Humanitarian action: the duty of all doctors

Humanitarian issues, large and small, are all around us

Humanitarian is defined by Webster's dictionary as “having concern for or helping to improve the welfare and happiness of mankind.” In that sense all doctoring is humanitarian. A second definition goes further: “a person actively engaged in promoting human welfare and social reforms.” Many doctors are not active in promoting social reform, but should they be? Every doctor knows that those who live on the margins of our world—those who are poor, vulnerable, elderly, addicted, insane, imprisoned, unemployed, discriminated against, tortured, homeless, condemned, caught up in wars—have higher rates of sicknessand ill health. Doctors should be paying great attention to those people, but too often, like everyone else, they neglect them. The poor have greater difficulty than the rich in accessing health care; prisoners get a second class service; doctors propose that the addicted—smokers, drug misusers—should be denied treatments like coronary bypass grafting. This issue of the BMJ has gathered together articles that deal with humanitarian issues, and although many concern people in poor, war torn countries, not all do.

The main reason for publishing this special issue now is that next week in Ottawa the world's nations will try again to take effective action against antipersonnel landmines. A hundred years ago the BMJ published papers on the injuries caused by particular types of projectile,1 2 and the authors became part of the history of warfare and of humanitarian action by doctors. The world has, more or less, agreed that there should be limits to the weapons used in war time and enshrined these in global protocols. Despite these controls, humans' ability to design “better” weapons seems limitless, while our capacity for devising systems to control these weapons has only recently been rejuvenated.

The issue of landmine control is played out on a world stage, but not all humanitarian issues work at that level. Regardless of where doctors work, they are required to use their skills to benefit patients. As Leaning points out, the Universal Declaration of Human Rights requires that doctors recognise the separate, inviolate nature of the individual patients who face them (p 1390). Universal human rights, Eleanor Roosevelt argued, begin “in small places, close to home.”3

All those working in health care face challenges to these ethical precepts. These are often manifest as invitations to ignore the human rights of individuals or groups of patients. At other times doctors face demands to neglect one individual or group in favour of another, selected for political or other non-medical reasons. And finally there are challenges which place health care low in the priorities of national and international leaders.

Hornblum shows how the fundamental requirement to obtain consent from research subjects which is informed and genuine, and therefore free of coercion, was ignored for decades in American prisons (p 1437).4 The greater good of society was considered more important than the rights and liberties of prisoners. Such abuses may not compare in scale to the horrors catalogued at the Nuremberg trials, but they show how easily some or all ignore a collective ethic and value system.

The values which society places on health and health care may most clearly and obviously be seen by the expenditure governments make. Afghanistan and Sudan are just two examples of places where military spending increases while people starve or die of preventable diseases. The solutions are complex. Discussion of population control has a place (p 1441).5 Does the millennium gift—the cancellation of debt—that Logie and Benatar propose that the developed nations should give to the world's poorest debtor nations have a place in global politics (p 1444)?6 If we accept that doctors have a duty to their patients and societies, ought we, as doctors, be involved in educating politicians about the true value of this gift? The humanitarian needs of the poorest and most vulnerable are clearly exposed by Veeken (p 1458, 1460),7 8 Rogers (p 1472),9 Garfield et al (p 1474),10 Lambert et al (p 1425),11 and Reyes and Coninx (p 1447).12

Occasionally individuals stand out and confront us with these everyday challenges and the ways in which we face them. Charismatic individuals, such as Diana, Princess of Wales, can point out truths that are too often obscured by politics and apathy (p 1456).13 The debate on landmines has taken place over many years, and the campaign for a ban is five years old. But for those in Britain and in many other countries it came alive only when it was given a human face by Diana.

As Giannou says, some of the facts about landmines are irrelevant (p 1453).14 What matters is how and what we plan to do about them. A mined piece of land is useless for agriculture; it simply contributes to the dependence on external aid of a local population. The lesson we must learn as the Ottawa conference approaches is that the struggle to clear the world of unexploded ordinance and landmines is just beginning. A sustained effort for many decades will be needed to clear land and rehabilitate those who will continue to be maimed.

While the landmine problem is not solved, enormous strides have been taken. The role played by doctors in obtaining the global ban on blinding laser weapons was significant. Flawed though that ban is (p 1392),15 it shows that medical expertise can have a place in the process of building on the Geneva Protocols.

Can medicine do more? Can doctors find a way to prevent the development of new weapons? The SIrUS project may be an answer (p 1450).16 It places on doctors and other health workers a major role not only in dealing with the consequences of conflict, but in shaping and limiting those consequences. If this project from the International Committee of the Red Cross is not supported by doctors, their colleges, and associations signing up to these concepts then we may have little influence except as direct care givers.

This issue of the BMJ ranges over a wide territory of neglect and abuse of those who live on the margins of society. The challenge to doctors is to try and understand the deprivations and problems of the marginalised. This is hard, especially when doctors are everywhere part of the elite. But many brave doctors have shown that it can be done.