In October, a video from Gaza began to circulate that horrified the world. It showed an injured teenager lying on a hospital gurney with an intravenous drip in his arm. As flames engulf him, he can do nothing but wave his arms in agony.

The fire that swallowed Shaban al-Dalou in front of our eyes, and that also killed his mother and younger brother and sister, was set off by a bomb dropped by the Israeli army on the courtyard of Al-Aqsa Martyrs Hospital in Deir el-Balah, where he was being treated for injuries sustained when he survived another Israeli bombing. The video of al-Dalou’s death – likened by many observers to atrocity-defining images like the Pulitzer Prize-winning 1972 photograph of nine-year-old Phan Thị Kim Phúc being burned by US napalm in Vietnam – is far from an isolated nightmare.

Various forms of brutal death have taken place thousands of times across Gaza over the past 15 months, often as a result of US weapons provided to Israel by the United States government. These deaths are neither simply individual tragedies nor unintended consequences; they are symptoms of an Israeli strategy of total war and overwhelming horror inflicted against an entire people. This reality, and how we must respond to it, is nowhere clearer than at the ruins of Gaza’s hospitals.

A recent peer-reviewed study, of which one of us is a co-author, examined patterns in Israel’s bombing of the Gaza Strip during the first 40 days after October 7, 2023. It specifically analyses Israeli use of US-supplied Mark-84 bombs (MK-84s) around hospitals, which by international law and basic ethical imperatives, are afforded special protections against acts of war. MK-84s are 2,000-pound (900kg) air-dropped explosives – otherwise known as “bunker busters” – designed to destroy infrastructure and kill human beings within hundreds of metres of where they land. They are weapons of indiscriminate destruction and annihilation, not “targeted strikes” against discrete targets.

Using geospatial data, the study found that Israel dropped MK-84s within blast range of more than 80 percent of hospitals in Gaza in just the first 40 days of its war, including one bomb that was dropped 14.7 metres (48 feet) from a hospital – effectively a direct hit. Many hospitals had not just one but multiple of these massive bombs dropped around them. Two hospitals had more than 20 MK-84 bomb craters within 800 metres (the upper end of the MK-84’s infrastructural damage and serious injury blast range) of their facilities; another hospital had seven bomb craters within 360 metres (MK-84’s lethal range) of its patient wards. Thirty-eight MK-84s were detonated within the range of hospitals inside Israel-defined evacuation zones.

By December 2024, more than 1,000 Palestinian health workers were killed by Israeli attacks and unequivocal evidence shows that not just one but nearly all hospitals in Gaza have been deliberately and repeatedly targeted by the Israeli military armed with US weapons. What was once said to reflect an outrageous and libellous accusation is now taken for granted as a key component of everyday Israeli military conduct.

In May, in an implied recognition of this reality after eight months of watching Israel use thousands of US-supplied bombs to destroy heavily populated areas of Gaza and kill countless civilians, the Biden administration placed a hold on shipment of MK-84s to Israel, sending 500-pound (227kg) bombs instead. Last week, the Trump administration announced it is resuming shipment of MK-84s to Israel without any conditions.

Philosopher Adriana Cavarero has written about such acts of horror through a framework she calls “horrorism”. With this term, she describes a form of impersonal violation rooted in disfiguration – like the burning alive of patients in hospital beds – and massacres, such as those we were witnessing on a daily basis in Gaza. The concept of horrorism demands we approach violence not from the perspective of the perpetrator – as is often done in war – but of the victim. It is only the victim who has the authority to name violence, to decide its meaning and value. The figure of the defenceless victim is most clearly represented for Cavarero by children, such as the thousands of Palestinian children who have been mutilated and killed by Israeli soldiers and US weapons over the last 15 months.

The hope for horrorism as an ethical paradigm is that by displacing preoccupation with “terrorists” and reframing violence through the lens of the most vulnerable, or those most in need of care, we might end the endless-by-design “war on terror” that reproduces horror upon horror for the world’s most dispossessed people, who, unsurprisingly, continue to revolt. In this paradigm, the human effects of violence, not intentions or justifications for it, are all that matter.

As US-based physicians, we have repeatedly called upon our profession – one that claims to be rooted in a commitment to care, human dignity, and the most vulnerable – to change course and to act boldly against violence in Gaza in accordance with our supposed principles. Now, as a tentative ceasefire has been reached, this must include critical retrospection and accountability for our gross ethical and political shortcomings that genocide in Gaza has put on full display.

But we cannot stop at simply rhetoric and moralising self-reflection. We must insist on reparative action, including the release of thousands of Palestinian civilians – including Dr Hussam Abu Safia and many other health workers – taken hostage by Israel, the restoration of the entire territory of the Gaza Strip to the Palestinians, and the payment of reparations by Israel, the US, and European nations that have enabled genocide so as to support the full reconstruction of Gaza, including its homes, hospitals, universities, sanitation infrastructure, and schools that now lie in ruins.

We must also demand an end to Israeli occupation and ongoing violent seizure of Palestinian lands and an embargo on the provision of arms to an Israeli government that has very clearly proven itself willing and eager to use them against civilian populations in violation of international law.

If the US government supports Israeli efforts to occupy Gaza, to force its Palestinian residents into exile, and to refuse Palestinians their rights to return to their land, as we are now seeing early indications of, then we have an obligation to forcefully decry and oppose such crimes. The reality is that the violence against Palestinians has not stopped, and we must not deceive ourselves into thinking that our ethical obligations in relation to it have ended. As we organise with one another to begin the impossible but necessary task of atoning for the violence with which our nation and its medical field have been – and continue to be – complicit, we must own our ethical responsibility to the memory of those who, like Shabaan al-Dalou, have been killed and to those who must now attempt to live in the shadow of immeasurable horror.