• Clinical Ethics
• Political Philosophy
• Public Policy
• Torture and Genocide

Australia has arguably led the developed world in implementing the most damaging and regressive measures aimed at deterring asylum seekers and refugees. The harms of this system have long been documented and only re-enforced more recently in a number of investigations that have detailed riots, violence and widespread physical and sexual abuse in offshore detention, with adults and children reported as victims.1 ,2

After time spent in an offshore processing centre on Nauru, Isaacs has emerged as a vocal critic of Australia's immigration detention policies. In his article,3 he argues that the mandatory and prolonged detention of asylum seekers and refugees is analogous to torture, drawing comparisons between Australian immigration detention and other notorious sites where torture has taken place. This provocative argument gives a new urgency for long overdue action. Similar concerns have also been raised by other former clinicians and academics (J-P Sanggaran and D Zion. Is Australia engaged in torturing asylum seekers? What this means for medical practise and legislation. Manuscript in preparation.) and follow from comments from the United Nations accusing Australia of systematically violating the international Convention Against Torture by detaining children in immigration detention and holding asylum seekers in dangerous and violent conditions on Manus Island.4

While the harm of immigration detention is undeniable, with the immigration department itself acknowledging the ‘well-established’ impact immigration detention has on mental health,5 Isaacs argues that the purpose of Australian immigration detention is not always made explicit stating that, ‘While the Australian Government does not specify the intention of prolonged immigration detention, it is arguably to coerce asylum seekers into voluntarily returning to their own or another country and to deter others from seeking asylum’. Although serving a number of purposes, the main intent of immigration detention is arguably clearer than this. The government's commitment to ‘stopping the boats’ has been made explicit for years with this ends justifying the means rhetoric being unapologetically echoed by successive governments. There are countless examples throughout the literature that highlight the use of exclusionary and binary language that only serves to further this agenda6 ,7 and one need only look at the media releases of past and present immigration ministers or at the recent Parliamentary Inquiry2 to see how immigration detention's, and particularly offshore detention’s, main purpose lies in it deterring further asylum seeker boat arrivals.

Questioning clinicians’ roles in these environments, Isaacs goes on to consider whether clinicians are condoning torture? This is an interesting question in itself and raises the larger issue of clinicians having to engage with wrongdoing while attempting to do some good, something that is not isolated to immigration detention. How should clinicians engage with wrongdoing? What good can be done in such environments?

The compromised nature of healthcare has now been well documented8 ,9 along with the pervasive nature of dual agency (or dual loyalty) obligations, between that of patients, the immigration department and other contractors.10 This has only served to restrict and distort the nature of healthcare and limit clinicians in their roles with healthcare frequently subverted to other policy goals. Accountability is obscured and oversight is limited with arrangements that attempt to divest responsibility from the immigration department. At best clinicians are required to navigate ethically fraught terrain where they frequently have to compromise what may be ideal or even generally accepted treatment, at worst this promotes conduct that is clearly unethical. Along with the detention environment this all serves to curtail what benefits may usually be gained from treatment. These issues have played out in a more acute form in offshore detention where there has been a number of examples of the immigration department intervening in medical transfers and treatment recommendations.2 ,11 A leaked report that shed light on the extent of these tensions was obtained by the Australian Broadcasting Corporation.12 Centred around the performance of the detention healthcare provider (International Health and Medical Services; IHMS), this report revealed that IHMS risked losing its contract if a number of the immigration department’s concerns were not addressed including clinicians ‘advocating for transferees beyond the services IHMS is contracted to deliver’ and that ‘IHMS need to ensure medical staff who do reviews are not against Offshore Processing Centres (OPCs)’.

Isaacs rightly identifies the important role former clinicians have played in bringing to light these issues and how they are now limited in speaking about their experiences, faced with the prospect of 2 years’ gaol. It is noteworthy that many of the sources cited by Isaacs and this article would now be illegal under recently introduced legislation. This has come at a time when the government has attacked and attempted to silence critics1 ,13 while also covering up allegations of abuse1 ,2 ,14 and has been one of many recent regressive steps that has only served to diminish clinicians’ capacity to act in their patients best interests and advocate for change. What good can be done in such environments? Recent events suggest less and less.

So on balance can clinicians continue to justify their involvement in Australian immigration detention? Isaacs argument, along with the recent steps that have been taken to limit and increasingly compromise the role of clinicians are compelling arguments among others for a boycott, however this article stops short of calling for this as has been done previously.15 ,16 Isaacs instead calls for clinicians to carefully weigh their options in regards to engaging with this system, giving yet another reason for clinicians to rethink their involvement and for significant reform.