Personal Views: Time to act against medical collusion in punitive amputations
Authors: Adebayo Adejumo, Prisca Olabisi Adejumo
Journal: BMJ (2005)

Punitive surgical amputations are a negation of the basic principles and ethics of surgery taught in medical schools. Media reports show a frightening picture. For example, in Iraq a physician who worked in a Baghdad hospital in 1994 estimated that 1700 amputations had been performed on army deserters between August and mid-September 1994 (Daily Telegraph 1994. Nov 1: 21). This physician reported that procedures were often done without anaesthesia and that the risk of infection was high because of poor hygiene. Another physician in Iraq participated in an ear amputation while the patient was tied to a bed. In northern Nigeria the amputation of the hand of a cow thief, Buba Jangebe, as sharia punishment for cow theft was carried out within the purview of physicians (http://news.bbc.co.uk/2/hi/africa/2587039.stm). On 28 February 1998 four doctors in Kabul performed amputations on two men before a stadium crowd of 30 000 in keeping with an earlier sharia judgment. Worse still, some victims committed suicide after suffering amputations.


Doctors must rise above religious and political influences


The participation of doctors in any form of non-medical amputation, especially when required by religious convictions, is a negation of medical ethics. The global medical community can no longer afford to deny the ethical implications of such practices. Therefore, regulatory bodies such as the World Medical Association as well as the United Nations need to take a categorical stand and intervene globally by investigating and effectively curtailing this problem.

The need for urgent intervention is more critical now that an ardent Shiite loyalist and doctor, Ibrahim al Jaafari, has been nominated as the Iraqi prime minister. Will the Shiite dominated legislature in Iraq interpret sharia as Afghanistan has done or turn Iraq into the religious and ideological twin of neighbouring Iran?

Many doctors have dual loyalties: they face the dilemma of choosing between their employers' directives and their profession's ethical code. To healthcare consumers the relative silence of local and international medical associations at present with respect to doctors' enforcement of sharia punishment in places such as Iraq, Afghanistan, and northern Nigeria is worrisome. It may imply doctors' helplessness in the face of enforcement of state or “religious order” as justification for non-medical amputations. Where then is the distinction between professional ethics and religious practice? This distinction needs to be clarified, coupled with new ideas to help doctors and other healthcare workers draw the line.

Doctors who perform such procedures also violate the human rights of the victims concerned. A 1982 document of the United Nations general assembly (Resolution 37/94, 18 December) affirms this. Furthermore, in 1975 the World Medical Association issued a statement declaring that “a doctor shall not countenance, condone or participate in the practice of torture or other forms of cruel, inhuman or degrading procedures, whatever the offense of which the victim of such procedures is suspected, accused or guilty.”

In their daily work doctors engage with the concepts of “doing no harm,” beneficence, justice, and autonomy. These are the principles of medical ethics that should direct doctors in instances of moral conflict (BMJ 1994;308: 666). Some people may argue that there is no way that Muslim doctors could jettison their religious convictions in fulfilling medical duties and obligations. Without going into the legality or otherwise of this position, we consider it critical always to affirm the uniqueness, in comparison with other professions, of the call of doctors and the obligations of medical practice.

Local and regional as well as world medical assemblies should make a joint declarative statement on state enforced amputations. This should complement the existing regulations of the World Medical Association and the United Nations and should consider modern sociopolitical challenges. Trainers of medical students should emphasise the role that medical professionals can play in advocacy for patients, especially when patients can't speak for themselves.

Participation in punitive surgical procedures polarises medical practitioners along religious and political lines. It also raises questions about the independence enjoyed by the medical profession in all settings. Punitive surgical amputations erode the dignity of medicine and the age old trust in doctors held by the public.

Safeguarding people's health is medicine's utmost goal. Doctors must rise above religious and political influences. The time to salvage the situation is now, before medical ethics assumes different standards in different cultures.