Dual Loyalty (DL) of Healthcare Professionals Zeev Wiener, MD.

International medical Codes “ The health of my patient shall be my first consideration ” (WMA Declaration of Geneva 1949). “ A physician shall owe his patients complete loyalty and all the resources of his science ” (WMA International Code of Medical Ethics 1983)

The Problem of DL Simultaneous obligations, expressed or implied, to a patient and to a third party.

Clinical Definition Clinical role conflict between professional duties to a patient and obligations, expressed or implied, real or perceived, to the interest of a third party such as an employer, an insurer or the state that can violate patient ’ s rights. Conflict-obligation-pressure-risk

Difficult Settings Prisons Refugee and immigrants camps Workplace Forensic evaluation Military

Case Examples of DL Violation Using medical skills to inflict unnecessary damage or pain on behalf of society or state. Subordinating independent medical treatment or judgment to state policy or interest. Limiting or denying medical treatment or information related to individual or subgroup. Disclosing patient ’ s medical confidentiality to state and powerful non-state authorities. Using medical skills to develop CBW. Remaining silent in the face of health care abuse.

Social Context in Which DL Occurs Environment where the health system itself violates HR because it fails to meet basic health needs, can lead health professionals to become complicit in HR violation.

Risk Factors for DL Conflict Totalitarian regime Military/Police Area of violent conflict Position of worker at risk Treating minorities/stigmatized patients Discrimination (personal or istitutional)

Bioethics Discipline that enables clinicians to analyze their actions in morally complex clinical situations and to identify rational arguments to substantiate their moral choices.

Principles of Bioethics Autonomy-Respect the decision-making ability of autonomous person. Beneficence-The duty to maximize benefit to the person or people in care. Non-Maleficence-The mandate to avoid harm. Justice-Fairness in deciding competing claims Beauchamp and Childress, Principles of Biomedical Ethics,2001.

Dual Loyalty and Human Rights When the health professional acts on duty, to support the interest of the state or other entity instead of those of the individual in a manner that violates the human rights of the individual. Repressive government, closed institutions (prisons, military, psychiatric facilities), health policy. Discrimination against: gender, ethnic, religious, refugees, immigrants.

Human Rights Definition Rights of individuals in society that take the form of legitimate, valid, justified claims upon his or her society to various “ goods ” and “ benefits ” deemed essential for dignity and well being. Henkin, The age of rights,1990 The Right for Health

Human Rights Codes “ All human beings are born free and equal in dignity and rights ”. (UDHR,1948, art.1) “ Every human being is entitled to the enjoyment of the highest attainable standard of health conductive to living a life of dignity ”. (The International Covenant on Economic, Social and Cultural Rights 1966, art 12). Respect, protect, fulfill. (See above, 2000)

Health Professionals and Human Rights professionalism Society Expects Vulnerable profession HR language in professional ethical cods

Human Rights and Bioethics BIOETHICSHuman Rights Dyadic Relations Context (Access, discrimination) Justice

Principle of Solving the DL Conflict Mediating the clinical circumstances in a way that preserves the primacy of keeping faith with patients while conceding the legitimacy of third party’s other expectations of medicine.

Resolving DL Conflicts Within Bioethics-Hr Framework Human Rights Human rights analysis enables the health professional to resolve DL conflicts by reference to agreed- upon universally applicable set of moral principles. Human rights principles are not subject to balancing against other interests and none may be derogated or suspended. Bioethics Autonomy Beneficence Non-Maleficence Justice

DL Problem Solving Algorithm DL Problem? Define! Yes Operational Strategies HR Violation? Yes Alternative Strategy NO Bioethics Violation? Yes Alternative Strategy No Share, Consult, Re-Evaluate Alternative Strategy Act NO Action Strategies

Institutional Mechanisms Monitoring Speaking out Advisory service Encouragement of best practices Proscription undesirable practices Victim redress Education and training Protection from reprisal Professional Accountability

Military Health Professional Inherent Role Conflict Health Professional Soldier Preserve life Reduce suffering Inflict harm to enemy

Israeli-Palestinian Conflict DL Obligations of Health Personal Prison Holding Palestinians Occupied Territories Civil/Military Court Israeli State Hospital Site Role Triage Treatment quality Emergency triage Triage Treatment quality Clinical Funding Institutional guidelines Access to healthcare Funding Institutional guidelines Management Medical Investigation Fitness to interrogation Expert witness Forensic

SUPPORTING DL Conflict Resolution Professional Organization Education Institutional Mechanisms NGO’S & PUBLIC

DL Guidelines A Project of the International Dual Loyalty Group. A Collaborative Initiative of Physicians for Human Rights and the School of Public Health and Primary Health Care, University of Cape Town, Health Science Faculty,2002.