Health professionals and human rights

Amnesty International (AI) urged the World Health Organisation (WHO) to support health . professionals in documenting violations of human rights

Doctors and nurses have been killed and jailed because they refused to cover up medical evidence of torture and other abuses or gave medical care to government opponents.

In an 46 page report, the human rights organization said doctors have been coerced sometimes by law — into assisting at amputations, and have been threatened for treating protesters, or pressured to issue false medical reports.

‘Medical evidence of abuse is a powerful aid in search for justice by those who have been ill- treated which governments are often anxious to cover up.’

In launching its report — which gives examples from 12 countries — the organization called on the WHO, the United Nations, governments and national medical associations to strengthen mechanisms for the reporting of human rights violations.

In Iraq in 1994, doctors were required by law to amputate the ears and brand the foreheads of military and civilian ‘deserters’. Doctors were told that if they refused the same would happen to them. One doctor was reportedly executed and many were imprisoned for their refusal to carry out these orders.

Some doctors assist governments passively through tolerance of abuses or actively through advice and assistance in the coverup of human rights violations. ‘The vulnerability of doctors or nurses results from the absence of a strong collective refusal to compromise ethical and professional standards. It is time for the principles of rights and ethics to be realised. ‘

Health professionals and medical associations can contribute to the prevention of different abuses by refusing to be exploited in any way for the purpose of torture, interrogation or punishment. Moreover, they can assist the detection, documentation and exposure of human rights violations. The medical examination of prisoners at the time of arrest and regularly during detention is a potential safeguard against physical and mental abuse.

In India, a doctor at the Bone and Joint Hospital in Srinagar said that a prisoner who had to have both feet amputated after developing gangrene, had in fact been kept on ice resulting in frost bite, that acid had been sprinkled on his feet and that all his blood capillaries had been destroyed.

The Turkish -Medical Association has carried out a number of investigations into complicity of doctors, nurses and other health professionals in torture, in Turkey, including an inquiry initiated in 1995 into an apparent medical coverup of torture. Two physicians had prepared medical reports alleging that Ahmetzcil had not been tortured while he was kept in custody despite other reports verifying torture.

In Kenya, there have been several incidents of the police attempting to influence what doctors write in the reports of their medical examinations of detainees, especially when it is obvious a suspect has been tortured. One doctor said: ‘Many times I have been advised [by police] to stop writing medical reports on torture victims. ‘

In 1995, the Bahraini security authorities reportedly warned doctors that if they treated any of those wounded during anti- government protests, they would suffer repercussions. They also prevented ambulances from taking some of the wounded to hospital.

‘Some governments showing a cynical disregard for ethics, try to put pressure on doctors to produce false evidence or no evidence at all. Health workers who see the results of human rights abuses daily need support obviously from their professional associations but also from the wider community. Governments should be accountable for their suppression or manipulation of medical evidence.’

If medical examinations and investigations are to play any role in protecting prisoners certain minimum conditions must be met. Currently these are not met in many countries. In its new report, Amnesty International documents a number of reasons for the failure of health professionals to effectively expose human rights violations and calls for these impediments to ethical practice to be addressed.

WHO should undertake more initiatives and give a higher priority to the defence of health professionals under threat for carrying out the ethical practice of their profession.

The organization’s health professionals network, which has members in more than 30 countries, will be undertaking a campaign on these themes over the next six months.

Amnesty International answers commonly asked questions

AI has issued the following circular to international health professionals answering commonly asked questions on its campaign on violations of human rights:

Q. What is the AI campaign about?

A. AI wants governments to address the fact that human rights violations are frequently not investigated adequately or at all. In some cases, doctors and other health professionals who have evidence of human rights abuses are subject to pressure to stay silent. In other cases, they are pressured not to include certain facts in their medical reports or even to falsify medical documentation in order to hide abuses. In a minority of cases, doctors are actively complicit in abuses. AI wants governments to act and wants to encourage the international community and particularly health bodies such as the World Health Organization and the World Medical Association to take action to address the suppression .of medical evidence in human rights cases. It also wants to support the work of local human rights organizations and professional bodies which are tackling these problems. This human rights problem is illustrated in the AI report, Prescription for Change: Health Professionals and the Exposure of Human Rights Violations. (For a free copy of this report write to CEHAT, 519 Prabhu Darshan, S. S. Nagar, Amboli, Andheri (West), Bombay 400 058.)

Q. Why is AI conducting a campaign at this time?

A. This human rights problem is long- standing and AI has had concerns about the suppression of both legal and medical evidence of human rights violations for many years. It is campaigning now for action in the light of continuing evidence of risks faced by health professionals in many countries and the failure of governments to encourage, use or protect medical expertise in the search for justice in cases of human rights violations. Q. What does AI hope to achieve by this campaign? A. There are a number of goals for this campaign. To put effective pressure on governments to respect, protect and strengthen the medical and medico-legal role in exposing human rights violations. To encourage the international health sectors, WHO and the various professional associations to take action to address the problem of pressure on health professionals to cover up human rights violations.To support and encourage local human rights activists, individual professionals and those professional associations who are working to expose abuses and to press associations to monitor ethical standards. Where such work is not being carried out or is being thwarted for whatever reason, AI wants to stimulate it. AI has prepared Principles for the Medical Investigation of Torture and Other Cruel Inhuman or Degrading Treatment which it is urging governments to adopt. These would contribute to the documentation of torture and the protection of detainees.

Q. Which countries are the worst for repressing doctors or pressuring them to falsify medical evidence?

A. AI does not compare countries or list best or worst countries. The AI report Prescription for Change gives a number of examples of countries where the suppression of medical evidence, silencing of health professionals or lack of professionals skills contribute to the covering up of human rights abuses. In Turkey, doctors have complained that police prevent the writing of honest and accurate medical reports and there is evidence that medical reports may actually assist the cover up of torture [see report p. 1,15,21,27]. In India, a prisoner had both feet amputated after being tortured and not being seen early by a doctor [p. 16]. In Kenya, a doctor was arrested in November 1993, just before he was due to present medicalevidence in court on behalf of several political prisoners [p. 27]. In Peru, two doctors have been sentenced to 22 years imprisonment after false accusations by arrested members of the armed opposition; AI has adopted them as prisoners o f conscience.[ p. 26] I n Mexico, AI medical delegates examined two prisoners who showed signs of ill- treatment; the prisoners had received inadequate medical care in detention and had been given false medical certification There are many other countries with major human rights abuses not covered in the report which does not pretend to be definitive. AI will be individual incidents with particular governments throughout the period of the campaign and in they come to the organization. the future notice 0f when the organisation

Q. Is AI saying that doctors -and nurses have greater obligations to report human rights violations than ordinary citizens?

A. What AI is saying is that health professionals have opportunities to see people at risk of abuses, to witness the effects of such abuses and ethical obligations to take action; these are very particular to the health professions. Medicine is dedicated to the protection of life and the well- being of the patient. With their access to potential victims and their professional ethics, health professionals have a particular role to play in the exposure of abuses.

Q. There must be times when health professionals cannot report abuses because it is just too dangerous to do so?

A. AI is encouraged by the number of such health workers who maintain respect for their patients and their- ethics even in the face of serious risk. In many cases, health professionals have shown that it is possible to act ethically and remain at liberty. In some cases doctors have been prosecuted for promoting ethical behaviour in the face of state opposition and some doctors have even been killed for their adherence to human rights standards. AI believes that asking individuals to resist oppressive forces by themselves reduces the chances of effective resistance to repressive power, even if it welcomes examples of such courageous behaviour. The organisation therefore seeks . to encourage governments to make clear that threats and actual harm must never be used to silence health professionals; to persuade the international health community, in particular the WHO, that it has a significant role to play in promoting the protection of health workers; and to persuade professional associations to fulfil their role in protecting their membership and monitoring standards.

Q. What can professional associations do to defend medical ethics and human rights in the face of government repression?

A. Some associations have undertaken persistent and commendable activities in defence of human rights over a long period under difficult conditions. The report gives examples of action taken by the Turkish and Peruvian medical associations both of which have investigated the situation of doctors under emergency legislation and have supported their own members at risk of unjustified prosecution. Others have taken little action in circumstances when they reasonably could have been expected to speak out. The determining factor is not just the power of the government or the risks involved but the will of the association to act. AI hopes to persuade associations during the course of this campaign that there are strong reasons for taking action in defence of human rights and in support of members who may face risks because of their wish to practice their profession ethically.

Q. What about governments? Don’t they have legitimate rights to combat terrorism which may mean restricting the rights of doctors? If doctors treat terrorists surely they have to accept being punished?

A. Medical ethics do not support the view that doctors should withhold medical treatment from anyone. When called upon to give medical care, it is the doctor’s responsibility to give that care or to refer the patient on to another doctor who can provide care. It is widely recognised that doctors have ethical obligations to maintain confidentiality and to act in their patients’ interests.

Q. Does AI’s call for doctors to have the unrestricted right to see violent guerillas amount to a call for special privileges for terrorists?

A. AI does not support ‘terrorism’ or ‘terrorists’. It calls for the protection of human rights whether they are under threat from the state or from armed opposition groups. It calls for the protection of the health professional’s role as carer.

Q. How can we believe doctors’ reports of torture? Not all of them are experts in detecting torture and some may have a political agenda.

A. There are well recognized methods for the carrying out of medical examinations and the preparation of medical reports. A doctor writing a report documenting torture must expect to have that report scrutinised by other doctors. AI commonly asks experienced doctors to evaluate medical evidence submitted to the organisation and through this peer review has been able to come to its own judgments about the accuracy or credibility of medical reports of torture.

Q. Surely some countries can’t afford the resources to put into forensic medicine?

A. The problems documented in the AI report are not usually the result of lack of training but are caused by de1 i berate decisions, either by military, security or police officers to pressure a doctor into falsifying a certificate or report, or by doctors who deliberately breach their professional ethics and collude with the authorities. In some cases, inadequate reports result from lack of proper training or experience but these are generally not the root of the problem.

Q. What does AI want done when a doctor collaborates with the authorities by falsifying reports or helping to cover up abuses?

A. AI believes that all alleged cases of medical participation in human rights violations should b e thoroughly investigated by professional associations and, where there is prima facie evidence of an illegal action by a doctor or other health professional, by law enforcement agents. During such an investigation, any mitigating circumstances, such as the existence of coercion against the doctor, should be taken into account. Those who are under severe pressure to cooperate with those carrying out human rights violations should not, in AI’s view, be simply condemned; they should be given a fair chance to explain their actions.

III World Congress of Bioethics

“Bioethics in an interdependent world”

The International Association of Bioethics announces the third world congress 20- 24 November 1996 at the Crowne Plaza Hotal, San Francisco, California. The keynote address is on medicine, public health, ethics and human rights.The plenary address is on Access to care -international rights and national duties. ‘Breakout sessions include such issues as the ethics of managed care; the ethics of emerging therapies; gay and lesbian perspectives on healthcare ethics; race, ethnicity and class; research ethics; bioethics and university scandals; reproductive health care and eugenics. Post-congress symposia include , Studying human diversity – can we do it right? (25 November) and The globalisation of bioethics – international human rights and health professions (24-25 November).

Further information and registration:

Congress Secretariat, III World Congress of Bioethics, Pacific Center for Health Policy and Ethics, University of Southern California, Los Angeles, CA. 90089- 007 1 USA. Telephone: (213) 740- 2541 Fax: (213) 740- 5502

1996 Annual meeting:

Maintaining responsive health care for everyone in the 21st century – accountability, quality and erosion of traditional roles and. relationships in developing health care world. 15- 16 November 1996 at Royal Sonesta, Boston, Massachusetts. Further information: American Society of Law, Medicine & Ethics, 765 Commonwealth Avenue, 16th floor, Boston, MA 02215 USA.

Euthanasia – resource volume

The University of Otago announces the availability of the volume entitled Euthanasia – resources for community discussion. As the namer implies, this is a ‘collection of material that can form the basis for group discussions or workshops up to 6 hours long. Copies are available at the cost of $25+$ 1 for packing and postage from Bioethics Research Centre, P. 0. Box 913, Dunedin, New Zealand.

Graduate diploma in bioethics by distance education

Write to The Distance Education Coordinator, Centre for Human Bioethics, Monash University, Clayton, Victoria, Australia 3168 for details on an interdisciplinary course designed to educate health care professionals in the field of bioethics; develop and extend individual’s understanding of the nature of ethical issues in health care and equip the individual with a solid theoretical framework with which issues in bioethics can be analysed. The course content includes as subject heads – ethics; questions of life and death; ethical issues in patient care and legal issues in bioethics.

During each semester students receive printed material including reading assignments and activities. A part time student would normally spend 10 hours a week on these. E- mail, fax or air mail can be used for this purpose.

The current fee is A$ 5000 for the entire course.