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(Oct 2004) PHR-UK editorial in the Student British Medical Journal
http://www.studentbmj.com/issues/04/10/editorials/351.php

The importance of human rights to health

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    Peter Hall considers the effect that human rights have on health and how denial of those rights has grave implications on wellbeing

    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.16, 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

    Email: phall@gn.apc.org

    Visit www.phruk.org for more information about 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://phruk.shared-inter.net/index.php?php=true&content=showitem&table=reports&item=16&previouscontent=reports&previousphp=true (accessed 30 Jul 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.) 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. New York: United Nations, 1999. http://ods-dds-ny.un.org/doc/UNDOC/GEN/N99/395/47/IMG/N9939547.pdf?OpenElement (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. Independent Inquiry into the Actions of the United Nations During the 1994 Genocide in Rwanda. p 1. New York, United Nations, 1999 www.visiontv.ca/RememberRwanda/Report.pdf (accessed 16/7/04)

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

    21. www.unaids.org/NetTools/Misc/DocInfo.aspx?href=http://gva-doc owl/WEBcontent/Documents/pub/Publications/External-Documents/UNFPA_UNAIDS_UNIFEM_womenAIDS_en.pdf



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