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The BMA's special interest in human rights goes back to the 1970s, when resolutions at annual meetings indicated continuing concern about the fate of colleagues and patients in repressive regimes, the denial of adequate healthcare to marginalized populations and other issues of social justice. In 1984 the BMA annual meeting called for a working party to investigate allegations that doctors in some countries were colluding with State torture. Two years later, the first BMA pamphlet on the issue, The Torture Report, found ‘incontrovertible evidence of doctor's involvement in planning and assisting in torture, not only under duress, but also voluntarily as an exercise of the doctor's free will.’ Medical and humanitarian groups began to turn to the BMA with testimonies and appeals. In 1992 a more substantial report Medicine Betrayed was published, broadening the scope to consider also the role of doctors in a range of human rights violations and in judicially sanctioned procedures such as executions and corporal punishment. Now, The Medical Profession and Human Rights1 is more ambitious still, attempting to encompass a yet wider and evolving set of debates, including the question of whether it is useful to consider ‘health’ as a human rights objective, to stimulate cooperation between medical bodies, non-governmental organizations and others who recognize that political and social reform is the best medicine, and to provide practical guidance in areas as varied as protective measures for whistleblowers, ethics training, the medical examination of asylum-seekers and the creation of support systems for prison doctors.
There is a strong chapter on ethics, morals, needs and rights, and how such concepts evolve over time in one society and across cultures. Do some rights matter more than others? As the economist and Nobel laureate Amartya Sen points out, no simple equation can be made about which rights confer most benefit to most people. Intuitively, he says, all societies experience much greater outrage at serious violations of civil and political rights than at neglect of economic, social and cultural rights. Political imprisonment, torture and assassinations seem more shocking and more ‘wrong’ than the failure of States to provide basic means of survival, even though the latter typically causes far greater loss of life. Sen has also shown that no substantial famine has ever occurred in a country with a democratic form of government and a relatively free press.
One recurring criticism of the human rights debate is that it is essentially Eurocentric, based on Western liberal values, and also unduly legalistic. Non-Western cultures frequently embody value systems which are less individualistic and more sociocentric, so that personal liberty is less of an ideal. The fact that judicial punishments such as amputation appear to be based on a country's religious or cultural traditions has sometimes made the international community, including the Red Cross, reluctant to comment on them. Can arguments about cultural relativism legitimately undermine protests by such as the BMA about the sale of organs from executed prisoners in China or the forcible termination of pregnancies?
This leads on to the role of doctors in capital and corporal punishment. Is it possible to set the limits, universally applicable, of acceptable practice? What of the tough choices facing doctors in highly repressive regimes such as Iraq, where in 1994 nearly 100 people per week were recorded as brought to a single hospital for amputation of an ear or branding. If the patient (patient?) could not pay 600 dinars for an anaesthetic, he had to go without. The director of the Al-Basra Hospital and another doctor at the Saddam Hospital were executed for refusing to comply.
Doctors may be drawn into certifying fitness for punishment, monitoring its infliction, training others to do likewise, as well as certifying death afterwards. In Guatemala and the Philippines, following protests by their medical associations, the governments declared that paramedics rather than doctors should administer lethal injections. In the USA concern was expressed when doctors treated a prisoner for a mental illness so that he could be deemed fit for execution. The American Medical Association concluded that ‘testifying as to medical diagnoses as they relate to the legal assessment of competence for execution’ does not constitute participation in execution. This contrasts with the BMA's stance that provision of medical opinion on ‘fitness for execution’ is an inappropriate role for doctors. There is controversy too about the influence of psychiatric opinion as to ‘future dangerousness’ on the sentence handed down, and in particular whether such opinions could incline a court towards a death sentence. In an appeal to the US Supreme Court in 1982 by Thomas Barefoot, a prisoner awaiting execution, the American Psychiatric Association submitted a brief suggesting that assessment of future dangerousness could not be based on expert psychiatric knowledge and lacked scientific validity. The BMA later expressed similar reservations. I hope this will be noted by those in the UK who favour a new category, ‘dangerously severe personality disorder’, in the forthcoming new Mental Health Act as a justification for indeterminate detention in a psychiatric facility.
In a retrospective study in three former Latin-American dictatorships in the early 1990s, Dr Horacio Riquelme found that doctors' interpretations of their ethical obligations varied with their political beliefs and backgrounds. During this oppressive period doctors continued to recognize normal ethical duties such as confidentiality, but medical ethics seemed to impact little on the bigger questions such as collaboration with torturers. My own connection with these questions arose out of my campaigning during the 1990s on the persistent silence of the Israeli Medical Association (IMA) about what Amnesty International, Physicians for Human Rights (USA) and Human Rights Watch had concluded was the institutionalized torture of Palestinians during interrogation, and the role of doctors in the facilities where this took place2. The IMA tended to ignore letters but, remarkably, responded to me in The Lancet by justifying the use of ‘moderate physical pressure’, then the euphemism in Israel for torture3. Two years ago Professor E Dolev, head of the Ethics Committee of the IMA, told a delegation from the London-based Medical Foundation for the Care of Victims of Torture that ‘a couple of broken fingers’ was a small price to pay for the information the interrogators might obtain (H Bamber, personal communication). Imagine if his BMA equivalent had said this.
In short, the doctor is not a man or woman apart. He or she is a citizen who has political and social attitudes that will not be left outside the clinic door. Professor Dolev and the IMA have tacitly accepted a version of loyal citizenship which holds that unpleasant things need to be done to Palestinians in the name of national security. This points to inherent limitations in the capacity of, for example, ethical training in medical schools to make a long-term difference.
Chapter 17 looks at questions of truth and justice and the role of national and international legal mechanisms, including war-crimes tribunals, and proposals for an international criminal court. Truth commissions are discussed, and a BMJ editorial of mine is cited on assumptions about the power of ‘truth’. In the South African case in particular, the Commission was a kind of social ritual with considerable resonance across the country, but what of its formal objective as a promoter of social healing? What can be reliably claimed about the social efficacy of public apology, acknowledgment and forgiveness in the aftermath of political violence. Does ‘truth’ purify, even on the rare occasions when it can be unearthed in pristine condition, uninfluenced by subsequent events and interpretations? Given that perpetrators are generally given immunity from prosecution, can ‘truth’ deliver something in the absence of justice? How would we assess this in comparison with, say, what accrues from economic improvement?
The Medical Profession and Human Rights has breadth, depth and range, and represents an outstanding piece of scholarship, collation and organization. It should turn out to be a seminal work of reference. My admiration goes to Ann Sommerville, Lucy Heath and colleagues at the BMA.