When we think about the complicity of health professionals in breaching their professional obligations by engaging in cruel, inhuman, or degrading treatment or punishment or torture, we tend to focus on their role in the abuse of prisoners or detainees. The record of CIA and military of health professionals in contributing their medical skills and professional opinions to support the use of isolation, sleep deprivation, shackling in extremely painful positions, and even waterboarding of detainees is now well known. The behavior of the doctors, psychologists and other health professionals who engaged in these practices constitutes a gross breach of professional responsibilities as well a violation of human rights.
What is less recognized, though, is how state-sponsored violations of human rights can undermine medical professionalism in day-to-day clinical practice.
The concept of professionalism is based on principles of the primacy of patient welfare, respect for patient autonomy, and social justice. Doctors (and other health professionals) as well as the public tend to view professionalism as solely within the control of the individual health provider, who is responsible to adhere to the values and expectations of the profession.
In a commentary a colleague, Dr. Farrah Matteen, and I wrote for the Journal of the American Medical Association, "Government Policies in Violation of Human Rights as a Barrier to Professionalism," we explore how violations of human rights by states, either by direct violation or support for socially sanctioned discrimination against disenfranchised groups, also undermine professionalism. We look at three examples of circumstances where human rights violations impact professionalism.
The first is restrictions on or unwarranted bureaucratic hurdles to obtaining medical equipment, supplies, or medications essential for the provision of competent care. We know, of course, that sometimes the absence of these tools is a product of resource shortages. But in many circumstances, they instead reflect gross abdication of government responsibility to provide essential resources that are within their means. As Human Rights Watch and others have documented, many governments throughout the world obstruct the ability of physicians to prescribe and administer medications such as morphine and other opioids to control severe and chronic pain from cancer and other conditions. For example, states may require multiple signatures on prescriptions, limit prescription authority to certain specialists, or restrict the places where medication can be administered. These practices violate the right to the highest attainable standard of health and, where the pain that results is severe, can amount to cruel treatment of the patient; at the same time, they prevent the physician from complying with professional responsibilities to the patient to provide relief from pain.
The commentary also considers how restrictions on training can violate human rights and compromise professionalism. Once again taking the example of restrictions on access to pain relief, the denial of training medical professionals on proper dosing and administration of opioid medication both infringes human rights and subverts the professional obligation to competently and conscientiously take care of patients.
Perhaps in no area of practice do human rights violations compromise professionalism more than in the realm of reproduction and sexuality. For example, in the 1990s, as a result of government policy, physicians sterilized more than 300,000 Peruvians, mostly poor, indigenous people against their will. There is little doubt that the physicians felt pressure to participate in this gross breach of human rights and of their professional responsibility to respect patient autonomy and obtain informed consent.
Members of the medical community have generally not understood the connection between human rights violations and the compromise of professionalism. Often, the violations are seen as part of the landscape of practice. Even when clinicians do appreciate the problem, they often feel powerless to do anything about them. But neither lack of knowledge nor perceived lack of ability to change the policies excuse individual clinicians from action. They need to educate themselves about the relationship between human rights and professionalism so they can recognize the problem, avoid complicity, and advocate on behalf of their values and obligations.
Still, the principal responsibility here lies with organizations that represent the collective voice of the medical community. Associations of health professionals should act to defend professionalism and human rights. How? By educating their members about the connections, by speaking out in defense of clinicians who seek to adhere to professional values, and by building alliances with civil society and human rights groups to change the underlying policies and practices by governments that violate both professionalism and human rights.