Medical Ethics and Human Rights in Psychiatric Care

Article excerpt

I. Introduction

This paper explores normative connections between human rights and medical ethics. My interest in this topic was first stimulated in 1988 when I became involved in the investigation of medically unwarranted psychiatric hospitalization of political and religious dissidents in the Soviet Union. (See Bonnie, 1990). From the beginning, it seemed to me that the human rights objections to this practice needed to be disentangled from objections grounded in medical ethics. On the one hand, detention of a person for the purpose of suppressing unorthodox political or religious expression is a violation of human rights, whether it occurs in a jail or a hospital, and whether or not the person has a mental disorder. On the other hand, coercive hospitalization without a medical basis violates medical ethics even if detention for punitive or incapacitative purposes is otherwise justified. The Soviet practice of hospitalizing mentally healthy dissidents solely for criticizing the regime was clearly objectionable on both grounds.

My interest in these overlapping and interacting normative systems was further aroused by a 1992 report on medicine and human rights entitled Medicine Betrayed, prepared by a Working Party of the British Medical Association. I was asked to write an editorial for the British Medical Journal commenting on the report's chapter on the death penalty. (See Bonnie, 1992). In this chapter, the Working Party expressed reservations about numerous forms of medical participation in the judicial and correctional processes, ranging from the gruesome task of carrying out the punishment (e.g., by preparing and administering a lethal injection) to less direct forms of involvement such as assessing and treating allegedly incompetent condemned prisoners. I was struck by the intertwining of medical ethics and human rights concerns in the Working Party's analysis. Ultimately, I concluded that the Working Party's recommendations cannot be defended solely within the normative logic of medical ethics and that some of its proposals were rooted in an abolitionist stance toward the death penalty.

These speculations about Soviet psychiatry and medical participation in punishment led me to think more systematically about the normative connections between human rights and medical ethics. At the outset, we should note two similarities between these two normative systems. First, according to contemporary thought, medical ethics and human rights both purport to represent universal normative requirements. The ethical tradition of medicine is generally thought to be independent of particular cultures, representing universal ideas about the nature and purposes of medicine. Similarly, according to the prevailing point of view, norms of human rights are also universal and are not dependent upon the legal traditions and values of particular cultures. Although the idea that all states are bound to respect certain rights of the individual has deep roots in human history, it was strongly reinforced by the Nuremberg trials and is now embedded in numerous international legal documents.

The second point is that norms of medical ethics and human rights are not static; they evolve over time, reflecting transcultural changes in technology and human values. For example, ethical ideas about abortion and about the physician's obligations to dying patients have changed significantly in the past two decades. In the sphere of human rights, ideas regarding the acceptability of different forms of punishment have changed, and there is now a worldwide debate on whether caning and other forms of corporal punishment (as well as the death penalty) are any longer acceptable under contemporary standards of decency.

We see, then, that although medical ethics and human rights reflect separate normative traditions, each body of ideas and norms is influenced by underlying changes in human circumstances. Moreover, these normative traditions affect one another. …