Correspondence
Human Costs of Economic Sanctions
N Engl J Med 1997; 337:642-644August 28, 1997
- Article
To the Editor:
As former heads of medical-exemption committees in the Israeli Defense Force, we dealt with soldiers who tried to use the medical system to avoid their duties. With regard to such malingering, described in the article by Andrews et al. on Cuban migrants detained at Guantanamo Bay, Cuba (April 24 issue),1 we fully agree with Dr. Eisenberg's view in his editorial 2 that serving as gatekeepers (trying to detect malingerers seeking privileges that are reserved for the sick) frequently presents physicians with a moral dilemma. We agree with others 3 that most physicians cannot diagnose malingering reliably.
We have served as reviewers in cases of physicians who delayed treating potentially serious diseases because they had misdiagnosed “malingering.” Almost all the clinicians who admitted to entertaining presumptive diagnoses of malingering were found to be negligent. Our solution was to educate the physicians under our command about their lack of knowledge in this area and instruct them to evaluate their patients' symptoms as though they really existed in all but the most obvious cases. This approach may occasionally put the whole organization under strain. In our experience, it leads to a quicker and usually effective “administrative” solution that may have positive effects on the patients' health; for example, clean and temperature-controlled rooms were installed for patients who said they suffered from asthma, so that they would not be able to claim that they could sleep only at home.
Dr. Eisenberg contends that physicians should resist becoming gatekeepers in morally questionable circumstances. We add that to most physicians, gatekeeping is generally counterintuitive. It not only presents us with an ethical dilemma, but also exposes us to the risks of negligence and of jeopardizing our patients' care. It is better avoided entirely, even at the cost of apparent “disloyalty” to one's organization.
3 ReferencesEyal Shemesh, M.D.
Mount Sinai Medical Center, New York, NY 10029Abraham Rudnick, M.D.
Tel Aviv Community Mental Health Center, Tel Aviv 67197, Israel1
Andrews TC ,Cull DL ,Pelton JJ ,Massey SO Jr ,Bostwick JM . Self-mutilation and malingering among Cuban migrants detained at Guantanamo Bay. N Engl J Med 1997;336:1251-1253
Full Text | Web of Science | Medline2
Eisenberg L . The sleep of reason produces monsters -- human costs of economic sanctions. N Engl J Med 1997;336:1248-1250
Full Text | Web of Science | Medline3
Laor N, Agassi J. Diagnosis: philosophical and medical perspectives. Dordrecht, the Netherlands: Kluwer, 1990.
To the Editor:
As career military physicians currently studying at Harvard School of Public Health who were each deployed to the Persian Gulf and to Guantanamo Bay to provide medical support, we venture to reply to Eisenberg's argument.
He declares “a moral imperative [for physicians] to call for the end of sanctions” and scolds those “accepting medical assignments constrained by larger political decisions.” Although we envy Eisenberg his ability to pursue career goals free of “political” constraints, we think the case against sanctions (and physicians' involvement in the military) has been rather crudely made. There may well be good reasons for opposing the U.S. quarantine on Cuba, and even the international sanctions against Iraq. Unquestionably, both have ruinous effects on the local public health. Any elementally decent human would regret this outcome and insist that they be discontinued immediately, except for the likelihood of an eventual worse outcome should they be removed.
Unfailing respect for basic human rights and consequent advances in public health can never take root except in an open, democratic society. Eisenberg does not mention the key fact that the sanctions against Iraq would be lifted promptly if Saddam Hussein (whose extreme violations of human rights are widely known) simply complied with the terms of the United Nations treaty. He recently relented in part and allowed oil to be sold for the procurement of food and medicine. Fidel Castro (whose substantial human-rights violations are also notable, but less widely known) could also end his quarantine if he allowed internationally observed elections.
U.S. involvement in these matters deserves the widest and most deliberate public discussion, but it deserves informed discussion. By presenting his argument in such narrow terms, Eisenberg does not inform the debate and ultimately helps no one, least of all the hapless victims of ruthless dictators with whom he so feelingly empathizes.
Mark R. Withers, Maj., M.C., U.S.A.
Bryan J. Funke, Lt. Col., M.C., U.S.A.F.
Harvard School of Public Health, Boston, MA 02115To the Editor:
As a military physician who served at Guantanamo Bay in 1994–1995 during the refugee crisis, I find that Eisenberg misses the boat with regard to what went on at Guantanamo Bay.
Although as care givers we might in a limited sense be seen as gatekeepers, in truth we were not, as Eisenberg asserts, “guards manning the portals of their prison” (there were, in fact, military police guarding the camps who had that role). We provided an extraordinary amount of health care for more than 50,000 refugees, Cuban and Haitian, in a very challenging environment, including immunizations and care for patients infected with tuberculosis and the human immunodeficiency virus (HIV). We saw ourselves as committed professionals doing our best to identify and treat true illness.
I would venture to say that the problem was not the “military command” in which we were embedded, but the inconsistent, ever-changing, and unrealistic political policies of the U.S. civilian agencies (the State Department and the Immigration and Naturalization Service). It was quite clear to most of us that the policy of “medical parole” described in the article was an abysmal failure with tragic human consequences.
One final comment: we should not ignore the other part of the Guantanamo crisis, the plight of the 20,000 Haitian refugees detained there. In contrast to the Cuban refugees, these desperate men, women, and children were never given hope that they might go to the United States, and with rare exceptions medical parole was not available to them. There were many factors behind their different perception of the medical system at Guantanamo Bay, but we did not see widespread malingering or self-mutilation among the Haitian refugees. They accepted their 10-month detention in Cuba and their return to an uncertain future in Haiti with equanimity.
Jeffrey S. Sartin, M.D., Maj., M.C., U.S.A.F.
Landstuhl Regional Medical Center, Landstuhl, GermanyTo the Editor:
Compassion is an admirable trait. Compassion even toward one's enemies shows empathy and human understanding. However, compassionate behavior toward one's enemies has practical limitations, and possibly moral ones.
That children often suffer as a result of their parents' misguided activities is unfortunate, but it is a fact of life, almost a natural law; it is a situation extremely difficult, if not impossible, to avoid. Does Dr. Eisenberg have any doubt that in a few short years these same children will don the military uniforms and the dogma of the regimes that have killed other children, killed our citizens, and expropriated property and that by all reports would annihilate us, if only they had the capability?
Likewise, Dr. Eisenberg seems to consider the citizens of these rogue countries as more deserving and less responsible than the evil dictators and their regimes. This is undoubtedly so in the case of many, but thinking back to the Nazi Germans and the Vichy French, one suspects that moral sensibilities may sometimes be strongly affected by who seems to be winning.
Finally, Dr. Eisenberg invokes Hippocratic ethics to support eliminating sanctions, using a rather tortured argument to claim that my “self-interest” (presumably the self-interest of protecting my citizens and my own children) is not ethically permissible as a reason to withhold economic and medical aid from these enemy populations.
I reject that argument. The Hippocratic oath that I have taken can in no way be construed to refer to anyone other than people with whom I have direct contact. It contains no reference to global public health or many other unquestionably desirable goals, and it contains no statement similar to the quotation Dr. Eisenberg uses — “acting for the benefit of the sick . . . and keeping them from harm and injustice.”
Sherman B. Child, M.D.
2315 Newton Ave. S., Minneapolis, MN 55405Author/Editor Response
Dr. Eisenberg replies:
To the Editor: Can Dr. Child possibly mean what his letter implies? He appears willing to sacrifice the children of Cuba and Iraq because they may “in a few short years . . . don the military uniforms” of their totalitarian countries. On the one hand, he labels the regimes as dictatorial; on the other, he holds the citizens, including the children, responsible for what the rulers do. I disagree.
Major Withers and Colonel Funke propose that “decent humans” would regret the ruinous effects of the embargo on public health were it not “for the likelihood of an eventual worse outcome should they be removed.” They seem to believe that a quarantine affecting food and medicine will yet defeat Saddam Hussein and Fidel Castro. Their governments appear to be stable after years of embargo. The only evidence we have is that public health is deteriorating, levels of nutrition continue declining, and deaths from infectious diseases and injuries are increasing.1 The 1996 Helms–Burton Act that tightened the embargo of Cuba by threatening reprisals against foreign companies engaged in trade with that country was described as causing “outrage around the world.” 2 The Inter-American Commission on Human Rights of the Organization of American States requested the United States to take immediate steps to exempt food and medicine from the embargo because such actions violate international law.3
Major Sartin, who was at Guantanamo Bay during the refugee crisis, agrees that “medical parole” was an abysmal failure with tragic consequences. He holds the State Department rather than the military command responsible. I do not dispute his conclusion. He reminds readers that there was a second population at the base: 20,000 Haitian refugees. Like the Cubans, they were denied U.S. political asylum even though they were fleeing a repressive military government. But were they well cared for, and did the Haitians accept their detention “with equanimity”? Judge Sterling Johnson of the U.S. District Court disagreed.4 He ordered the U.S. government to shut down its HIV detention center at Guantanamo because it violated detainees' constitutional rights. The judge concluded that “the doctor–patient relationship has been frustrated” because the authorities “repeatedly failed” to act on the recommendation of military physicians. Some detainees reported being “treated like animals,” being beaten “when we protested,” and undergoing forced medical treatment.5
Probably none of my critics regard Bernard Cardinal Law of Boston as a Castro sympathizer. Yet he traveled to Cuba this year with more than 1700 kg of medicine in advance of the visit of Pope John Paul II in January 1998. In his archdiocesan newspaper, The Pilot, the cardinal wrote: “Is it in the best interests of the Cuban people or of the encouragement of democratic reforms that Cuba be economically isolated from the U.S.? Our present policy penalizes the Cuban people and . . . also retards democratic reforms within Cuba.” 6
I agree.
6 ReferencesLeon Eisenberg, M.D.
Harvard Medical School, Boston, MA 021151
Garfield R ,Santana S . The impact of the economic crisis and the U.S. embargo on health in Cuba. Am J Public Health 1997;87:15-20
CrossRef | Web of Science | Medline2
Sanctions on health in CubaLancet 1996;348:1461-1461
CrossRef | Web of Science | Medline3
Kirkpatrick AF . Role of the USA in shortage of food and medicine in Cuba. Lancet 1996;348:1489-1491
CrossRef | Web of Science | Medline4
Annas GJ . Detention of HIV-positive Haitians at Guantánamo -- human rights and medical care. N Engl J Med 1993;329:589-592
Full Text | Web of Science | Medline5
Farmer P. Pestilence and restraint: Haitians, Guantánamo, and the logic of quarantine. In: Hannaway C, Harden VA, Parascandola J, eds. AIDS and the public debate. Amsterdam: IOS Press, 1995:139-52.
6
Law BF. Cardinal's column. The Pilot. April 11, 1997.
