Medicine Betrayed: The Participation of Doctors in Human Rights

Book Revi

Iew

MEDICINE

BETRAYED:

The Participation

of

Doctors

in

Human

Rights

Abuses

By British Medical

Association,

Zed

Books, London,

1992.

234

pp.

Reviewed

by Jennifer

Leaning,

MD

1996 is the

5Oth anniversary

of the International

Medical

Trials

(1946-47),

held before an international

tribunal

in

Nuremberg,

where 23

physicians

and

scientists

who

cooperated

in

the eugenics programs,

medical experiments,

and extermina-

tions of the Third Reich were tried

for war crimes and crimes

against

humanity.

The

concluding

section of the

judgment

of

the tribunal, enshrined

since as the Nuremberg Code,

was a

simple

but

unequivocal

ten-point

statement of the

terms under

which

physicians

could

ethically

conduct

experiments

on

their

patients.

The

code, implicitly grounded

on the Hippocratic

in-

junction, primum

non

nocere, provides

the fundamental elements

of

what we

now call the doctrine of informed consent.

In the

years

since

Nuremberg,

there have been several

important

docu-

ments

in

medical ethics and international

human

rights

law

that

have built

upon

this foundation,

in

particular

the Declaration of

Geneva

(1948),

the Declaration

of Helsinki

(1964)

and the Dec-

laration of

Tokyo

(

1975),

all

developed

by

the World Medical

As-

sociation

(WMA).

Taken

together,

these documents

define the

broad ethical and

legal

limits of

physician

interaction with other

human

beings.

Failure to abide

by

the

precepts

contained

in

these

Jennifer Leaning

is the Medical Director

in

the

Health Centers Division at

Harvard

Community

Health Plan. Please address correspondence to

Jennifer

Leaning,

Harvard

Community

Health Plan, 10

Brookline Place

West,

Brookline,

MA

02146,

USA.

HEALTH AND HUMAN

RIGHTS

141

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documents leads physicians

down the path

toward torture and

other gross violations

of human rights, medical

ethics, and

in-

ternational law.

Yet

despite

the

starkness

of historical example

and the richness

of

international standards,

there are still physi-

cians throughout

the world who continue

to comply with gov-

ernments

in

supporting

the use of torture

or other inhumane

punishment as

a

means

of

exercising

state control, repression, or

terror.

Responding

to a

growing

burden of concern about this

per-

sistent

issue,

the British Medical Association

(BMA) published

The Torture Report

in

1986. This was the

first attempt by

a na-

tional

medical

society

to look at the

problem

of

physician par-

ticipation

in

torture,

wherever it was found to be used

by gov-

ernments as

"a routine instrument of

repression."

The

report,

two years

in

the making, found "incontrovertible

evidence of

doctors'

involvement

in

planning

and

assisting

in

torture,

not

only

under

duress,

but also

voluntarily

as an exercise of the

doctor's free will." This

report

committed

the

BMA

to a

policy

agenda

on this

subject

that

it

has affirmed

in a

range

of activities

relating

to education and

advocacy,

both domestically

and over-

seas.

In

that

mode,

the BMA noted

in

1989

that the involvement

of

physicians

in human

rights

abuses

appeared

to be

continuing

in

many parts of

the

world,

and it directed that another Working

Party be formed

and

charged

it

with

writing a follow-up to the

1986

document.

This

report,

Medicine

Betrayed:

The

Participa-

tion

of

Doctors

in

Human

Rights Abuses,

was

published

in

1992.

The

report

is dedicated to the

memory

of Dr.

John Dawson,

the head of the

BMA's

International

Division and the force be-

hind the

Working

Parties

that

wrote both

the

1986

and the

1992

report.

A

visionary

physician

whose

spirited

intelligence and

informed social

conscience

powered many

of the BMA's

reports

and

investigations

during

the

1980s (including

influential texts

on the

medical

consequences

of nuclear

weapons

and nuclear

war),

Dr.

Dawson,

despite

his

untimely

death from cancer

in

1990,

has continued

to exert influence on the moral direction

of

this

prominent

medical

society.

Medicine Betrayed

is

very well organized

by

main

subject

topics

in the

sequence

a rational reader would wish:

an overview

of ethics

and law

relating

to

torture,

a discussion of

the use of

evidence,

an

analysis

of

physician

motivation,

and

then a review

of

major issues,

such as abuse of

psychiatry,

corporal punish-

142

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2 No.

1

ment, capital punishment

and treatment of

hunger

strikers. The

report also

devotes considerable attention to the

oppression of

physicians

who refuse to

comply with orders that violate

recog-

nized tenets of

medical ethics and international

law.

In

defer-

ence to its status as a

follow-up report, frequent reference is made

to changes

which have occurred

since the

1986 assessment,

in-

cluding

the

expansion

of

information now available

from East-

ern

Europe

and

the

former Soviet

Union.

A

major change

since

1986

is the increased number of human

rights

organizations

now

active

in

the

field,

whose

separate

sources of information

pro-

vided

the

Working Party

with a

much richer database than had

been available

to it

for the earlier

report.

The index

is

good

and

the

bibliography

and extensive notes are

responsibly

detailed.

The text could have been

enlivened

by

better use of

tables,

graphs,

and

photographs.

The

reportorial

nature of the text

(writ-

ten

by

committee, reviewing

individual

allegations

and

rebut-

tals)

packs

the book with anecdote but

makes it hard to read at

one

sitting

and

prevents easy

ascertainment of overall trends. As

the

report

is

organized

by topic,

and not

by

country,

it

is difficult

to assess medical

practice relating

to torture and

inhumane treat-

ment

in

any particular

country.

The report is

uniquely

effective in its

discussion of the role

of various national medical

societies

in

combatting

the

forces

within

their countries that

compel physician

participation

in

torture,

and

documenting inadequacies

in

Argentina,

the former

Soviet

Union,

and

Syria,

while

noting

some

progress

in

Brazil,

Chile, Pakistan,

and

Turkey.

The

report

begins

this section

by

stating

that it is "invidious

to

single

out

associations

for

par-

ticular

praise

or criticism"

but

in

fact that is

what is

necessary

and

what,

in

some

instances,

the

Working

Party

found itself re-

quired

to do.

Written

by

physicians

and

jurists,

and

directed at the

physi-

cian

community worldwide,

the

report

is

temperate, wise,

and

empathetic

in

its

analysis

of

why doctors,

who

begin usually by

seeking

to do the

right thing, can, through

circumstance,

condi-

tioning, fear,

ignorance,

or extreme coercion

commit

gross

vio-

lations of

human

rights. Uncompromising

in

tone and

content,

the

report

succeeds

in

outlining

the

major

ways

in

which medi-

cal

educators,

governments,

and

national societies can institu-

tionalize the

supports

that

are needed to

prevent

the excesses

that

are now

taking place.

HEALTH AND HUMAN

RIGHTS

143

Thus the most powerful

and enduring

feature

of the

report

is its

concluding

section

with

its list of 46

recommendations.

Coming

after the

thoughtful

and detailed discussion

of affida-

vits,

testimony,

and

anecdote,

sifted

soberly

in the

context

of

evidentiary

standards,

medical

ethics,

and international

law,

these

recommendations

carry

much

authority.

They

are phrased

as clear

instructions

to the

physician

community

and to

governments

throughout

the world,

and are organized

according

to

the follow-

ing

categories:

involvement of

doctors

in

torture;

provision

of

medical

care to

prisoners

and torture

victims; treatment

of hun-

ger-strikers;

doctors working

in

the

armed

forces,

prisons,

and

other non-civilian

institutions; support

for doctors entering

the

prison

service

and

armed

forces;

strengthening

medical

ethics;

action

by

national medical associations;

doctors and

the

death

penalty;

whipping

and

amputations;

the role of forensic

medi-

cine; protection

of

health

professionals;

care for victims

of hu-

man rights

violations;

other

issues;

and

further actions.

These

recommendations

are

eminently practical

and use-

ful,

not

only

to

those

physicians

whose work

in

prisons

or

the

military

might place

them

in

immediate

jeopardy,

but to all

who

practice

medicine

and see

the need to remain

alert

to ethical

boundaries.

As

further

action,

the

BMA in

accepting

this

report

has

pledged

to

engage

in

a review

of

physician

involvement

in

human

rights

abuses

every

five

years.

It is most

encouraging

to

know

that the

BMA will continue

to

play

its acclaimed

interna-

tional watchdog

role

in

this

arena,

where

it is

increasingly

clear

that while

vigilance

may

not

suffice,

it is essential.

144

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