Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Isn't conscience part of our ethical guard?
- Trevor Stammers (13 March 2006)
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Guantanamo: a call for action
- Sabahat A Wasti, Sajid Z Bhatti Staff Physician Rehabilitation Medicine Portsmouth Hospitals Trust Portsmouth (14 March 2006)
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Would GMC dismiss a complaint against Dr.Mengele of Guantanamo?
- Christopher J Burns-Cox, Andrew Rouse, David Halpin, Vidhu Mayor and Tom Marshall (17 March 2006)
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Guantanamo: a call for action
- David J Nicholl (27 March 2006)
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Guantanamo: a call for action
- Dr Michael Wilks (27 March 2006)
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Trevor Stammers, Senior Tutor in General Practice St George's, University of London
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I agree with Michael Wilks that Lifton has "shown the ease with doctors can drop their ethical guard"(1), as I pointed out in my response (2) to Savulescu's recent article opposing conscientious objection in medicine (3). Whilst fully endorsing Wilks’ call to action, the irony of it appearing to be totally undermined by the ethical position recently championed in the BMJ by Savulescu, should not pass without comment. Conscience is surely an essential part of our 'ethical guard' which, according to Wilks, we have a 'duty' to exercise? Savulescu’s few supporters however claim that, like soldiers, doctors “owe obedience to the chain of command” (4) and should simply obey orders. Could Dr. Wilks explain why I should oppose the force-feeding of prisoners and yet comply with the euthanasia of disabled infants? 1. Wilks M Guantanamo: a call for action BMJ 2006 332 560-1 2. Stammers T Six objections to Savulescu’s Salvos http://bmj.bmjjournals.com/cgi/eletters/332/7536/294#127505 3. Savulescu J Conscientious objection in medicine BMJ 2006 332 294-7 4. Rhodes R The priority of professional ethics over personal morality http://bmj.bmjjournals.com/cgi/eletters/332/7536/294#127926 Competing interests: None declared |
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Sabahat A Wasti, Consulant in Rehabilitation Medicine Northern General Hospital Sheffield S5 7AU, Sajid Z Bhatti Staff Physician Rehabilitation Medicine Portsmouth Hospitals Trust Portsmouth
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Editor Wilks(1) make a compelling case for doctors to adhere to the ethical parameters set in the Tokyo(2) and Malta(3) declarations. Another concern for the medical practioners working in centres where torture is practised must be about treating individuals for moderate to severe medical and surgical conditions only to render them fit to face further torture and abuse. Evidence exist that inmates can suffer from variety of mental health problems in detention centres(4,5). Furthermore, It can be difficult for the medical practitioners to adequately assess the mental state of thier patients, when in weak and poor physical condition. In this context Captain Edmondson's comments, in a letter to Dr Nicholl, on his role in forced feeding of the inmates in Guantanamo are somewhat understandable, even if not totally justified (Owen Dyer. Force feeding at Guantanamo breaches ethics, doctors say (BMJ 2006;332:569 (11 March), doi:10.1136/bmj.332.7541.569-c). In order to prevent inmates being exposed to imposed or forced treatments there needs to be international consensus on obtaining an independently witnessed (representatives of Red Cross or other such organizations) and explicitly worded written consent. This consenr must be periodically reviewed. There should also be an arrangement for legally binding advance directives for catastrophic surgical or medical emergencies. World Medical Association must also seek to encourage world governments to compel prison authorities to keep a consistent and up to date medical records for all inmates. Lastly abusive use of medical data of the prisoners for developmental and research purposes must not be allowed. Tony Blair in the aftermath of 7th July 2005 atrocities said that the rules of the game have changed. Medical practitioners must not allow the politicians to change the ethical basis of medical practice. 1. Guantanamo: a call for action M Wilks BMJ 2006; 332: 560-561 2. World Medical Association. Declaration of Tokyo. WMA, 1975. (Revised 2005) 3. World Medical Association. Declaration of Malta. Geneva: WMA, 1991. 4. Psychiatric disorders among tortured Bhutanese refugees in Nepal; Van Ommeren M, de Jong Joop T, Sharma B, et al: Arch Gen Psychiatry 2001, 58: 475-482. 5. The mental health implications of detaining asylum seekers; Zachary Steel, Derrick M Silo: MJA 2001; 175: 596-605 Competing interests: None declared |
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Christopher J Burns-Cox, Consultant Physician Southend Farm, Wotton-under-Edge, GLOS GL12 7PB, Andrew Rouse, David Halpin, Vidhu Mayor and Tom Marshall
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Changed on legal advice, 3 April 2006 Recently the Californian Medical Board dismissed a complaint of medical mistreatment brought against Dr.E (1) (2). The complaint was dismissed because Dr.E was superintendent of medical services at Guantanamo. He works for the military (1) (2). By dismissing the complaint on these grounds the Board has clearly subjugated its authority to the army and legitimised the the employment of a modern day State Inquisitor. We suggest our own GMC acts just as spinelessly abrogating its responsiblities to unnamed military authorities. In 2004 one of us (AR) asked the legal adviser to the GMC to consider a report that British doctors regularly supported torture (sorry, "stressing") sessions (4). He wrote to the British Surgeon General's Office who "rejected any suggestion of British Forces being involved in torture". More importantly, he informed us that the GMC would not investigate the claim, not because he doubted its seriousness but because the Council has a policy of not investigating claims of professional misconduct unless a doctor is named (5). This stance is clearly absurd. For instance it means that many prisoners who have obviously been abused can never file a complaint because they can never identify the abusing doctor through being hooded, brain damaged or sedated. Were doctors involved in the recently reported force-feeding of detainess by the British in Basra? The British army spokesman refused to give names or other details when requested (B-C). Considering the column-feet devoted to military prisoner abuse, we believe the public and profession could reasonably expect the GMC to isssue clear guidelines for doctors working in the military and act when these are not adhered to. We could also expect the GMC to adopt investigative procedures suitable for use in military situations. What action will it take over the current military actions against the very brave Dr.Kendall-Smith? (6) We suggest the GMC does whatever is necessary to remove these Kafkaesque anomalies. Perhaps it might do well to seek help from Amnesty International, Medact and Doctors for Human Rights. We apologise to the GMC if our interpretation is incorrect. 1 Lawyers will appeal ruling that cleared Guantanamo doctor of ethics violations Janice Hopkins Tanne http://bmjjournals.com/cgi/content/full/331/7510/180-b 2 Force feeding at Guantanamo breaches ethics, doctors say. Owen Dyer http://bmj.bmjjournals.com/cgi/content/full/332/7541/569-c 3 In a quote which would make Joseph Heller proud, Dr.E denied that he force fed prisoners, but that he was "providing nutritional supplementation on a voluntary basis to detainees who wish to protest their confinement by not taking oral nourishment" David J Nicholl, Holly G Atkinson, John Kalk, William Hopkins, Elwyn Elias, Adnan Siddiqui, Ronald E Cranford and Oliver Sacks, on behalf of 255 other doctors. Force feeding and restraint of Guantanamo Bay hunger strikers. Lancet 2006;367:811 4 McManners H. The truth about torture and interrogation. Independent 2004 May 12:37. 5 Correspondence available 6 RAF doctor will face court martial for refusing to return to Iraq. Owen Dyer BMJ 2006;332:748, doi:10.1136/bmj.332.7544.748-h Competing interests: None declared |
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David J Nicholl, Consultant Neurologist Department of Neurology, City Hospital, Birmingham, B18 7QH
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I agree with Michael Wilks (1) that the declarations of the World Medical Association in relation to forcefeeding of hunger strikers will “have limited effect unless national medical associations are willing to make their members accountable when practice departs from principles”. Sadly, it has not been my recent experience that national medical associations and the medical establishment are prepared to fully investigate such breaches. In response to our letter (2), Dr Duane Cady (Chair of the American Medical Association) issued a press statement confirming the AMAs endorsement of the Declaration of Tokyo, yet stating that the AMA is “not a regulatory or licensing agency”. Although this is factually correct, it is simply not sufficient for the AMA to avoid this issue when some of its own members have been involved with forcefeeding in Guantanamo. Clearly, it is incumbent upon the AMA to investigate such serious allegations when the individuals concerned are in danger of bringing the AMA into disrespute. Secondly, our letter was originally submitted to the New England Journal of Medicine in November 2005, but publication was declined “strictly on editorial considerations” nearly 3 months later. Finally, Michael Wilks was originally a co-signatory to the letter, and due to concerns within the BMA’s legal department, had to withdraw as a co-author. I was not prepared to accept a sanitised version of our letter suggested by the BMA when over 250 co-authors, the Lancet, and our own legal advice were all satisfied with the published version. Thus, I would fully agree with Wilks that international medical bodies have a basic ethical duty to use their power to enforce their declarations. In relation to Guantanamo, the international medical community could do well to remember the words of the philosopher Edmund Burke “The only thing necessary for the triumph of evil is for good men to do nothing”. 1. Wilks M Guantanamo: a call for action BMJ 2006 332 560-1 2. Nicholl DJ, Atkinson HG, Kalk J, Hopkins W, Elias E, Siddiqui A, Cranford RE, Sacks O. Forcefeeding and restraint of Guantanamo Bay hunger strikers Lancet 2006;367:811. 3. Cady D. AMA reiterates opposition to feeding individuals against their will. Press release (March, 10th 2006) http://www.ama- assn.org/ama/pub/category/16086.html Competing interests: None declared |
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Dr Michael Wilks, Chair, BMA Ethics Committee c/o Ethics Department, British Medical Association, BMA House, London WC1H 9JP
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I was saddened to see David Nicholl’s rapid response to my letter since it seems unfortunate that we should risk internal divisions in the face of the major problems that need to be addressed. By implication, he also gives a misleading impression in relation to the BMA’s responses to the situation in Guantanamo. The BMA has been in the forefront of lobbying the AMA and other US professional bodies and working with organisations like Physicians for Human Rights and Amnesty International on this issue. It is true that I originally intended to be a co-signatory to his letter to the Lancet but withdrew following legal advice. I did, however, first ask for a revised version to be considered by the other signatories as the BMA remains committed to the underlying approach. As David points out, he refused to consider a revised version. An important part of the reason for my request for the letter to be amended was because the BMA had just finished doing an immense amount of work to revise the World Medical Association’s Declaration of Malta. The aim of this work has been to make unambiguously clear the ethical duty of doctors and other health personnel in this kind of scenario. Advice was taken from experts in management of hunger strikes. The BMA is hopeful that the revision – which was submitted to the WMA Council in early March – will generate greater awareness amongst all national medical associations as well as address the particularly urgent concerns we all have about Guantanamo. Dr M Wilks Competing interests: None declared |
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