AAMC Reporter: January 2007

Viewpoint:
"The Human Rights Imperative in Medical Education"

Leonard S. Rubenstein, J.D., President, Physicians for Human Rights

Medical students are hungering to know more about health and human rights. This hunger develops as they confront the enormous discontinuities between the sophisticated, high-tech medicine central to their training and the stark reality of morbidity and mortality resulting from widespread violations of the most basic human rights. It develops as they confront the highly visible impact of poverty and discrimination on the health of their patients during clinical rounds and the unfathomable denial of access to medical care to almost 50 million of their fellow Americans. It happens as they confront the needless deaths of millions from lack of clean water and routine health interventions in Africa and other developing nations. Many students search for a framework that will both provide them with principled solutions and channel their idealism into action. They find it in human rights, a set of ideas and values that provides a powerful framework for identifying the violations of human dignity that account for such inequities; standards for judging health and social policy; motivation to act and the tools to do so: documentation, policy and legal analysis, mobilization, and advocacy.

It is not just the nation's and the world's injustices, though, that direct these students' attention to human rights. Thinking about their personal responsibilities as future physicians makes them uneasy when they see physicians asked—or forced—to serve policies that infringe on the human rights and undermine the health of those under their care. How should they respond if, serving as a physician in the military reserve, they are ordered to participate in force-feeding of hunger strikers at Guantanamo? What should they do if laws or regulations restrict the information they are allowed to provide to patients, or the manner in which they provide it?

They want to know, too, what their responsibilities are in addressing nonmedical factors that compromise quality of care. What is their obligation to assure that language barriers do not impede access? How can they deal with unconscious biases in themselves and others that contribute to disparities in the quality of medical care?

These questions in turn provoke broader questions of professional obligation. What is the profession's collective responsibility to support its members who face untenable choices under pressure from governments to conform to restrictive policies, not patients' needs and rights? And what are physicians obligated to do to redress larger public health and human rights concerns that impact individual health, e.g., that their government is engaging in torture, that millions of Americans are uninsured, that millions of people die from preventable or easily treatable causes? When I speak to Physicians for Human Rights' medical student chapters I hear these questions all the time. The answers, unfortunately, are not forthcoming in students' formal medical education.

Traditional medical ethics training typically ignores these issues at the intersection of medical practice, social roles, and government conduct. This is not to say that traditional training is not useful. To be sure, there is great value in teaching students how to negotiate the maze of intimate and compelling ethical questions in clinical practice— patient autonomy in medical decision making, problems of consent when capacity is compromised, and confidentiality in family relationships, among many others. And it's important for students to have a sense of how to approach the relationship between available resources and patient needs, and broader questions of social good, such as breaching confidentiality in the prevention of child or spouse abuse, or in the control of epidemics.

Traditional ethics education is not as helpful, however, in addressing providers' responsibilities in redressing gross inequities in access to health services, and in responding to governmental demands to subordinate patient interests to its own goals. The obligations of the profession as a whole to address human rights violations, in particular, get short shrift, especially in situations where it is not reasonable to expect individual physicians to take principled ethical stances because of potentially severe consequences for their careers, and where only institutional support can assure protection of deeply held professional values.

The reluctance of medical schools to address these issues is understandable. The curriculum is already crowded. Few faculty have experience in addressing these issues. And most of all, there is distinct queasiness about bringing human rights concerns into medical education because it is somehow "political" and therefore has no place in an education founded in scientific evidence. If the next generation of physicians is to be fully prepared to deal with the social and moral dilemmas they will face in the coming decades, however, medical education will need to push its way through these barriers. Curriculum priorities can be changed. Faculty can be trained. And resistance to human rights training on the grounds that it counts as "politics" amounts to denial of the realities the students will face, and leaves them ill prepared to act according to the enduring values of the field. Failure to provide medical students with strong, focused human rights education essentially withholds important tools and resources they need to act ethically in their careers, especially those who work in settings where human rights violations are most common, such as prisons, the military, and clinics serving immigrants or the poor.

Medical educators and the AAMC can provide enormous leadership in preparing our future physicians to be effective proponents of human rights. There are models to follow. For example, the Health Professions Council of South Africa, which oversees medical education, is about to require human rights training as part of the core curriculum, and have established core competencies that are to be achieved. The leaders in medical education in the United States are certainly no less committed to human rights; they simply need to equip students to meet the human rights challenges they will face.

For more information on Physicians for Human Rights and its student programs, go to www.physiciansforhumanrights.org.

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