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BMJ No 7120 Volume 315 Editorial Saturday 29 November 1997 Human rights and medical education Why every medical student should learn the Universal Declaration of Human Rights See Education and debate p 1455 The Universal Declaration of Human Rights enters its 50th anniversary year in 1998. Around the world efforts are under way to celebrate this event and accelerate efforts to disseminate the contents of the declaration. These efforts are undertaken in recognition that progress has been at best uneven since that early morning of 10 December 1948 when the United Nations General Assembly formally adopted this document and thereby sought to enshrine in world consciousness a commitment to secure basic human rights around the world. In 1948 there were 58 member nations of the UN; there are now 185. For this world community the declaration has acquired the status of international law and all governments can be held to its principles. Many other international treaties and charters have incorporated the language of the declaration or referred to it; and many national governments have included its language and principles in their constitutions.(1) The declaration encompasses civil and political rights of individuals (in the first 21 articles); economic and social rights, including to health care (articles 22-27); and reciprocal obligations and constraints conferred by participation in a community (articles 28-30) (see p 1455). There are several histories of this document which are relevant to those interested in the struggle to persuade human beings to find common ground and push off to higher reaches from it. Yet for the medical community in general, and for the subset who are medical students, the history is less crucial than is the fact of what this document now has become, 50 years from its making. With astonishing durability it has withstood the test of time and has become the minimum consensus statement for all cultures and creeds of what each human being has the right to expect on entering the world. Key elements are that rights inhere in human beings, rather than being conferred by the state; that these rights are universal, applying to all human beings regardless of any differentiating characteristics; and that the nations of the world unite in pledging their efforts to promote these rights within their own boundaries and, through the persuasive powers of the UN, across boundaries. This document, written in deliberately simple language, susceptible to translation in many languages, has become the reference point for appeals from the human rights community on behalf of beleaguered individuals and oppressed peoples throughout the world.(2) Western medical students have traditionally been asked to recite the Hippocratic oath on graduation, and recently an increasing number have also included the prayer of Maimonides in their valedictory pledges. These exhortations, although noble and necessary, are essentially self referential. Those who would enter the practice of medicine promise to maintain the highest standards of personal integrity and competence and to have compassion for those placed in their care. They acknowledge that, in seeking to become medical professionals with special powers and responsibilities, they have entered a very special guild. What is missing in these commitments, and what the Universal Declaration of Human Rights 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. The beneficent aspects of the medical tradition (the doctor knows best, the doctor will decide, the patient does not need to know) are still very strong themes in training and play a legitimate part in medical practice, in particular instances at particular times. Prevailing discussions of medical ethics, however, launched since Nuremberg, emphasise the notion of patients' autonomy and patients' rights, in which the patient is seen as an independent actor who can claim a standing of respect and responsibility simply because he or she is a human being.(3) In the vocabulary of the human rights movement this notion is introduced in the words "human dignity," the attribute of beings with rights, whether or not they know they have them.(4) T S Eliot speaks of the need to see every other person as "a stranger," an unknown about whom one cannot make assumptions or presume prior knowledge.(5) Martin Buber describes the unique separateness of the other person by stating: "When we walk our way and encounter a man who comes toward us, walking his way, we know our way only and not his; for his comes to life for us only in the encounter."(6) Does it matter whether medical students learn to see patients as "other," as autonomous beings whom each day they have to struggle to apprehend, listen to, and understand? Several lines of observation and evidence suggest that it does. Firstly, the complexity of medical practice now involves many choices of diagnostic and therapeutic routes, in the course of which a doctor is well advised to communicate closely and empathetically with the patient's preferences or become embroiled in disagreement, mistrust, and potentially poor outcome.(7) Secondly, the composition of society is changing rapidly, so that doctors can now expect to be taking care of many patients who speak a language and live within a culture different from that in which they were raised and trained. To take an adequate history, let alone accompany a patient through life, requires a supple and educated capacity to connect empathetically across substantial barriers.(8) Thirdly, the position of medicine within society is in flux, as financial barriers to access and analyses of poor quality have spurred the general public to critical engagement in issues of healthcare policy. Doctors are now impelled to strengthen their skills as communicators, patient advocates, and negotiators between and among systems and expectations.(9) Fourthly, our understanding of determinants of health status and outcome has deepened to the point where it is now clear wherever we look that access to the goods and freedoms of society plays an important part in whether an individual patient experiences a particular illness or whether an illness is particularly severe.(10) Unless doctors can talk to their patients about issues of work, home, life stresses, poverty, loneliness, and humiliation we will never learn what steps medicine and society must take to intervene.(11) Fifthly, doctors who spend part of their lives working in underprivileged areas cannot escape the constraints imposed by the link between the health of populations and the human rights they enjoy.(12) Although it is violated every day in every country around the world, article 25 states: "Everyone has the right to a standard of living adequate for the health and wellbeing of himself and of his family." On the tenth anniversary of the declaration, Eleanor Roosevelt, chairwoman of the original UN drafting committee, spoke again to the UN General Assembly of her commitment to this document and the pursuit of its realisation:Where, after all, do universal human rights begin? In small places, close to home - so close and so small that they cannot be seen on any map of the world. Yet they are the world of the individual person: the neighborhood he lives in; the school or college he attends; the factory, farm, or office where he works. Such are the places where every man, woman, and child seeks equal justice, equal opportunity, equal dignity without discrimination. Unless these rights have meaning here, they have little meaning anywhere. Without concerted citizen action to uphold them close to home, we shall look in vain for progress in the larger world.(13) There is perhaps no better place to begin to impart an awareness of human dignity than in the small world of the doctor-patient relationship. At entry to medical school, were each student to be given a copy of the Universal Declaration of Human Rights and asked to commend its essence to memory, by the time of graduation each article would be linked to recollections of people met and understood, people taken care of as patients and encountered as peers. Thus are patterns of a lifetime set, preparing this next generation of practitioners for practice into the next century. Hippocrates and Maimonides still abide, but the vast changes in situation and circumstance since they spoke create the need for other canons. Jennifer Leaning Senior research fellow Harvard Centre for Population and Development Studies, Cambridge, MA 02140, USA email: jleaning@tiac.net References 1 National Coordinating Committee for UDHR60. Drafting and adoption: The Universal Declaration of Human Rights. Washington: Franklin and Eleanor Roosevelt Institute, 1997 (http://www.udhr50.org/history/overview.htm). 2 Mann J M. The post-war quest for universal human rights. Medicine and Global Survival 1995;2:130-2. 3 Pellegrino E D. Towards an expanded medical ethics: the Hippocratic ethic revisited. In: Bulger RJ, ed. In search of the modern Hippocrates. Iowa: University of Iowa Press, 1987:45-64. 4 Leary VA. The right to health in international human rights law. Health and Human Rights 1994;1:25-6. 5 Eliot T S. The cocktail party. The complete poems and plays 1909-1950. New York: Harcourt Brace and World Inc, 1962:329. 6 Buber M. I and thou. Kaufmann W, trans. New York: Scribner's and Sons, 1970:124. 7 Relman A, Berrien R, Alper P R, Kralewski J E, Dowd B, Reldman R, et al. The changing climate of medical practice. N Engl J Med 1987;316:333-42. 8 Redelmeier D A, Rozin P, Kahneman D. Understanding patients' decisions. JAMA 1993;270:72-6. 9 Smith R. Rationing health care: moving the debate forward. BMJ 1996;312:1553-4. 10 Evans R G, Morris L B, Marmor T R. Why are some people healthy and others not? The determinants of health of populations. New York: Aldine de Gruyter, 1994. 11 Angell M. Privilege and health: what is the connection? N Engl J Med 1993;329:126-7. 12 Slim H. The continuing metamorphosis of the humanitarian practitioner: some new colours for an endangered chameleon. Disasters 1995;19:110-26. 13 Roosevelt E. In your hands: a guide for community action for the tenth anniversary of the Universal declaration of Human Rights. New York: United Nations, 1958 (http://www.udhr50.org/history/default.htm). 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