Portal de Periódicos da CAPES

Medical journals and human rights

1998; Elsevier BV; Volume: 352; Linguagem: Inglês

10.1016/s0140-6736(98)90292-6

1474-547X

Peter Kandela,

Ethics and Legal Issues in Pediatric Healthcare

Peter Kandela is a general practitioner and medical writer. In 1978, be became a founder member of the British Medical Group of Amnesty international and in 1989 he co-founded Physicians for Human Rights (UK). Since then. he has taken part in various fact-finding missions for both organisations, and is currently an adviser to a number of human rights groups For nearly two decades he has been contributing features on medical and human rights issues to The Lancet and other medical journals: and he is an editorial adviser for the Harvard journal Health and Human Rights. In 1994, Dr Kandela was elected a member of the Royal Institute of international Affairs and he is currently President of Physicians for Human Rights (UK). Today, the principle that all people "are born free and equal in dignity and rights" 1Universal Declaration of Human Rights, adopted and proclaimed by the UN General Assembly resolution 217A(III). December 10, 1948Google Scholar is rarely challenged, but the question of how this can be understood in terms of the relation between health and human rights is still being explored. It has been argued recently that one of the links comes from the recognition that "promotion and protection of health are inextricably linked to promotion and protection of human rights and dignity";2Mann J et al.Health and Human Rights.Health Hum Rights. 1994; 1: 7-23Crossref Scopus (248) Google Scholar and it is precisely this insight that has characterised so much of The Lancety's campaigning work on issues from apartheid and asylums to flogging and forced feeding over the past 175 years. The campaigning aspect of the journal can be traced back to the character and circumstances of its founder and first editor, Thomas Wakley. Initially he had hoped to use the journal to criticise the Peter Kandela behaviour of the medical establishment, but his radical zeal was sharpened by a highly unusual personal experience, which is worth recounting in detail because it explains his relentless championing of the "disadvantaged" of his day. In the spring of 1820, a group of men led by Arthur Thistlewood, a commissioned officer in an underground militia force operating in London, were found guilty of plotting to assassinate a number of government ministers in what has become known as the Cato Street Conspiracy. Six of them were sentenced to be hung, drawn, and quartered. When the time came for them to be taken clown from the gibbet and decapitated, it was said that "so deftly and speedily did the masked operator perform the act that he roused in the minds of those who saw him, a suspicion that he was a member of the medical profession". The following day, a newspaper report claimed that responsibility lay with "a young surgeon of Argyll Street". Wakley, being the only surgeon occupying a house in that street, was— quite wrongly—identified as the person who carried out that "unsavoury" task.3Thomas Wakley The founder of The Lancet, a biography.Lancet. 1896; Vol I (London) (Chapter V): 313-316Google Scholar After receiving several threatening letters, Wakley was physically attacked and his house burnt to the ground. Even though he had recently increased his home insurance cover, his insurers refused to honour their agreement, until Wakley took them to court. Eventually the Lord Chief Justice summed up entirely in Wakley's favour. He was paid in full and his name was also cleared4Thomas Wakley The founder of The Lancet, a biography.Lancet. 1896; Vol I (Chapter VII): 440-442Google Scholar During this time he struck up a friendship with William Cobbett, then editor of the Weekly Political Register, and with other reforming journalists; he saw "how instinctively these men tumed to pen and ink for the redress of any wrong". This was an example that Wakley followed to powerful effect during the 39 years of his editorship. Perhaps the most famous case in which he became involved was that of the Tolpuddle Martyrs. In 1834, six agricultural labourer8 were accused of "combining to resist the reduction of their wages from seven shillings a week to six" and sentenced to 7 years' transportation.5Thomas Wakley The founder of The Lancet, a biography.Lancet. 1896; Vol II (London) (chapter XXIX): 247-250Google Scholar Wakley was by then a Member of Parliament, and was chosen as mouthpiece for the national protest that had been organised to free these men. His Parliamentary speech was powerful, and, although the vote was lost, it was not long before the government was eventually persuaded that the popular sentiment was also the humane one and granted the men a free pardon. 3 years later in 1837, the first of a series of articles appeared in The Lancet on prison life and the effects of solitary confinement. J G Malcolmson, late secretary to the Madras Medical Board, wrote to express his fear that the "anxiety to avoid flogging may lead to punishments which are incomparably more cruel and destructive", concluding that "lengthened periods of solitary confinement are destructive of the health and efficiency of the soldier".6Malcolmson J On the effects of solitary confinement upon health.Lancet. 1837; ii: 163-165Abstract Scopus (1) Google Scholar These concerns were taken up in a strongly worded editorial, which concluded: "To reform and to prevent, not professedly to inflict punishment—too often synonymous with torture, should be the object of penal laws which relate to crime. The subject of solitary confinement demands the attention and interference of wise and benevolent men".7Prison discipline.Lancet. 1837; ii (Anonymous): 169Google Scholar Even so, more than a century later in 1971 concerns about prisons were still being reported. The journal described the effects of sensory deprivation on prisoners, linking research findings with the conclusions of the Compton Committee on the treatment of some Northern Ireland detainees.8Sensory deprivation.Lancet. 1971; ii (Anonymous): 1244Google Scholar Then 3 years later, a letter on the subject of the use of solitary confinement in British prisons concluded: "Granted that capital punishment is eliminated, it will be socially dangerous to substitute a slower, more emotional, and more dehumanising nemesis"9Maclay D Solitary confinement in conrol units.Lancet. 1975; ii: 408Abstract Scopus (1) Google Scholar—sentiments similar to those expressed by Malcolmson so many years before.6Malcolmson J On the effects of solitary confinement upon health.Lancet. 1837; ii: 163-165Abstract Scopus (1) Google Scholar The rights of prisoners to medical care were also debated in the pages of The Lancet, starting in 1863 when a "medical man" Charles Law was taken into Hoxton police station charged with "surreptitiously disposing of the dead bodies of two new-born children"10Disease and death in police station.Lancet. 1863; ii (Anonymous): 711-712Google Scholar 2 days later, he died, and the attending doctor attributed his death to the treatment he received while in police custody, but the coroner "objected to any blame being fastened on the policeman". After this incident The Lancet concluded: "In police stations, … the chance of the prisoner receiving proper medical attention is extremely rough and uncertain … errors of judgment or neglect are constantly occurring".10Disease and death in police station.Lancet. 1863; ii (Anonymous): 711-712Google Scholar The journal continued to publish reports of deaths in police stations and prisons, and in 1914 published an article on the Training of Medical Officers in Prisons, which emphasised the need to sever the prevalent "military" approach to prison life, and to "establish the paramount importance of psychiatry in the treatment of the criminal world [which] would be welcomed by the medical profession",11The training of medical officers of prisons.Lancet. 1914; i (Anonymous): 479Google Scholar Subsequent articles on prison medicine recognised this humane approach and in the 1970s a number of items appeared under the general heading Prison and Humanity. Most human rights organisations today have a clear aversion to the use of both corporal punishment and the death penalty, and for the medical profession there is the added concern (still very current) that doctors should not be required to take part in such acts, or indeed in the practice of torture. This issue was first discussed in the journal in respect of a proposal that deserters from the army should be branded with a large D on the forehead and that this procedure should be undertaken by military medical officers. An anonymous letter from a surgeon in the armed forces pointed out that medical officers are required to attend the use of corporal punishment but that they do so as "the prisoner's protector …, to arrest and stop the punishment before it is carried to the extent of endangering either the life or health of the prisoner".12Branding deserters.Lancet. 1842; ii (Anonymous): 578-579Google Scholar It is dispiriting to find that medical human rights groups are still campaigning vigorously on behalf of colleagues throughout the world who are put under similar pressure to take part in punishment and torture. The involvement of the medical profession in the death penalty became a critical issue when Luigi Buranelli was executed in 1855 "in spite of the clearest evidence of his insanity".13The execution of Buranelli in contempt of the clearest evidence of his insanity.Lancet. 1855; i (Anonymous): 518-519Google Scholar A lengthy editorial 13The execution of Buranelli in contempt of the clearest evidence of his insanity.Lancet. 1855; i (Anonymous): 518-519Google Scholar drew attention to the proper role of medicine in drawing the line "between sanity and insanity—between health and disease" and concluded: "by the aid of science it is possible to determine with precision where lies the boundary". However, this case was considered "almost singular in the determined resolution of the judge and Jury to shut their eyes against evidence such as it seems impossible to render clearer or stronger". Consequently, the editor lambasted the legal system, which could so blatantly ignore medical advice, and promised to bring the matter into the public domain the following week by analysing the medical evidence on both sides "with minuteness". On the morality of capital punishment itself, The Lancet remained rather coy. In 1864, the editor castigated those people who had passed the time during the latest public execution "in levity, jeering, laughing, hooting, whistling, and obscenity". However he refused to condemn or condone the practice explicitly, although he indicated where his sympathies lay by describing the provisions made by the State of Louisiana, USA, which had then abandoned corporal punishment, leaving the decision to "Divine justice".14Moral of public execution.Lancet. 1864; i (Anonymous): 251Google Scholar A century later, when the House of Commons debated the death penalty in 1956, the attitude of The Lancet, then under the editorship of Theodore Fox, was unequivocal: "There being no good evidence that hanging murderers checks the number of murders, the case for discontinuing this rough justice seems to be unanswerable"?15The death penalty.Lancet. 1956; i (Anonymous): 301Google Scholar During the 19th century, the journal displayed a somewhat inconsistent line on corporal punishment. In 1898, The Lancet condemned "the silly sentimentality and nauseous sympathy occasionally expressed in regard to cowardly ruffians" and reminded readers that "Everybody with any real knowledge of this class of criminals knows that there is nothing these bullies fear so much as the physical suffering which they do not hesitate to inflict on others … flogging has a deterrent effect on ruffians of this class"?16The flogging movement.Lancet. 1898; ii (Anonymous): 1146Google Scholar On the other hand, the journal found much to criticise in the use of corporal punishment in the armed forces, particularly the navy. When the use of the "cat" to punish boys was finally replaced with the birchrod, this was welcomed, and further leniency was urged?17Flogging in the navy.Lancet. 1866; i (Anonymous): 183Google Scholar 2 years later, an article condemning the use of gagging ended on a campaigning note: "Our readers will doubtless be tempted to ask, Is this the only improvement which a competent and impartial investigation into the enforcement of discipline in the Navy would effect?18Gagging in the navy.Lancet. 1868; i (Anonymous): 418-419Google Scholar Shortly afterwards the editor was able to report with unconcealed pleasure the abolition of corporal punishment in the army: "We can scarcely pass over this subject in complete silence considering the part we took in it in past years"?19The abolition of corporal punishment in the army.Lancet. 1868; i (Anonymous): 449Google Scholar Today human rights organisations tend to have a clear agenda in terms of civil and political rights, but they sometimes struggle with wider questions of equality or "social rights". Questions of entitlement to employment, basic wages, and shelter have always served to bring "rights" issues squarely into the political arena, but this -did not deter the journal in its early days. The 1834 Act, which modified the existing Poor Laws and strengthened the workhouse system, was vigorously opposed by Thomas Wakley who in "his desire to champion the cause of the poor", "could grasp no stick too heavy with which to beat it".20Workhouse administration: Anstie's work.Lancet. 1923; ii (Anonymous): 724-725Google Scholar When his son James took over as editor in 1862, he "considered it a legacy from his father to make a complete investigation into the treatment of the sick poor in workhouses")20Workhouse administration: Anstie's work.Lancet. 1923; ii (Anonymous): 724-725Google Scholar He commissioned a number of inquiries, which led directly to an improvement in conditions. For example, a forthright report on the state of the Farnham workhouse undertaken by F E Anstie was published with a warning to the government that it should not continue to ignore such poor conditions. In direct response to this, the government undertook its own investigation and "admitted that the majority of the things brought forward in THE LANCET required the special attention of the guardians, and immediate reforms followed")20Workhouse administration: Anstie's work.Lancet. 1923; ii (Anonymous): 724-725Google Scholar 15 years later, reports of increasing levels of infanticide among the poor were characterised not by condemnation but by pity for the plight of the "Poor, wretched, hungry women [who] have been driven to devise forms of child-murder")21The poor and lying in charities.Lancet. 1850; i (Anonymous): 23Google Scholar This led to a very clear statement about the duty of the medical profession in respect of poverty and health: "One of the noblest attributes of our profession is its practical humanity towards the poor. The medical man is often, in truth, the natural defender of the poor and needy against oppressive laws, and against the vicious errors of our social régime".21The poor and lying in charities.Lancet. 1850; i (Anonymous): 23Google Scholar Similarly, at the beginning of this century, an editorial advertised a National Conference on the Prevention of Destitution, taking the view that "many of the subjects to be dealt with are not only of supreme interest to the medical profession, but are also of such a nature as to be materially elucidated by medical experience; and we may therefore expect important contributions in relation to them from members of our calling".22The prevention of destitution.Lancet. 1912; i (Anonymous): 1350-1351Google Scholar These subjects included unemployment, housing, crime, and the minimum wage, all of which continue to be of contemporary interest, although the role of the medical profession in addressing them is perhaps less clear today. While the journal has consistently championed the rights of women if they happened to be poor, unemployed, homeless, or unmarried mothers, it showed no such sympathy for the rights of women when it came to entry to the medical profession, believing that women's natures suited them to the domestic sphere and that any other aspirations were confined to "a few male minded ladies". An editorial on women's rights in 1862 was categorical: "Woman is not man and cannot be made man".23Women's rights.Lancet. 1862; ii (Anonymous): 123Google Scholar No doubt the editor would have preferred to ignore the issue but found himself unable to do so, because, as he explained, "By some unaccountable accident, the medical profession is brought, almost alone, into collision with the 'rights-of-women' movement".23Women's rights.Lancet. 1862; ii (Anonymous): 123Google Scholar Matters came to a head when the journal poured scorn on the attempts of Elizabeth Garrett (later Elizabeth Garrett Anderson) to qualify as a doctor at St Andrews. "The great objections to ladies …, entering the profession have their foundation in nature and taste … The medical profession is, in our opinion, the least adapted to the female nature")24The female students question.Lancet. 1862; ii (Anonymous): 657Google Scholar Anderson was refused admission to medical schools in Britain, so she began to study privately with accredited physicians and in London hospitals and was licensed to practice in 1865 by the Society of Apothecaries. In 1870, she received an MD from the University of Paris. Even when these barriers were finally removed, further obstacles faced women seeking equality within the profession. In 1916, Mary Williams used the pages of the journal to complain that the War Office was recruiting women doctors for munition works at £400 a year, whereas men were to receive £500. She concluded: "We women doctors have stood out so hard for equal pay for equal work that it is to be hoped these differences will be rectified"?25Williams MH Medical women and equality of pay.Lancet. 1916; ii: 692Abstract Scopus (1) Google Scholar Since World War II, the pages of the journal have reflected changing world problems and new human rights issues. The cold war and fear of further international conflicts led Richard Doll to write to The Lancet the "Prospect of war" letter, which advocated the peaceful settlement of disputes and world disarmament: "We appeal to all our fellow doctors who think that there may yet be an alternative to merely providing treatment for casualties; we ask them to join us".26Doll R Joules H Esterman A et al.Prospect of war.Lancet. 1951; i: 170Abstract Scopus (8) Google Scholar Correspondence flooded in, both in support of and in opposition to the ideas, and out of this the Medical Association for the Prevention of War (MAPW) was born. Other organisations followed, including the International Physicians for Prevention of Nuclear War (IPPNW), which was awarded the 1985 Nobel Peace Prize, and Physicians for Human Rights (UK), of which a former Lancet editor, the late Ian Munro, was the first president. In the late 1970s and 1980s, the emphasis again changed as the journal reflected international aspects of medicine and human rights. In 1976, an article drew attention to an Amnesty International list of 99 doctors and health workers detained for political reasons in 22 countries. It reminded readers of the World Medical Association's declaration, which protects a doctor's right to refuse to have anything to do with the practice of torture or other forms of cruel, inhuman, or degrading treatment.27Political prisoners.Lancet. 1976; ii (Anonymous): 243Google Scholar With increasing emphasis on inequalities in health care overseas, a series of articles on South Africa in the 1970s and the Palestinian uprising in the late 1980s drew fierce criticism from pressure groups and those doctors who thought there was no place for politics in a scientific journal. However, successive editors have maintained that the two cannot always be easily separated. The Lancet has not been the only medical journal to take up human rights issues, but it was certainly the first one to do so. The British Medical Journal, the New England Journal of Medicine, and other worldwide medical publications entered the field much later but are still making a major contribution to medicine and human rights. Unlike The Lancet, which was under the control of the Wakley family for nearly 80 years, some of these periodicals were influenced by the fact that they were the official voices of professional organisations, such as the British Medical Association (BMA) and its American counterpart, the AMA, and therefore had to reflect official policy. In the case of the BMff, although the BMA constitution gave it editorial independence, there were instances—in the last century during the editorship of Ernest Hart and as recently as the 1940s and 1950s during the reign of Hugh Clegg—when the editors found themselves challenged by the Council for publishing articles of, which it did not approve.28Bartrip P Mirror of Medicine.in: A history of the British Medical Journal. Clarendon Press, Oxford1990: 83-90Google ScholarBartrip P Mirror of medicine.in: A history of the British Medical Journal. Clarendon Press, Oxford1990: 275-278Google ScholarBartrip P Mirror of medicine.in: A history of the British Medical Journal. 2nd edn. Clarendon Press, Clarendon1990: 288-293Google Scholar Until two decades ago, there seems to have been little support from many Council members for the idea that the BMA itself or the pages of its journal should deal with human rights issues. However, there was a discernible shift in 1978 after the death of Steve Biko, a South African medical student activist, as a result of medical negligence. The BMJ published a letter from the South African born Raymond Hoffenburg, urging the BMA to exert pressure on the South African Medical Association.29Hoffenberg R The Steve Biko inquest.BMJ. 1978; 1: 112Crossref PubMed Scopus (2) Google Scholar At about the same time, reports were emerging from Latin America, especially from Argentina and Chile, of gross violations of human rights, including the widespread use of torture with evidence of doctors' participation. Slowly, links were established between the newly formed British medical group of Amnesty International and BMA officials. In 1980, the BMJ published a letter announcing the existence and purpose of the medical group and invited doctors to join.30Pollert J Gordon EM Amnesty International's medical group.BMJ. 1980; 280: 48-49Crossref PubMed Scopus (1) Google Scholar Many concerned doctors who felt that their voices had not been heard by the BMA now took the opportunity to address their concerns through the letters pages of the BMJ on a range of issues; one such correspondent, F de Zulueta, called on the BMA to support a group of Harvard doctors in rejecting involvement in the death penalty.31de Zulueta F Participating in execution and medical ethics.BMJ. 1980; 280: 486Crossref PubMed Scopus (2) Google Scholar From then on, the BMJ became a forum for debate on various human rights issues, ranging from hunger strikes to human rights abuses in Turkey. Furthermore, in 1992 the current editor, Richard Smith, co-chaired a meeting on Medicine in British Prisons organised by Physicians for Human Rights (UK). For the American journals, the question of "rights" was initially pursued in respect of their own domestic issues, notably the right to access to health care. These were tackled by both JAMA and the NEJM. However, as with the BMJ, the significant interest in global human rights issues came in the late 1970s, mainly as a result of the upheaval in Latin America and the influx of persecuted doctors from Chile and Argentina to the USA. In 1978, the NEJM in its Sounding Board series published a report on torture and the medical profession, which was based on an Amnesty International medical seminar that had recently taken place in Athens.32Gellhorn A Violation of human rights: torture and the medical profession.N Engl J Med. 1978; 299: 358-359Crossref PubMed Scopus (8) Google Scholar For many health professionals in Europe and the USA, this was perhaps the first introduction to Amnesty International's involvement in sending investigative medical teams to gather evidence on the increasing use of torture. At that time, Danish doctors led the way in this work, and publication of the results of their investigation~ had a major impact, which led eventually to a proliferation of medical human rights groups worldwide. Although the NEJM did not see itself as a major campaigner on human rights issues, it was clear that when it did speak out, it would be certain to have a significant impact on worldwide medical opinion. Examples include influential articles on the boycott of Soviet scientific meetings33Boycott of Soviet meetiongN Engl J Med. 1982; 306: 1298-1299Crossref PubMed Scopus (1) Google Scholar and, of course, the death penalty. This question of the participation of doctors in the death penalty has remained a key one, not only for the NEJM but also for JAMA. In the case of the latter, the AMA, at the Lisbon meeting of the World Medical Association in October, 1981, came under intense pressure to speak out against such involvement of doctors. Here the AMA took a positive stance on the issue, and this was reflected in the pages of JAMA.34Bolsen B Strange bed fellows: death penalty and medicine.JAMA. 1982; 248: 518-519Crossref PubMed Google Scholar Since then, JAMA has continued to take interest in such issues, and in 1993 it went as far as to publish a "partial list of health professionals persecuted in violation of their human rights", which had been drawn up by the American Association for the Advancement of Science human rights programme, and readers were invited to send updates on the cases published.35Health Professionals persecuted in violation of their human rights. 2nd edn. JAMA. 270. 1993: 554-560Google Scholar The place of human rights reporting in medical journals is now taken for granted in many countries, with the emphasis reflecting both the history and geography of the country. Journals in Scandinavia, for example, had a major role in exposing abuses in Argentina and Chile, whereas Japanese journals have highlighted issues relating to torture, following the 1975 World Medical Association meeting and the Tokyo declaration against torture.36Matsuda M Shimizu A Medicine and human rights.in: A discussion. 2nd edn. Kango Kyoiku Japanese J Nurses Educ. 4. 1975: 200-208Google Scholar In the past 30 years, nearly 2000 editorials, reports, and letters have been published in medical journals worldwide, but it was The Lancet that led the way. During its 175-year history, the pages of the journal have highlighted the close links between health and human rights over a very wide range of issues. The history of the period shows that when the "rights and dignity" of people are undermined—whether by political or social actions—there is frequently an implication for the health of the community and responsibilities for its health workers. Alas, the need for vigilance and action against infringements of human rights is as great as ever.