Should doctors boycott working in Australia’s immigration detention centres?
BMJ 2016; 352 doi: https://doi.org/10.1136/bmj.i1600 (Published 22 March 2016) Cite this as: BMJ 2016;352:i1600
All rapid responses
The allure of exercising power or seeking political influence through withholding medical services is not insignificant and maybe a cause of unacknowledged conflicts of interest. Withdrawal of medical service is in its most favourable light directing people to increase their suffering for their own or for others' long term good. Our government uses similar logic to justify mandatory detention.
Informing each asylum seeker of the risks involved in a medical boycott, the specific aim of the boycott, the likelihood of successfully realising that aim and then asking each person to consent to have their own or their child's medical care withdrawn is arguably a more ethical approach.
Competing interests: No competing interests
The choice presented is boycott or commit a crime daring prosecution, I sympathise with the former but salute the latter. Make no mistake that with an election looming examples of those speaking out in favor of asylum seekers will be used for political ends. Up till now doctors have undertaken activities that range from collaborative care through to research with publication and even some civil disobedience (protesting and refusing patients from being discharged from hospital) but which are now, through legislation (Australian Border Protrol Act 2015), have been reconfigured as a crime. It can also be said that encouraging doctors working in detention centres to seek clinical opinions from colleagues or peers through chat forums, CME activities or corridor conversations can also now be considered as committing a crime as the doctor will be discussing the patients condition outside of the detention centre and not directly related to a referral. This will apply to any government employee (specialist, surgeon or ED staff) who have treated an asylum seeker in a public hospital as well , requiring them not to discuss the clinical issues outside the immediate care setting. One can not help but conclude that the doctors have been restrained and have been forced to deliver substandard care ( as they are unable to involve other doctors outside the referral process in the care pathway - think second opinions, review by independent specialists or peer review of management practice ) so that they will be unwittingly part of the brutalisation and psychological torture currently being delivered inside detention centres. This does not apply to doctors treating convicted prisoners in Australia and is out of keeping with Australian standards of freedom of speech, doctors ethical rights to protect the doctor patient relationship and the role of mandatory reporting of child abuse.
What is worse is that abandoning the asylum seekers from receiving medical care is likely to draw attention to the asylum seekers issue at a time when the country is poised for an election and therefore likely to obtain the most impact or change. Perhaps the best approach is a boycott with allowances for skeleton staff to offer the necessary emergency treatments.
Competing interests: No competing interests
Both UNHCR and MSF have now suspended operations on Lesbos:
"The conversion of reception centers for refugees and migrants into detention facilities has led to the withdrawal of support by the U.N. Refugee Agency (UNHCR) and Doctors Without Borders. An agreement struck last week between the European Union and Turkey to return people passing through the country and onward to Greece. It fundamentally shifts the response in Greece from supporting asylum seekers to detaining and returning people who arrive."
http://www.humanosphere.org/human-rights/2016/03/aid-groups-suspend-work...
"UNHCR and MSF withdraw from hotspots describing them as prisons"
http://neurope.eu/article/unhcr-msf-withdraw-hotspots-calling-prisons/
Asylum seekers are detained indefinitely if they manage to arrive on Australian shores and if they are caught at sea they are turned back, including to Sri Lanka, where they are then incarcerated in unknown conditions. The Australian response to the refugee crisis is also not to "support asylum seekers", but to "detain and return people who arrive". And that detention is in conditions so bad it amounts to torture. What is happening in the Australian immigration detention regime is actually much worse than what is currently happening on Lesbos.
My question to Professor Miles is: "How bad does it have to get before it is no longer ethical for medical staff to support this system of detention, refoulement and torture?"
There must be a level at which he feels it is bad enough that it is no longer ethical. For myself, I think we reached it long ago.
Competing interests: As in the original article.
Doctors working at off-shore detention centres in Australia, are unable to work to Australian standards according to their job description. I have worked on Christmas Is and it was impossible to provide even adequate emergency care, let alone everyday care, yet the case is made that we can and do. We cannot and do not. We as medical officers are therefore complicit in further harming these people in the detention centres by continuing the charade that we are practising medical care to Australian standards. If the Government insist IHMS stay and run the so called medical centres, let's call it for what it is; the job descriptions need to accurately reflect the inadequate and unhygienic spaces where 'care' is given; the reality of inadequate medical provisions, equipment, computers and IT services; the logistics nightmare in getting access to some even basic tests; the inability to get sick people to specialist help and the
list goes on. Those in the detention centres understand the charade being played out and emotions range from anger, hate, despair and hopelessness. That includes staff who realise the great game that is being played; we pretend we are caring for you but really it is a pretence as we are making you detainees suffer to try and prevent you wanting to stay or encourage others to come.
So of course Aus doctors should boycott working in detention centres and then perhaps the Government might take appropriate responsible care for those who are in desperate need.
Charity should begin at home.
Competing interests: No competing interests
Without giving mind to the red herrings, ill thought out, misinformed and debunked positions some entirely relevant news has surfaced
MSF are withdrawing from Lesvos, the head of their Greece mission stating:
“We took the extremely difficult decision to end our activities in Moria because continuing to work inside would make us complicit in a system we consider to be both unfair and inhumane,”
There are further statements discussing substandard conditions and the disregard of humanitarian and protection needs.
They discuss their service becoming instrumentalised with the centre changing from becoming a registration centre from which people could find protection in Europe to becoming a mass expulsion operation.
MSF’s explanation continues:
“As an independent humanitarian organisation, MSF is appalled by the adoption of this deal that aims at preventing people from seeking asylum in Europe and doesn’t want to participate to a cynical agreement that doesn’t guarantee that the basic protection and humanitarian needs are covered.”
Thank you MSF for showing what true integrity and medical ethics looks like. How much worse is it that there are still those that argue we should continue to be involved in Australia!
The ethics in the Australian situation are indeed worse. To all the reasons given above we must add indefinite detention, child abuse and torture.
Bear in mind that Australian healthcare staff are not working in a humanitarian capacity, they are infact remunerated very well indeed.
The excuses for not adopting a boycott are now worn very thin.
Competing interests: No competing interests
I appreciate Dr. Berger's quote of the MSF action however he elected to omit MSF's significant elaboration on its action which includes other NGOs working on site among other activities.
"We will continue to run all lifesaving activities and emergency medical care. In Lesvos we will continue to operate in our transit centre in Mantamados where new arrivals are offered first assistance and our sea rescue activities on the northern beaches of Lesvos. We will also continue to run mobile clinics on the island of Lesvos for those outside of the hotspot.
MSF will do its best to mitigate the impact of this decision on the health and conditions of refugees and migrants arriving on the island. We will continue to conduct lifesaving rescue activities at sea and to guarantee medical emergency care after landing. ... a medical mobile team will operate out of the centre to cover the needs.
MSF has never been the sole and only actor providing medical care in Moria: after our departure, other NGOs are still accepting to provide medical attention to people inside the camp. Nonetheless, it remains understood that a gap in assistance will be created after wedepart. We will continue to provide assistance after arrival on the island in case of people’s overflow out of Moria camp with dedicated mobile teams. We are also currently exploring the possibility to support local hospitals in case of severe referrals out of Moria." http://www.msf.org.uk/node/30511
Competing interests: No competing interests
Published today, 23rd March 2016. I completely support MSF's position in refusing to be complicit in an 'unfair and inhumane system', which 'has no regard for the humanitarian or protection needs of asylum seekers and migrants'. James Lawler, this really is not an 'abstract ethical debate'.
Greece: MSF ends activities inside the Lesvos “hotspot”
http://www.msf.org.uk/article/greece-msf-ends-activities-inside-the-lesv...
< “We took the extremely difficult decision to end our activities in Moria because continuing to work inside would make us complicit in a system we consider to be both unfair and inhumane,” said Marie Elisabeth Ingres, MSF Head of Mission in Greece. “We will not allow our assistance to be instrumentalised for a mass expulsion operation and we refuse to be part of a system that has no regard for the humanitarian or protection needs of asylum seekers and migrants.”>>
Competing interests: As in the original article.
Naturally, I disagree with James Lawler. This is not an 'abstract ethical debate' at all. Doctors working in these centres are in an impossibly conflicted ethical position. There is a point where the level of ethical conflict is too high for doctors to be able to continue to practice and I believe we have reached that point for all the reasons outlined in the main article.
In practical terms, as he says, many of the positions are already being filled with overseas doctors anyway and the operational impact of a boycott would be limited, but that was never my argument for a boycott. Of course, a boycott by medical professionals makes a clear moral statement and sends a message of abhorrence from the profession, by-products which are to be welcomed, but they are secondary to the fact that a boycott is an ethical necessity.
Competing interests: As in the main article.
I respect the views of both DB and SM with regards to an important ethical and moral issue (1). However the abstract ethical debate about the possibility of Australian doctors boycotting working in immigration detention centres is nothing but a distraction from the practical realities which the profession faces.
As the President of the Australian Medical Association (AMA) Professor Brian Owler has pointed out on multiple occasions (2), he nor the AMA could stop doctors working in detention centers if they tried. Any call for a boycott will continued to be ignored by those who consider it their moral duty to care for asylum seekers, regardless of DB's fear of how they will be remembered by "historians".
Importantly, Australia's Government does not employ doctors directly to work in immigration detention, but rather contracts International Health and Medical Services (IHMS) to deliver medical care to detainees (3). IHMS has no obligation to employ Australian doctors, and were they to boycott those positions, IHMS would hire doctors from overseas - a practice which is in fact already occurring (2). Thus a boycott would not affect the Australian Government's ability to provide health services to asylum seekers, and would instead leave Australian doctors with an interest in advocating for their patients unable to effectively advocate to the Australian public for change.
Both of these factors make the philosophical ethical debate on a doctor boycott of immigration detention null and void. The medical profession will not be able to clear its conscience of the "state-sanctioned child abuse" (2) committed by our government by simply deciding not to be involved. The only effective solution is for Australian doctors to continue to provide medical care for asylum seekers to the best standard they can, whilst continuing to shift public opinion and government policy in order to withdraw refugees from indefinite detention.
References:
1. BMJ 2016;352:i1600 http://www.bmj.com/content/352/bmj.i1600
2. Owler B. Speech at AMA Asylum Seeker Health Forum, 21 Feb 2016. https://ama.com.au/media/ama-speech-prof-owler-ama-asylum-seeker-health-...
3. Joint Select Committee on Australia's Immigration Detention Network. Final report. Chapter 4 — Provision of health services to people in detention. Canberra: Commonwealth of Australia, 2012. http://www.aph.gov.au/Parliamentary_Business/Committees/Joint/Former_Com...
Competing interests: I am the immediate Past President of the Australian Medical Students' Association, which has a policy on refugee and asylum seeker health which can be found here: http://media.amsa.org.au.s3.amazonaws.com/policy/2013/2nd%20Council/201307_refugee_and_asylum_seeker_health_policy.pdf
Re: Should doctors boycott working in Australia’s immigration detention centres?
By Gary Flynn's argument, no doctor can ever withdraw medical services for ethical reasons unless the patient explicitly consents.
A man who has had his leg broken by an iron bar under torture is unlikely to agree that a doctor on site should withhold treatment for it, even if it means that by doing so he will then be rendered fit for further torture. Does that mean that doctors can never refuse to offer treatment as an integral part of a torture regime? Do doctors have no ethical autonomy? Are they compelled to do whatever patients tell them in all circumstances?
Presumably, he thinks that MSF, UNHCR and all the other agencies should have sought explicit consent from every refugee in the detention camps on Lesbos for their decision to cease providing medical services and so cease to be an enabling factor in a regime of detention and forced return. Are they really acting out of a sense of power at the allure of withholding medical services?
One can take the path of moral self-reflection too far. Sometimes, one just has to stop tying oneself in ever decreasing knots in the quest for moral purity and just act, lest the opportunity be lost.
Competing interests: As per the original article.