Ethics and human rights are core values in medical activity. Doctors may become involved in situations where they are at risk of violating human rights, or they may become subject to such violations themselves. In 1991, the Norwegian Medical Association therefore established its human rights committee, which remained engaged in a number of international projects until 2012.
Outside Sarajevo airport. Photo: Private
There were several reasons why the Norwegian Medical Association established a human rights committee in 1991 (Box 1). In some countries, doctors have been accessories to torture, in others they have actively opposed violations of human rights. It is essential for medical associations to support colleagues who are exposed to human rights violations and help promote human rights internationally.
In 1991, the Norwegian Medical Association established a separate committee for human rights.
The committee shall be engaged in the relationship between human rights and medical activity.
To seek to prevent violations of human rights.
To engage on behalf of people who are afflicted with injuries, diseases or late-onset effects stemming from violations of human rights.
To seek to enhance acknowledgement of the correlation between health and human rights.
The right to health is also embedded in the International Covenant of Economic, Social and Cultural Rights (1) and is included in several other UN declarations. It was natural for the Norwegian Psychiatric Association, represented by Otto W. Steenfeldt-Foss, its leader at the time, to take the initiative to establish the committee. Psychiatry is a field where human rights dilemmas arise, for example in situations involving coercion, but also public-health specialists and medical officers in prisons, the police or the armed forces may become entangled in situations where they risk violating human rights.
The authors of this article have all served as leaders or coordinators of the committee’s activities in different periods, and they have participated in the projects described. At the time of its establishment, the tasks that the committee were to address were not defined, but quite early on it became clear that its engagement should extend beyond Norway’s borders. The most important projects undertaken by the committee in this period include reconciliation between the medical associations in the former Yugoslavia, efforts to stop torture in Turkey, and psychiatry and human rights in China.
Reconciliation in the Balkans
Health can be a good basis for establishing contact between the parties to a conflict, and doctors and medical associations may well play a role in promoting peace. This is stated in, for example, the document Health as a bridge to peace, adopted by the World Health Organization (WHO) in 1998. (2). Moreover, doctors are ethically obligated to treat all patients equally, irrespective of their ethnicity and nationality (3). In wars and other conflicts, we believe that doctors should help put pressure on the authorities to ensure that the population is provided with humanitarian aid.
Against this background, the committee arranged a conference on medical activity and human rights in Oslo in May 1993. The situation in the former Yugoslavia was a key topic at the conference. UN sanctions had been imposed on Serbia, and war raged in Bosnia and Herzegovina. As a result of the conference, it was decided that the Norwegian Medical Association, represented by its human rights committee, should take the initiative to convene the medical associations in the new republics for a meeting in Oslo. Objectives included providing assistance to re-establish contact between the associations and discussing the humanitarian situation for the civilian population during the armed conflicts.
Even though the situation in the former Yugoslavia was turbulent, we succeeded in gathering representatives of all associations in Oslo in September 1993. Prior to the meeting, we had met all of them on a journey to the new republics of the former Yugoslavia (4). The participants represented countries that either had recently been or still were at war with each other, and some also reported to feel bitterness over having been let down by their colleagues in difficult times.
In personal conversations with us, the representatives of the various medical associations accused the other ethnic groups of violence and abuse. This notwithstanding, in the final document all associations committed to helping provide humanitarian aid to the civilian population, and they would report it if they discovered unequal access to health services on the basis of nationality or ethnicity (5). Such commitments can be difficult to live up to, and we were anxious to see whether the doctors would let their national and ethnic sympathies overrule their professional obligations. The local WHO offices in the region followed up the agreement stated in the final document, and nobody found any grounds to report violations of the ethical commitments (personal communication, Richard Alderslade, WHO’s Belgrade office).
During the period 1993 – 1997, the Norwegian Medical Association’s human rights committee had a total of five meetings with the medical associations in the former Yugoslavia. Over this period we could observe that the cooperation between the parties gradually improved. Currently, all the associations are members of or observers in international medical associations, and the need for specially designed forums has abated.
Reconciliation work in the Middle East
Since the experience from its mediation efforts in the Balkans was good, the committee assessed the opportunities for a similar undertaking in the Middle East. Joined by the World Medical Association (WMA), an attempt was made to gather the medical associations of the region for a meeting in Turkey. The objective of the meeting would be to identify health-related topics on which the countries could cooperate. The goal was to enlist the medical associations of Egypt, Jordan, Syria, Lebanon, Iraq, Palestine and Israel.
However, we received feedback to the effect that none of the medical associations in the Arab countries wished to participate, with the exception of Palestine. It soon became clear that a process similar to the one in the former Yugoslavia would be difficult to achieve. The conflicts ran too deep and their history was too long. In the Balkans, the wars had lasted for only a few years, and in spite of their differences, the antagonists had lived together in a shared state for many years, with family ties and friends across the ethnic divides.
The Palestinian participants told us that it was difficult, or even impossible, to engage in cooperation with those they regarded as occupiers, even though the people with whom they should cooperate represented a profession and not the state.
Our experience indicates that the political conditions must be sorted out before health-related collaborative projects can be established. Health work can hardly lead to peace in a conflict area, although cooperation on health issues may have a potential to strengthen peace once it has been established.
Ethics and human rights in Chinese psychiatry
From several quarters, China has been accused of abusing psychiatry for political purposes. Dissidents have been given psychiatric diagnoses and committed to psychiatric hospitals (6). In the early 2000s, the Chinese Society of Psychiatry came under pressure from the World Psychiatric Association (WPA) because of these allegations.
After an agreement with the Chinese Society of Psychiatry (CSP), the WPA sent a fact-finding commission to China to investigate. The group was headed by Otto W. Steenfeldt-Foss, who represented the WPA. The commission revealed a high incidence of erroneous diagnoses, but no indications of abuse of these for political purposes. The WPA and the CSP signed an agreement on a systematic training programme on ethical and diagnostic issues in psychiatry (7, 8).
In 2004, at the time when the cooperation with the CSP and later the Chinese Psychiatric Association (CPA) was initiated, China had no national legislation on mental health care. A law had been in preparation since 1985, but it was not until 2012 that it was adopted by the People’s Congress. The use of coercion in psychiatry and a legal act on mental health care have been key issues in the cooperation between the Chinese Psychiatric Association and the Norwegian Medical Association.
Since 2004, annual seminars on ethics and human rights in psychiatry have been held, and mutual study visits have been undertaken. With the Chinese Psychiatric Association, an educational programme has been developed that includes annual sessions with 50 – 60 participants in each over a three-year period. In total, nearly 600 psychiatrists have participated in these seminars. The participants come from all of China’s provinces, where they occupy key positions in regional psychiatry. Topics such as patients’ rights, human rights and ethics related to coercion have been discussed. Case histories, Norwegian as well as Chinese, have served as the basis for these discussions, which have been conducted with openness. Norwegian psychiatry also faces challenges, and the seminars have provided an opportunity for exchange of experience and mutual learning.
Torture in Turkey
Jointly with several other organisations, the Turkish Medical Association has established the Human Rights Foundation of Turkey (HRFT). This organisation operates five centres that are engaged in documentation of torture and treatment of people who have been subjected to torture in Turkey (9).
The centres are staffed by doctors, social workers and lawyers. There is a small permanent staff, supplemented by volunteers who contribute in various specialisations. In the early 2000s there was a small decline in the number of people who sought help for physical or mental injuries from torture. The human rights situation in Turkey improved as the authorities adapted to the requirements from the EU in light of a future application for membership (10).
Since 2005, the situation has deteriorated. The use of torture, especially by the police, has increased and freedom of speech has been curtailed (10). According to the HRFT, these changes have been caused by new legal regulations. The armed conflicts in the Kurdish areas have served as a pretext to tighten regulations, for example the anti-terrorist act, which has expanded the powers of the police. The situation is especially difficult in the Kurdish areas, where guerrillas remain active and engage in frequent skirmishes with the army (10).
Since 1997, the human rights committee of the Norwegian Medical Association has engaged in cooperation with its Turkish counterpart and the HRFT on various human rights-related projects. In addition to providing medical treatment and legal assistance to people who have been subjected to torture, the HRFT also attempts to reintegrate victims of torture into society. Our collaborative projects have included efforts ranging from seminars on rehabilitation of persons with mental traumas to health services for detainees and contributions to large conferences on human rights.
The HRFT enjoys widespread international recognition and receives support from the EU and the UN. Norwegian authorities also provide annual funding to the treatment centres.
Trust, equality and taking a long-term view
Doctors share a set of core values that extend across national and ethnic interests. This value basis is embedded in shared codes of conduct formulated by the profession itself, for example in the World Medical Association’s Declaration of Geneva (3). This means that doctors and medical associations have a particular responsibility for ensuring equal access to health services, including in wars and other armed conflicts. The Geneva Conventions (Red Cross) require doctors and other health personnel to remain neutral and ensure safe access to those who need medical help.
In the committee’s collaborative projects we have sought to emphasise mutual trust and equality. We have invited participation in projects in which we believed that everybody could learn from each other. In such projects, taking a long-term view is equally important. On several occasions, we have seen that human rights activists or organisations arrange conferences where most of the contributions come from foreigners who present all the solutions. As a rule, our local colleagues will be familiar with the problems and know how to address them, but they may need external resources and support.
Our collaboration partners in Turkey have told us that they have occasionally been harassed by the authorities because of their engagement with human rights. In these situations, support from abroad has been crucial. For example, we have been present during several trials of doctors in Izmir, Adana and Diyarbakir. In China, we have had the opportunity to provide input to the new act on mental health care, even though the act must necessarily be adapted to conditions in China. During the conflicts in the former Yugoslavia the committee helped doctors and medical associations in the new republics re-establish contact while the wars still raged, and assisted the parties in exchange of wounded combatants and cooperation on humanitarian aid. We believe that our approach has helped us establish trust among our collaboration partners, and that this has been conducive to long-term engagement.
All these international projects have received financial support from the Norwegian Ministry of Foreign Affairs. From 2012, the human rights committee is part of the Norwegian Medical Association’s committee on human rights, climate change and global health.