Usually, when one thinks of torture or cruel, inhuman, or degrading treatment, prisoners--not patients-- come to mind. The mistreatment of detainees in Abu Ghraib-0 and Guantanamo prison involved medically trained individuals participating in so-called "biscuit" or "behavioral science consultation teams," but we rarely hear about ill-treatment by health providers as part of more routine medical practice.
That doesn't mean it's not happening.
Recent research by Human Rights Watch in Egypt, Libya, Jordan, Iraq, China, Cambodia, Nicaragua, and India, found that government health policies and health providers were deliberately and unjustifiably causing severe mental or physical suffering. That meets the definition in the Convention against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment for cruel, inhuman or degrading treatment. Where there is state involvement and specific intent, it can be considered torture.
Beyond the ethical prohibitions of the Hippocratic Oath to do no "harm or injustice," and beyond a sense of "malpractice", the involvement of health providers in the cases we cite are violations of international law.
Here is what Human Rights Watch found. In Egypt, men suspected of homosexual activity, in violation of that country's legal codes banning "debauchery," are subject to state-sponsored forcible anal exams by physicians. Prosecutors declare these exams necessary to establish criminality, but examining physicians have admitted they do not actually determine if sexual activity occurred. Doctors are performing exams that further injustice and cause patients to suffer humiliation and abuse.
Similarly, in Libya and Jordan Human Rights Watch found evidence that women have been forced to undergo vaginal exams. Physicians conduct these exams to determine virginity for prosecutorial purposes -- or to help a family decide on whether to institutionalize, harm or abandon a woman who has been accused of having sex outside of marriage. The exams have a key role in deciding a woman's fate, often for the worse.
Female genital mutilation is another practice that can cause severe suffering for no medical purpose. Human Rights Watch spoke with midwives and government physicians in Iraqi Kurdistan who perform or promote FGM, and who deny that it has any negative health consequence. By contrast, the UN Human Rights Committee has said that female genital mutilation undeniably causes long-term harm and violates protections against torture or cruel, inhuman, or degrading treatment.
Some medical professionals and human rights experts have also found that withholding medical treatment for drug dependency and withdrawal can be considered cruel and inhuman treatment. A recent Human Rights Watch report on drug detention centers in China highlighted the abuses and government policies that prohibit effective treatment for those who use drugs. Detainees are subjected to forced, unpaid labor, and no medical treatment is provided to aid their drug addiction.
Government policies that prohibit effective treatment for individuals who use drugs, and instead endorse forced labor and detention can meet the specific criteria for torture as set out in article 1 of the Convention against Torture: the intentional infliction of severe pain and suffering by government officials as punishment for addiction, or based upon discrimination due to a characterizing feature (in these cases, drug use).
Inhuman treatment doesn't always come from active abuses. In India Human Rights Watch documented that patients are denied pain medication when they are suffering severe, treatable pain. This report illustrated how government policies that constrain health care providers from offering treatment - through regulation or even criminal sanction - can make them complicit in abuse. In India overly restrictive regulations on morphine made it nearly impossible to prescribe. In Nicaragua, doctors who perform life-saving abortions may face criminal charges. In these cases, health care providers and human rights advocates need to work together to speak out and challenge abusive laws.
The prohibition to do "no harm or injustice" seems to be a simple and straightforward one, but it has not led to torture-free health care. Perhaps recognizing this, the World Medical Association has expanded upon this maxim, and encouraged doctors to "honour their commitment as physicians to serve humanity and to resist any pressure to act contrary to the ethical principles governing their dedication to this task; to support physicians experiencing difficulties as a result of their resistance to any such pressure or as a result of their attempts to speak out or to act against such inhuman procedures."
Greater understanding of what constitutes torture and cruel, inhuman or degrading treatment among health providers is important, but is not enough. Health providers should be held accountable for their actions and inaction that result in unjustifiable suffering - not only as ethical transgressions, but as human rights abuses - and governments need to be held accountable for policies that compel health providers to be complicit in such abuse.