigns provoked by articles in medical journals critical of Israeli policies, including allegations of hyperbole, accusations of antisemitism, and threats of boycott.17 18 Criticism of Israel, or more specifically of Israeli government policy, is not ipso facto antisemitic, and to label it as such is a tactic to stifle debate. It is possible to be a non-Jew or Jew (or in the case of one of the authors, Jew-ish19) and to oppose Israeli actions or policies without being antisemitic. One former medical journal editor who has been subjected to such a campaign believes that “the best way to blunt the effectiveness of this type of bullying is to expose it to public scrutiny.”18 This is the purpose of this editorial.

The reports published by the UN and others all point to the need for an independent investigation into the conflict by international teams of humanitarian, arms, and legal experts to determine whether and by whom—from either side of the conflict—violations of international human rights and humanitarian law were committed. The effect of this war on civilian mental health, morale, and assets is magnified by the cumulative burden of still destroyed houses and livelihoods dating from previous conflicts. As a deputy editor of The BMJ has pointed out, “Future generations will judge the journal harshly if we avert our gaze from the medical consequences of what is happening to the occupants of the Palestinian territories and to the Israelis next door.”20


Re: Politics, medical journals, the medical profession and the Israel lobby

The heavy-handed attempt by Pepys et al to force The Lancet to withdraw the Open Letter is better understood as part of a pattern, one that extends well beyond medical journals and even beyond the media.

Two further examples must suffice, but there are many more. In summer 2014, sparked by the events in Gaza (as was the Open Letter) the well-respected Tricycle Theatre in North London asked the Jewish Film Festival which it was due to host not to accept financial support provided by the Israeli Embassy. (The Tricycle offered to make good the short-fall.) The theatre’s grounds for the request was that it felt that to accept such funding in current circumstances would be to compromise its political neutrality in a highly charged situation. A public campaign against Tricycle was launched by a pro-Israeli group Campaign Against Antisemitism, leading to threats of withdrawal by funders and to statements by politicians including the then Culture Secretary Sajid Javid linking the decision to antisemitism. The Jewish Chronicle reported that it was a joint intervention by Javid and the Ambassador Daniel Taub which resulted in the Tricycle capitulating.

Still more recently the same pattern has affected academia. In April an international conference on International Law and the State of Israel: Legitimacy, Responsibility and Exceptionalism due to be held at the University of Southampton was cancelled at short notice by the University. Its distinguished organising committee included two Southampton Professors, one Israeli and the other Palestinian. The cancellation followed a campaign by pro-Israel groups, leading to criticism by two cabinet ministers, one of whom called it “an anti-Israel hate-fest”.

In all three cases – the Lancet, the arts and the universities – there is a common theme: the attempt to selectively curtail the range of views that may be expressed. The shared modus operandi has been to suppress criticism of Israel’s actions and policies by alleging an antisemitic bias. Those who care about the freedom of expression should be concerned. Those who care about real, as opposed to confected, antisemitism should be concerned about the devaluation of its currency through misuse.

A response and challenge to Pepys et al

As one of the signatories of the Manduca et al letter I wish to respond to the attack by Pepys et al and to issue a challenge.
An early indication that the Pepys et al document is simply an indiscriminate smear letter is the inclusion of entirely irrelevant material - the Lancet publication of the Wakefield MMR paper 17 years ago, the reference to what one signatory might have said in a talk somewhere, what Internet material another signatory might have looked at etc.
Our case rests on the substantive evidence base from a range of international and regional human rights and documentation centres generated by Operation Protective Edge and precedent events like the long-running seige of Gaza. The pitiless bombardment and mass killing of a helpless, trapped civilian population (including the bombing of 7 well-flagged UN schools serving as emergency shelters, leaving 271 civilians dead and injured here alone, the killing of hospital patients in their beds and of health professionals on duty) is at the centre of all these accounts. Pepys et al cannot be unaware of this evidence base but they ignore it entirely. I cite just one example, an independent medical fact-finding report organised by Physicians for Human Rights-Israel and other reputable documentation centres. (1)
A blithe detachment from the human costs of Operation Protective Edge, and the medical ethical issues thrown up, was there from the start. Sir Mark Pepys was quoted in the Telegraph of 22 September 2014 as saying on 29 August, at the height of the bombardment, that the Manduca et al authors were displaying "most serious, unprofessional and unethical errors". Not a word about events on the ground in Gaza, yet these were the events which even then the UN, Amnesty International and Human Rights Watch were all recording as prima facie evidence of war crimes!
Since then The International Criminal Court has opened a preliminary examination of war crimes violations during Operation Protective Edge.
I would suggest that if a letter of protest with exactly the same contents had appeared in The Lancet, but where the State concerned was, say, Sudan or Syria, Pepys et al would have no reason to see as it as objectionable or as inappropriate material for a medical journal, and might well have applauded such coverage- after all, the medical profession has a duty to individual patients, but also a generally recognised wider ethical duty to address the social origins of distress and disease. So how are we to understand the apparent exceptionalism displayed here? In his classic work "Phenomenology of Sociopolitical Actions: A Methodological Approach to Conflict", the sociologist Max Weber distinguished between an "ethic of responsibility" and an "ethic of conviction". By "ethic of responsibility", Weber meant conformity to professional standards and accountability. In our profession this means the ethical standards by which doctors should practice, including a commitment to factual evidence - standards determined by their peers, employers, the General Medical Council and, on the international scene, by the World Medical Association. By "ethic of conviction", Weber was identifying actions that were inspired by personally valued ideals, political or other philosophies, or identities. In my 29 years of conflict-related human rights work (23 on Israel-Palestine), I have witnessed how regularly an ethic of conviction trumps an ethic of responsibility, not least amongst doctors, and this is sadly true of you too. Pepys et al seem united around a felt connection with Israel and a wish to defend it, and this is what counts for them. In the service of this they can dismiss war crimes, seek to bludgeon a medical journal into silence, and demand that a letter grounded on so multiply documented an evidence base be retracted. This is a flagrant abuse of medical ethics. They write as if they had the moral clarity and duty to speak out that would attach to, say, the discovery of research fraud in a published paper, and the further discovery that the editor of the journal concerned had been in knowing collusion with this fraud! Indeed this is precisely what they are alleging.
Those signatories who are Israeli are in support of the state of which they are citizens; the majority of signatories who reside elsewhere are serving the propaganda interests of a foreign power.
The allegations by Pepys et al are defamatory and libellous: that we published "deliberately inflammatory falsehoods....abusive dishonesty.....unverifiable dishonest 'facts'.....malignant wilful disregard of honest and ethical medical authorship and editorship.....under the direction of Horton, The Lancet has become a vehicle for publication of deliberately false material..." So we - both authors and editor - are publishing lies which we know to be lies in a famous international medical journal? Few allegations made against a doctor could be much graver than this. Moreover, there is the assertion that our motivation is racist: as Yudkin and Leaning note, in an email chain soliciting support for this action, Pepys writes that the Manduca et al letter was "written by dedicated Jew haters...(who) would have made Goebbels proud".
I quote from the GMC publication Good Medical Practice (2006). In the section on Working with colleagues, doctors must "respect the skills and contributions of your colleagues" (para 41); "you must treat your colleagues fairly and with respect. You must not bully or harass them or unfairly discriminate against them by allowing your personal views to affect adversely your professional relationship with them. You should challenge colleagues if their behaviour does not comply with this guidance" (para 46); "you must not make malicious and unfounded criticisms of colleagues that may undermine patients' trust in the care or treatment they receive, or in the judgement of those treating them" (para 47). In the section on Probity, the GMC says that "probity means being honest and trustworthy, and acting with integrity: this is at the
heart of medical professionalism" (para 56); "you must make sure that your conduct at all times justifies your patients' trust in you and the public's trust in the profession" (para 57). In the section on Writing reports, giving evidence etc, the GMC says that "you must do your best to make sure that any documents you write or sign are not false or misleading. This means that you must take reasonable steps to verify the information in the documents, and that you must not deliberately leave out relevant information" (para 65); must be honest in all your spoken and written statements. You must make clear the limits of your knowledge or competence" (para 67).
As one of the signatories whose academic reputation Pepys et al seek to blacken, I am an involved party and I challenge them to justify their allegations evidentially or retract them. I have already written directly to them, so this is the second call. If Pepys et al fail to retract by the end of May, I and others will look to appropriate action, starting with a formal complaint to the General Medical Council.
1. Gaza 2014. Findings of an independent medical fact-finding mission. Physicians for Human Rights-Israel, Al Mezan Center for Human Rights-Gaza, Gaza Community Mental Health Programme, Palestinian Centre for Human Rights-Gaza.
Competing interests: I have been involved in academic, human rights and medical ethical issues in Israel-Palestine since 1992.
14 May 2015
Derek A Summerfield
Consultant Psychiatrist/Hon Sen Lecturer
Institute of Psychiatry, King's College




Page last updated May 18, 2015