Recent events have drawn attention to three related issues of interest to this part-time blogger with an interest in health care. One shows the high value that Western democracies place on freedom of speech. Another illustrates a contrasting value system and, in a curious way, highlights the complicity of doctors in torture. Could these events on the world’s stage have any resonance within the microcosm of the NHS?
The attack on the French satirical magazine Charlie Hebdo provoked a robust defence of freedom of speech from nations across the world. Even the Saudi Arabian ambassador took part in a solidarity march in France. Which is ironic – back in Saudi Arabia, Raif Badawi faces 50 lashes a week for 20 weeks outside of al-Jafali mosque in Jeddah. His crime was to write a blog criticising religious authorities in Saudi Arabia. The right to criticise is not universally valued and speaking out can be construed as disloyalty.
Fortunately, the latest instalment of his sentence has been postponed because the prison doctor decided that his wounds had not sufficiently healed. Medical intervention has gained Raif Badawi a week’s respite, but it also raises the question of medical complicity in torture. Interestingly this phenomenon is not confined to Saudi Arabia. Medical complicity in legally sanctioned torture has also occurred in Western democracies. How can this happen?
Over a decade ago in the BMJ I predicted that doctors in Guantanamo Bay risked becoming accessories to torture. Three doctors responded to my letter, vying each other in outrage at my suggestion. Anyone with the tiniest knowledge of social psychology would have made the same prediction. Individuals’ behaviour is constrained by the norms of the organisation. In his famous 1971 Stanford Prison Experiment, Zimbardo demonstrated that given the power over others, some individuals will behave sadistically, while others feel unable to intervene. This was of course exactly what happened in Guantanamo. It had previously happened in Abu Ghraib. It will happen again in similar circumstances unless specific measures are put in place to create an organisational culture where this is unacceptable. This means leadership, clear standards of behaviour, external oversight, and open reporting of lapses in standards of behaviour.
Are there any lessons for health services? Freedom of speech is important. The NHS does not flog whistle-blowers in public places, but they often suffer punishment.  Organisational culture shapes behaviour, even among health professionals. Without leadership, transparency and external oversight, any organisation risks slipping into poor practice. Cartoonists, bloggers and whistle-blowers may make us feel uncomfortable. But this is all the more reason not to silence them.
— Tom Marshall, Deputy Director CLAHRC WM, Prevention and Detection of Diseases
- Tran M. Saudi blogger Raif Badawi’s case referred to supreme court, says his wife. The Guardian. 2015-01-16. [Online].
- Marshall T. Doctors in Guantanamo Bay are at risk of being accessories to torture. BMJ. 2002. 324: 235.
- Haney C, Banks C, Zimbardo P. A Study of Prisoners and Guards in a Simulated Prison. Washington, D.C.: Office of Naval Research. 1973.
- Nye J. U.S. military doctors broke oath to design new torture techniques to be used at Guantanamo Bay. Daily Mail. 2013-11-04. [Online].
- Public Concern at Work. Whistleblowing the inside story – Main report. 2013. [Online].
- BBC News. Worcestershire hospitals ban paramedic Stuart Gardner. BBC News. 2015-01-16. [Online].