A research study on Genocide in Gaza
In the chaos of conflict zones like Gaza, medical research ethics faces unprecedented challenges (Bruno and Haar Citation2020; Chiumento et al. Citation2016; Sen, Hussain, and Al-Faisal Citation2016). The traditional pillars of informed consent and institutional review boards (IRB) oversight often crumble under the weight of humanitarian crises, delaying data collection essential for care and the research that underpins it. This commentary builds on initiatives for an adaptive model: verbal consent in lieu of written forms, active partnerships with local medical staff, the suspension of requiring automatic prospective registration in emergencies, and oversight committees blending local and international expertise whenever needed to monitor and guide research. Grounded in international legal precedents like the Fourth Geneva Convention and the ICCPR, this working model balances the urgency of life-saving research with the need for ethical accountability. Safeguards such as anonymized data, community engagement, and retrospective reviews ensure integrity while enabling essential studies on paediatric health, maternal mortality, and public health crises. Medical research ethics must evolve to remain relevant by prioritizing adaptive models over rigid standards to meet the urgent needs of populations in conflict zones.
This is the reality in Gaza: where bombs fall as often as the need arises for granular medical data to inform humanitarian responses, traditional safeguards, particularly for paediatric research, have become impossible. Informed consent and IRBs have become roadblocks. In such situations, there must be a willingness to temporarily waive or reconfigure adherence to traditional, Western-based, research ethical norms. Alternative, non-Western ethical frameworks exist including those grounded in Islamic bioethics, Confucian ethics in parts of East Asia, and community-based consent practices common in many parts of the world including regions of sub-Saharan Africa may be relevant. These emphasize variations on communal welfare, verbal consent processes, and contextually relevant safeguards that may be tailored to local cultural and religious contexts.
The context in Gaza
The Ministry of Health (MoH) in Gaza is a shattered, partly functional, entity due to the constant aerial bombardment and targeting of healthcare workers in the Strip (Ahmed Citation2023). Article 18 of the Fourth Geneva Convention clearly states that ‘civilian hospitals organized to give care to the wounded […] may in no circumstances be the object of attack’ (“Convention (IV) Relative to the Protection of Civilian Persons in Time of War. Geneva, 12 August 1949” Citation2024). Article 8(2)(b)(ix) of the Rome Statute of the International Criminal Court similarly defines intentional attacks against hospitals as a war crime (Citation2024). These legal instruments lay bare the severity and illegality of attacks against medical infrastructure and personnel under international law; they also illustrate the extreme circumstances that hinder the ability of institutions to carry out standard ethical oversight. Such destruction directly impacts the functioning of IRBs, and the ability to obtain informed consent and maintain compliance with traditional research ethics norms, thus necessitating modified procedures.
One example of how difficult it can be in Gaza is described by Alser et al. in the The Lancet. Their proposal was to deliver trauma care through global telemedical efforts. This was unable to receive approval for nearly 6 months. The lead author of the paper was abducted by the IDF and held in detention under conditions of severe abuse for much of the year, and the head of the relevant Helsinki Committee (which oversees ethical guidelines) was trapped in northern Gaza under siege and heavy bombardment (Alser et al. Citation2024). After direct communication was re-established, an emergency IRB was issued given the exceptional circumstances (“Israel Releases Palestinian Dr. Khaled Alser, Half a Year After Abducting Him from Gaza Hospital” Citation2024).
Another example is when the quantity or scope of certain medications that are needed can be reasonably informed by the nature of the cases that are seen in the clinic (Irfan, Lulu, et al. Citation2024; Irfan, Sultan, et al. Citation2024). Identifying prevalent antibiotic-resistant bacterial strains from clinical cases in Gaza could quickly inform medical NGOs as to the appropriate antibiotic supplies needed for urgent medical missions. While quality improvement initiatives can facilitate rapid local changes without formal IRB approvals, a structured ethical review may be requested for broader dissemination of findings for international coordination and supply logistics, when an expedited process is clearly needed.
International guidelines for adapting to conflict situations
It can be a slippery slope, as relaxing ethical standards can set dangerous precedents (“Research in Conflict Zones: Ethics and Accountability” Citation2024). Entirely valid concerns about protection for research participants have to be weighed against protecting lives through research and knowledge generation (Ford et al. Citation2009); inaction due to long waiting times for IRB approvals may prolong preventable suffering. Verbal consent, for example, is often allowed in conflict situations while continuing to anonymize data, allowing research to continue justified by its importance for public health.
The need for paediatric research in Gaza is immense. Malnutrition, trauma and infectious diseases plague children in ways that will echo for generations. Verbal consent becomes a pragmatic necessity, though it feels like a compromise. To this effect, the international legal community established precedents for modified consent procedures in crisis situations.
Various guidelines have been developed to allow research to continue in conflict situations. The WHO’s 2020 Guidance for Research Ethics Committees for Rapid Review of Research During Public-Health Emergencies activates an ‘emergency mode’ as soon as a national authority declares an outbreak (“Guidance for Research Ethics Committees for Rapid Review of Research During Public Health Emergencies” Citation2020). Protocols must be emailed to reviewers within 24 hours; reviewers complete their assessments in 3 days; and a consolidated decision is returned to researchers within 5 days, allowing the core deliberation to occur in a 24- to 72-hour window. This guidance also allows a pre-identified quorum of one-third of committee members (meeting virtually) to replace a full-board meeting whenever further delay threatens public health, establishing a clear normative precedent for rapid ethics review in Gaza.
Médecins Sans Frontière produced a Research Ethics Framework in 2013 which creates a dedicated track for ‘emergency research’, studies that carry more than minimal risk yet are ‘urgent and time-sensitive’ (Board, MSF Ethics Review Citation2013). In this case the Ethics Review Board can pre-approve a generic template in peacetime and, when a crisis occurs, activate an expedited review handled by the chair plus any two members, with a turnaround time of 48 hours from submission to decision. All other MSF standards (independent scrutiny, risk-benefit assessment, local collaboration) remain in force, but the streamlined quorum ensures that life-saving studies are not held up by the need for a full-board meeting.
Legal and normative foundations for adaptive research protocols
New guidelines are supported by international legal frameworks that recognize special circumstances in conflict zones. The Fourth Geneva Convention, while emphasizing protection of civilian populations, includes provisions for modified protocols during active violence. Although the Geneva Conventions do not explicitly define research protocols, they establish guidelines allowing modifications to standard humanitarian and medical procedures, including those related to obtaining consent, treatment documentation, and ethical oversight. Israel’s decimation of civil and medical infrastructure in Gaza satisfies the need for such modified protocols. Similarly, the International Covenant on Civil and Political Rights (ICCPR), an internationally binding legal document, recognizes that ‘in times of public emergency which threatens the life of the nation’, measures that diverge from the standard can be taken as long as they are consistent with other obligations of law (“International Covenant on Civil and Political Rights” Citation2024). This includes deviations related to informed consent and IRB oversight and legally supports the adaptation of research ethics protocols during humanitarian crises such as the Gaza conflict.
Although not necessarily binding in this conflict, Article 8 of the European Convention on Human Rights and Biomedicine recognizes that while informed consent remains fundamental, its implementation should be adapted in emergency situations to ‘the benefit of the health of the individual’ (“Convention for the Protection of Human Rights and Dignity of the Human Being with Regard to the Application of Biology and Medicine: Convention on Human Rights and Biomedicine” Citation1997). The World Medical Association’s Declaration of Helsinki also acknowledges that while they posit ethical principles as being globally relevant, their application may need to be locally contextualized, especially during a crisis (“WMA – The World Medical Association-Declaration of Helsinki” Citation2024). The protection for human subjects outlined by the U.S. Department for Health and Human Services already recognizes that certain situations allow for consent exceptions.
Experience to date: how high is the ethical bar and for whom?
The most systematic audit to date of ethics practice in conflict scholarship, Ataullahjan et al.’s Citation2022 scoping review of 498 peer-reviewed studies on refugees and war-affected civilians, illustrates how lenient the ethical bar has actually become in practice (Ataullahjan et al. Citation2022). Authors of only 48.2% of papers said they had obtained ethics-committee approval (a further 2.4% reported a waiver) and just 46.6% documented any form of informed consent. Among the 236 articles whose authors gave no information on ethical approval, 88.5% still appeared in journals whose author guidelines require such reporting, showing that editorial enforcement is largely symbolic or context-dependent. Ethical reporting was poorest when the lead investigators were affiliated with universities outside the study country: international teams disclosed ethics clearance in just 43% of cases, versus 87% for studies led by national institutions, reviving long-standing worries about double standards in ‘parachute research’. The same review found that of 32 guidance documents issued by UN agencies, major donors, and conflict-affected governments and mentioned in the articles, 87.5% didn’t mention war-displaced populations, and only one guideline (Australia’s National Statement) addressed the practical complexities of consent or researcher safety in violent settings.
Shanks and Paulson’s (Citation2022) review of the ethical research landscapes in fragile states shows that most misconduct originates well before an interviewer meets a participant: funding calls framed in London or Washington predetermine ‘what is research-worthy’, procurement rules lock Southern partners into subordinate roles, and university due-diligence or reimbursement systems transfer financial risk to local scholars (Shanks and Paulson Citation2022). Drawing on workshops with 109 researchers from Iraq, Colombia, Jordan, and Bangladesh, the authors document how these upstream choices cascade into what they term ‘ethics-dumping’: Northern teams parachute in for rapid data harvests, rely on fixers who reproduce local power imbalances, and leave without translating findings or validating them with participants. This is precisely what unfolded after Mosul’s 2017 liberation. Because standard research ethics committee (REC) or IRB reviews focus almost exclusively on data-collection minutiae, they rarely detect these systemic harms; ethical accountability, Shanks and Paulson argue, must therefore span ‘the entire ecosystem of a research project’, from agenda-setting and partnership contracts to authorship and open access.
The above studies confirm that the scholarly ecosystem routinely tolerates minimal ethics documentation for conflict research, making the stringent demands now imposed on Gaza-based investigators an anomalous, and arguably politicized, intransigence rather than the norm. They also underscore that rapid, context-sensitive oversight mechanisms are not a dilution of standards but a necessary corrective to the prevailing vacuum. This reinforces our contention that Gaza’s scholars are being asked to clear a procedural bar that most conflict-zone research elsewhere, often celebrated and published without such scrutiny, has never met.
The collection of data regarding the health crisis in Gaza, and its dissemination in research has been viewed by many Palestinian scholars as an act of resistance in of itself. Recent evidence from another active-war setting showcases how ethical inquiry itself can become an act of civic resistance (Alamrain and Irfan Citation2025). In a 2025 mixed-methods study of 120 survey respondents and 10 in-depth interviews from 41 Ukrainian universities, Kushnir and Zabolotna found that ethical research is consciously framed by scholars as ‘a practice of freedom’, a way of defending the academy against Russian aggression and a culture of top-down control (Kushnir and Zabolotna Citation2025). Although only 60% of institutions had formal mechanisms for handling ethical dilemmas and barely half offered any well-being support, 71.7% still managed to provide resources for ethical decision-making, and researchers interpreted those fledgling structures as symbols of national resilience. The authors show that even skeletal oversight, often improvised because ethics committees are dormant or focus solely on plagiarism, can catalyse a bottom-up ethic of care when it is linked to internationally recognized benchmarks such as the BERA (Ethical Guidelines for Educational Research) Guidelines. The Ukrainian case demonstrates that in war zones the pursuit of rigorous ethics is not a luxury but a strategic assertion of autonomy and legitimacy, reinforcing an argument that adaptive yet principled review processes in Gaza would strengthen, rather than weaken, local scholarly self-determination.
Barriers to research ethics implementation in Gaza
At the time of writing, there are a few hospitals partially operational left in Gaza where 36 existed before October 2023 (“UN Commission Finds War Crimes and Crimes against Humanity in Israeli Attacks on Gaza Health Facilities and Treatment of Detainees, Hostages” Citation2024). Medical staff struggle to oversee data collection and keep hospitals running with limited infrastructure and resources, and to maintain coordination with the WHO, leaving research ethics and committees to take a backseat. The standard guideline of prospective registration with the MoH and Helsinki committees can be difficult, as both organizations suspended certain operations at times during 2024 (Alser et al. Citation2024). In fact, many specialists and faculty who oversaw such measures have now been killed alongside the destruction of every university in the Strip (Human Rights Watch” Citation2024; “UN Experts Deeply Concerned over ‘Scholasticide’ in Gaza” Citation2024).
Previously, clinical research primarily had to go through the local Helsinki Committee (the commonly used name in Palestine for institutional review boards responsible for research ethics approval), which consisted of a group of independent researchers with some affiliation potentially to the MoH. It required a local principal investigator affiliated with a local university to receive IRB approval. In the past year, a myriad of papers have been published on Gaza utilizing a variety of consent/ethics approval processes. These include citing the operations of visiting medical NGOs as broad-spanning agreements for data collection with the MoH that existed prior to the war, approval from local Gaza-based universities, IRB approval from a foreign-based university, recognition directly by the MoH, communication and approval from local medical staff and directors at a given hospital, and/or research subjects themselves, to name but a few (Aldabbour et al. Citation2024; Alser et al. Citation2024; Irfan, Abu Shammala, et al. Citation2024; Nasser et al. Citation2024).
The informed consent process, a cornerstone of research ethics, is fraught with pragmatic obstacles when attempting to collect pertinent medical data for research purposes in Gaza. Patients in Gaza frequently present with severe trauma causing acute disabilities, such as substantial visual impairment, loss of limbs, or impaired consciousness due to maxillofacial or neurological injuries, making standard written consent impractical in time-sensitive clinical scenarios. The rapid and fluid context presents unique, immediate logistical barriers necessitating alternative consent methods. Patients are on the move, fleeing airstrikes and guardians are lost or deceased. How does one obtain written consent from a parent who is buried under rubble?
As medical staff in Gaza and visiting international healthcare workers have witnessed first-hand, consent for children is at times obtained from whoever happened to accompany this person to the hospital, regardless of any relationship. Sometimes even that cannot be obtained due to maxillofacial trauma and/or orthopedic/plastic injuries rendering communication with the patient or presumed guardian futile, or patients who have died but whose cases may still need to be reported on. Weighed against the alternative – no research to improve interventions – it is an ethical compromise that one must be willing to make in partnership with the affected community.
As in many other conflict situations, the current research paradigm in Gaza is largely centred around documenting the health crisis and informing policy interventions. This includes noting the harsh reality of paediatric and maternal mortality, trends in acute care and evacuation needs, assessing the most useful medications for infection risks and determining how to mitigate suffering in real-time. To insist on demanding the same standards required for peacetime research may risk prioritizing standards over people. The Islamic tradition places an emphasis on the presence of a specific number of witnesses when making certain verbal contracts like a nikah (marriage) or financial transactions, or the use of darura (necessity) to inform practice, which may provide inspiration for some healthcare workers attempting to delineate some safeguards or structure (‘المصنف لابن أبي شيبة’ Citation2024; Alfahmi Citation2022; Esposito Citation2003; ‘Surah Al-Baqarah − 282’ Citation2024).
A further, often invisible, obstacle is the weaponization of Gaza-derived datasets in the international arena. Israeli and U.S. officials have repeatedly cast doubt on any number that originates with the Gaza Ministry of Health: President Biden said he had ‘no confidence’ in the Ministry’s fatality ledger and White House spokesman John Kirby urged reporters not to take the figures ‘at face value’ (Reuters Citation2023; Sawafta, Fick, and Fick Citation2023; Serhan Citation2023). Such scepticism is then amplified in the media, accusing the Ministry of Health of ‘fabricating’ thousands of child deaths (Peyser Citation2025). This is despite numerous studies showing the death toll has not been inflated and in fact has been undercounted; this is the double-edged sword of data collection and availability which both defends and criminalizes the Palestinian healthcare system (Huynh, Chin, and Spiegel Citation2024; Jamaluddine et al. Citation2025). Parallel narratives from the Israeli military portray Gaza’s hospitals as dual-use ‘command centres’, leading to armed raids, prolonged closures, and the arrest of senior clinicians such as Al-Shifa’s medical director, Dr Mohammed Abu Salmiya, who was held for 7 months before being released without charge. Each public challenge, detention or raid signals to editors, funders, and even ethics boards that every Palestinian data point is politically suspect and that those who collect it may be subject to attacks rather than recognized in their role as caregivers or researchers.
Inside Gaza, this climate has immediate chilling effects. Hospital teams have shared that trauma registries and antibiotic-resistance surveying has sometimes been left unfinished because a single transcription error, once seized upon by hostile commentators, could be spun as proof that ‘terrorist doctors’ are inflating the crisis. International collaborators, meanwhile, sometimes delay research submissions for fear that an over-burdened IRB will miss a minor formatting irregularity or leave unfinished a procedural review that critics could weaponize. We are personally aware of several single and multi-centre studies, ranging from neonatal health, dialysis interruptions, burn mortality, orthopaedic injury patterns, post-amputation outcomes, and a range of other health metrics, that have remained unpublished for months not for lack of data but because the authors are triple-checking every spreadsheet against the possibility of politically motivated ‘fraud’ allegations. Furthermore, delays or an inability to receive an ethics review and approval has made many Palestinian and international authors delay submitting their research. The result is a perverse inversion of research ethics: hyper-diligence meant to protect investigators from defamation slows the very evidence-generation needed to protect patients. Adaptive frameworks for Gaza could therefore include protective measures, anonymous author options, secure data repositories, and rapid third-party verification, to insulate healthcare workers from the reputational and physical risks created when medical statistics become a battlefield narrative.
Proposing an adaptive framework
As above, relaxing research ethics protocols for conflict-based research raises valid concerns and the possibility of abuse. Vulnerable populations are, by definition, at risk of exploitation (Gordon Citation2020), for example desperation might compel people to agree to studies without fully understanding the risks. Oversight, even in crisis, is critical and verbal consent should not mean coercion. Independent audits by a specialized committee of the WHO to address this, anonymized data, and community engagement are possible safeguards. Involving local healthcare workers and community members is essential to inform interventions based on the voices of people who understand the context better than outside observers. Even with the destruction of universities and hospitals, and the killings of specialists, medical staff remain in hospitals who should be consulted as active collaborators in research endeavours in the Gaza Strip. Research must remain grounded in the reality of Gaza’s complexity.
The utilitarian argument is important. Public health crises demand data without which resources cannot be efficiently allocated, interventions prepared and lives saved. Data is needed for medical missions to decide which medications they need to take. Research in Gaza seeks to aid the survival of the besieged Palestinian population. To delay research because IRBs are no longer in commission or because written consent is unattainable is a moral failing in and of itself. Beneficence and justice demand action. The moral rigidity and silence of the global bioethics community in relation to research in Gaza is deafening.
Some ethics are accepted as holding global legitimacy, but this is contradicted when they paralyze research in places like Gaza. A malnourished child should not die because every procedural box has not been ticked so as to provide an assessment of the rate of death or disease in a specific area. Hesitancy to embrace the exceptions described above, even when it remains clear that adhering to peacetime norms is impossible, paralyses live-saving research.
Furthermore, it must also be noted that implementing American standards, or that of any singular country, even when visiting physicians serving in Gaza hail from such national backgrounds, may introduce its own set of ethical challenges. The Palestinian Ministry of Health based in the West Bank, which has little de facto oversight in Gaza, a foreign institution, or even an international body and their respective regulatory guidelines, may not be entirely appropriate in a given situation in Gaza.
It is beyond the scope of this commentary to fully address the complexities and practical consequences of rigid research ethics adherence in the face of war. Nor is it possible to propose a comprehensive list of recommendations and guidelines to address the nuance of each unique situation, whether concerning research subjects with limited capacity, special anonymization and data protection, considerations particular to paediatric research, the constraints of limited resources, and many other concerns.
It is worth considering some key broad-based ideas that can help form a functional basis for a working discussion, and perhaps a model, for research standards in conflict zones that would draw on the adapted guidelines and legal underpinning described above. This model and these deliberations would include an emphasis on the following considerations and factors, especially for visiting medical NGOs:
- considering the appropriateness of verbal consent in lieu of written consent
- involving and partnering with local medical staff in research activity
- the foregoing of prospective registration and approval of data collection in certain environments
- an oversight committee with local stakeholders and international support to monitor progress and adherence.
The exact configurations, scope, status, binding nature, and follow-up review protocols are fluid and negotiable aspects of such a model, but these considerations are salient broad-based considerations that could be central in discussions on ethical research conduct, recognizing that every situation is different and may require adaptation.
We do not argue for a free-for-all. There must be boundaries. Expedited ethics review processes, led by international bodies when local systems are incapacitated, but with the involvement of subject-area experts and leveraging local expertise, could offer a way forward (Figure 1). It is important to attempt to avoid circumventing the authority and jurisdiction of local healthcare workers and systems such as the MoH, even if partially operational, in the implementation of any amendments to research protocols. This can aid in ensuring compliance and respect for local customs, regulations, and needs. We recognize also that this view is not without contention, even from other physicians in Gaza who have expressed hesitancy to amending standard operating procedures for research protocols and data collection. Such disagreement should be respected and can be used as a basis for further collaborative discussion.
Conclusion
We argue that verbal consent should be enough when written forms are unattainable. Data anonymization must be non-negotiable, especially given the risks of retaliation to those involved in research. And we must remain accountable to the principles of governing international laws and protocols, with retrospective reviews of our processes to ensure that even in crisis, our moral compass holds steady. Research ethics must evolve, or they risk becoming another casualty of war: irrelevant when they are most needed. The greatest ethical failing is inaction, so we must adapt. For Gaza and for every conflict zone where suffering demands solutions, we must do more.
