ethical pitfalls can be hard to avoid
http://www.100md.com
《英国医生杂志》
1 Health Professionals' Network, Amnesty International UK London EC1R 4RE
Correspondence to: D Forrest steve.ballinger@amnesty.org.uk
Many clinicians will have memories of slightly disturbing encounters—perhaps while in training—when they felt that a patient was suffering unnecessarily thoughtless, humiliating, or frankly brutal treatment. It is difficult for junior doctors to make a complaint. Perhaps it becomes slightly easier with growing experience and seniority, but it is never straightforward and many encounters go by without protest. Although ethical norms have improved in recent years, there are still many working environments where doctors daily witness doubtful practices and have to decide whether to confront or ignore them.1 When should you blow the whistle?
Doctors whose work involves divided loyalties, such as police surgeons, prison doctors, or medical officers in the armed forces, are most likely to encounter these ethical problems. Of course, in countries where torture is practised, doctors in such jobs face more serious choices and risks than doctors in the NHS. If they do not cooperate with their employers, they can risk dismissal or even physical danger to themselves or their families. Some have been seduced not only into compliance but complicity or actual participation in torture. Similar dangers must also exist in countries that practise "moderate physical pressure"2 or "torturelite."3 We can only wonder what the doctors in the US detention centre in Guantanamo Bay or Abu Ghraib prison in Iraq have seen.
Reasons for collusion
It is easy for those of us who do not work in these environments to be critical, but in some circumstances vulnerable doctors are in danger of being drawn in. In 1990, Amnesty International produced a report that identified some reasons for medical participation in torture.4 Doctors rarely talk about their role in human rights violations, and the reasons behind it are therefore mostly speculative. However, those participating in torture or other abuses will probably be doing so for one or more of the following reasons:
Identification with the cause of the torturers—Doctors working with security forces may absorb (or fundamentally identify with) the values of those carrying out torture, particularly in countries with sharp political, social, or racial divisions
Fear of the consequences of refusal—In some countries doctors have been forced to serve a period of military service and may believe that opposition to military superiors is impossible. Doctors sometimes face contradictory obligations—for example, to medical ethics and to legal strictures against the public exposure of abuses occurring in government service.
"Bureaucratisation" of the medical role— Some doctors seem to have been able to distance themselves from the abuses being inflicted on prisoners by adopting the role of uninvolved technician, carrying out a purely technical function.
Inadequate understanding of medical ethics—Doctors may see their role as that of a healer, minimising the pain resulting from torture or ill treatment. This may be particularly so in the case of capital and corporal punishments, where there is a legal framework for the medical role.5-7
Most doctors will not come into contact with these serious problems, but there are more subtle and insidious areas where doctors who think they are working in a humanitarian field may fall into the trap of conniving with unethical practices. Harding-Pink draws attention to the problems for doctors working with asylum seekers.1 Clearly, asylum seekers need special protection. Individuals who have had their basic human rights violated in their country of origin are the least able to withstand further abuse in the country where they seek refuge. Yet by its nature, this work carries the possibility that human rights violations may occur when the care of refugees falls into the hands of staff who are not bound by the ethical principles that bind doctors.
Supporting doctors
The BMA's updated publication on human rights gives more attention to the rising problems related to immigrants and asylum seekers.8 This, together with Medical Ethics Today,9 should be a regular reference for all clinicians. Further specific guidance and detailed commentary are given in a publication by Physicians for Human Rights.10 However, those looking for a "recipe book" approach may be disappointed. The examples Harding-Pink poses are difficult to resolve in practice even if some might find them clear in theory.
The teaching of medical ethics in medical schools has improved immeasurably in recent years, but all practising clinicians have a responsibility to keep up to date as new situations arise and new ethical pitfalls appear. Nevertheless, as Harding-Pink shows, health professionals can be isolated and left to make difficult decisions under pressure by those not committed to ethics. Professional bodies need to give ethical leadership and to constantly review the transparency and accountability of those authorities employing medical staff. The extraordinary turn around in public opinion after revelations of US torture at Abu Ghraib shows the effect of just a small amount of involuntary glasnost. We should be calling on governments and international agencies to account for their policies and practices, including those situations where they use medical staff.
Competing interests: None declared.
References
Harding- Pink D. Humanitarian medicine: up the garden path and down the slippery slope. BMJ 2004;329: 398-9.
Ziv H. Physicians and torture—the case of Israel. Tel Aviv: Physicians for Human Rights Israel, 1999.
Campbell D. US interrogators turn to "torture-lite." Guardian 2003 Jan 25.
Amnesty International. Involvement of medical personnel in abuses against detainees and prisoners (revised and updated). http://web.amnesty.org/library/index/engact750081990 (accessed 19 Jul 2004).
Amnesty International. Medicine at risk: the doctor as human rights abuser and victim. London: Amnesty International, 1990. http://web.amnesty.org/library/index/engact750011989 (accessed 19 Jul 2004).
Amnesty International. Médecins tortionnaires, médecins résistants. Paris: La Découverte, 1989 .
Lifton RJ. The Nazi doctors. London: Papermac, 1987.
British Medical Association. The medical profession and human rights: handbook for a changing agenda. London. Zed Books, 2001.
British Medical Association. Medical ethics today. 2nd ed. London: BMJ, 2004.
Physicians for Human Rights. Dual loyalty and human rights in health professional practice: proposed guidelines and institutional mechanisms. Boston: PHR, 2002.(Duncan Forrest, retired c)
Correspondence to: D Forrest steve.ballinger@amnesty.org.uk
Many clinicians will have memories of slightly disturbing encounters—perhaps while in training—when they felt that a patient was suffering unnecessarily thoughtless, humiliating, or frankly brutal treatment. It is difficult for junior doctors to make a complaint. Perhaps it becomes slightly easier with growing experience and seniority, but it is never straightforward and many encounters go by without protest. Although ethical norms have improved in recent years, there are still many working environments where doctors daily witness doubtful practices and have to decide whether to confront or ignore them.1 When should you blow the whistle?
Doctors whose work involves divided loyalties, such as police surgeons, prison doctors, or medical officers in the armed forces, are most likely to encounter these ethical problems. Of course, in countries where torture is practised, doctors in such jobs face more serious choices and risks than doctors in the NHS. If they do not cooperate with their employers, they can risk dismissal or even physical danger to themselves or their families. Some have been seduced not only into compliance but complicity or actual participation in torture. Similar dangers must also exist in countries that practise "moderate physical pressure"2 or "torturelite."3 We can only wonder what the doctors in the US detention centre in Guantanamo Bay or Abu Ghraib prison in Iraq have seen.
Reasons for collusion
It is easy for those of us who do not work in these environments to be critical, but in some circumstances vulnerable doctors are in danger of being drawn in. In 1990, Amnesty International produced a report that identified some reasons for medical participation in torture.4 Doctors rarely talk about their role in human rights violations, and the reasons behind it are therefore mostly speculative. However, those participating in torture or other abuses will probably be doing so for one or more of the following reasons:
Identification with the cause of the torturers—Doctors working with security forces may absorb (or fundamentally identify with) the values of those carrying out torture, particularly in countries with sharp political, social, or racial divisions
Fear of the consequences of refusal—In some countries doctors have been forced to serve a period of military service and may believe that opposition to military superiors is impossible. Doctors sometimes face contradictory obligations—for example, to medical ethics and to legal strictures against the public exposure of abuses occurring in government service.
"Bureaucratisation" of the medical role— Some doctors seem to have been able to distance themselves from the abuses being inflicted on prisoners by adopting the role of uninvolved technician, carrying out a purely technical function.
Inadequate understanding of medical ethics—Doctors may see their role as that of a healer, minimising the pain resulting from torture or ill treatment. This may be particularly so in the case of capital and corporal punishments, where there is a legal framework for the medical role.5-7
Most doctors will not come into contact with these serious problems, but there are more subtle and insidious areas where doctors who think they are working in a humanitarian field may fall into the trap of conniving with unethical practices. Harding-Pink draws attention to the problems for doctors working with asylum seekers.1 Clearly, asylum seekers need special protection. Individuals who have had their basic human rights violated in their country of origin are the least able to withstand further abuse in the country where they seek refuge. Yet by its nature, this work carries the possibility that human rights violations may occur when the care of refugees falls into the hands of staff who are not bound by the ethical principles that bind doctors.
Supporting doctors
The BMA's updated publication on human rights gives more attention to the rising problems related to immigrants and asylum seekers.8 This, together with Medical Ethics Today,9 should be a regular reference for all clinicians. Further specific guidance and detailed commentary are given in a publication by Physicians for Human Rights.10 However, those looking for a "recipe book" approach may be disappointed. The examples Harding-Pink poses are difficult to resolve in practice even if some might find them clear in theory.
The teaching of medical ethics in medical schools has improved immeasurably in recent years, but all practising clinicians have a responsibility to keep up to date as new situations arise and new ethical pitfalls appear. Nevertheless, as Harding-Pink shows, health professionals can be isolated and left to make difficult decisions under pressure by those not committed to ethics. Professional bodies need to give ethical leadership and to constantly review the transparency and accountability of those authorities employing medical staff. The extraordinary turn around in public opinion after revelations of US torture at Abu Ghraib shows the effect of just a small amount of involuntary glasnost. We should be calling on governments and international agencies to account for their policies and practices, including those situations where they use medical staff.
Competing interests: None declared.
References
Harding- Pink D. Humanitarian medicine: up the garden path and down the slippery slope. BMJ 2004;329: 398-9.
Ziv H. Physicians and torture—the case of Israel. Tel Aviv: Physicians for Human Rights Israel, 1999.
Campbell D. US interrogators turn to "torture-lite." Guardian 2003 Jan 25.
Amnesty International. Involvement of medical personnel in abuses against detainees and prisoners (revised and updated). http://web.amnesty.org/library/index/engact750081990 (accessed 19 Jul 2004).
Amnesty International. Medicine at risk: the doctor as human rights abuser and victim. London: Amnesty International, 1990. http://web.amnesty.org/library/index/engact750011989 (accessed 19 Jul 2004).
Amnesty International. Médecins tortionnaires, médecins résistants. Paris: La Découverte, 1989 .
Lifton RJ. The Nazi doctors. London: Papermac, 1987.
British Medical Association. The medical profession and human rights: handbook for a changing agenda. London. Zed Books, 2001.
British Medical Association. Medical ethics today. 2nd ed. London: BMJ, 2004.
Physicians for Human Rights. Dual loyalty and human rights in health professional practice: proposed guidelines and institutional mechanisms. Boston: PHR, 2002.(Duncan Forrest, retired c)