Judicial amputations in Sudan

According to news and NGO reports, a judicial cross amputation recently took place in Sudan. The cross amputation, in this case, was the amputation of a man's right hand and left foot. The man was charged with armed robbery, and this was part of his punishment. But amputation is usually a medical procedure, so it is suspected that health professionals and institutions were involved, more specifically doctors at Khartoum's Al-Ribat University Hospital.

Human rights groups and representative of medical associations are protesting this form of punishment as barbaric, and the involvement of medical practitioners in judicial amputation as reprehensible. Amnesty International calls the practice a clear violation of prohibitions against cruel and inhumane punishment. A spokesman for the World Medical Association said judicial amputation is contrary to their guidelines regarding physician participation in torture and ill-treatment of persons. Similarly, the British Medical Association issued a statement about the impermissibility of using clinical skills for non-clinical, judicial purposes.

The involvement of medical professionals in anti-Hippocratic activities -- in order to promote the morally questionable purposes of a state -- is fairly widespread. Judicial amputation is just a particularly vivid form. Less vivid, but no less questionable, is the involvement of physicians in capital punishment or 'harsh interrogations.' Anti-Hippocratic activities elsewhere may be regarded as a form of justice or justified by national interests closer to home.

Human rights, science and development spotlight at Sci.Dev

The SciDev.net website is devoted to communicating news and views about science, technology and the developing world. I have used material from their excellent website to blog in the past, particularly their informative section on research ethics. Last week, they published a Spotlight entitled Linking Human Rights, Science and Development, including a number of opinion pieces about the promise of technological development (particularly in medicine, agriculture, and communications) for developing countries.  The main thrust of the articles is that technological advances and investments in the developing world must be informed by/constrained by human rights considerations in order to avoid exploitation of persons and natural resources, to combat research being disproportionally focused on disease affecting the more world's affluent nations, to ensure equitable access to health and health care, to involve more women in science and otherwise combat gender inequity, and to increase benefits of scientific advances for local communities. All of this sounds fine and good, but of course the more you put into the job description of human rights, the more expectations you create, as well as more skepticism: to what extent can human rights really deliver any of this?

I have been in two minds about human rights approaches to anything for quite awhile. On the one hand, human rights approaches can sometimes get positive things done by using the law as a way of forcing reigning powers to change their ways. One can hardly doubt the relevance of human rights discourse in settings plagued by oppression and poverty. On the other hand, ethics has more to it than rights, and bioethics has more to it than human rights. It is important to develop ethical arguments pro and contra practices, trends, and actions even if these arguments are not easily or immediately translatable into law. It is about developing, maintaining and questioning what Simon Blackburn calls the 'ethical climate', using the full vocabulary of ethics: virtues, consequences, obligations, care, compassion, solidarity and so on. Those voices too have to be brought to bear as the developing world is increasingly integrated into the (capitalism-driven) science and technology bandwagon, with all its benefits, seductions and pitfalls.    

Are countries that ratify human rights treatises more healthy than others?

One might think that a country which has ratified human rights treaties, and thus has made them to some extent law, will have better health outcomes than countries where this is not the case, all things being equal or at least controlled for. A study just published in The Lancet indicates otherwise. The researchers looked at some key and often-measured health and social indicators, and sought correlations between number of treatises ratified and changes in health/social indicators before and after ratification of health-related human rights treatises, as well as making comparisons between health/social indicators in a total of 170 countries that did or did not ratify certain treatises.

The results are sobering, or perhaps predictable, depending on one's pre-existing opinions about the power of human rights approaches to health. Ratification of human rights treatises does not seem to have any significant effect on maternal mortality, infant/child mortality and life expectancy. The researchers try to put a brave face on the data, by adding that ratification of human rights treatises can have some indirect (but hard to pin down) effect on health by strengthening legal arguments aiming to ensure access to health care. But in the end, money trumps law: there is much greater evidence of an association between economic conditions and health than there is between the ratification of human rights and health.

One might object by saying that ratification is the mere promise of action, just the signing of a paper, and we should only expect an effect in terms of health outcomes in countries that rigorously monitor, enforce and make its human rights commitments real. In other words, in finding no significant association, what the researchers have actually done is study the global absence of political will in regard to human rights relevant to health.

Bioethics and democracy in developing countries

The fields of bioethics in many developing countries -- despite some important 'capacity-building' initiatives -- have a very limited impact. There are a few people trained in bioethics here and there, some (underfunded) centers and attenuated networks, a few scattered publications. But why should that be the case? Bioethics is decades old by now, and research and medical practice among vulnerable populations in such settings raise a great many ethical challenges. So you would think there would be more activity, more interest.

In BMC Medical Ethics (free online access here), Ghaiath Hussein takes a shot at an answer. And his answer is: politics. The flourishing of bioethics, according to Hussein, depends on a number of political factors that are not present, or only faintly present, in developing countries. The first is an 'atmosphere of freedom' where people can engage in moral reasoning without fear of censorship of or punishment for their beliefs. That atmosphere of freedom in turn depends on a socio-legal framework in which the rights, duties and responsibilities of individual citizens -- both in regard to health and other important values -- are spelled out, understood by the populace, and protected by legislative and judiciary systems. Of course, the development of bioethics is aided to some extent by economic factors, in particular the progress in health systems development and creation of medical technologies. But these would not give rise to bioethics debates they did not engage with public expectations of receiving decent medical care, and citizens having some say in health policy decisions.

It is easier to see what Hussein is saying by reflecting on the place of bioethics within totalitarian or politically oppressive regimes. Where there is little press freedom, there will be less (and less diverse) public debate about controversial issues in medical research and practice. Where those working in bioethics are regarded as 'human rights activists' and subject to special state scrutiny, it will be difficult to motivate people to pursue these interests. Where people think of health care as a 'gift', and death as a common (and mostly unavoidable) event, the provision of sub-standard medical services will not be regarded as a failure of government and a moral outrage. Where Ministries of Health have historically acted (or currently act) as an arm of an oppressive state, and are as corrupt as any other branch of government, there will be little public trust in ethical codes, regulations, licencing boards, or ethics committees that are attached to these ministries or have received their seal of approval. All of these factors, according to Hussein, have diminished the impact of bioethics in many developing countries, and have reduced it to a mere academic pursuit, tolerated by the powers that be because it is poses no threat to them.

Hussein suggests that bioethics, in some places, is a deeply subversive activity. If real bioethical activity took place in some developing countries (he includes his own Sudan), there would be an ugly and dangerous clash with the established political order. So he suggests a softer approach: depict bioethics as a mere aid to decision-making (rather than embodying important rights and values); couch bioethics in religious or religious-friendly terms; adapt bioethics to local contexts rather than depict it as a fancy 'Western' import. Once it is conceptualized this way, it becomes clearer how long and difficult the road will be before bioethics becomes a social force in developing countries.

Health and Human Rights: new online journal

The journal Health and Human Rights has been around since 1994, and it started out under the editorship of Jonathan Mann. Paul Farmer has took over the reins in 2007, and now it has gone online and open access. The inaugural edition of the journal in this new format has a host of interesting looking articles, but my eye was caught by the piece entitled 'Notes on the rights of a poor woman in a poor country' by Tarek Meguid, Deputy Head of the Department ofObstetrics and Gynecology at Bwaila Hospital and Kamuzu Central Hospital in Lilongwe, Malawi. What is striking about the article is its graphic -- and moving -- description of a vast gap between the human right to health (often in the form of access to basic medical supplies) and what actually happens in health care centers in low-income countries like Malawi. The disjunction between rights and reality can be regarded as a source of inspiration and idealism, in so far as one recognizes the existence of the gap and is committed to narrowing it. But as Dr. Meguid's article illustrates, the commitment and idealism of health care workers in many parts of the world are subject to alarming challenges on every work shift. When the situation on ground is that dire, and the prospects for change seem dim, can the human right to health continue to function as an ideal, rather than a haunting spectre, a biting reminder of failure or source of profound shame?

A world of pain

Pain is oddly subjective and universal. Although you may sympathize, you cannot literally 'feel my pain.' It's mine. But everybody, regardless of historical period or culture, knows what pain feels like: it hurts. And in hurting, it debilitates. Pain has been installed in us (and other sentient beings) for good evolutionary reasons: we need to know when our bodies are damaged. But, unfortunately, pain is a crude messenger. Pain often continues on, and even increases in strength, when we have already long got the point.

The journal Anesthesia and Analgesia is not exactly daily fare of the average bioethics worker, but the July issue contains a number of fascinating articles about the ethics of pain management. One striking consideration is the unequal global distribution of untreated pain. Pain may be universal, but access to pain management is certainly is not: if you suffer from chronic or acute pain, you are better off being Austrian than African. The former stands a good chance of getting opiate or non-opiate treatments; the latter is more likely to have to bite the bullet. And given the HIV/AIDS epidemic, the effects of war, poor sanitation, and the effects of treatable (but not treated) diseases, there may be just more pain needing treatment -- and not getting it -- among poor countries.

While there is distributive injustice in untreated pain between rich and poor countries, the undertreatment of pain is a worldwide phenomenon. Contributors to Anesthesia and Analgesia tackle explanations of the undertreatment of pain, what is ethically wrong about the status quo, and what to do about it. There seems to be a consensus that legal and political pressures (remember the 'war against drugs'?) about potential drug abuse and addiction have hindered aggressive pain treatment by clinicians, even in better-off nations. There are also cultural barriers, such as the belief that pain is natural and inevitable, or that it is a sign of a strong moral character to bear pain than have it relieved. Authors work both sides of the ethical street, arguing that appropriate pain management should be regarded as a human right while also documenting the social and economic consequences of untreated pain.