A question of ethics?
Humanitarian medicine: up the garden path and down the slippery slope Deborah Harding-Pink, former medical officer1 Twelve years ago, I joined an International Committee of theRed Cross mission to visit detainees in South African policestations under apartheid. As I was leaving, a colleague gaveme Medicine Betrayed, the BMA's pioneering report on the participationof doctors in human rights abuses. It seemed so relevant tothe issues with which I was confronted as a "humanitarian" doctor.My missions with the Red Cross and then with MédecinsSans Frontières took me to countries at war such as Liberia,Tajikistan, Rwanda, Burundi, and Kosovo. These experiences reinforcedmy conviction that humanitarian medicine was a powerful antidoteto the violations I had read about in Medicine Betrayed. I nowworry that it can also become an unsuspecting accomplice ofthese same violations.In 1995, I joined the International Organisation of Migration(IOM), another organisation with a humanitarian mandate. Asits occupational health officer, I followed the work of IOMstaff in over 70 countries, many of which I visited, includingAfghanistan and East Timor. My work has slowly made me realisehow easy it is to be absorbed in a system and to slide downthe slippery slope of failing to perceive human rights abuseswhen dealing with migrants and asylum seekers. This issue wasmentioned only briefly in Medicine Betrayed. The politicisation of migration has meant that doctors are underincreasing pressure to participate in actions to prevent peopleseeking asylum in rich countries. Doctors can thus become involvedin actions that are at the limit of international humanitarianlaw and human rights. Some doctors have acted courageously. Dr Ginette Marchant wasemployed as a doctor in the Vottem centre for asylum seekersin Belgium in 1999. Eleven months later she resigned. She realisedthat she was being used as an alibi to give the centre a caringsocial image. She found it impossible to provide adequate medicalcare to detainees subjected to psychological violence and toensure that confidentiality was respected. She tried to informdetainees of their rights, incurring the wrath of officials.Finally, she became convinced that the detention was totallyunjustified and that she had been drawn unwittingly into supportinga system that violated human rights.Dr Maarten Dormaar left after four months working for the IOM.He was employed as a psychiatrist to work on the Pacific islandof Nauru, where hundreds of asylum seekers (men, women, andchildren) had been detained since September 2001condemnedto idleness and constantly guarded by more than 100 securityguards. Some of the asylum seekers had been rescued at sea bythe Norwegian ship Tampa; others had tried to enter Australia. Since his return Dr Dormaar has tried to mobilise public opinionin the Netherlands and Australia (with some success). In December2002 riots broke out in a Nauru camp. IOM staff, including nursesand doctors, were threatened by asylum seekers, who could nolonger tolerate indeterminate detention and constant pressureto return to their countries of origin, which included Iraq,Afghanistan, and Iran. The Australian government finances the whole Nauru operation.IOM is the main contractor. Thus even a well established organisationlike IOM, which has repeatedly proved its value in difficultsituations, becomes compromised as the de facto detaining authority.Its medical staff thus face ethical dilemmas for which theydo not receive clear guidance. An internet advertisement foran obstetrician and gynaecologist to be contracted by IOM reads,"Working in Nauru will give you a flavour for the `Pacific Way.'You will be able to experience the relaxed lifestyle and savoursome of what the Pacific has to offer with the sea, sand andsmiling faces." They were kept on Nauru as part of the Australian government's"Pacific solution," designed to prevent asylum seekers reachingits territory. Dr Dormaar witnessed worsening mental healthproblems, including depression and acute stress reactions, andclaims that IOM did not act on his reports.It does not mention the complex human rightsand ethical issues facing doctors who have to deal with refugeeswho have become prisoners.Last summer I visited the Hiroshima Peace Museum, the KyotoMuseum for World Peace, and London's Imperial War Museum (whereI saw the Holocaust exhibition). All three showed how easilydoctors can become involved in abuses. The risk is that we rememberthe most grotesque casesthe collusion of the German medicalprofession with the Nazis, the active involvement of Japanesedoctors in experiments on humans, and the Allies' inadequatecare for the victims of the Hiroshima bombwhile failingto react in a timely way to new potential abuses.Summary points Political action to control migration to richercountries makes asylum seekers vulnerable Doctors working withasylum seekers may find tension between professional valuesand the policies of their employers Stronger guidelines areneeded on human rights and ethical issuesThe issue here is not how the Belgian authorities, IOM, or theAustralian government deal with asylum seekers. It is abouthow doctors find themselves torn between the policies of theiremployers and their professional values, thus allowing projectsto get into tight corners. We lack a strong system of standardsand ethical guidelines for doctors dealing with migrants andespecially with asylum seekers. There are several settings wherethis lack of directives makes doctors vulnerable: Working in detention facilities for asylum seekers or in holdingareas at airports for illegal migrants Assessing the medicalconsequences of torture and more generallyproviding reportswhich can influence the destiny of migrantsand their families Treating seriously ill patients who face expulsion to countrieswith inadequate health facilities Coping with the psychologicaldisturbances of children of illegalmigrants facing constantuncertainty Being directly involved in expulsionprocedures.The rhetoric about human rights and humanitarian law at thelevel of international organisations, congresses, and medicaljournals does little to help such doctors. Perhaps the discourseabout health and human rights and humanitarian action shouldconcentrate more on failures in enforcement and a patchy settingof standards. In the past 12 years, I have learnt how medicinecan be betrayed in many ways and how we need to be especiallyvigilant when cloaked in a humanitarian mantle.Doctors dealing with asylum seekers need clearer direction onhow to manage human rights issues and avoid being drawn intoabuses Competing interests: DH-P worked for the International Organisationof Migration from 1995 to 2003  |
