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Loes van Willigen, Utrecht, Royal Tropical Institute, 1998, 119 pages, £17.95
I opened this book, eager to discover the medical ethical problems of torture and systematic abuse of citizens, arising from “unethical interventions and unethical professional attitudes”. At the end of the book I was little wiser. Of course, torture and abuse of human rights are unethical and an affront to human dignity, but what are these ethical standards which health care workers must adopt? Firstly, the book is only incidentally concerned with torture. Secondly, most of the issues which it identifies - autonomy, consent, cross-cultural approaches and the avoidance of cultural imperialism are common to a variety of settings. Indeed the book states, “these goals are generally considered self-evident.....”.
Perhaps the most valuable contribution questions the appropriateness of counselling, whose role in the care of people, following severe traumatic events, is already under scrutiny. People trust doctors, even when deeply traumatised, but the danger is that doctors may become, “the prime authenticators of suffering, legitimators of the sick role and gatekeepers to victim groups”. The very existence of a special expertise in the care of traumatised victims is questioned. Whilst specialists will be needed to detect the more subtle consequences of physical violence, using only a special cadre of doctors and psychologists to detect mental trauma may be self-defeating. It de-skills other professionals from their major role in empathetic understanding and listening, and separates victims from their own cultural perceptions of pain and distress. Such specialists, by providing evidence in support of a request for asylum, may easily become merely an entrance ticket to another country.
War presents very severe moral problems and some of these are peculiar to the role of the doctor. Can ethical “rules”, which the book advocates, ever be designed for a whole series of novel individual situations? Indeed, can medical acts ever be neutral in war? By seeking to ameliorate its consequences, it could be argued that we are conniving with the war itself.
The book is least satisfactory in the chapters on research. A case study gives a classical example of unethical research, without illustrating problems peculiar to the situation. The study showed poor science, incompetent researchers, inadequate consent, lack of either cultural sensitivity or confidentiality, poor execution and poor analysis of results. It was not even published! In my view it is difficult to justify research for its own sake in torture victims, even if, in the long term, it may help future victims. It also runs the risk that research on the effectiveness of organised violence may become useful to those who practise it. Of course, treatment techniques must be carefully and thoroughly evaluated, but until these essential preliminaries have been completed, even the collection of data for apparently non-intrusive epidemiological studies from vulnerable, socially marginalised populations from different cultures should not be considered.
The book states that principlism is in retreat and that virtue ethics is beginning to creep back. Virtue ethics has much to offer in situations where ethical dilemmas are incapable of reconciliation. Also, in a post-modern culture, it is strange that ethical reasoning about why we should help such victims should lead to the Christian principle that anyone in need is my neighbour and deserving of my help.
The book is a useful contribution to European social policy. Its thirteen recommendations are all worthy of implementation by policy-makers. It is always useful to publish conference proceedings, if only for the benefit of those who would have liked to have been there themselves. For the medical ethicist however, even for one involved in mental health services, the book is likely to be less than satisfying.