Artificial intelligence (AI) is rapidly transforming pre-hospital emergency medicine (PHEM). In Israel, systems already deployed at Magen David Adom and hospitals such as Sheba Medical Center, Ichilov Hospital, and Barzilai Medical Center demonstrate AI’s potential to improve triage, despatch, and emergency preparedness. Yet, this accelerated adoption has outpaced ethical, legal, and institutional safeguards. This commentary analyses the governance challenges of AI in Israeli PHEM — focusing on informed consent, data ownership, bias, liability, oversight, and public trust — and proposes practical recommendations for responsible implementation.

Six critical gaps are identified: (1) absence of patient-centred consent mechanisms; (2) fragmented data ownership and vendor dependence; (3) lack of equity audits; (4) unresolved liability standards; (5) insufficient institutional oversight; and (6) limited public consultation. These gaps pose immediate risks for patients and long-term threats to trust and legitimacy. To address these challenges, we propose the establishment of AI ethics committees, transparent consent protocols, a national data governance framework, mandatory fairness audits, clarified liability rules, and structured public engagement. Israel’s experience underscores the need to build ethical frameworks in parallel with technological innovation, offering lessons for other healthcare systems seeking to balance innovation with accountability and patient rights.