Medical Professionalism and Human Dignity

Dr. Myint Oo (GP)

Professionalism• It is a vocation or the practice of an art founded upon it is

used in the service of others• Its members profess a commitment to competence,

integrity and morality, altruism, and the promotion of the public good within their domain

• These commitments form the basis of a social contract between a profession and society, which in return grants the profession the right to autonomy in practice and the privilege of self-regulation

• Professions and their members are accountable to those serviced and to society

Oxford English Dictionary

What is Medical Professionalism?

• Basis of medicine’s contract with society

• Places interests of patients above those of physician, provides expert advice on health to society, and maintains standards of competence and integrity

• Physicians can play as guardians of human rights http://physiciansforhumanrights.org

Medical Professionalism

As “commitments” to the:• integrity of the human body• informed consent and freedom from coercion• equity and fairness in health care• principle of medical ethics — do no harm

Hippocratic Professionalism

• When taking the Hippocratic Oath, a doctor makes a promise to his or her patients to “keep them from harm and injustice”

Three Fundamental principles of Medical Professionalism

A guide to understanding physicians’ professional responsibilities to individual patients and society as a whole

Primacy of Patient Welfare Patient Autonomy Social Justice

Primacy of Patient Welfare

• The principle is based on a dedication to serving the interest of the patient

• Altruism contributes to the trust that is central to the physician-patient relationship

• Market forces, societal pressures, and administrative exigencies must not compromise this principle

Patient Autonomy

• Physicians must have respect for patient autonomy. Physicians must be honest with their patients and empower them to make informed decisions about their treatment

• Patients’ decisions about their care must be paramount, as long as those decisions are in keeping with ethical practice and do not lead to demands for inappropriate care

Social Justice

• The medical profession must promote justice in the health care system, including the fair distribution of health care resources

• Physicians should work actively to eliminate discrimination in health care, whether based on race, gender, socioeconomic status, ethnicity, religion, or any other social category

Today's Definition of Medical Professionalism

Medical professionalism is evolving from: 1. autonomy to accountability 2. expert opinion to evidence-based medicine 3. self-interest to teamwork and shared

responsibility

Physician's Rights in Patient's Care

• (1) decent working conditions and fair pay; • (2) freedom of association, including

unionization; • (3) due process and related rights such as fair

hearing; protection of privacy and reputation; and freedom of expression and information

Advancing Human Rights in Patient's Care

Human Dignity

Means protecting another's self-esteem, a sense of pride that causes you treat yourself and others with self respect, placing value on life

Human Dignity is inviolable. It must be respected and protected ѽ Dignity gives an individual a sense of value and worth ѽ

Human Dignity It denotes respect and

status, and it is often used to suggest that someone is not receiving a proper degree of respect, or even that they are failing to treat themselves with proper self-respect

Health Systems Versus Human Dignity

• Health systems can too often be places of punishment, coercion, and violations of basic rights—rather than places of treatment and care

• In many cases, existing laws and tools that provide remedies are not adequately used to protect rights

Twenty Mechanisms for Addressing Torture in Healthcare : Publication of Open Society Foundations

Physician and Human Dignity

A PHYSICIAN SHALLin all types of medical practice, be dedicated to providing competentmedical service in full technical and moral independence, with compassion and respect

for human dignity

World Medical Association

Physician and Human Dignity

• physicians shall commit to "respect human life and the dignity of every individual; ...refrain from supporting or committing crimes against humanity and condemn all such acts

• physicians shall commit to advocate for social, economic, educational, and political changes that ameliorate suffering and contribute to human well-being"

American Medical Association

Crimes Against Humanity• deportation or forcible transfer of population• enforced sterilization, or any other form of sexual

violence• enforced disappearance of persons• inhumane acts intentionally causing great suffering or

serious bodily or mental injury• Refusal to allow humanitarian aids/inadequate and

inhumane response to natural disaster – R2P• Ethnic cleansing (genocide)• Enslavement

International Criminal Court (ICC)

UNESCO Declaration

The Article 2 states

"Everyone has a right to respect for their dignity"

Declaration of Helsinki (DoH)

• The Article 11: "It is the duty of physicians who participate in medical research to protect the life, health, dignity, integrity, right to self-determination, privacy, and confidentiality of personal information of research subjects

World Medical Association 1964

Convention for the

Protection of Human Rights and Dignity of the Human Being

The convention's preamble contains:• Convinced of the need to respect the human being

both as an individual and as a member of the human species and recognizing the importance of ensuring the dignity of the human being

• Conscious that the misuse of medicine may lead to acts endangering human dignity

• Measures are necessary to safeguard human dignity and the fundamental rights and freedoms of the individual with regard to the application of medicineCouncil of Europe 1999 Treaty

Universal Declaration of Human Rights

Article Three:

“ Everyone has the right to life, liberty and security of person ”

Universal Declaration of Human Rights

No one shall be subjected to torture or to cruel, inhuman or degrading treatment or punishment

Article 5

Universal Declaration of Human Rights

Human Rights Basis for Professionalism in Health

Care• Improve patient care by enhancing

cultural competency, recognizing root causes of disease, and helping people stay healthier longer

• Build community health to provide accessible, affordable, and quality care

• Enhance health policy by using human rights to advocate for closing of racial disparities

Human Rights Approach to Health Care

• The principles of patient welfare and social justice are central to the right to health and medical professionalism

• The commitment to improving access and quality of care mirror the right to health’s fundamental “AAAQ” framework, which demands health services be available, accessible, acceptable, and of good quality.

• the commitment to science and the assurance of confidentiality are critical concepts to a human rights approach to health

AAAQ Framework

• Availability- health facilities, goods, and services must be available in sufficient quantity

• Accessibility- health services must be accessible to everyone without discrimination

• Acceptability- health services must be respectful of medical ethics, culturally appropriate and gender sensitive

• Quality- health services must be scientifically and medically appropriate and of good quality

What is Medical Neutrality?

Is the principle of noninterference with medical services in times of armed conflict/civil unrest

Warring factions must: protect civilians; allow sick and wounded civilians and soldiers both

to receive care regardless of their political affiliations; and

refrain from interfering with medical facilities, transport, and personnel PHR Toolkit

Principle of Medical Neutrality

• Medical professionals are trained to treat those in need – regardless of politics, race, or religion – and governments must respect that duty

• Attacks on health professionals and the sick and wounded violate the principle of medical neutrality and are grave breaches of international law

PHR Toolkit

Medical Neutrality Ensures:• The protection of medical personnel, patients,

facilities, and transport from attack or interference

• Unhindered access to medical care and treatment

• The humane treatment of all civilians; and• Nondiscriminatory treatment of the injured

and sick

Violations of Medical Neutrality• Attacks on health care facilities,

medical personnel, and patients

PHR Toolkits

• Wanton destruction of medical supplies• Willful obstruction of medical ethics• Deliberate misuse of health care facilities, services, uniforms, or insignia• Deliberate blocking of access to healthcare facilities and care• Arbitrary arrest or detention of medical professionals or patients

Violations of Medical Neutrality• occur when civilians are turned into deliberate targets during

times of war or civil unrest• Armies shell cities, obstruct the flow of food and medical

supplies, and use human shields• Militaries undermine health care and retaliate against the health

professionals who treat the sick and wounded• Violations of medical neutrality can rise to the status of war

crimes, a grave breach of the Geneva Conventions, which govern the laws of war

• As well, during periods of civil unrest, violations of medical neutrality can violate important human rights treaties such as the International Convention on Civil and Political Rights (ICCPR), the International Convention on Economic, Social, and Cultural Rights (ICESCR), and the Convention Against Torture (CAT)PHR Toolkits

Hospital Under Attack

Physician persecution anywhere is a threat to professionalism everywhere

AMA Ad hoc Physicians Persecution Advisory Group (PAG)

Laws of War• Laws of war protect the sick and wounded and the

medical professionals who treat them during times of armed conflict/civil unrest

• The Medical Neutrality Protection Act of 2011: Authorizes the United States to withhold military assistance to countries found to be in violation of the principle of medical neutrality; and

• Encourages the US to use its voice at the UN Human Rights Council to establish a Special Rapporteur on medical neutrality

Universal Declaration of HR• All human beings are born free and equal in

dignity and rights• Everyone has the right to life, liberty and

security of person• No one shall be subjected to torture or to cruel,

inhuman or degrading treatment or punishment

• Everyone has the right to recognition everywhere as a person before the law

Human Rights and Good Health

• Physician has obligation to respect and advocate for the human rights of their patients and society, as a means to promoting good health

American Medical Association

WMA Human Rights• The (WMA) focuses its human rights advocacy

on promoting the universal ethical practice of medicine

• Specifically, WMA seeks to protect the rights of physicians to practice according to the ethical precepts of our profession, without persecution or interference from the state or others

WHO Human Rights

• WHO Constitution: "the enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being..."

"The world needs a global health guardian, a custodian of values, a protector and defender of health, including the right to health"

Dr Margaret Chan, Director-General, WHO

Linkage between Health and Human Rights

Violations or lack of attention to human rights can have serious health consequences

Harmful traditional practices Slavery Torture and inhuman and degrading treatment Violence against women and children

Linkage between Health and Human Rights

Health policies and programs can promote or violate human rights in their design or implementation

Freedom from discrimination Individual autonomy Rights to participation, privacy and

information

Linkage between Health and Human Rights

Vulnerability to ill-health can be reduced by taking steps to respect, protect and fulfill human rights

Freedom from discrimination on account of race, sex and gender roles

Rights to health, food and nutrition, education, housing

Linkage Between Health and Human Rights

Medicine and Human Rights

The learning objectives for this issue on medicine and human rights are:

1. Understand the physician's role as an advocate for human rights, especially for vulnerable populations2. Recognize how health professionals may be involved in the documentation and adjudication of cases of human rights abuses3. Recognize that physicians have been used as agents of the state in abusing human rights.4. Understand the rights-based approach to promoting health

• As physicians, we have a special responsibility to be defenders of human rights, one that is grounded in our heritage of caring for the sick and suffering

• We are bound by a principle of medical neutrality which requires us to treat the wounded and injured whether they are friend or enemy

• Because of our social status, when we speak, people listen, and thus we must speak up for people who have no voice and hold accountable those who commit human rights abuses

(AMA- Virtual Mentor)

Declaration of Geneva - WMA 2006

I WILL NOT USE my medical knowledge to violate human rights and civil liberties, even under threat

Torture in the World Today• Amnesty International documented cases of torture and

other cruel, inhuman or degrading treatment in 81 countries in 2007

• Some studies indicate that between 5 and 35% of the world’s refugees have been estimated to have experienced torture

• In 2007, there were 15.9 million refugees around the world and an estimated 26 million people displaced internally by conflict

• The number of torture survivors in the world today may range from 2 to 15 million

• These estimates do not include those affected by war or other human rights violations

Abusive medical treatment

• Health professionals should also be wary of any attempts (from officials) to ask them to administer treatment or medication that are not aimed at benefiting the physical or mental health of the patient, but only at assisting an interrogation or the management of a patient or detainee

• The individual need not be in prison, or in detention at all, to be tortured. Health professionals must be aware that they might be considered responsible for ill-treatment in settings where patients do not have freedom of movement, for example, those detained under mental health legislation or in facilities for the elderly

• Inappropriate use of medical treatment, such as overuse of sedatives, may also be ill-treatment

Duties of the health professional

• Health professionals have a duty to treat all patients without any form of discrimination and to provide treatment based only upon medical criteria without outside influence

• In cases where torture or other ill-treatment is suspected, the health professional must keep in mind that these are crimes under international law, and probably domestic law

• The health professional’s duty is to document objectively any psychological or physical findings and, where pertinent, provide treatment or referral to colleagues for treatment

• To do nothing may be seen as acquiescence and as compounding the abuse

Physician and Torture

Ethical rules directly prohibiting involvement in torture

The World Medical Association’s 1975 Declaration of Tokyo, Guidelines for Medical Doctors Concerning Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment in Relation to Detention and Imprisonment, contains an unequivocal prohibition on any form of active or passive participation of a doctor in torture or other ill-treatment

WMA Guidelines

• The doctor shall not provide any premises, instruments, substances or knowledge to facilitate the practice of torture or other forms of cruel, inhuman or degrading treatment or to diminish the ability of the victim to resist such treatment

• The doctor shall not be present during any procedure during which torture or other forms of cruel, inhuman or degrading treatment are used or threatened

Medical Torture

Primary loyalty to the patient

• According to the Tokyo Declaration “…the doctor’s fundamental role is to alleviate the distress of his or her fellow men, and no motive whether personal, collective or political shall prevail against this higher purpose.”

• According to the World Medical Association’s Declaration on the Rights of the Patient, “whenever legislation, government action or any other administration or institution denies patients these rights, physicians should pursue appropriate means to assure or to restore them"

Dual Obligations

• Health professionals have dual obligations or ‘dual loyalties’

• They owe a primary duty to the patient to promote his or her best interests and often a separate duty to employers

• There is also a general duty to society to ensure that violations of human rights are prevented

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DISCUSSION TIME

Group Exercises

• Please mention three methods of inhuman treatment you have seen or heard?

• Did you witness any violation of medical neutrality in your country?

• As a physician, how would you protect and defend Human Rights?