On June 14, 2012, a court verdict was issued in the trial of Bahrain medical personnel on charges related to the February and March 2011 unrest in the kingdom. In brief, nine medics were found innocent, five were released for time served and four were convicted with the right for appeal.
World reaction was varied, but for the most part it suffered from the misconception that the medical personnel were on trial for treating protesters. Opinions were furthermore influenced by reports of torture the accused were allegedly subjected to while in detention.
One interesting example was the reaction of Michael Posner, United States Assistant Secretary of State for Democracy, Human Rights and Labor. Commenting on the court’s ruling, he expressed the view that the U.S. were “deeply disappointed by the convictions” as well as by the Bahraini government’s failure “…to use alternative means to address these cases.” Posner used the report of the Bahrain Independent Commission of Inquiry (BICI) as a source of verifiable evidence to hold Bahraini authorities accountable to the injustices incurred on a segment of the population, but seems to have selectively reviewed its findings.
According to Chapter V of the BICI report, which examined the four-week protests in the Salmaniya Medical Complex (SMC), the main district general hospital in Bahrain, medical personnel effectively jeopardized medical neutrality and impartiality while allowing personal (political and religious) beliefs to infiltrate their healthcare provision (paragraphs 833, 834, 837, 847). The Commission also concluded that during this period of political and sectarian strife, patient confidentiality and consent were breached (paragraphs 836, 847) and patients’ lives endangered. The most worrying finding described the way in which expatriate patients’ non-maleficence and dignity were compromised by medical personnel (paragraph 838).
In medical ethical terms, what some of my colleagues encountered and failed to overcome was a “dual loyalties challenge.” The BICI statement that, “…these persons (some medical personnel) moved in and out of their roles as political activists and medical personnel, the latter being expected to carry out their professional, ethical and legal duties and responsibilities” (paragraph 834) succinctly simplifies for the layman how the medical obligations of some of my colleagues (at certain times during the unrest) were overshadowed by their non-medical obligations, namely their political and religious beliefs. Yet, while the BICI report is upheld by all quarters and regularly quoted, this obscured narrative dealt with in this particular chapter is not given any attention.
Even prior to the issuance of the notorious Commission report, in April 2011 “Doctors Without Borders” (Médecins Sans Frontières -MSF) described their findings on Bahrain healthcare neutrality:
“…regardless of the reasons, health professionals making speeches and leading protests directly from the steps of the entrance to the hospital undermined the concept of a neutral hospital, as did the anti-government slogans painted onto the walls of the hospital.” Their report continued, “…the opposition protestors should also guarantee that the hospital will not be used as a political platform or a rallying point for protests.”
It should be noted that the globally acclaimed MSF witnessed the unrest and events in SMC during February and March. Yet their findings have been disregarded internationally, ultimately neglecting the very serious threat of repeated healthcare politicization and ethical misconduct in Bahrain. To this day, junior colleagues and medical students consider these politicized and unethical actions as the norm. For the majority of my colleagues who practiced diligently and apolitically during the unrest (without compromising medical obligations), these inclinations are dangerous for the future of a profession which cannot continue in disregard of its ethical code.
Without a doubt, these were heated times but from the findings described, medical personnel in the SMC allowed their personal beliefs to become entangled with their healthcare provision during the unrest, thereby breaching the code of medical ethical conduct. In doing so, be it inadvertent or otherwise, they illustrated that patient care, at times, was not their primary concern. Daily politicized protesting imposed the beliefs of medical personnel on their patients causing distress and alienation as a result of inappropriate and insensitive expression of religious beliefs and political views. The international consensus has remained silent on this obscured reality, this new paradigm shift in physicians being politicized – why?
To my mind, the reason is twofold. Firstly, the disproportionate response by some rogue elements in the Bahrain military apparatus to the unrest and the arrest of medical personnel has been the most important consideration. The BICI found that “… [Bahrain] security services executed unlawful arrests on SMC premises, and attacked and mistreated some individuals (although the identity of some of the attackers could not be ascertained), including medical personnel” (paragraph 842, 843, 847). This escalatory reaction sadly ended with some colleagues being subjected to prolonged incarceration, as well as alleged mistreatment and torture in detention.
This is absolutely condemnable, and these rogue elements should be held accountable. However, that does not mean that the cases of ethical misconduct should be ignored when, in fact, they can be addressed proportionately through the healthcare-governing bodies in Bahrain. These medical personnel are colleagues and friends whose actions I may disagree with, but whose plight deeply disturbs me and I can never fully appreciate their loss. Despite the ethical and professional differences, a degree of respect will always be maintained but the question which we must ask ourselves, however, as physicians, healthcare providers and patients, is if this is an acceptable end for this noble vocation.
The second reason is that rarely in history have medical personnel politicized their profession in this fashion. It remains an outlandish and profound concept to most that healthcare workers would compromise their medical obligations in such a manner. Being the only active maxillofacial surgeon on the island during the last 15 months, I have exclusively treated head and neck injuries resulting from clashes between law enforcement officers and rioters as well as protesters and bystanders. My experiences have been presented in international maxillofacial conferences from Tunisia to more recently, the United Kingdom. From an anecdotal perspective, in my lecturing tours I have noticed a worrying trend amongst healthcare personnel in the countries of the so-called “Arab Spring” wherein medical personnel are becoming increasingly politicized, and to some extent militant. If this trend is allowed to develop unaddressed, the concept of “healthcare neutrality,” as we know it, may be changed drastically with potentially dangerous social reverberations.
It is my opinion that politically motivated non-medical obligations are patently irrelevant to medical decision making, but unfortunately during the unrest, medical decision making in SMC was too often blurred by political motivation and ambition…. The role of Bahrain’s medical personnel is still very much a part of the political unrest, having played a crucial role in the February and March escalation as well as in the continuing political instability and dialogue. It has polarized both the larger Bahrain community, as well as the local medical community, to what now seems an irreparable divide, which is deeply worrying for the future of healthcare in Bahrain and the torn social fabric internationally decried by the likes of Posner and a wide range of other officials and observers.
A comprehensive review of the Bahrain unrest and its many errors should acknowledge this very serious medical ethical breach and seek to address it so that the country may proceed on the path of reform and reconciliation, necessary for the future of Bahrain and, indeed, the region.
 The last year, 2011, has been a turbulent one for the Kingdom of Bahrain since the beginning of the February 2011 protest. What has most caught the world’s attention was the arrest of a number of Bahraini healthcare workers, their subsequent detention, trials and allegations of mistreatment. Recently the court cases have neared a resolution following verdicts issued by the civilian High Criminal Court of Appeal in Manama. Being a physician myself I will not comment on the legal process, which has gained much attention due to the serious errors which have occurred, but I will raise concerns relating to healthcare and the obscured reality, which people shy from highlighting.
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Dr. Mohammed A. Al-Muharraqi is a UK-trained Bahraini consultant Maxillo-Facial Surgeon and a Senior Lecturer in Anatomy as well as the head of the Bahrain Dental licensing body. He has had numerous publications on head & neck surgery in peer reviewed journals and takes a keen interest in medical ethics, sociology and evidence-based healthcare.