Editorials

Health and human rights

The BMA's latest handbook on human rights challenges us all

In 1986 and 1992 the BMA broke new ground in publishing reports on human rights that documented what physicians were doing to the detriment of their patients and profession and identified ways in which medical associations could help constrain such behaviour. ^{1 2} The definition of human rights remained relatively restricted, however, in concentrating on rights in closed institutions such as prisons and psychiatric hospitals. In its latest book, The Medical Profession and Human Rights: A Handbook for a Changing Agenda,³ published last month, the BMA has set its sights on a much wider range of issues and a wider audienceall mainstream physicians and healthcare professionals in Europe and North America.

Certainly, much of relevance to human rights has happened in the past decade, including wars in the former Yugoslavia, Rwanda, and Chechnya; trials and truth and reconciliation processes; the development of the Istanbul Protocol on physicians and torture; and civil campaigns to ban landmines and establish an international criminal court. As a result of these experiences a small segment of the medical community is growing knowledgable about dealing with health and human rights issues of psychological trauma, ^{4 5} cultural and religious clashes on health practices,⁶ the complicity of physicians in repressive regimes,⁷ investigations into mass killings and terror,⁸ and the medical arguments against certain weapons systems.⁹ The BMA could have recounted the lessons learnt, updated its findings on doctors' participation in torture, and considered its job done.

To its credit it has instead taken the opportunity to consider what we all recognisethat the last decade of the 20th century has introduced an explosion of change. The end of the cold war brought sweeping political transformation, release of regional tensions, and increasing forced migration in the wake of conflict and distress. Globalisation, by providing a commercial and technological engine for the movement of people, capital, and information, has accelerated and complicated issues of social proximity. More than ever the world, in all its diversity and pain, is at our doorsteps.

The BMA intends that the medical profession should not escape the moral and social consequences of these changes. Its ambition is to raise awareness among ordinary doctors about the links between health and human rights and to create a framework for advocacy throughout the world. The book outlines the background and history of human rights, analyses practical problems and issues, and moves to philosophical and political discussion of wider universal values (such as dignity and right to asylum) and instruction in how to approach local or cultural norms and practices. Its 550 pages provide a definitive and thoughtful account of what has happened in health and human rights in the past 10 years.

The starting point is the report's recognition that health professionals in the developed world are now dealing with patients from an extraordinary range of populations undergoing extremes of distress. This diversity creates a much wider gap between the provider and the patient, that other person in the examining room, than the traditional power imbalance imposes, and this heightens the potential for unhelpful or harmful interactions. Contacts with people in flight or migration confront the physician with dimensions of human pain and vulnerability that cannot be understood from within the framework of one's own culture.

The Western physician's carefully honed precepts of informed consent, beneficence, and autonomy do not prepare healthcare practitioners to understand the patterns of individual and community harm that can arise from experience of forced migration, mass killings, torture, targeted abuse, systematic rape, loss of home and family, obliteration of culture, denial of political status or economic opportunity, and rejection of personal or group values. Good intentions are not enough. Acting from presumed beneficence but ignorant of what a person has endured before reaching the doctor's office may inflict further injury. Assuming patient autonomy in discussions with prisoners or torture victims may subvert the informed consent process. One must turn to the evolving notions of human rights to find a more comprehensive context in which to recognise how people are affected by power structures that have assaulted and harmed them.

Human rights establishes aspirational definitions of the protections people can claim from the state (such as freedom of expression and the opportunity to practice one's religion) and what constitutes violations of these rights. Human rights does not supplant medical ethics but it provides a counterbalance and wider perspective. Within the medical ethics framework people are patients whose health must be assured and who must be protected from the improper exercise of medical authority and scientific curiosity. From the human rights perspective people are approached as persons who can claim rights from the state and must be protected from the predations of power. Violations of human rights produce health consequences, whether hypertension, psychological distress, genitourinary impairment, or musculoskeletal disability, whose origins physicians must understand if they hope to treat the person, and the person as a member of a community, as well as addressing the symptoms.

Yet it is not just to be able to treat the occasional refugee that the BMA considers it important to educate its constituency in human rights issues. Ignorance of human rights permits physicians to be drawn into unacceptable practices, such as participation in the death penalty or design of inhumane weapons systems. Moreover, the world is inflicting injury on millions of people as a matter of routine oppressionand the medical profession cannot just sit by. The BMA considers it the responsibility of organised medicine to mobilise the profession towards prevention and mitigation. The goal is to propel physicians into proactive protection of individuals and populations from state inflicted harm.

This extraordinary ambition will certainly be perceived in some circles as adding an unacceptable burden to medical training and continuing education. Although the book does not take on all possible sources of resistance, it constructs reasoned limits around the notion of the "right to health," presents a nuanced argument to deflect assertions of cultural relativism, and asserts that for most medical professionals in daily practice in the West the issues raised will occur relatively infrequently. Exceptions will be among those who work with immigrant populations, in humanitarian response overseas, and in institutions, such as prisons, where the will of the state looms large.

Nevertheless, the basic thrust of this book is militantly expansive. The medical profession must move out from its narrow normative niche in medical ethics into the globalised secular debate on suffering and human values, first broached with the Geneva Conventions in 1864, continued by the Nuremberg Trials in 1945-47, and launched fully in 1948 with the Universal Declaration of Human Rights. This book marks a watershed in thinking about how to approach major violations of norms in peace and war. In this brave and laborious effort the BMA has provided the profession with a vast and vigorous perspective on the human condition that will change the life and motivation of every person who reads it.

Jennifer Leaning, professor of international health. 

Harvard Medical School, Harvard School of Public Health, 651 Huntingdon Aveneue, Boston, MA 02115, USA (jleaning{at}hsph.harvard.edu)