Can politics contravene duty of care?
This article is sponsored by Uniting, the Board of the NSW and ACT Synod of the Uniting Church responsible for the work of community services, chaplaincy and social justice advocacy.
Mentally ill and suicidal people are being forced to endure or re-enter detention, against medical advice, at the directive of the government.
Human services professionals have recognised a professional responsibility to clearly oppose injustice. They have revealed and advocated against abuse when policies are harmful, known to be harmful and are deliberately harmful.
There is not a need for immigration detention with its inevitable abuses. Other countries are able to do identity, health and security checks in other ways.
A doctor’s sacred commitment
The Hippocratic Oath is one of the oldest binding documents in history. The oath, written by Hippocrates, is taken by physicians and refers to their sacred commitment – to treat the ill to the best of one’s ability; to preserve doctor-patient confidentiality; and to pass on the secrets of medicine to the next generation.
By taking the oath, there is an understanding that doctors will be impartial and unbiased, and will exercise their duty of care equitably for all. Does this oath leave any room for doctors to have political views, or to be actively engaged in politics? Does the Hippocratic Oath – or contemporary equivalents such as the International Code of Medical Ethics – transcend politics? Or would a doctor’s political views – say, on the issue of asylum seekers – impede their ability to provide good care?
The issue of immigration detention
Health, wellbeing and human rights are interconnected. A now massive body of multidisciplinary inquiries and research, both Australian and international, establishes indisputably that these immigration detention policies, supported by successive Australian governments and both major political parties, result in a significant range of health, including psychiatric and emotional, problems. No published research significantly dissents. In fact, government-commissioned research and government officials agree that mental health worsens with time detained.
At the Australian Human Rights Commission Forgotten Children hearings, the former immigration minister, Scott Morrison and Immigration Secretary Bowles separately acknowledged immigration detention’s harmful impacts: “ … there is a reasonably solid literature base which we’re not contesting … which associates a length of detention with a whole range of adverse health conditions … ” (DIBP Secretary M. Bowles) (AHRC, 2014: third public hearing, July 31: p.12; AHRC, 2014: fourth public hearing, August 22: p.40).
The continuing impacts on asylum-seeking children and their development are particularly worrying. Health and human services work at this intersection of mental health and human rights springs from the encounter with asylum seekers’ lives and predicaments.
Human wellbeing and policy objectives are incompatible
Many doctors experience the ethical framework of healthcare and human wellbeing and the policy objectives of detention as incompatible. Human services professionals can also get caught up in conflicts of interest with their employers. A recent example includes patient transfers from Manus Island and Nauru which were stopped or delayed, with death sometimes the result. Mentally ill and suicidal people are being forced to endure or re-enter detention, against medical advice, at the directive of the government.
Asylum seekers are also being required to undergo health assessments while exhausted, dehydrated and filthy, with clothing soiled by urine and faeces. And individuals are being addressed by boat number rather than name, according to multiple consistent eyewitness accounts (Sangarran 2016).
Human services professionals have recognised a professional responsibility to clearly oppose injustice. They have revealed and advocated against abuse when policies are harmful, known to be harmful and are deliberately harmful. They have done this in the face of state resistance and possible punishment.
Meanwhile, national institutional bodies of medicine, social work, paediatrics, psychiatry, nursing, psychology and public health have now all collectively opposed immigration detention. These organisations are not regarded as radical, nor are they synchronised in any way, which makes this alignment the more remarkable.
Why would doctors work in detention sites?
All of this raises the question of whether doctors and other human service workers should continue to work where health and human rights are seen to conflict. Human service professionals may continue to work in detention sites for many reasons. It may be due to the belief that they are doing vital service for the nation (this happened at Guantanamo Bay in the “War on Terror”). Or their reasoning could be more monetary, as there are handsome financial and career rewards ($13,000 per week for a medical post on Nauru recently).
The reason could also be more idealistic. Human service employees or contractors with the Department of Immigration and Border Protection (DIBP) may feel that they can still meaningfully assist asylum seekers within this system. A compassionate person may consider it preferable to deliver the best care possible care within the constraints of the system, rather than hand over to a new, unknown replacement. They may also be concerned that leaving may jeopardise asylum seekers’ care by causing workforce shortages. They may also wish to advocate on behalf of asylum seekers from within the system.
However, DIBP detention work cultures strongly discourage advocacy. Advocacy often ends in dismissal or no change. Advocacy seldom tackles the systemic nature of the DIBP problems and additionally, is obstructed by the diffusion of responsibility.
Professionals can turn whistle-blower (reporting externally) but they risk prosecution for breaching confidentiality agreements. There is also the argument that health and human service professionals may provide scrutiny for what is going on, but how do they get the word out? Furthermore, is there a point at which scrutiny becomes collusion?
Should there be a boycott?
Should there, then, be a boycott of services to Australian immigration detention? This would mean health and human service workers being asked not to work within Australian immigration detention unless appropriate conditions are met.
While this would remove the “loaning of respectability and legitimacy”, it may have little impact on medical treatment in detention centres, because the government now uses mainly non-Australian personnel (Sangarrin 2016).
So what can health and human service professionals do? There are ways forward. These include: gathering information on human rights violations and substandard care; preparing independent medico-legal reports, including claims for injuries incurred and documenting payout costs; advocating for appropriate and comprehensive settlement and support services; engaging with international and national bodies to highlight asylum seekers’ predicaments; and where death has occurred and health remedies and recommendations have not been applied, pursuing coronial inquiries and consequent actions.
There is not a need for immigration detention with its inevitable abuses. Other countries are able to do identity, health and security checks in other ways. Australia has to let go of this – and the Australian community will be healthier as a whole if we do.
Dr Michael Dudley (School of Psychiatry, University of New South Wales) and Dr Fran Gale (School of Social Science and Psychology, Western Sydney University).
Prefer to see the SSH as it appears in print?
Download SSH older issues as a PDF here.