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This paper discusses the global role of doctors in light of a new piece of legislation passed by Turkey on January 17, 2014 that criminalizes emergency medical care outside of hospitals. In particular, I will compare the activist goals of the trend-setting physician outreach groups (Doctors without Borders, Doctors for the World, and Physicians for Human Rights) to the international guidelines of medical neutrality that Turkey’s bill blatantly violates. Medical neutrality, the principle of noninterference with medical services, precludes detrimental actions directed towards healthcare workers, medical facilities, and patients during conflict. The First Geneva Convention, one of the four treaties of the Geneva Convention, declares that the violation of medical neutrality constitutes a war crime. The underlying premise of this statement is that healthcare workers and their patients are removed from politics. Since their conception, however, the aforementioned physician outreach groups have arguably contradicted this premise in their goal to act as witnesses to human rights violations, and have consequently created a new role and set of responsibilities for global physicians.
Turkey first began limiting medical autonomy after the Gezi Park protests on May 30, 2013. The protests were originally organized by environmentalists as a peaceful sit in that opposed the government’s urban development plans. Events escalated after the police brutally evicted the protesters from the park. Not only did the police use rubber bullets, tear gas, water cannons, and live ammunition, there were also reports of sexual assault and beatings. In a reaction that has been compared to Occupy Wall Street, anti-government demonstrations arose around the country, which the government continued to repress violently. Over the next couple of months, Amnesty International recorded at least 8,000 people injured and three deaths that could be positively connected to police brutality.[i] Besides targeting protestors, the police also attacked anyone who tried to give medical care to the protestors.[ii] The concept of medical neutrality was not only disregarded, it was actively destroyed as police raided hospitals and demanded that healthcare workers give them the names of their patients, as well as a list of the doctors who had treated the injured. Even without the names, the police arrested many injured patients in the medical facilities.
In August, the Turkish parliament announced that it was writing a new bill that would include Article 33, a declaration that criminalized emergency medical care given outside of the hospital. The article would force healthcare workers to wait for a government authorized ambulance to retrieve the injured; they would not even be able to administer the most basic first aid without authorization. Physicians would have to go through an additional licensing process before they could work in hospitals. “If convicted, violators could be imprisoned for up to three years and face fines of nearly $1 million.”[iii] Significantly, three years is the same amount of prison time given to someone who deliberately injures another person.[iv]
Leading up to the moment when the bill was officially passed on January 17, international humanitarian groups protested its implications. They were concerned primarily with two issues. First, the groups accused the Turkish government of eliminating medical autonomy in order to spread terror and silence dissenting voices. Many factions before the Turkish government have ignored medical neutrality, presumably in order to strengthen their positions, and Turkey would not even be the first government to use this tactic in an official capacity. For example, in 2011, the Bahrain government accused 47 Bahraini medical staff, 23 doctors, and 24 nurses of anti-state activities and brought them to trial in a military court. At the time, the Johns Hopkins Berman Institute of Bioethics published an op-ed piece that discussed the importance of maintaining global medical neutrality.[v] The author, Sabeeh Baig, explains that medical neutrality grew out of a need to prevent an increasing number of civilian causalities during the post World War II years. These civilians had been victims of political forces out of their control, and the world powers agreed that these civilians should be protected. In order for this to work, the conflicting factions had to allow everyone access to medical care, and the physicians had to stay out of politics and treat everyone who came to them, no matter if they were innocent bystanders or active soldiers.
The government’s response in Turkey emphasizes a major problem with the assumption that conflicting factions would adhere to medical neutrality. The Turkish government is trying to repress their people. If they allow healthcare workers to treat the very people that the police have intentionally injured, then they are allowing healthcare workers to undermine their actions. Even if healthcare workers help injured police officers as well, their actions cannot be considered as neutral by the government. This is not a game where once you are tagged, you are “out” and no longer involved. Healthy or injured, civilians are still a part of the country, and the conflict is internal between the government and its civilians. It is dangerously idealistic to believe that the same government that brutalized its civilians because of a peaceful protest against urban development would respect medical care as existing beyond its control. Once the government’s goals are recognized, then it is impossible for healthcare workers to maintain a neutral position, because these goals refuse to acknowledge a middle ground between supporting the government and supporting the civilians. No matter how humanitarian groups choose to act, they cannot avoid making a political choice.
This conclusion appears to contradict the idealism of the medical profession and the impartial humanitarian aid that international groups strive to provide, but it actually brings to the surface the political aspect of global medicine that has existed for years. Doctors without Borders, Doctors for the World, and Physicians for Human Rights wrote charters that have implicitly reinterpreted the Hippocratic Oath in order to expand physician duty to include “the victim”. These groups have adopted the protection of human rights as one of their many responsibilities as physicians, and Physicians for Human Rights (PHR) is the strongest advocate for this stance. On their webpage, they state that “PHR was founded in 1986 on the idea that health professionals, with their specialized skills, ethical duties, and credible voices, are uniquely positioned to stop human rights violations.”[vi] While historically physicians have made house calls to patients within their communities, these humanitarian groups actively seek out the sick and the injured outside of the physicians’ immediate reach. Moreover, although many of the people whom they treat are inflicted with a disease or injury that is not directly attributable to human influence, such as malaria or an earthquake, most of the people they treat have been hurt in some way by their social conditions. PHR gathers evidence of humans rights violations and trains their physicians to testify in court. Doctors without Borders and Doctors for the World do not go as far as creating court cases, but they do claim to bear witness to human rights violations and “may speak out publicly in an effort to bring a forgotten crises to view, alert the public to abuses occurring beyond the headlines, criticize the inadequacies of the aid system, challenge the diversion of humanitarian aid for political interests, or call out policies that restrict access to medical care or essential medicines.”[vii] As much as these groups claim to provide impartial medical care, their impartiality only applies outside of their responsibility to their patients. When it comes to protecting their patients, these groups are unequivocally political.
While the first issue raised by the humanitarian groups centers on the Turkish government manipulating its people through medical care, the second issue reveals the political nature of the groups. The Physicians for Human Rights (PHR)’s press release stated that the “bill will put doctors in direct conflict with their ethical and professional responsibilities to care for the sick and wounded.”[viii] At first glance, this is clearly not a political statement. The majority of physicians and civilians take it for granted that physicians have a responsibility to people who are in physical need of treatment. This responsibility is considered ethical, not political. That is true only until a government disagrees. Although it is difficult to accept that a human rights violator has a valid political stance in the issue of medical care, it is possible to find examples of politicized medical care closer to home. In the United States, people do not have the right to medical care. They only have the right to treatment under certain situations, such as emergency care as stipulated by EMTALA. Currently the biggest difference between the United States and Turkey, is that the Turkish government is restricting access to medical care in order to bring further harm to its citizens. Nevertheless, this is still a political choice by the government, and the humanitarian groups are expressing the opposing political policy that both governmental supporters and protesters have the right to access medical care.
Disagreements between humanitarian physicians and human rights violators raise the question of whether physicians are acting outside of their traditional roles, or if their roles have just appropriately expanded to account for their globalized patient population. Are physicians making modern house calls when they travel to different countries, or are they taking on a new role with different responsibilities and professional guidelines? These questions are in part answered by analyzing medical neutrality in the context of the new law in Turkey. Although medical neutrality itself has been placed outside of human rights violation discussions so that physicians could work within countries that are experiencing internal conflict and external criticism, violating medical neutrality is the same as committing a human rights violation; the Turkish government has denied access to autonomous medical care in order to increase governmental influence against dissenters. In this scenario, physicians are not only providing medical treatment, they are acting as advocates for the people’s rights to humane treatment.
Through these international humanitarian groups, global physicians have taken on the responsibility of protecting their patients not only from physical ailments and the injuries created by natural disasters, but also from social ills. Currently these groups are hiding behind the shield of expressed impartiality, but once they openly admit that their actions cannot be interpreted as impartial, then they will be left unprotected by their shield of medical neutrality. This could put global physicians in a dangerous position, and yet it could also be an opportunity to discuss how global medicine is more specialized and requires a different set of skills than traditional, single community medicine. PHR is currently experimenting by teaching their physicians how to recognize torture in their patients, but there are many other skills that could improve physicians’ efficiency and success in the field both in protecting human rights and improving human health.
[i] "Turkey Accused of Gross Human Rights Violations in Gezi Park Protests." Amnesty International, last modified October 2, 2013, http://www.amnesty.org/en/news/turkey-accused-gross-human-rights-violations-gezi-park-protests-2013-10-02.
[ii] Murat Çekiç, June 14, 2013, comment on the protests in Turkey, "A Hospital in Amnesty's Office." http://livewire.amnesty.org/2013/06/14/a-hospital-in-amnestys-office/.
[iv] Tulin Daloglu, "Emergency Care Criminalized in Turkey," Al-Monitor, June 15, 2013. Accessed February 13, 2014. http://www.al-monitor.com/pulse/originals/2014/01/turkey-criminalizes-emergency-care.html.
[v] Sabeeh Baig, "Op-Ed: Medical Neutrality on Trial," Berman Institute Bioethics Bulletin, July 27, 2011. Accessed February 13, 2014. http://bioethicsbulletin.org/archive/op-ed-medical-neutrality-on-trial/.
[vii] "History & Principles," Médecins Sans Frontières (MSF), accessed February 13, 2014. http://www.doctorswithoutborders.org/aboutus/?ref=main-menu
[viii] "Turkish President Signs Bill That Criminalizes Emergency Medical Care." Physicians for Human Rights, last modified January 17, 2014, accessed February 13, 2014. 17 Jan. 2014. Web. 13 Feb. 2014. http://physiciansforhumanrights.org/press/press-releases/turkish-president-signs-bill-that-criminalizes-emergency-medical-care.html