Human Rights & Human Responsibilities

1. Human Rights & Human Responsibilities Donna Knapp van Bogaert, PhD, D. Phil Ethics & Moral Philosophy Faculties of Medicine & Dentistry University of Limpopo Medunsa Campus

2. Outline • Ethics & Moral Philosophy (EMP) • Example: Three-year EMP Programme • Human Rights and Human Responsibility Block • Outcomes/Standards, Assessments, Suggested Core Competencies • Conclusion

3. I. Aim of the Ethics & Moral Philosophy Programme • The creation of good people who will inculcate the Art intrinsic in the professions of Medicine & Dentistry by accepting their moral responsibility to • enhance and promote the health and medical welfare of the people they serve • in ways which, in the practice of fairness and justice, respect their rights, values, interests, and dignity.

4. Sub-text of the EMP Programme • Emphasises responsibility, the things for which people are accountable. • Professional or social roles are defined in terms of the responsibilities they involve. • Focus on the person as a professional and respected community member: • Build on their good character. • Define the parameters of ethical (right / good) & unethical (wrong / bad) human conduct.

5. Faculty of Medicine Ethics & Moral Philosophy Programme • Year 1 MBChB: 8 hours / academic year full class sessions (class ± 220 students). • Year 2 MBChB: 12 hours / academic year full class sessions (class ± 230 students). • Clinical Ethics Blocks (Block is 3 hrs week x 6 weeks. Six groups - group size ± 40). Total year = 30 hours. • Year 3 MBChB: 3 x 40 min sessions / academic year full class sessions (class ± 230 students). • Year 4 MBChB: 3 x 40 min. sessions / academic year full class sessions (class ± 250 students).

6. Faculty of Dentistry • BDT years 2 & 3 One 40 minute session per week x 40 sessions (± 10 students each class; 6 blocks / year). • BDS years 3, 4 *,5 (OC), 6 (OC) One 40 minute session per week x 40 sessions (± 35 students each class; 6 blocks / year). • BDS 5 (NC) Ethics projects 1:1 tutorials. * plus research project

7. EMP Programme: Cross-Faculties • Both follow same general EMP curriculum. • Curriculum modified according to time constraints. • Each successive year builds upon prior learning. • Each year integrates / has relevance to particular learning of that year viz. greater emphasis on ethics in practice (ethical-clinical dilemmas) increases with increasing clinical duties.

8. II Example: Faculty of Dentistry 3 Year Curriculum Ethics & Moral Philosophy

9. Faculty of Dentistry • Supportive Dean & Faculty • Continuing CPD programmes in Ethics • Faculty Ethics Committee • Dr. Marcelle Harris, HOD Integrated Curriculum Development • Ethical Practice Management Programme (EPMP): • Ethics & Moral Philosophy 50%, • Business Practice Management & Law 50% • Patient Interviewing Skills (student video sessions) • EPMP required and assessed as part of core curriculum. • Advantages: Small classes, stringent student selection, “buy-in” by faculty.

10. Year 1 Block 1Ideology, Logic & Critical Thinking Skills • Logic & critical thinking skills 1-3. • Moral reasoning, Ethical decision-making guidelines. • Ideology: Globalisation of ‘the good life’, advertising & the media. • Plagiarism: Class and university rules, referencing basics.

11. Year 1 Block 2 Introduction to Ethics & Moral Philosophy • Why be ethical? • World-views & Ways of Life. • Overview Systems of Ethics • (Hippocratic Oath & method, Traditional approaches to ethics, Rights-based approaches, Ethics of Care, Pragmatism, Relativism, Postmodern approach).

12. Year 1 Block 3 Virtues & Values • Aristotle’s virtues. • Virtues in the practice of good medicine & dentistry. • Truth-telling: Legal and ethical boundaries. • Who or what is of value? • From professional values to standards.

13. Year 1 Block 4 Approaches to Ethical Problems: Deontology & Consequentialism / Utilitarianism • Duty & Respect for Persons • Duties, obligations, and responsibilities • Categorical Imperatives • Consequentialism • Utilitarianism • Act and Rule utilitarianism • The Principle of Utility • The Harm Principle

14. Year 1 Block 5 Approaches to Ethical Problems: Principlism & Communitarianism • Principlism • Beauchamp & Childress’s Principlism: Autonomy, Non-maleficence, Beneficence, Justice. • Tavistock Principles: Rights,Balance,Comprehensiveness,Cooperation, Improvement, Safety, Openness. • Communitarianism • African Philosophy: Personhood & Community • Etizoni’s Communitarianism

15. Year 1 Block 6 Professionalism & Responsibility • Students & Quotas • Etiquette & Ethics • The ‘Difficult’ Ones: Patients, staff, family, self. • Advocacy & Health Promotion. • The Dental Hierarchy: Questioning & acting against authority. • Conflicts of Interest & Conflict Resolution: Faculty Ethics Committee. • Placing blame, asking for help. • Limits of tolerance.

16. Year 2 Block 1 Accepting Responsibility • HPCSA professional ethical guidelines, regulations, boundaries. • Being Afraid & Admitting Mistakes: Omissions & commissions in student professional & personal life. • “Name and Shame” – does it matter? • Power & responsibility the healthcare hierarchy: dentists & patients, lecturers & students, men & women. • Whistleblowing: concept & warrant. • HIV risks, duties, responsibilities – doctor, student & patient.

17. Year 2 Bock 2 Issues in Ethics: Confidentiality • Professional information, privacy and respect for persons . • Trust, secrecy and security in the sharing of information: practical considerations. • Students, staff & supervisors; Patients, families, friends: moral tensions. • Disclosure of information: Public versus private interests. • Compulsory and discretionary disclosure of confidential information.

18. Year 2 Block 3 Issues in Ethics:Professional relationships • Truth & Truthfulness • Paternalism debate • The patient’s story as sub-text. • Collisions of Cultures and Traditions • Respect and tolerance – any difference?

19. Year 2 Block 4 Issues in Ethics: The Responsibility of Informing • Informed consent & the refusal of treatment. • Respect for persons. • Process of informed consent. • Competence: ethical and legal aspects. • Comprehension: ethical and legal aspects. • Voluntary acts. • Acting without consent – when & why & justifiability. • Refusing treatment:ethical and legal aspects.

20. Year 2 Block 5 Issues in Ethics: Public Health & the Environment • Public Health • Infection control in dental practice • Contested illnesses: difficulties in dealing with doubts & discords. • Disease in individuals vs. communities: individual rights & quarantine / isolation management • Emerging infectious diseases, bioterrorism • Toxic Substances: Disposal of Hazardous Waste-ethical & legal issues • Environmental health • Human health & health of the environment • Fluoridation debate • Anthropocentrism • Principles of environmental justice • Environmental pragmatism

21. Year 2 Block 6 Issues in Ethics: Distributive Justice & Resource Allocation • Theories of Justice. • Inadequate health resources and distributive justice. • Equitable health care: needs, rights, utility, efficiency, desert, autonomy. • Complexity: rights (individual & collective), legislative reform, need for institutional development. • Rationing and inequality international/ national / provincial allocations. • Boundaries of responsibility debate: individuals & self-induced illnesses; cost of violence inc. MVA, PVA to public / healthcare system.

22. Year 3 Block 1 Issues in Ethics: the Abortion Debate • Reproductive Rights & Reproductive Responsibilities. • Doctrine of Double Effect, Doctrine of Self-Defense. • Women’s Rights, Health-professional’s rights, fetal rights. • The TOP Act: South African professional guidelines, legal requirements. • Personhood: maternal / fetal / community relationship. • Family Planning & Reproduction: Advocacy.

23. Year 3 Block 2 Issues in Ethics: Liberty • How free is free? • Freedom of thought & discussion in private and public life. • Affecting choices? Globalisation and the mediasation of the ‘good life’. • Pornography. • Substance Abuse: Legal & ethical issues.

24. Year 3 Block 3 Clinical Research • Human participants in research: Historical and contemporary examples of abuses of medical / clinical research. • Conflicts of interest in therapeutic and non therapeutic research. • HPCSA, national, & international research guidelines. • Research on animals: ethical debate • Writing research proposals: process, guidelines. • Vulnerable Populations: HIV infected, Disabled Persons, Women, Children, the Elderly, Prisoners, Refugees & Displaced Persons, Students,patients.

25. Year 3 Block 4 Ethical Issues: Death & Dying - Who lives? Who dies? Who chooses? • Punishment & the death penalty debate. • Quality of life- who’s quality? • Palliative care. • Treatment provision, non-provision, killing and letting die, double effect, ordinary and extra ordinary care. • Advanced directives & living wills: ethical groundings. • Euthanasia and physician-assisted suicide: ethical and legal arguments . • Tissue, organ, bone & tooth: SA Anatomy Act. • Suicide.

26. Year 3 Bock 5 Human Rights & Human Responsibilities • Culpable healthcare professionals (police interrogation & torture). • Rights, duties, and responsibilities. • National & international documents concerning human rights. • Relationship between health & human rights. • Human security, human interests, human rights: the debate. • Dual loyalty and human rights.

27. Year 3 Block 6 Ethical Issues at Chair-side • Abuse: Physical & sexual abuse, sexual advances: What’s wrong with rape, what’s wrong with the “Willing patient, willing doctor”, sex as bargaining tool. • Social conduct: Sexist, racial, cultural slurs; derogatory references to patients; psychological abuse. • Student Dentists: Case studies from previous classes.

28. III Block FocusHuman Rights & Human Responsibilities

29. Why Responsibilityas in Human Rights & Human Responsibility ? • Terms are co-relative & concordant • Without acceptance of responsibility, rights are empty claims. • Who should accept responsibility? • All human beings especially healthcare professionals who are highly regarded & trusted members of the community.

30. Block Objectives • Identify and develop novel and effective strategies, means and methods for the strengthening of the democratic fabric of South African society through the promotion of human rights & responsibilities. • Inculcate in healthcare professionals their responsibility to protect and respect human rights.

31. Block Outcomes / Unit Standards • At the end of this block you will demonstrate the ability to: • Discuss the concept of human rights & dual loyalty and identify some of the reasons why, how, and in in what forms of society healthcare professionals may become involved in human rights violations; • Demonstrate professional awareness of individuals' rights and understanding of their responsibilities; • Relate the links between health and human rights; between rights, duties, and responsibility;

32. Block Outcomes / Unit Standards At the end of this block you will demonstrate the ability to • Give examples of ways in which the exchange and dissemination of knowledge, experience, and good human rights practice in South Africa may be enhanced & • Construct a transparent and decisive policy concerning institutional accountability in documenting, reporting, and disciplining human rights violators & violations.

33. HRR Block Required Readings / Audio-visual Materials • TRC Report on the Healthcare Sector (transcripts used in class role-play). • Dual Loyalty & Human Rights (phrusa org.), • “Cape Town Case” • UNDHR, Tokyo Declaration, WMA documents. • Excerpts from Tolstoy’s Crime & Punishment, Scarry’s The Body in Pain, Nietzsche’s Thus Spoke Zarathustra, & Millgram’s Obedience to Authority. • Audio-visual (film) Death the Maiden.

34. Prior Knowledge • Preceding HRR block students have background in e.g. • Ethical theories, principles, virtues, & values, • Ideology, influence of media & asymmetrical power relationships, logic & argumentation, e.g. punishment & death penalty debate. • South African Constitution including Bill of Rights, Patients ’ Rights Charter, & basic principles of law, notes & record writing & keeping (from practice management section), • HPCSA & other professional guidelines, • Individualist & communitarian approaches to ethics. • Historical grounding of consent (Nuremberg Code), principles of informed consent, concept & identification of vulnerable populations. • Institutional ethics; class, race gender, & economic disparities & distinctions; effects of globalisation of ‘good life’; social responsibility as professional in the community ; theoretical dimensions of concepts of rights, historical documentation of human rights abuses …

35. Assessment Methods (1) Example: In-class test • Questions include e.g. • Define and discuss the problem of dual loyalty in health care. • Identify the links between health and human rights. • Give examples of human rights abuses occurring in ‘open’ societies; in ‘closed’ ‘repressive societies. • Discuss some reasons why healthcare professionals are targeted by morally corrupted governments. • List three important documents which support human rights.

36. Assessment (2) Case study example: • From your own clinical experience, you will identify an incident of human rights abuse. In your case study analysis you will include: • An introduction to the case in which you discuss your responsibility to protect and respect human rights. • Then you will: • Describe the circumstances of the abuse (role-players & their relationships), • Provide a description of the type of HR violation (including the name of the document (s) in which the abuse is identified). • Include your personal documentation of the abuse, • Identify to whom you reported the abuse, & • Discuss the final resolution to the incident. • You will conclude with your ideas concerning institutional mechanisms that should be put in place for prevention of future abuses.

37. Assessment • (2) Case study example: • In the “Cape Town” case, doctors were removed from becoming gatekeepers viz. reporting to government health authorities non-citizens / aliens requesting health care. Instead, the responsibility for this was given to ward clerks.

38. Assessment, cont. • In this assignment you will critisise the case focusing on the issue of dual loyalty., • First, you will summarise the case. Then, you will define the term ‘dual loyalty’. • Next, you will provide arguments for the application of the concept dual loyalty being applied only to healthcare professionals as opposed to it being extended to all workers within the healthcare system. • Then you will argue against the positions you have just identified. • You will conclude by developing your personal argument pro or con the case’s resolution.

39. Assessment (3) Institutional Human Rights Accountability Policy Example • In this assignment you will develop a document in which you identify institutional accountability mechanisms for holding those who violate human rights accountable for their actions. You will • Refer to South African history and include the ethical reasons for holding individuals accountable for their actions (you will necessarily discuss the concept of collective responsibility), • the professional standards (HPCSA) concerning human rights violations, and • references to documents articulating the need for protection from human rights abuses. • Then you will discuss problems you anticipate in implementing this policy (e.g. who decides, who monitors), • Finally, you will provide some ideas for resolving the problems you have identified.

40. EMP Programme’s Educational Objectives • Knowledge • To know specific facts, concepts, principles or theories. • Comprehension • To understand, interpret, compare or contrast. • Application • To solve problems, to render ideas for solutions, to apply knowledge to new dilemmas. • Analysis • To identify organisational structure, to recognise relationships, organising principles. • Synthesis • To create something new, to think outside the box, to propose an action. • Evaluation • To judge the quality of something based on its adequacy, value, logic or use.

41. Core HRR Competencies • Evaluation , treatment, documentation, and institutional policy development concerning human rights violations including disciplinary measures. • Fundamental knowledge of human rights and the laws, documents, and declarations which support promotion of human rights in the healthcare context. • Recognition of why healthcare professionals are targets for immoral governments in power quests. • Acceptance of responsibility of healthcare professionals to advocate for, respect, and protect human rights. • Exchange and dissemination of knowledge, experience, and good human rights practice. • Recognition and protection of the rights of vulnerable populations.

42. IV. Conclusion • Overviewed the Ethics & Moral Philosophy (EMP) Programme and outlined the HRR block within it at the UL Medunsa Campus. • Described the HRR Block’s • Outcomes / Block standards • Assessments • Objectives • Provided our core competencies • Argue that when human rights and human responsibilities are embedded within an Ethics / Ethics & Moral Philosophy programme, students are empowered with a richer and deeper understanding of their personal and professional responsibilities to protect, respect, and advocate for human rights.

43. No conflicts of interest. Thank you.