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Jan-Mar2003-11(1)
INTERNATIONAL ETHICS
Recommendations concerning human
rights for the medical profession
Ann Sommerville
In 2001, the British Medical Association (BMA)
launched its third and by far its most ambitious report on medicine and human
rights. (1) The report lists 76 recommendations, covering issues from ethics
teaching and research to the involvement of doctors in weapons' development and
international justice. The association spent four years collecting a massive
amount of evidence to capture a sense of how human rights affect doctors
worldwide.
One key recommendation is that the medical
profession needs to be sensitive to the routine infringements of human rights
that occur to some degree in almost every society as well as to the gross
violations. The latest report, therefore, is not just about the medical role in
torture, capital and corporal punishments or medical neglect in prisons. It also
carries recommendations about how the profession can attempt to diminish a range
of abusive practices against institutionalised people and marginalised
populations. It also considers issues such as female infanticide, coerced
abortion, "honour killings", child labour, prostitution, people trafficking,
domestic violence and attacks on detained women and children. In many of these
violations of human rights, healthcare professionals are not directly involved
but as witnesses and care providers can draw them to public attention and be
very influential in changing societal attitudes.
The BMA's general recommendation in this
context is: "Doctors and professional medical organisations can have a profound
influence on attitudes and prejudices within the communities in which they
work.Compliance with practices that help promote inequality and disadvantaging
of girl children, for example, will be seen as endorsement of the attitudes that
underpin them. Medical education must raise awareness of the possibilities for
influencing society in a positive direction and reducing unfair gender
discrimination." (2)
The report seeks to provide practical advice and to
encourage health professionals to pre-empt rather than simply respond to
violations of human rights by identifying early indicators of a potential for
abuse. In closed institutions, for example, health professionals are among the
first to encounter evidence of human rights violations. They also have
opportunities to see abusive situations developing as they are often the only
"outsiders" visiting prisons, police stations and residential institutions for
children, the elderly or people with disabilities. The report recommends that
they familiarise themselves with best practice in order to be able to recognise
the absence of effective safeguards to prevent brutality in such situations. In
many situations, however, health workers have little room to manoeuvre. When
they protest, they often find themselves victimised or ostracised. They may face
pressure from the police and the political hierarchy to keep quiet about
evidence of human rights violations. They may also face pressure from the
victim's family who fear reprisals. This does not mean that they can ignore
abuse but they may need to think laterally about how to protest effectively. One
of the most damaging aspects of many abuses is that individuals caught up in
them feel isolated and unsupported. The desirability of network building across
traditional professional boundaries, involving health workers, lawyers, human
rights activists and the responsible media, is a recommendation running through
all the chapters of the report. Another concerns the obligations of professional
organisations to support their own members as well as colleagues in other
countries where human rights are under attack.
The BMA is a voluntary professional organisation
representing the interests of doctors in Britain. Its policies and priorities
are determined by its members at annual meetings, many of which have shown a
continuing preoccupation with issues of human rights, social justice and the
poor health of marginalised populations. The view, argued in this and previous
BMA reports, is that such issues form natural and correct areas of concern for
the medical profession and professional organisations. The latest report shows
how doctors deal with challenges to well-established ethical principles that
also happen to coincide with fundamental principles of human rights.
Nevertheless, little of the information in the
latest BMA report is surprising. Medical human rights groups around the world
have a good record of monitoring human rights. The BMA report pulls together
many strands, including documented case histories, evidence from doctors, ideas
for strategies to deal with abuse and solid ethical and public health arguments
for getting involved in human rights from medical school onwards.
Professionals such as doctors, lawyers and
academics, because of their education and earning power, can often exercise an
influence over the values of the societies in which they work. One of the key
recommendations of the report is that where they can have an influence, they
should use it positively. Many human rights abuses are tacitly tolerated because
they focus on an unpopular victim group portrayed as undeserving of sympathy -
prisoners, criminals, street children, ethnic or religious minorities and
political dissidents. By co-ordinated action through their professional bodies,
health professionals can try to change societal attitudes that discriminate
against certain marginalised groups and permit harmful practices to flourish.
They cannot stop violence against such populations or religious groups or
against women and children but they can show how discrimination impairs people's
health, impacts badly on public health and undermines respect for the society
that tolerates them.
Among other things, the BMA's report looks at how
human rights violations may result from an accumulation of many small acts or
omissions by people who should protest but for a variety of reasons fail to do
so. Fear may prevent them but often it is more mundane than that. Doctors - like
anyone else - often just want to concentrate on doing their job, turn a blind
eye to things they would rather not see and persuade themselves that they are
not the real wrongdoers even if they go along with a flawed or corrupt system.
Rather than acknowledging that their own failure to act in defence of basic
rights contributes to the chain of abuse, they may reassure themselves with the
excuse that their small part in the process is insignificant.
One problem, therefore, is how to convince doctors
and medical organisations of the relevance of human rights to their own work by
showing how their inaction can allow abuse to happen under their noses. Health
professionals see their role as predominantly being humanitarian service
providers. In the past, few health organisations have envisaged their role as
encompassing a socio-political dimension which could address the root causes of
human rights violations. This has begun to change, however. The recently updated
Code of Medical Ethics from the Medical Council of India (3), for example, now
mentions human rights as well as ethical duties. In many countries, there is
growing evidence of a willingness within medical bodies to become involved in
political action and education. Frequently, this involves working with
politically outspoken non-governmental organisations, including those involved
in human rights, redress, refugee welfare and prison reform.
An argument in favour of medical organisations
becoming involved in human rights is the fact that they exist to serve the
interests of the medical profession. Prominent among those interests must be the
preservation of the honour and high ideals traditionally associated with
medicine. Therefore, the BMA has long argued that raising awareness of human
rights is a key duty of professional bodies and that this duty fits well with
the role of providing guidance on professional ethics.
For over 50 years, the BMA argued that:
'Doctors must be quick to point out to their fellow members of society the
likely consequences of policies that degrade or deny fundamental human rights.
The profession must be vigilant to observe and to combat developments which
might ensnare its members and debase the high purpose of its ideals." (4)
Public health concerns are another argument for
such involvement. Some medical organisations are increasingly showing interest
in human rights where there are clear public health consequences, such as when
people are likely to be left dependent and disabled. Some are taking action to
try abolish practices such as the flogging of prisoners, judicial amputation and
sale of organs. Practices such as female infanticide and restrictions on the
education of females also impact directly on the health and balance of society.
Moving from documenting abuse to seeking practical safeguards to minimise it,
medical organisations are increasingly identifying a humanitarian and public
health role which coincides with the protection of human rights. Nevertheless,
there is no room for complacency and it is still far from easy to mobilise the
profession to take up the health challenges that arise from persistent violation
of human rights.
More generally, the way in which such challenges
are addressed is changing. Effective interchange between different disciplines
on human rights issues is developing rapidly as e-mail and the Internet
facilitate projects involving a range of specialists around the globe. Lawyers,
journalists, medical groups and human rights organisations have more
opportunities than ever to co-ordinate their campaigns and information
gathering. Frameworks for co-operation already exist but they have been
developing in a piecemeal fashion. Too often different professionals still work
on parallel, rather than intersecting lines, without pooling acquired expertise.
Individuals and organisations still invest time and effort in reinventing action
programmes that have already been tried out elsewhere. Where strategies have
proved successful in one context, information about them needs to be shared with
others facing similar human rights challenges.
Finally, the report also calls for more
multi-professional discussion about the development of proactive measures to
give some advance protection to those who are most likely to witness evidence of
human rights violations. Disseminating information about abuse is no longer
enough. Practical measures are needed for moving the debate forward. The BMA is
well aware that recommendations alone change nothing and that by far the harder
task lies in pressing for their implementation.
References:
1. BMA. The Medical Profession & Human
Rights: handbook for a changing agenda, Zed books, 2001. 2. Recommendation 48,
p.530.
3. MCI. Indian Medical Council (Professional Conduct, Etiquette and Ethics) Regulations, 2002. Gazette of India dated 06.04.02, part III, section 4.
4. Statement published by the BMA Council in 1947. Quoted in the Introduction to the BMA report, p.xix.
3. MCI. Indian Medical Council (Professional Conduct, Etiquette and Ethics) Regulations, 2002. Gazette of India dated 06.04.02, part III, section 4.
4. Statement published by the BMA Council in 1947. Quoted in the Introduction to the BMA report, p.xix.
Ann Sommerville,
British Medical Association, BMA House, Tavistock Square, London WC1H 9JR, UK.
Email:asommerville@bma.org.uk