Government Policies in Violation of Human Rights as a Barrier to Professionalism

In recent decades, a set of reciprocal obligations between physicians and society have been identified as central to the concept of professionalism. In return for the high degree of autonomy society grants physicians, including licensure and self-regulation, the profession is expected to serve patients' interests. At the heart of professionalism lie 3 fundamental principles: primacy of patient welfare, founded on altruism, trust, competence, and patient interest; patient autonomy, including educating and empowering patients to make appropriate medical decisions; and social justice, which considers available resources and the needs of all patients while taking care of an individual patient.¹ However, deeply embedded institutional and organizational impediments often beyond the control of the physician (eg, inequitable access to care and reimbursement systems that create disincentives to proper care) can undermine physicians' ability to adhere to these professional obligations in clinical practice.²

Although often unrecognized, government-sanctioned human rights violations add additional barriers to adherence to the norms of professionalism. In some cases, governments fail to meet their obligation under human rights treaties to provide core health services, thus denying professionals the resources they need to provide competent treatment. Less familiar government-imposed barriers to professionalism include, among others, (1) overt restrictions on or bureaucratic hurdles to obtaining essential medical equipment, supplies, or medications; (2) abdication of responsibility to ensure medical training for the health needs of those whose status or condition may be unpopular; and (3) government support for or tolerance of practices that deliberately inflict harm on women or persons from marginalized groups, especially in the context of sexuality and reproductive health. These practices deny patients their right to the highest attainable standard of health, can bring about severe pain or suffering and can constitute cruel or degrading treatment. Because physicians are embedded in the cultures in which they practice, they may be unaware of these human rights–related barriers to professionalism. Moreover, individual physicians are often not well positioned to challenge restrictions on professionalism, so collective action by the community of physicians is needed.

Shortages of essential equipment, facilities, medications, and supplies needed for competent patient-centered care may be a result of national resource shortages and such deficiencies may be present even when governments are in compliance with their human rights obligation to make progress toward meeting the population's health needs. But these deficiencies may also be a product of policies and practices that infringe human rights. For example, some governments impede access to opioid medications to control pain by inadequate distribution networks or stiff restrictions on prescribing by physicians. Russia, Mongolia, Ukraine, Kyrgyzstan, South Africa, India, and Peru either impose limitations on which licensed physicians can prescribe opioids, require multiple approvals for prescribing, or limit the settings in which these drugs can be used.³ In a number of African countries such as Zambia, magnesium sulfate (essential to treat preeclampsia) is not procured by ministries of health.⁴

Lack of adequate training of physicians, including passage of intergenerational attitudes, beliefs, and clinical practices to new practitioners in a biased or uninformed manner, can result in devaluation of certain groups or subordination of medical needs to invidious social policies. Stigma associated with human immunodeficiency virus (HIV) and AIDS, or certain groups at high risk of HIV infection, led some governments to minimize education on treatment and management of patients with HIV. Another example is endorsement or acceptance of negative attitudes about opioid medications that have resulted in limited medical training for their use in areas such as appropriate dose, titration, and timing of administration in ill patients, even when these medications are available. A survey of 52 facilities in 12 sub-Saharan African countries found that clinicians frequently lacked knowledge on how to prescribe opioid medications, refused to prescribe them for children, and had uninformed views on their harms.⁵ Such lack of training undermines values of competence, patient autonomy, and social justice.

Professionalism also is undermined when governments promote or fail to stop medical practices rooted in social attitudes or norms seeking to control sexuality or reproduction. These practices are inconsistent with the respect for patient-centeredness, autonomy, and social justice that are hallmarks of both human rights and professionalism. For example, with government sanction or acquiescence, physicians in Turkey have been called on by family members, schools, and state institutions to conduct examinations for the purported purpose of determining a woman's virginity; nearly half of physicians questioned in a survey acknowledged performing those examinations.⁶ Physicians in Chile and Namibia reportedly participated in forcibly or coercively sterilizing individuals who are marginalized, have tested positive for HIV, or are impoverished.⁷ During the 1990s, physicians in Peru were encouraged and pressured to advance a government policy on sterilization of rural, mainly indigenous people, including a reported 300 000 tubal ligations and 20 000 vasectomies.⁸ In Egypt, men suspected of engaging in homosexual activity in violation of moral codes banning “debauchery” have been subject to forcible anal examinations by the Forensic Medical Authority, an agency of the Ministry of Justice, seeking evidence of “habitual” homosexuality.⁹ Under the currently rescinded “global gag rule,” health organizations abroad receiving US financial assistance, and thus physicians working for them, were prohibited from providing information or referrals for legal abortion, even if US funds were not used for that purpose, regardless of the health needs of the woman. The restriction compromised professionalism by prohibiting physicians from exercising judgment based on their competence, acumen, and training, and sharing information that could be central to their patients' reproductive health.

In these situations, governments rely on physicians for more than clinical skill. Their esteem, access to vulnerable groups, communication skills, knowledge of specialized procedures, and established relationships in the community are used to facilitate cruel or degrading practices. Physicians often understand the tension between enforcing discriminatory norms or policies and obligations to act in patients' interest and respect their rights. The pressure on physicians to conform to social expectations is often high, however, and they may fear ostracism within their social circle, loss of professional opportunities, or coercion from the government if they do not accede.

Professional organizations should consider how policies adopted by governments and social practices tolerated by them that violate human rights can undermine professionally appropriate actions, clinical and scientific standards, and professional values. An understanding of these policies can lower barriers to professionalism by enhancing individual competence, promoting adherence to professional norms, and ensuring respect for their patients' human rights. This understanding can also expand a vision that emphasizes health as a central social value, stimulate reflection about how competing values can undermine professionalism, and play an advocacy role on behalf of patients and professionalism.¹⁰ In addition, such understanding can lead to action to challenge directly the policies and practices that undermine professionalism and violate human rights.

In many cases, a single physician cannot meaningfully alter the source of a threat to professionalism and human rights. However, individual physicians are not absolved of the responsibility for addressing human rights barriers to professionalism. At a minimum, physicians and medical students should educate themselves about the relationship between human rights violations inflicted or tolerated by the governments and ethical obligations. They can then seek to navigate restrictions to and report on barriers to professionalism with the goal of ameliorating their impact. Physicians should avoid passivity, instead using their experience to contribute to collective action by the profession.

Professional groups should also provide leadership to build greater public awareness of human rights, educate their members on human rights and professionalism, and protect physicians from becoming tools for discriminatory or cruel treatment of patients. Professional groups are well positioned and should be expected to oppose administrative or legislative policies, rules, and norms that amount to human rights barriers to professionalism. Alliances between professionals and stakeholders such as patient groups and community organizations should be forged to demand government respect for human rights. Such alliances can inform a new generation of health professionals and may effect change, including through political action, so that physicians can provide their patients the highest standard of care while also protecting their rights.