August 15, 2011

Human rights violations undermine medical professionalism

Law scholar at Johns Hopkins Berman Institute of Bioethics urges collective outcry

Doctors need to become more aware of how governments subtly but profoundly interfere with their professional obligations, with the result that patients’ human rights are violated, a law scholar at the Johns Hopkins Berman Institute of Bioethics says in a commentary published Aug. 3 in the Journal of the American Medical Association.

The JAMA article argues that social policies restrict physicians from doing what’s best for certain patients, says co-author Leonard Rubenstein, an associate faculty member at the Berman Institute. The piece was co-written by Farrah Mateen, a Sommer Scholar in the Department of International Health at the Johns Hopkins Bloomberg School of Public Health.

The authors cite glaring human rights violations overseas. In Turkey, doctors have been asked by schools and state institutions to verify a female’s virginity, with nearly half of surveyed Turkish physicians saying they have performed such an examination. In the 1990s, doctors in Peru carried out a government policy to sterilize rural indigenous people, with 300,000 tubal ligations and 20,000 vasectomies reported. The article also details how government-enforced human rights violations occur in Egypt, where men suspected of having gay sex have been forced to undergo anal inspections by doctors from the Forensics Medical Authority, an agency of the Ministry of Justice.

“While physicians can’t address these infringements on their own, they can and should act collectively to stand up for the human rights of patients, both for their own sake and in order to fulfill their professional obligations,” said Rubenstein, who focuses on the intersection of bioethics and human rights. “In many countries, restrictions on providing medication for pain are so draconian as to prevent doctors from meeting patients’ needs for pain relief.”

Rubenstein says that the issue is largely unrecognized in the United States, even though examples abound of how laws in this country undermine professionalism in medical practice. For instance, North Dakota outlawed an approved pill for first-trimester abortions, which then forced doctors to perform a surgical abortion, even though most physicians would say a drug is safer and less intrusive, Rubenstein said. (A state court recently issued a temporary injunction against this law.)

Rubenstein contends that in the United States, the most notorious example of how some laws result in human rights violations, and thwart doctors’ efforts to act on professional judgment, is the treatment of Guantanamo Bay detainees by military physicians. Rubenstein points to doctors who force-fed inmates on hunger strikes through the use of five-point restraint chairs, based on command decisions rather than independent clinical judgment.

“It is worth noting, too, that U.S. policy requires physicians to act contrary to international and domestic ethical standards,” said Rubenstein, who is also a senior scholar at the Center for Public Health and Human Rights at the Johns Hopkins Bloomberg School of Public Health. “We also know that doctors at Guantanamo were constrained in the medical interventions they could provide for detainees who were tortured.”

The JAMA essay begins by explaining how the trust placed in physicians rests on the assumption that they will follow three fundamental principles of professionalism: acting in patients’ best interests, respecting their autonomy and heeding social justice concerns; in other words, considering available resources and the needs of all patients while at the same time taking care of an individual patient.

The article also asserts that more systemic biases, which doctors cannot defeat through individual actions, can discourage them from following those principles in unseen ways. For example, the passage of prejudicial laws against certain groups, such as those at higher risk of HIV infections, can perpetuate the devaluation of those groups and lead to restrictions on appropriate clinical options for physicians. In the article, the authors say that such stigmas have led some “governments to minimize education on treatment and management of HIV patients.”

The authors conclude that physicians have an obligation to address threats to human rights and medical professionalism, if not by isolated acts, then through collective advocacy. Doctors should turn to professional societies to provide leadership and increase public awareness on human rights.

“Organizations like these can protect physicians from becoming tools for discriminatory or cruel treatment of patients,” Rubenstein said.

Co-author Mateen holds an appointment in the Department of Neurology at the Johns Hopkins University School of Medicine. The article appears in an annual issue of JAMA devoted to human rights and violence.

The Johns Hopkins Berman Institute of Bioethics conducts advanced scholarship on the ethics of clinical practice, biomedical science and public health, both locally and globally. With more than 30 faculty members, most of whom are jointly appointed in the Johns Hopkins schools of Medicine, Public Health, Nursing or Arts and Sciences, the Berman Institute is one of the largest centers of its kind in the world.