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EDUCATION AND DEBATE: Duncan Forrest and James Barrett ethical pitfalls can be hard to avoid BMJ 2004; 329: 399-400 [Full text]

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Teaching Human Rights May Help Doctors to Avoid Ethical Pitfalls.

Helen A Bygrave   (18 August 2004)

Teaching Human Rights May Help Doctors to Avoid Ethical Pitfalls. 18 August 2004
Helen A Bygrave, Physicians for Human Rights UK Parliament Hill Surgery Send response to journal: Re: Teaching Human Rights May Help Doctors to Avoid Ethical Pitfalls.	Drs Forrest and Barrett have usefully reviewed some of the problems facing doctors arising from ethical dilemmas (1). Two important issues emerge from their paper and should be addressed - one an amplification, the other a remedy. Firstly, the use of the terms "moderate physical pressure" or "torturelite", risks euphemising torture into acceptability. On January 25 1976,the European Commission on Human Rights held, in a complaint brought by Ireland against the United Kingdom, that certain techniques employed by the British security forces in Northern Ireland constituted torture (2). These included forcing detainees to remain for some hours in a "stress position", keeping a black or navy blue bag over the detainee's head, subjecting the detainee to a continuous loud and hissing noise pending their interrogation, depriving detainees of sleep pending interrogation and subjecting detainees to a reduced diet of food and drink pending interrogation. The UK undertook not to employ the techniques again. Judicial bodies recognize that, in the words of Judge Evrigenis of the European Court of Human Rights,"torture may be constituted by the infliction of mental suffering through the creation of a state of anguish and stress by means other than bodily assault"(3). Calling it "moderate physical pressure" or "torturelite" does not mean it isn't torture. In 1997, when a Government delegation from Israel told the UN Committee against Torture that the use of "moderate physical pressure" was not of sufficient severity to constitute torture, the Committee concluded that the use of such methods did constitute torture (4).On September 16,1999, Israel's Supreme Court, acting as the High Court of Justice, ruled that Israel's interrogation methods amounted to torture and were therefore illegal. Doctors can see from this that the standards of international law regarding the prohibition of torture have been upheld in a consistent manner by the appropriate UN, regional and national bodies. The wording of the principle treaties on the prohibition of torture is remarkably similar, and torture is also prohibited under customary international law. The prohibition on States to use torture is absolute, non-derogable and unqualified.The majority of States have ratified the Geneva Conventions, which apply to situations of armed conflict. The Conventions prohibit torture and oblige States to teach this to their armed forces. Secondly, and importantly for doctors, the international human right to the highest attainable standard of health is a measure which, by placing a patient's health as a doctor's prime concern provides at one an ethical rationale, a nonpartisan canon and a legal justification to resist coercion to discriminate against individual patients, much less be complicit in torture. The right to the highest attainable standard of health has as much force as any other international law, including, for the sake of argument, the Convention against Torture. It is at its most authoritative in Article 12 of the International Covenant on Economic, Social and Cultural Rights, is comprehensively defined in the 65 paragraph General Comment 14, and has been ratified by most countries (5). It obligates both States and health professionals to adhere to its requirements, in contrast to medical ethical codes which are essentially professional, albeit hallowed, guidelines. Doctors should, through their professional associations and other means call governments and intergovernmental bodies to account for policies or practices that lead to torture, including those situations where medical personnel are employed; but they need to do something further. They must call for medical education to include a human rights component.Unlike ethics, which can be culture-bound and are not owned by the patients, human rights codify universally accepted standards that are enforceable by law. Tomorrow's doctors deserve to be taught this. It can help save them and those with whom they work a considerable amount of suffering. 1. Forrest D, Barrett J. Ethical pitfalls can be hard to avoid. BMJ 2004;329:399-400 (14 August) 2. Ireland v UK (5310/71) Report: 25 January 1976 3. Ireland v UK Judgment: 2 EHRR 25 4.. Office of the High Commissioner for Human Rights, Israel M. Concluding observations of the committee against torture: Israel. 09/05/97. A/52/44, paras.253-260 (concluding observations/comments). www.unhchr.ch/tbs/doc.nsf/9c663e9ef8a0d080c12565a9004 db9f7/69b6685c93d9f25180256498005063da?OpenDocument (accessed 17/8/ 2004) 5. United Nations. General Comment No 14; United Nations. 2000 http://www.unhchr.ch/tbs/doc.nsf/(symbol)/E.C.12.2000.4.En?OpenDocument (accessed 17/8/04). Competing interests: None declared