RECOMMENDATIONS

One of the most important recommendations that has come out of the health sector hearings of the Truth and Reconciliation Commission is the need for educational reforms for health professionals. Many health sector submissions to the TRC include recommendations for such reforms, including the incorporation of human rights and ethics training for health professionals in the curriculum.

Recommendations for the integration of human rights concerns into health education should have special significance for the TRC. Human rights education represents a long-term strategy for developing a civil society that respects and nurtures human dignity. Conversely, the protection and promotion of human rights is perhaps one of the most effective means of promoting health and human well-being.

However, it is clear from our interviews with health professionals in South Africa, and review of health sector submissions to the TRC, that conceptualizations of human rights and its relationship to health are quite variable and often limited in scope. For example, health professionals often equate human rights with traditional bioethics concerns, the rights of patients, or the rights of health professionals themselves. Such conceptualizations are not well founded in international human rights law or contemporary human rights discourse.
1. General recommendations

All health professionals should receive training in human rights and relevant bioethics principles. The conception of human rights imparted should be based on international human rights principles. This training should be an integral and required component of their professional education. To underscore the importance of human rights, it should be a subject on which students are examined.

The training in human rights may be divided into several courses over time, and the content geared toward specific educational levels. For example, in the case of medical training, students could receive the following sequence of courses: (1) a comprehensive, semester-long course on health and human rights during one of the pre-clinical years, (2) a semester-long course on bioethics during one of the pre-clinical years, (3) a course on clinically relevant human rights and bioethics issues during one of the clinical years, (4) exposure to human rights and bioethics issues in other pre-clinical courses and during clinical training, and (5) special elective courses on clinical forensic medicine.

Most importantly, medical faculty should be only those who are role models in care of patients with respect to protection and promotion of human rights. Courses designed for various health professionals should, at a minimum, define human rights, articulate the relationship between human rights and health, and discuss the role of health professionals in promoting health by protecting and promoting human rights. It will be helpful for the courses to give students the opportunity for substantive discussions on the significance of human rights and the relationship between human rights and bioethics concerns. The courses should be both informed by international human rights understandings and relevant to the South African situation. Whenever possible, case study material should be included. It would be helpful for human rights courses to include outcome evaluations by students and colleagues.

To compensate for the deficiencies in the past training of health professionals, we recommend that continuing education human rights courses be developed and instituted for current health professionals. This could best be done by instituting a system, comparable to that of the United States and many other countries, that links maintaining certification to requirements for ongoing continuing education. The need for such instruction in human rights is made all the greater by the fact that most of these professionals have practiced in a health care system with pervasive human rights violations and an inadequate sense of the responsibilities of health professionals. Beyond instruction in human rights and ethical norms, it will be important for such courses to examine patterns of human rights violations in the health sector during the apartheid era and the factors contributing to these abuses. The courses should emphasize the responsibilities of health professionals to promote and protect human rights and should link these obligations to concrete standards of behavior.

A central authority for human rights and ethics education should be established and assigned the responsibilities for developing resources, establishing educational guidelines, disseminating successful pilot initiatives, and monitoring progress. It would be preferable for this authority to take a "bottom up" rather than a "top down" approach so as to benefit from a variety of contributions and to engage health educators.

2. Incorporate specific objectives into human rights
education

There are a number of objectives that should be kept in mind in when integrating human rights and bioethics concerns into the education of health professionals:

(a) Promote understanding of the relationship between health and human rights

With few exceptions, human rights have not been the expressed concern of the medical or other health professions in South Africa, as is the case in most countries. Although the World Medical Association and the United Nations have established codes of conduct for medical practitioners, neither these codes nor international principles of medical ethics address the relationship between the protection and promotion of human rights and the promotion of the conditions for health and well-being in the world. By promoting understanding of the relationship between health and human rights, South African health professionals have an opportunity to demonstrate leadership in health promotion in civil society.
Health professionals should recognize that contemporary human rights discourse is dynamic. Historically, the principal actors in human rights discourse have been states and legal experts. Increasingly, non-governmental human rights organizations have contributed to, and influenced, the course of human rights discourse. Over the past fifty years, international human rights law has grown from a handful of articles in the Universal Declaration of Human Rights in 1948 to more that fifty declarations, covenants, and conventions. Recently, there has been substantial debate over the issues of universal application of human rights, accountability of human rights violators, the priority of certain rights relative to others, and concepts of truth, justice and reconciliation. In addition, concepts of the right to economic and social development, peace, health, a balanced environment, and humanitarian disaster relief are under consideration. Because protecting and promoting human rights has direct bearing on the health of individuals and communities, health professionals should be active participants in debates on these and other human rights issues.

Health professionals should understand that human rights are interdependent and indivisible. The spectrum of human rights violations that may potentially affect health includes a broad range of possibilities: civil, political, economic, social, cultural and others. Efforts to focus exclusively on a select group of rights is not justifiable from a health promotion perspective, and should raise suspicions of either an inadequate understanding of health and human rights, or the possibility of an alternative agenda. Health professionals with a selective human rights focus may actually undermine efforts to promote health.

(b) Promote discourse on human rights in the health sector

Before any strategy of implementing human rights concerns may be realized in South Africa, human rights must first become an issue of concern. The development of human rights concerns among health professionals in the years ahead will depend largely on the degree to which health professionals recognize the health consequences of human rights violations and conceptualize the relationship between health and human rights. Meaningful dialogue within the health sector will ultimately guide the development and expression of human rights concerns in medicine and health care.

Ultimately, health professionals will need to question and redefine their definitions of health and human suffering; they will need to study and articulate the relationship between health and human rights and learn to improve their responses to human rights problems. Academic discourse on human rights may be facilitated by undergraduate and graduate courses in the health sciences, fellowship and graduate research programs in human rights, and greater emphasis on primary health care experiences. Educational training for clinicians may be initiated through continuing medical and health education courses and symposia. Publication of original research, books, and news articles relevant to human rights would increase awareness and understanding of human rights issues.

Also, the degree to which human rights concerns are actively supported by health educators will have far-reaching and long-lasting effects on students' conceptualizations of health and human suffering, and thus on the scope of their professional interests in society. Health educators provide role models which students often emulate, and ideas about questioning authority and one's role in relation to the state.

Human rights discourse should involve a wide range of participants, including stakeholders in the health sector, government representatives, consumers of health services, and other individuals in the public domain. The credibility and legitimacy of any consensus in human rights discourse will turn on the degree of representation achieved.

(c) Reconcile human rights and bioethics agendas

In the course of the progressive inclusion of human rights and bioethics concerns in the educational curricula, it is important that the similarities and difference between these fields be well understood. Human rights are social claims or values, which simultaneously impose limits on the power of the state (i.e. civil and political rights) and require the state to use its power to promote equity (i.e. economic, social and cultural rights). Human rights norms are rooted in the dignity and worth of all human beings and as such are universally applicable. Human rights principles place a great deal of emphasis on protections against discrimination and on the equality of all persons. The realization of such claims or rights are, in effect, a means of achieving the conditions for health and well-being in a democratic civil society.

Bioethical principles such as beneficence, non-maleficence, confidentiality, autonomy, equity, and informed consent are principles of conduct which regulate the clinical encounters of health professionals with individual patients. These principles do not attempt to define health and well-being, nor do they indicate possible causes of human suffering. In fact, it is fair to state that the discipline of bioethics was born of the misconduct of physicians and other health personnel. Historically, bioethicists have limited their concerns to within the disease paradigm; the discipline has evolved more in response to increasing ethical dilemmas that arise from disease-based medicine, than it has from an active agenda for health promotion. Only recently have bioethicists begun to examine the relationship between health and human rights.

Educational initiatives on human rights and bioethics should be complementary, and by no means should one preclude the other. Proposals for education on human rights and bioethics should be carefully examined to assess whether one discipline is, in fact, being subsumed by the other.

One example that needs careful scrutiny is the MASA proposal to the TRC for "general human rights training within medical ethics education."⁷ This proposal was supported by an eleven-page appendix that mentioned the words "human rights" only once, and in the following context: "The student will become more aware of current human rights issues."⁸ While the document appears to be a fine start for the inclusion of traditional bioethics concerns in the medical curriculum, it does not constitute a serious effort to integrate human rights concerns in the medical curriculum.
3. Human rights education campaigns

Health professionals also have the responsibility of advocating for health and human dignity. Human rights educational campaigns are critical not only because they are essential to raising awareness, but because they are essential to overcoming the tremendous resistance inherent in confronting painful issues. Advocating for health is both a political and a professional responsibility; it calls attention to the physical and psychological consequences of deliberate and systematic acts of violence which aim to destroy individuals and communities. However, advocacy to prevent and alleviate suffering must remain non-partisan to be credible and effective.

Those who suffer human rights violations often lack the means and/or capacity to represent their own interests. Health practitioners, as advocates of health and human dignity, have a duty to speak to the health and human rights concerns of vulnerable populations and should work to develop self-agency among those for whom they advocate.

4. Structural considerations

(a) Coordinate planning activities on human rights and ethics education in the health sector

Promoting understanding of the relationship between health and human rights, and promoting human rights discourse will require a central coordinating organization and interaction between various stakeholders. Organizations such as the Department of Health, professional and regulatory bodies, treatment centers for survivors of torture, the Health and Human Rights Project, the Progressive Primary Health Care Network, academicians, clinicians, human rights experts, consumers of health services, and others should participate in meetings and conferences on the subject of human rights and ethics education. Consensus on a strategic plan is likely to emerge through an iterative process.

The formation of a Committee on Health and Human Rights should facilitate the coordination of planning activities. In addition, individual organizations within the health sector should consider establishing an institutional task force or equivalent structure, to participate in human rights and bioethics education planning.

The need for diverse representation, including government representatives and statutory councils in the health sector, health professional organizations, members of the health professions, academicians, human rights experts, and others, cannot be overstated. These representatives should reflect geographic and racial diversity as well.

(b) Ensure adequate resource allocation

Implementing effective human rights and ethics education in the health sector will depend on adequate resource allocation. A formal accounting process should be undertaken prior to implementation and/or legislation of any costly education reform measures. In addition, human rights and ethics educators should be compensated at a fair wage for their services.

5. Curricular reforms and training in human rights and bioethics in the health sector

(a) Establish objectives for human rights and bioethics education

The objectives and goals of human rights and bioethics education should be clearly articulated prior to widespread implementation. These objectives may include the following: (1) providing improved conditions for health by protecting and promoting human rights; (2) understanding, alleviating and preventing human suffering; (3) ensuring respect for dignity and autonomy in clinical encounters; (4) promoting equity and access in the delivery of health services; and (5) promoting the concept of human dignity as the foundation for peace, freedom and justice in the world.
(b) Assess educational initiatives in South Africa and abroad

The Committee on Health and Human Rights, or an equivalent entity, should conduct an assessment of educational initiatives in South Africa and abroad to inform its strategic planning process. This is particularly important in human rights education for health professionals, as this is a relatively new area of study. Such assessments may be facilitated by meetings with national and international human rights and bioethics educators. The assessment will most likely aid in development of educational resource materials and pilot initiatives.

(c) Develop educational resource materials

Materials should be gathered from a diverse sample of human rights and bioethics educators and reviewed for possible inclusion in curricular studies in South Africa. Such materials may also serve as useful library references for instructors and students. Eventually, the materials gathered should be modified and consolidated for the purpose of specific human rights and ethics training in South Africa.

(d) Develop and evaluate pilot initiatives

Pilot initiatives should be identified and/or developed for various health professional target groups and evaluated for outcome. Teaching methods and the format of curricular studies should be periodically re-evaluated to assess their effectiveness.

(e) Consider elements of effective human rights and bioethics education

Human rights and bioethics education should be based on a coherent and comprehensive understanding of the relationship between health and human rights and bioethics. Since these areas of study cross many disciplines, educators must first educate themselves on a variety of new subjects. Also, collaboration from colleagues in disciplines such as law, philosophy, anthropology, history, women's studies, etc., are important components of effective education.
Educational initiatives should be grounded in real issues.
Educators should make deliberate efforts to bridge abstract learning in the academy with practical human rights problems and ethical dilemmas. Examples of practical problems should draw on South African experiences and be related to international experiences when appropriate. Establishing bridges between the academy and the "real world" may be enhanced by providing students with opportunities for human rights experiences, encouraging colleagues to engage in socially relevant issues, and providing advocates with opportunities for reflection and analysis within the academy.

Teaching methods should be varied and stimulate interest among students. In addition to didactic seminars, other possibilities may include: student presentations, small group discussions, role play, visits by special guests such as survivors of torture, the use of film and audiotapes, and field trips. Student activities, for example, research internships and informal social events, offer additional opportunities for learning. Methods for teaching human rights and ethics, particularly for those who have completed their health education, may include conferences, workshops, roundtable sessions, training courses, and publications in professional journals, books, and the media, among others.

Course material should be diverse, culturally sensitive, complementary and stimulating. Readings may consist of scientific articles, analytical reflections, human rights reports, and literature.

(f) Identify target groups

As mentioned earlier, target groups for human rights education should include all people, and at many levels of education, including graduate and professional school students (i.e. law, humanities, arts, sciences), as well as training for those in law enforcement and government service. Human rights education for health professionals alone will not be sufficient for the values of human rights to take hold in society.
6. Professional support for human rights and bioethics educators

The quality and effectiveness of human rights and medical ethics training in the future may benefit greatly from efforts to provide professional support for educators in the health sector. Some suggestions include the following: (1) establishing a health and human rights society; (2) holding annual national, and possibly regional, human rights and health meetings; (3) soliciting by medical journals in South Africa manuscripts on the subject of human rights and ethics; (4) creating academic posts for human rights and ethics educators; (5) encouraging research in human rights and ethics through increased availability of grants.

7. Monitoring implementation of human rights and bioethics education

The central authority for human rights and ethics education in the health sector, or an equivalent entity, should be responsible for ensuring the progressive implementation of human rights education in the health sector. This authority may consider establishing an independent, non-governmental review board for the purpose of monitoring progress in human rights and bioethics education. Whatever entity assumes this responsibility, it is important that stakeholders within and outside the health sector be adequately represented.

8. Licensing linked to human rights and bioethics education

As noted above, the Councils should establish human rights and
bioethics education criteria for the licensing of health professionals. In addition, human rights and bioethics education requirements should be established for continuing medical education for recertification purposes. These criteria for licensing and certification should be established in close association with representatives of medical professional organizations, non-governmental health and human rights organizations, and representatives in government.

NOTES

⁷ "MASA Submission to the Truth and Reconciliation Commission," June 1997, p. 98.

⁸ Id., Section D, p. 8.