Hathout Philosophy, Ethics, and Humanities in Medicine 2012, 7:11 http://www.peh-med.com/content/7/1/11 COMMENTARY Open Access The right to practice medicine without repercussions: ethical issues in times of political strife Leith Hathout Abstract This commentary examines the incursion on the neutrality of medical personnel now taking place as part of the human rights crises in Bahrain and Syria, and the ethical dilemmas which these incursions place not only in front of physicians practicing in those nations, but in front of the international community as a whole. In Bahrain, physicians have recently received harsh prison terms, apparently for treating demonstrators who clashed with government forces. In Syria, physicians are under the same political pressure to avoid treating political demonstrators or to act as informants against their own patients, turning them in to government authorities. This pressure has been severe, to the point that some physicians have become complicit in the abuse of patients who were also political demonstrators. This paper posits that physicians in certain countries in the Middle East during the “Arab Spring,” specifically Syria and Bahrain, are being used as both political pawns and political weapons in clear violation of Geneva Convention and World Medical Association guidelines, and that this puts them into the most extreme sort of “dual loyalty” dilemma. They are being forced to choose between their own safety and well-being and that of their patients – a negative sum scenario wherein there is no optimal choice. As such, an international call for a United Nations inquiry must be made in order to protect the neutrality of medical care and personnel during times of armed conflict. Keywords: Medical neutrality, Bahrain, Syria Introduction their autocratic governments – such as in Tunisia, In Western nations, it is clear that there is a significant Egypt, Libya, and Syria – has underscored some of the interplay between politics and the practice of medicine. ethical dilemmas and human rights issues which face The political process, in some sense, affects both the physicians working in regions of political turmoil. regulations upon, and the remunerations for, the provision of healthcare. For example, in the United Discussion States, during the Supreme Court session which opened This commentary will highlight recent events in Bahrain this October, the Court is expected to decide on whether and Syria, using these two nations as case studies in physicians and patients can sue states for limiting Me- what sometimes happens when the long arm of political dicaid payments, and to hear a constitutional challenge repression reaches into the hospital ward. The ethical to President Obama’s healthcare reform. dilemmas facing physicians in these countries essentially However, over the past several months, political dra- “speak for themselves,” and are presented to raise aware- mas of a very different sort have impacted physicians in ness and engender reflection. As background, it is im- some countries of the Middle East. The so called “Arab portant to note that clear and unequivocal international Spring,” wherein ordinary citizens have risen up against standards have long been established regarding the treat- ment of physicians during times of political strife. These Correspondence: [email protected] Department of Biology Stanford University P.O. Box 11042 Stanford CA rules, reflecting the norms of the Geneva Convention, 9430-–1042 USA are summarized in the World Medical Association © Hathout; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Hathout Philosophy, Ethics, and Humanities in Medicine 2012, 7:11 Page 2 of 6 http://www.peh-med.com/content/7/1/11 (WMA) guidelines. Article 5 of the “WMA Regulations may be because of both their willingness and ability to in Times of Armed Conflict,” states: use more brutal measures against their populations, such as violating medical neutrality. “Governments, armed forces and others in positions of power should comply with the Geneva Conventions to ensure that physicians and other health care I. Bahrain professionals can provide care to everyone in need in The “Arab Spring,” has also come to Bahrain. There, the situations of armed conflict. This obligation includes a population has begun to revolt against the ruling mon- requirement to protect health care personnel.” archy, and in the ensuing political upheaval, physicians and nurses have become a significant target of political Article 8 of the same guidelines more pointedly states repression and frank human rights violations. Several months ago, several dozen doctors and nurses were “Physicians have a clear duty to care for the sick and arrested, including some Irish-trained physicians prac- injured. Provision of such care should not be impeded ticing in Bahrain. Their crimes? The medical personnel or regarded as any kind of offence. Physicians must are officially charged with incitement to overthrow the never be prosecuted or punished for complying with regime. They contend, however, that their only crime any of their ethical obligations [1].” was treating political demonstrators after they were injured in clashes with the monarchy’s police forces [2]. Specific suggestions for some action items in the face After months in prison, the doctors and nurses were of these dilemmas are presented at the end of the released in early September. This came, at least partially, commentary. as the result of an international outcry over their arrests, It must be noted that these incursions against medical and after Irish and UK physicians started a rolling fast to personnel have been quite unique to Bahrain and Syria, support a hunger strike undertaken by the imprisoned and have not occurred in the remaining Arab nations medics [3]. Although the charges were not dropped, and during the protests of the Arab Spring. Perhaps the uni- a court was to try their case in late September, their re- fying factor in both of these cases is a very centralized lease was seen as a sign of hope that the government of authority in the head of state. Bahrain may be mitigating its stance, and that they By way of brief historical review, Bahrain is a small would be found innocent. Such hopes proved un- monarchy which gained its independence from the Uni- founded, as on September 29th, the Bahrain courts con- ted Kingdom in 1971. It is ruled by King Hamad bin Isa victed the 20 physicians and nurses and levied harsh Al-Khalifa, and the king has significant authority, such sentences against them, with thirteen doctors receiving as commanding the army, appojnting the Prime Minister fifteen year prison terms, and the remainder getting sen- and his cabinet, appointing the upper house of parlia- tences between five and ten years [4]. The physicians ment and dissolving its lower house. The Prime Minis- were convicted of a variety of offenses, including allega- ter, Khalifa ibn Salman Al-Khalifa is the king’s uncle. tions of stockpiling weapons in the Salmaniya hospital In Syria, President Bashar al-Assad took the reins of and of “fabricating stories to disturb public security.” power in 2000 after the death of his father, Hafez al-Assad, Certainly, physicians are no strangers to human rights who had ruled Syria for 30 years. After the death of Hafez crises. They often put themselves in harm’s way as a part al-Assad, the Syrian Parliament quickly amended the con- of indigenous or international relief efforts. Alternatively, stitution to reduce the minimum presidential age from individual physicians may suffer political repression as 40 to 34, making Bashar eligible for the presidency, any ordinary citizen does under a repressive regime. where he was elected, as an unopposed candidate, by However, what has transpired in Bahrain is somewhat over 97% of the vote, according to Syrian authorities. In unique in the modern era. The doctors claim that med- Syria, Bashar al-Assad also has extraordinarily strong ical personnel are being punished solely for practicing ties to the military, such that soldiers who refused to the healing arts, ardently maintaining that their activities shoot civilian demonstrators in the 2011–2012 uprisings were entirely apolitical in nature. Dr. Ali Al-Akri, one of were summarily executed by the military. the imprisoned physicians, told The Guardian, “We were Therefore, in both nations, the ruler has significant as far away from politics as you could be but we found control of the armed forces, which have been instrumen- ourselves in the centre of it because we were treating the tal in quelling the civilian uprisings. Thus, while rulers victims [5].” In another statement released by the medics have fallen in Tunisia, Libya, Egypt and Yemen, and after the court ruling, they said, “During the times of un- some reforms have happened in Morocco, Jordan and rest in Bahrain, we honored our medical oath to treat Oman, the leaders of Bahrain and Syria have thus far the wounded and save lives. And as a result, we are been successful in retaining their hold on power. This being rewarded with unjust and harsh sentences [6].” Hathout Philosophy, Ethics, and Humanities in Medicine 2012, 7:11 Page 3 of 6 http://www.peh-med.com/content/7/1/11 The policy of the Bahrain government has drawn now playing out in Syria. In a report released October significant international criticism. In Geneva, the 25th , titled “Health Crisis: Syrian Government Targets spokesman for the U.N. Human Rights Office, Rupert the Wounded and Health Care Workers,” Amnesty Colville, said that there are “severe concerns” about International alleges a wide range of human rights viola- the sentences against the doctors and nurses.