Dual Loyalty and Human Rights in Health Professional Practice: Proposed Guidelines and Institutional Mechanisms (review)

What does the Hippocratic Oath stand for? In what way does it (and its modern reincarnation, the World Medical Association Declaration of Geneva) bind doctors to have unconditional loyalty to their patients? Is a doctor to promote a patient's health over all other considerations? Are intervening circumstances i.e. who the patient is and what pressures the doctor is subjected to—acceptable as exceptions to this rule? When do the declared interests of the state supercede the interests of one patient?

These and a great many other questions are the subject of an insightful study by Physicians for Human Rights (hereafter PHR) and the University of Capetown Health Sciences Faculty (hereafter UCTHS). There is a basic blind trust in most societies towards the men/women in the white coat. Surely, we think, they could not betray us. The report not only discusses the most egregious violations of medical trust as experienced in repressive societies but also discusses the many gradations and instances in countries like the United States where the issues of trust and loyalty come into question. There are many examples where the line between duty and loyalty are gray. However, the instance which is absolutely clear in terms of the medical professional's violations of his/her responsibility and of international human rights law is when physicians knowingly consent to be complicit with the state apparatus of torture, repression and death. Unfortunately, the examples are abundant in modern times—i.e. Nazi Germany, military junta's Argentina, South Africa under apartheid, Iraq under Saddam Hussein and so forth.

In April/May 2003, this author participated in a PHR investigation mission to explore human rights violations in Iraq. We spoke to more than two dozen health professionals. We not only got a sense of the vast net cast by the state of its apparatus of terror—but also learnt to our dismay of the level of participation by physicians in the horrors. While in some instances, the physicians themselves were under severe pressure and believed that they could not "disobey" the orders sent by the head of state, nonetheless, there seemed to be a number of instances where physicians participated with the government in acts that led to the torture, disappearance or death of their fellow citizens. We were told of one instance where a physician fired a handgun and killed another physician who had treated a member of the Shiite resistance and were given a letter written by a physician providing the government the names of three medical students whom he "suspected of planning against the State." The students were later "disappeared."

The more common incident that we heard about was that of forced participation in committing torture. In 1994-1995, Saddam Hussein passed a decree calling on all surgeons, regardless of their specialty, to participate in a national campaign to brand army deserters. The surgeons were called upon to cut the right ear ("saluting ear") of the deserters and to brand their forehead so that they would be recognized and shamed in their communities. The captured deserters were brought to the hospitals and the mutilations were carried out by the surgeons present. Apparently there were a number of cases where the victims had complications, there was no medical aftercare and there was at least one death due to complications.

One surgeon who first relayed this horrific incident to us told us that he had personally hid the entire day that the procedure was being carried out in his office closet. He mentioned that a few surgeons had developed serious mental issues after carrying out the process and a few were unable to practice medicine thereafter. These doctors felt that they had no choice and yet they participated in the state machinery of repression. Recently some in Iraq, including the interim health minister, have called for their...