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.