- Abusive situations rarely emerge suddenly.
- Perpetrating, being present at, being aware of, or being suspicious of abuse, and doing nothing. about it, are all unacceptable and unjustifiable.
- Doctors should be aware of the factors which can influence the likelihood that they will recognise. or report unethical or abusive practices.
- Doctors should keep their own record of all action they take in respect of reporting abuse.
Time and again, it is the medics who find out first what is going on, and tell the outside world about it.
Historically doctors have been prominent in champoining the cause of those subjected to abuse at the hands of state authorities across the world.
The 2011 report of the Baha Mousa public inquiry stated that procedures to enable the detection of abuse had not been instituted at the time of Baha Mousa’s death. While abuse is not tolerated within the UK military, British military doctors may still witness unethical practices perpetrated by other nations’ forces. A failure to act in the face of abuse could allow it to continue unhindered.
Military protocols and instruments of international humanitarian law detail the requirements and procedures for reporting abusive practices.
The following advice gives an overview of the principles that should guide doctors’ actions.
What amounts to unethical practices and abuse?
Abusive situations rarely emerge suddenly. The process of dehumanisation and desensitisation often begins with relatively minor disproportionate behaviour, which may go unnoticed or unremarked. Over time, this can escalate to practices that would generally be perceived as abuse, that is as breaching the core principle that military actions at all times be both proportionate and just. By this stage, those involved may be less likely to recognise the behaviour as ethically unjustifiable or illegal.
Perpetrating or being present during abuse is not the only behaviour that equates to involvement in abuse. Individuals are complicit in abuse where they are aware of it, but do nothing about it, or where they conceal the facts of abuse.
Members of the military are required to obey lawful orders. They work in closed and hierarchical command structures and identify closely with, and experience strong loyalty towards, the unit or service of which they are a part. Of course these factors do not make abuse inevitable. For example, an order which would lead to action contrary to medical ethics would be unlawful and as such must not be obeyed.
It is however important that doctors in the armed forces remain aware of the way in which such features of military life can influence the likelihood that they themselves will either recognise unethical or abusive practices, or have the moral courage to report such practices, especially where this would involve exposing colleagues to disciplinary procedures or questioning the actions of seniors.
Doctors should also be alert to any deterioration in the mental health of comrades. Established links between mental ill health and the perpetration of abuse emphasise the importance of the military doctor’s role in tending to the mental health problems of comrades.
Find out about making a disclosure in the public interest
What are doctors’ responsibilities in responding to evidence of abuse?
If doctors suspect practices that are harmful to the health and wellbeing of their patients, they must make immediate enquiries to verify or allay their suspicions. This can involve asking questions of colleagues, discussing concerns with other medical staff, and talking to military and medical commanders.
Following such enquiries, or as soon as doctors become aware of unethical practices or abuse, they have a responsibility to report this via both the military and medical chains of command, and to ensure that any relevant medical records or reports are accurate and up to date. Doctors should keep their own record of all action they take in respect of reporting abuse.
Their responsibilities require doctors not only to seek out information but also to act upon it. Where a doctor is unable to obtain the required information, he or she should escalate enquiries through local command structures and the medical chain of command. Doctors should also seek assurances that information they have reported is being acted upon.
Case study: looking the other way
You are asked to assess a civilian patient, who has recently sustained life-threatening injuries, and to advise whether she is well enough to be transferred to a medical facility under the command of another nation’s armed forces. You have reason to believe that staff within that facility have not complied with humanitarian principles in the past and that patients have been mistreated. This is something that is widely but informally acknowledged among members of your own unit.
What are your responsibilities here?
A doctor should decline to make any assessments that might contribute to the transfer of a patient in situations where the doctor has any significant concern that such transfer is to a facility in which the patient’s care will be adversely affected, diminished or compromised. Transfer decisions should be based on the expectation that equivalent or better circumstances can be provided. Doctors have clear responsibilities to act on their knowledge of suspected abuse.
It is unacceptable for a doctor to ignore the possibility that a patient who is currently under his or her care may be abused or exposed to ill-treatment. The doctor should use existing reporting systems to highlight his or her concerns to the senior medical officer of the medical facility at which he or she is based and to the medical director for the multinational forces HQ, and to seek assurances that they are being acted upon. In addition, legal advice may be required.
Ethical decision making for doctors in the armed forces tool kit (PDF)