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Student BMJ editorial written by the chair of Doctors for Human Rights explains how violations of human rights lead to increased mobidity and mortality http://www.studentbmj.com/issues/1004/editorials/351.html
The importance of human rights to health

Respect for human rights underpins ethical medical practice and is essential for a healthy population. The Hippocratic oath resembles contemporary health rights, as defined by international law.(1)

Human rights affect medical practice in several ways—they influence ethical codes; they justify each patient's claim to the best attainable physical and mental health through their emphasis on norms, obligations, and accountability; and health is jeopardised when generic human rights are violated. Moreover, the values enshrined in human rights are a reliable guide for contemporary practice because they are universal and focus on people as rights holders rather than patients.

The role of human rights in resolving ethical dilemmas was highlighted in 1999, when four medical specialists concluded that Senator Augusto Pinochet, Chile's former president, did not have the mental capacity to face extradition from the United Kingdom to Spain on charges of torture. The UK home secretary refused to release details of the assessment, claiming patient confidentiality as paramount. But the right to confidentiality is relative not absolute, and the right of 40,000 Chilean torture survivors to be informed—essential to the restorative process of justice—should have taken precedence.(2,3) As the Lancet put it, “without complete transparency, even independent-minded physicians who assist the judicial process of democratic nations can find their opinions manipulated for political purposes.”(4)

On a different but equally important level, a paper in the BMJ that exposed the practice of requiring medical students to intimately examine unconscious patients without consent proposed ethical drift as a confounding factor.(5) Had those responsible considered the values of the 55 year old Universal Declaration of Human Rights (UDHR), these assaults would not have been permitted.6 In her editorial in the BMJ, Jennifer Leaning, a senior research fellow at the Harvard Center for Population and Development Studies, said, "What the UDHR provides is a recognition of the separate, inviolate nature of the individual person who will face that young doctor in the casualty area, the examination room, the office, the conference room. From the opening statement in Article 1, that every human being is ‘born free and equal in dignity and rights,' the document enumerates the critical freedoms that fill the space surrounding every man, woman, and child on earth."(7)

Governments have a role too. Three in every four countries have ratified the international treaty that recognises every citizen's right to the highest standard of physical and mental health. General Comment 14 of the International Covenant on Economic, Social, and Cultural Rights in defining what the right means in practical terms, emphasises that the right to health is not a right to be healthy—rather it contains freedoms and entitlements.(8) Freedoms include the right to control your health and body. Entitlements take account of individuals' socioeconomic status and a country's resources and extend not only to health care but also to the underlying determinants of health, such as access to food, shelter, and healthy living and environmental conditions.8 Most notably, the covenant requires participating countries to respect the right to health of citizens of other countries when entering into international agreements or arrangements with international organisations.(8)

A central value of human rights is non-discrimination, yet inequitable access to health care persists in every country. Research shows that doctors, even those with the best of intentions, can subconsciously stigmatise some patients.(9) Physicians for Human Rights UK's 2002 “shadow” report to the Committee on Economic, Social and Cultural Rights shows that, despite the United Kingdom's national health service boasting a 55 year tradition as the first provider of universal access, some British doctors discriminate against vulnerable groups such as women, people with learning disabilities, and elderly people.(10)

Although widely perceived as being primarily issues of politicolegal rather than public health importance, violations of generic human rights commonly dwarf conventional risk factors in preventative medicine. During the 1994 Rwandan genocide, 800,000 civilians were murdered; two thirds of the hundreds of thousands rape survivors contracted HIV; 90% of child survivors expected to be murdered; and 700?000 refugees were infected with Vibrio cholerae.(11, 12, 13, 14, 15) When fleeing genocide perpetrators continued the genocide from neighbouring Zaire, the conflict spread to involve seven nations' armies, and the deaths of an estimated 3.3 million more civilians.(16,17) Prompt attention to international human rights obligations by the United Nations could have stifled the Rwandan genocide, but was thwarted through calculated obfuscation by Western governments.(18, 19)

A more pervasive example threatens human security even more widely. Violations of the human rights of women—to sexual and reproductive autonomy, to education and economic standing, and to freedom from violence—renders them prey to high risk sexual behaviour.(20) If women's human rights were respected, AIDS might be a controllable disease rather than a pandemic.(21)

Respect for human rights is integral to medical practice and indispensable to health. The international medical community must recognise the magnitude of its importance to preventative, curative, and palliative medicine, and adopt health and human rights education within medical curriculums. Medicine needs doctors with brilliant minds to advance medical science. Equally it needs doctors with the passion and drive to campaign for optimum use of present day means in the battle to protect health globally, where necessary enlisting or advancing human rights jurisprudence to compel compliance. As with academic research, international collaboration between likeminded doctors and institutions can provide the means to educate, promote, and campaign, and the internet can provide the medium. The potential for doctors to use human rights as a vehicle to preserve health is limited only by the size of the ambition.

Peter Hall chair, Physicians for Human Rights UK

studentBMJ 2004;12:349-392 October ISSN 0966-6494

References:

1. Hall P. Human rights in the Hippocratic oath. Physicians for Human Rights UK. http://www.phruk.org/index.php?php=true&content=showitem&table=reports&item=16&previouscontent=reports&previousphp=true (accessed 30 Aug 2004).

2. Kraus C. Pinochet case: reviving voices of the tortured. New York Times 2000 Jan 3: section A, 1. http://query.nytimes.com/gst/abstract.html?res=F10712FD355C0C708CDDA80894D8404482 (accessed 30 Jul 2004).

3. Redress. Torture survivors’ perceptions of reparation. Redress: London, 2001: 14. www.redress.org/publications/TSPR.pdf (accessed 30 Jul 2004).

4. When doctors become agents of the state. Lancet 2000;355:l245.

5. Coldicott Y, Pope C, Roberts C. The ethics of intimate examinations teaching tomorrow’s doctors. BMJ 2003;326:97-101.

6. United Nations. Universal declaration of human rights. Geneva: UN, 1948. www.unhchr.ch/udhr/lang/eng.htm (accessed 30 Jul 2004).

7. Leaning J. Human rights and medical education. BMJ 1997;315:1390-1.

8. United Nations. The right to the highest attainable standard of health. Geneva: UN, 2000. (General comment No 14.) http://www.unhchr.ch/tbs/doc.nsf/(symbol)/E.C.12.2000.4.En?OpenDocument (accessed 30 Jul 2004).

9. Smedley BD, Stith AY, Nelson AR. Unequal treatment: confronting racial and ethnic disparities in health care. Washington: National Academy Press, 2002. http://books.nap.edu/books/030908265X/html/1.html (accessed 30 Jul 2004).

10. Physicians for Human Rights UK. Response to the UK government’s fourth report under the International Covenant on Economic, Social, and Cultural Rights. St Albans: PHR-UK, 2002. http://phall.members.gn.apc.org/PHR-UK_April_2002_Report.doc (accessed 30 Jul 2004).

11. Independent Inquiry into the Actions of the United Nations During the 1994 Genocide in Rwanda. p 1. New York, United Nations, 1999 . http://www.un.org/News/dh/latest/rwanda.htm (accessed 15/7/04)

12. McGreal C. To the HIV-positive rape victims of 1994, children are a source of joy—and torment. Guardian 2001 Dec 5. http://society.guardian.co.uk/christmasappeal/story/0,11321,612365,00.html (accessed 30 Jul 2004).

13. United Nations, Report on the situation of human rights in rwanda submitted by Mr Renú Degni-Segui, special rapporteur of the Commission on Human Rights. New York: United Nations, 1996. www.unhchr.ch/Huridocda/Huridoca.nsf/TestFrame/aee2ff8ad005e2f6802566f30040a95a?Opendocument (accessed 30 Jul 2004).

14. Gupta L. Unicef trauma recovery programme: exposure to war-related violence among Rwandan children and adolescents: a brief report on the national baseline trauma survey. Kigali: Unicef Rwanda, 1996:6.

15. International Federation of Red Cross and Red Crescent Societies. Under the volcanoes: the world disasters report. IFoRCaRCS: Geneva, 1995

16. Organisation of African Unity. International panel of eminent personalities to investigate the 1994 genocide in Rwanda and the surrounding events. Addis Adaba: OAU, 2000: para 19.34-20.11. www.visiontv.ca/RememberRwanda/Report.pdf (accessed 30 Jul 2004).

17. International Rescue Committee. Mortality in the DRC: results from a nationwide survey. New York: IRC, 2003. www.theirc.org/DRCongo/index.cfm (accessed 30 Jul 2004).

18. United Nations. Convention on the prevention and punishment of the crime of genocide. Geneva: UN, 1948. www.unhchr.ch/html/menu3/b/p_genoci.htm (accessed 30 Jul 2004).

19. Organisation of African Unity Report, International Panel of Eminent Personalities to Investigate the 1994 Genocide in Rwanda and the Surrounding Events; paras 10.1-10.9. Addis Adaba: OAU, 2000. www.visiontv.ca/RememberRwanda/Report.pdf(accessed 16/7/04)

20. UNAIDS/UNFPA/UNIFEM. Women and HIV/AIDS: confronting the crisis. Geneva: UNAIDS, UNFPA, and UNIFEM, 2004.

21. Urdang S, Remarks spoken at conference - Human Rights Framework for the AIDS in Africa Crisis, Carr Center for Human Rights Policy, Kennedy School of Government, Harvard University, May 21, 2001

Responses

Matko Marusic, Editor-in-Chief, Croatian Medical Journal

EDITOR - Dr Peter Hall published a nice article in StudentBMJ on the importance of human rights to health1. All what is said in this article is right, but the author did not mention any examples where human rights and health do not act synergistically. In this respect, one would like to know what comes first, health or human rights, in cases where they contradict, at least partially. Let me give three examples.

1. A patient with AIDS has the human right that his or her disease is not disclosed, but, being the virus carrier, he or she endangers the health (and human rights?) of persons with whom he or she has sexual relationship. Is he or she obliged – by human rights or care for health - to tell his or her partner of the disease before they develop full relationship? What is the position of a physician in such cases? From a physician’s viewpoint, where is the place of Hippocratic oath, and where for the respect for human rights in such cases?

2. Homosexual preference is considered a human right, but knowing that this lifestyle is (on average) a risky lifestyle, what is truly (see the Hippocratic oath) the best care for health of the person in question? In case of smokers we readily advise quitting, but I am not sure we would dare to do the same in this case.

3. The so called complementary and alternative medicine (CAM) is widespread and associated with culture(s); yet, for most of these treatments we know that they have no effect.

Are we allowed to say that openly, for example for treatments that are thousands of years old, and a firm belief od millions of people – of a different culture? When such (e.g., ineffective) treatments are charged to patients, are we physicians, respecting both human rights and Hippocratic oath, obliged to inform police or some other authorities? As citizens, we are expected to report stealing to police, so are not physicians (even more) obliged to report cases when their patients receive treatments that are not only useless but are also contrary to common sense, divert patients from proven therapy, and are – charged to patients.

We need to hear more and talk much more openly about the relationship of health and human rights than was done in the article.

References

1. 1 Hall P. The importance of human rights to health. StudentBMJ. 2004;12:351. (October)



Douglas P. Olson, Medical student, George Washington University School of Medicine, Washington, DC, USA

The article by Peter Hall in the October 2004 edition of sBMJ aims to closely link health, human rights and medical ethics. I enjoyed the article, and it left with me with more questions than answers, a feeling that I experience often when considering these subjects simultaneously. While he is successful in providing many examples of the linked triad, there is little concrete discussion about their complementary relationships.

The classical tenets of medical ethics are justice, fidelity, beneficence, non-maleficence and autonomy. Hall clearly shows the link among health, human rights and justice via the example of Pinochet’s torture of thousands and his ultimate “acquittal” by a group of four UK physicians – one for every ten thousand tortured people! The fact that transparency was not apparent in this case should cause shame to the UK home secretary, and remind him that one only need look to the US-based Tuskegee experiments or the setting of 1930s Germany to appreciate large groups of physicians being coerced into practicing unethical medicine by a government.

Autonomy and beneficence are demonstrated by mention of medical students’ examination of anesthetized patients, with support from Jennifer Leaning citing the Universal Declaration of Human Rights. Leaning, a respected human rights leader and colleague of Hall’s within Physicians for Human Rights cites Article 1 of the UDHR to show that all people are “born free and equal in rights and dignity.” Her choice of reference is supreme, not even having to mention Article 25, the section that most implicitly deals with health.

The rights of women, coupled with war-related atrocities round out Hall’s link between health, human rights, and medical ethics. Dr. Khassan Baiev, a Chechen doctor who treated casualties from both sides of the Russian-Chechnyan conflict, might better elucidate the tenets of non-maleficence and beneficence related to war/conflict medicine. Rather than polarize himself and his services by siding with a particular faction or government, he chose to care for all sick and wounded, regardless of what cause they were fighting for. His actions in upholding the Hippocratic Oath and helping all in need drew threats and accusations from both sides. His practice of linking health, human rights and ethics eventually forced him to flee the arena and seek asylum in the United States.

Hall correctly asserts that governments have a role in protecting human rights, and cites lack of action on the part of the United Nations to end a great amount of trauma and death in Rawanda in 1994. With lamentable slogans such as “always remember, never forget” and “nunca mas” to invoke remembrance of the Holocaust and the Argentine Dirty War, respectably, we watch today as genocide continues in Sudan. With sadness and without shock, history yet again repeats itself.

Louis Virchow once remarked that “if medicine is to fulfill our greatest task, then she must enter the political and social life.” Hall’s multiple examples of physicians failing in this regard should serve as yet another rallying cry for all health professionals and students to actively engage in protecting the health and human rights of all people. The field of health and human rights, like molecular medicine, has a long, long way to go. It seems likely that there will always be more questions than answers in the complementary yet often-nebulous realm of health, ethics and human rights. As humans, we have yet to answer all the questions that even two of these principles share, never mind all three together. Yet asking the questions, working on the patient’s behalf, and constantly striving to better delineate [and improve] humanity’s moral compass is not only the role, but responsibility, of a physician.

The playwright Moliere once remarked that “it is not only what we do, but also that which we do not do, for which we are held accountable.”

First, do no harm.



Peter Hall, chair, Physicians for Human Rights UK

Dr Marusic suggests in his letter(1) that there may sometimes be a conflict between health and human rights, but health requires a milieu within which human rights are respected to flourish. Sometimes situations arise where two or more human rights are in conflict. As with medical ethics there is a hierachy of human rights and value judgements must be made as to which human right takes precedence.

A number of examples where a conflict of rights exists was described within the editorial(2). For instance the right of medical students to education, and of patients to be treated by comprehensively trained doctors, has to be balanced against the right of unconscious patients to an opportunity to decline intimate examinations. Clearly the right of the patient to not be subjected to what might be perceived as sexual assault has priority, and alternative arrangements will have to be made to meet competing rights.

To answer Dr Marusic's questions - someone who is aware of their HIV seropositivity should inform a sexual partner, their right to confidentiality taking second place. The UK General Medical Council advises a doctor whose patient is putting another person at risk of unknowingly acquiring HIV, to, after warning the seropositive person, inform the potential victim.(3)

Patients who carry out lifestyle high risk activities such as unprotected sexual intercourse with many partners, sharing needles, smoking, or eating or drinking too much, should be advised of the dangers to health. Indeed, patients have a right to health information, and that includes evidence of the effectiveness of any treatment whether complementary, traditional or high tech and modern(4).

yours sincerely

Dr Peter Hall

MBBS, MRCPI, DGM

Chair, Physicians for Human Rights-UK

References

1. Marusic M. Rapid response to:

Hall P. The importance of human rights to health. StudentBMJ. 2004;12:351. (October)

2. Hall P. The importance of human rights to health. StudentBMJ. 2004;12:351. (October)

3. GMC Guidance on good practice - serious Communicable Diseases. 1997: para 22. http://www.gmc-uk.org/standards/default.htm

4. United Nations. The right to the highest attainable standard of health. Geneva: UN, 2000. (General comment No 14.) http://www.unhchr.ch/tbs/doc.nsf/(symbol)/E.C.12.2000.4.En?OpenDocument (accessed 30 Jul 2004).



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