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Table of Contents

I. Introduction

II. Dimensions
of the Problem

III. Proposed
General Guidelines

IV. Proposed
Guidelines for
Difficult Settings

V. Institutional

VI. Appendices


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Dual Loyalty & Human Rights
In Health Professional Practice;
Proposed Guidelines & Institutional Mechanisms

A Project of the
International Dual Loyalty Working Group
A Collaborative Initiative of
Physicians for Human Rights
and the School of Public Health and Primary Health Care
University of Cape Town, Health Sciences Faculty

Table of Contents

    Copyright Information
    About Physicians for Human Rights
    About the University of Cape Town
    Preface and Acknowledgements

    I. Introduction
    • The Problem of Dual Loyalty and Human Rights
    • The Concept of Dual Loyalty
    • Dual Loyalty and Human Rights
    • Human Rights, Bioethics and the Resolution of Dual Loyalty Conflicts
    • The Obligation of Health Professionals to Respect Human Rights
    • Dual Loyalty and Human Rights: The Need for this Project
    • Scope of the Project and Products

    II. Dual Loyalty and Human Rights:The Dimensions of the Problem
    • Using medical skills or expertise on behalf of the state
    • Subordinating independent medical judgment, in therapeutic or evaluative settings
    • Limiting or denying medical treatment or information related to treatment to an individual
    • Disclosing confidential patient information to state authorities or powerful non-state actors
    • Performing evaluations for legal or administrative purposes
    • Remaining silent in the face of human rights abuses committed against individuals and groups in the care of health professionals

    III. Proposed General Guidelines for Health Professional Practice

    Proposed Guidelines for Practice in Difficult Settings
    • Prison, Detention and Other Custodial Settings
    • Health Care for Refugees and Immigrants
    • Health Professionals in the Workplace
    • Health Professionals Engaged in Forensic Evaluations
    • Military Health Professionals

    V .
    Institutional Mechanisms to Promote Human Rights in Health Practice
    • Introduction
    • Objectives of the Institutional Mechanisms
    • Institutional Mechanisms by Strategy
      • Employment relationships
      • Administrative and legal arrangements to preserve professional independence
      • Peer review, professional credibility, support
      • Monitoring
      • Education and Training
      • Accountability
      • Collective action by the professions
    • Institutional Mechanisms by Stakeholders/Agents
      • Roles for Professional Organizations: National
      • Roles for Professional Organizations: International
      • Roles for Statutory (licensing) Bodies
      • Roles for Civil Society
      • Roles for Government
      • Role of the United Nations and Related International and Regional Intergovernmental Bodies
      • Role of Training and Research Institutions

    VI . Appendices
    • Appendix 1: Works Cited
    • Appendix 2: Relevant Treaties, Professional Codes and Declarations


Copyright Information

© 2002, Physicians for Human Rights and School of Public Health and Primary Health Care, University of Cape Town, Health Sciences Faculty
All rights reserved.
Printed in the United States of America.
ISBN 1-879707-39-X
Library of Congress Control Number: 2003101403
Cover and report design: Glenn Ruga/Visual Communications

About Physicians for Human Rights

Physicians for Human Rights (PHR) promotes health by protecting human rights. PHR believes that respect for human rights is essential for the health and wellbeing of all members of the human family.

Since 1986, PHR members have worked to stop torture, disappearances, and political killings by governments and opposition groups and to investigate and expose violations, including: deaths, injuries, and trauma inflicted on civilians during conflicts; suffering and deprivation, including denial of access to health care, caused by ethnic and racial discrimination; mental and physical anguish inflicted on women by abuse; exploitation of children in labor practices; loss of life or limbs from landmines and other indiscriminate weapons; harsh methods of incarceration in prisons and detention centers; and poor health stemming from vast inequalities in societies. PHR also works to protect health professionals who are victims of violations of human rights and to prevent medical complicity in torture and other abuses. As one of the original steering committee members of the International Campaign to Ban Landmines, PHR shared the 1997 Nobel Peace Prize. Along with three other organizations, at the request of the Truth and Reconciliation Commission of South Africa, PHR prepared a report, Human Rights and Health: The Legacy of Apartheid, a review of human rights and ethical violations committed by members of the South African health professions under apartheid.

PHR has been at the forefront of integrating human rights and bioethics. Along with the American College of Physicians and other organizations, PHR published Breach of Trust, which analyzed the role of physicians in capital punishment. PHR has also been at the forefront of developing and sponsoring academic courses that integrate bioethics and international human rights at medical schools and schools of public health.

About the University of Cape Town

The University of Cape Town (UCT) is a leading academic institution in South Africa. Its Health Sciences Faculty has been deeply engaged in addressing human rights in the health sector, including research to promote human rights, sponsoring courses in health and human rights as part of its undergraduate and postgraduate programs, and its own post-apartheid institutional reconciliation process. Through these activities it is actively grappling with key transformation challenges facing training institutions for health professionals in South Africa at present. Along with the Trauma Centre for Survivors of Violence and Torture, the Department of Public Health of UCT, Health Sciences Faculty sponsored the Health and Human Rights Project, which provided technical assistance to South Africa’s Truth and Reconciliation Commission in connection with the Commission’s hearings on human rights violations in the health sector. It also prepared a comprehensive review of human rights abuses in the health sector during apartheid, entitled The HHRP Final Submission to the TRC: Professional Accountability in South Africa (1997). The HHRP was instrumental in establishing a regular series in the South African Medical Journal focusing specifically on human rights and health.

Physicians for Human Rights
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Preface and Acknowledgements

This project grew out of a disturbing trend: Governments and other third parties often demand that health professionals put allegiance to their patients aside, in deference to the demands of these powerful actors — often in a manner that violates patients’ human rights. Although documentation of this ethical and human rights problem, referred to here as the problem of dual loyalty and human rights — has been most thorough in South Africa, it is unfortunately a worldwide phenomenon. However, it is little recognized and rarely discussed. Indeed, in the course of this project we were surprised to see how few materials for guiding professional practice and institutional structures exist, even in organizations where this problem is pervasive, such as the military.

The report of South Africa’s Truth and Reconciliation Commission (TRC) documenting the complicity of health professionals in the apartheid regime, provides a particularly compelling illustration of the problem. The TRC report, based on hearings about human rights violations in the health sector, showed how health professionals had been complicit or silent in the face of torture as well as active participants in institutionalized racism in health services. The report urged the adoption of effective standards of conduct in situations of potential dual loyalty, as well as institutional arrangements and educational programs to ameliorate the problem.

We believe the dual loyalty problem needs the urgent attention of individual health professionals, national and international organizations of health professionals, international standard-setting bodies, governments, and civil society. For that reason, Physicians for Human Rights (USA) and the University of Cape Town Health Sciences Faculty (South Africa) brought together a working group of individuals from the health community experienced in human rights, as well as scholars and practitioners in bioethics, human rights and law, from South Africa and internationally, to address the problem. We are grateful to the Greenwall Foundation for its generous support of this project.

The goals of the project are: (1) to identify the problem of dual loyalty and human rights in its many dimensions; (2) develop an approach to the problem that stems from internationally-accepted human rights standards; (3) produce a set of proposed guidelines for health professionals that would apply to all professional practice and a set of specialized guidelines in settings that raise particularly troublesome human rights and ethical issues; and (4) propose institutional arrangements that can help prevent conflicts between a patient’s human rights and state or other powerful interests in the first place.

The Working Group convened for a meeting in November, 2000 in Durban, South Africa to review the dimensions of the problem, to take up the role of bioethics in addressing dual loyalty and human rights and, to begin work on appropriate responses. The participants in the Durban meeting are listed below. One product of the conference in Durban was the creation of a set of sub-groups to address particular issues, including the relevance of existing international codes of conduct, the interplay between human rights and bioethics, the relationship between dual loyalty and social, economic and cultural rights, and practice in five settings where dual loyalty and human rights problems arise frequently.

In the two years since the Durban meeting, the Working Group has, through its sub-groups, corresponding members and consulted experts, exchanged drafts, tested out approaches, and ultimately produced a document containing both an analysis of the problem and a set of proposals to address it. It is our hope that the proposals will stimulate wide discussion and be considered by national and international standard-setting bodies as well as organizations responsible for the structure of health practice, including governments, associations of health professionals and licensing and regulatory bodies.

The report and recommendations are available electronically at, and

The project was under the general direction of Leonard S. Rubenstein, J.D., Executive Director of Physicians for Human Rights (USA) in close collaboration with Leslie London, M.D., Associate Professor, Head of the Health and Human Rights Division, School of Public Health and Primary Health Care at the University of Cape Town Health Sciences Faculty, and Laurel Baldwin-Ragaven, M.D., now Henry R. Luce Professor of Health and Human Rights at Trinity College (Connecticut, USA) and formerly research fellow of the Health and Human Rights Project in South Africa.

The Participants* in the Durban, South Africa meeting included:

Bea Abrahams
South Africa
Progressive Primary Health Care Network

Enrique Accorsi
World Medical Association and Colegio Medico, Chilean Medical Association

Laurel Baldwin-Ragaven
South Africa
Health and Human Rights Project; Trinity College (USA)

Solomon Benatar
South Africa
University of Cape Town Department of Medicine

John H. Bryant
United States
President, Council of International Organizations in the Medical Sciences

Nancy Bryant
United States Nursing Consultant

M. Gregg Bloche
United States
Georgetown University Law Center; Johns Hopkins School of Public Health

John Chisholm
United Kingdom
British Medical Association

Saths Cooper
South Africa
Psychology Society of South Africa

Mahomed Dada
South Africa
Department of Forensic Medicine
University of Natal

Jeanelle de Gruchy
South Africa
Health and Human Rights Project

Marietjie de Villiers
South Africa
Health Professions Council of South Africa

Carnita Ernest
South Africa
Centre for the Study of Violence & Reconciliation

Mary Faure
South Africa
Society of Physiotherapists

Costa Gazi
South Africa
Eastern Cape Department of Public Health

Ranaan Gillon
United Kingdom
School of Medicine
Imperial College, London

Chandre Gould
South Africa
Centre for Conflict Resolution

Paul Gready
United Kingdom
University of London &British Medical Association

Sandhya Gupta
United States
Physicians for Human Rights

Thembeka Gwagwa
South Africa
Democratic Nurses Association

Erik Holst
ICAR Foundation-Romania

Amar Jesani
Centre for Enquiry into Health & Allied Themes

Kausar Khan
Medical School
Aga Khan University

Simon Lewin
South Africa
Medical Research Council

Leslie London
South Africa
Department of Public Health
University of Cape Town

Percy Mahlathi
South Africa
South African Medical Association

Charles Malcolm
South Africa
Department of Psychiatry
University of Cape Town

Charlotte McClain
South Africa
Human Rights Commission of South Africa

Indres Naidoo
South Africa
Former Senator

Lungisile Ntsebeza
South Africa
University of the Western Cape

Jumana Odeh-Issawi
Happy Child Centre

Wendy Orr
South Africa
Transformation and Employment Equity Office
Witwatersrand University

Karrisha Pillay
South Africa
Community Law Centre
University of the Western Cape

Rachel Prinsloo
South Africa
Human Sciences Research Council

Christian Pross
Center for the Treatment of Torture Victims

Solly Ratamane
South Africa
Department of Psychiatry
University of Free State

Norma Tsotsi
South Africa
South Africa Dental Association

Hernan Reyes
International Committee of the Red Cross

Leonard Rubenstein
United States
Physicians for Human Rights

Ann Sommerville
United Kingdom
British Medical Association

Hasina Subedar
South Africa
South African Nursing Council

Paul Theron
South Africa
Western Cape District
Surgeons Association

Adriaan van Es
International Federation of Health & Human Rights Organizations

Judith van Heerden
South Africa
Department of Primary Health Care & Family Medicine

Joe Veriava
South Africa
Health Sciences Faculty
University of Witwatersrand

Braam Volschenk
South Africa
South African Medical Association

Shabbir Wadee
South Africa
Department of Forensic Medicine
Stellenbosch University

James Welsh
United Kingdom
Amnesty International

Zeav Wiener
Physicians for Human Rights- Israel

Boris Yudin
Moscow State University & Russian Academy of Sciences

Others who did not attend the conference participated in various aspects of the Working Group’s activities. These individuals included:

Anna Bizos
South Africa
Physiotherapy Society of South Africa

Debra DeBruin
United StatesUniversity of Minnesota

Sebnem Fincanci
Department of Forensic Medicine, Istanbul University

Tesfamicael Ghebrehiwet
International Council of Nurses

Delon Human
World Medical Association

Vincent Iacopino
United States
Physicians for Human Rights

Lungisile Ntsebeza, of the Program for Land and Agrarian Studies at the University of the Western Cape, acted as facilitator for the meeting. Indres Nadoo, former political prisoner in South Africa and former Senator in the South African Parliament, was keynote speaker on the evening preceding the conference. Mahomed Dada, formerly Professor of Forensic Medicine at the Nelson Mandela School of Medicine at the University of Natal, acted as liaison between the working group and the Mandela School of Medicine. Barry Kistnasamy, Dean of the Mandela Medical School, also supported the Working Group meeting Izani Event Planners were instrumental in negotiating the logistics for the Durban meeting in 2000.

The bioethics consultant for the Durban meeting was Catherine Myser, Ph.D., who prepared a background paper on dual loyalty and bioethics for the meeting. The project received support from Professor M. Gregg Bloche and the Georgetown – Johns Hopkins program in Law and Public Health.

Members of the Dual Loyalty Working Group joined an on-line moderated list to facilitate discussion on issues related to dual loyalty and the project. The list was moderated by Sandhya Gupta and Nafia Tasmin Din of Physicians for Human Rights.

Drafts sections of the report were circulated for comments by members of the Working Group. We note that not all members of the Durban meeting participated in subsequent discussions and reviews of drafts, and some members had differing viewpoints. Therefore, all aspects of the final product do not represent the views of all participants in the meeting. An Editorial Review Committee reviewed all drafts. The Committee met face to face twice after the Durban meeting and conferred extensively in shaping the final product and in writing the introduction. The committee consisted of:

Laurel Baldwin-Ragaven
M. Gregg Bloche
John H. Bryant
Erik Holst
Leslie London
Wendy Orr
Leonard Rubenstein

Although not able to attend these meetings, Ann Sommerville contributed enormously to the editing of the final document.

Members of the Working Group participated in drafting and review of guidelines for particular settings and to address difficult substantive questions. Adriaan van Es, along with Chandre Gould and Zeav Wiener, led the work group on guidelines for military settings. Leonard Rubenstein and M. Gregg Bloche led the group on forensic health practice. Wendy Orr chaired the largest sub-group, on prisons, which included Jeanelle de Gruchy, Sebnem Fincanci, Jabu Ngwane, Bidur Osti, Hernan Reyes, and Judith van Heerden. Christian Pross led the subgroup on guidelines for health professionals evaluating refugees or in immigration settings. Leslie London led the subgroup on guidelines on workplace settings and drafted the section on institutional mechanisms based on information drawn from all the settings guidelines. A subgroup researching social and economic rights was chaired by Kausar Khan and included Enrique Accorsi, John H. Bryant, Jeanelle de Gruchy, and Amar Jesani. Future work of the Dual Loyalty Working Group on “toolkits” for health professionals is led by Laurel Baldwin-Ragaven and Ann Sommerville. James Welsh compiled and distributed existing international ethical codes and instruments. Chapter two, describing the circumstances of dual loyalty, was written by Leonard Rubenstein, with extensive research assistance from Sandhya Gupta and Nafia Tasmin Din. Boris Yudin, Kauser Khan, Debra DeBruin, Gregg Bloche, Soloman Benatar, Laurel Baldwin-Ragaven, Leslie London, and Ann Sommerville contibuted to the discussion of the relationship betwen bioethics and human rights.

Thomas Geoghegan provided research on human rights law. Lt. Col. Eugene Bonventre, United States Air Force, provided consultation (in his personal capacity) on problems in military medicine as did Michael Grodin, Boston University School of Public Health. Sandhya Gupta reviewed the products for clarity and consistency. In addition to her editorial and research role, Ms. Gupta, along with Ms. Din, provided invaluable support in logistics and communication. Additional research support was provided by Genevieve Grabman and Cordelia Frewen.

Barbara Ayotte, Director of Communications of Physicians for Human Rights, prepared the report for publication.

* Affiliations are those at the time of the Durban meeting and are for identification purposes only