You must, by now, have heard of the Saudi Arabian blogger Raif Badawi.  Just in case you haven’t (really?), here’s a potted biography: having set up the secularist forum Free Saudi Liberals, he was arrested for insulting Islam and showing disobedience.  Among the formal charges he faced was one for apostasy, which carries the death penalty in Saudi.  The apostasy charge was dropped, but he was convicted on other charges and sentenced to seven years in prison and 600 lashes.  He appealed, and this sentence was changed: it became 1000 lashes and 10 years in prison.  Why?  Does it matter?  Because Saudi Arabia.  The latest update is that the apostasy charge may be renewed, so for a second time, he faces beheading.  Part of the evidence against him is that he “Liked” a post on a Facebook page for Arab Christians.  (Remember: Saudi is one of our allies against religious extremism.)

The lashes were to be administered in batches of 50, weekly, after Friday prayers.  As I write this, he has only been flogged once; doctors have attested that he is not well enough to be flogged again.  And – with thanks to Ophelia for the link – it’s  not hard to see why:

Dr Juliet Cohen, head of doctors at Freedom from Torture, explained: “When the cane strikes, the blood is forced from the tissues beneath… Damage to the small blood vessels and individual cells causes leakage of blood and tissue fluid into the skin and underlying tissue, increasing the tension in these areas.

“The more blows are inflicted on top of one another, the more chance of open wounds being caused. This is important because they are likely to be more painful and at risk of infection, which will cause further pain over a prolonged period as infection delays the wounds’ healing.”

There is also the long-term damage done to the victim’s mental health caused by flogging.

“Psychologically, flogging may cause feelings of fear, anxiety, humiliation and shame. Anticipation of the next scheduled flogging is likely to cause heightened emotions especially of fear, anxiety and difficulty sleeping… pain and fear together over a prolonged period have a deeply debilitating effect and recovery from such experiences may take considerable time,” said Cohen.

At the beginning of February, Vincent Iacopino had a post on the main BMJ blog in which he claimed that health professionals should play no part in Badawi’s flogging:

Any form of participation by health professionals in this kind of punishment is prohibited, including assessing a prisoner’s ability to withstand the punishment, observing or monitoring the practice, evaluating a prisoner’s “fitness” for these types of harmful practices, or even being present and failing to take action and stop it. […]

As doctors, we have no greater duty than to heal and prevent human suffering. The integrity of our profession and the trust that society places in us depends on the actions we take individually and collectively to ensure respect for our professional ethical standards.

I think Iacopino is wrong.  Wrong because the principles that his position indicates are rather naive: they appear assume that medics not being involved would mean that the flogging would not take place.  That would be the natural way to make sense of this claim:

While it may appear that the doctors are assisting Badawi by delaying punishment, their participation is actually enabling the infliction of physical and mental pain.

I don’t see any reason to suppose that that’s true.  The evidence so far is that the involvement of medics has prevented the administration of further pain.  Of course, one can’t discount the possibility that the second, third, and nth round of flogging would have been deferred without medical opinion having been offered… but I’m not inclined to make that leap.  At the weakest, it’s simply not clear that medics’ participation has enabled such infliction; but my hunch is that the claim is false.  To show that they were enabling anything would mean demonstrating that it would and could not have gone ahead without them.  And that’s nonsense.

Maybe the worry is one about giving an aura of legitimacy to the procedure: maybe the Saudi government is using medical attention as a cover, to make it look as though they’re humane and moderate – and maybe, for this reason, they’d be unwilling to enforce the punishment without this cover.  On that basis, medical intervention would, in some sense, enable the flogging – and by standing aloof, doctors could prevent it.  But I don’t buy that, either.  If the Saudi government really did want to look moderate and humane, a much more effective way would be… oh, I don’t know: not beheading people who don’t want to be Muslim, and not flogging people for running a blog.

Besides: inasmuch as that the government has been forced to suspend the flogging, apparently on medical advice, Iacopino’s claim would appear to be false on this reading, too.  Maybe medics’ involvement has, in a roundabout kind of way, helped keep flogging on the books; but if at the same time it’s meant that it doesn’t actually happen in reality… well, that’s not trivial.

Besides: there’s always the question of what doctors are supposed to do in the context of brutal regimes.  One possibility would be to stand back and try to keep their hands clean.  But I don’t think that that’s a desirable response.  It doesn’t stop suffering, so much as waft a scent of lavender over it.

A couple of years ago, I wrote about the case of Mohammed al-Byati: he was a doctor who’d been struck off because of his involvement in torture in Ba’athist Iraq.  That sanction, I suggested, could be seen as unjust: doctors working for the Iraqi state did not notably have room to exercise their consciences; and the alternative would not have been that the torture stopped – it’d simply continue without medical intervention.  Of course, it would have been better for al-Byati not to have treated torture victims – but only on the understanding that there was none to have to treat.

The same kind of consideration applies here.  How, precisely, is someone obliged to take action to stop Badawi’s flogging?  Note that his own lawyer faced prosecution on grounds of “undermining the regime and officials”, “inciting public opinion” and “insulting the judiciary” – a charge sheet that would be hilarious if it weren’t so grotesque; so standing in the square, or trying to wrestle the guards to the ground, seems like a moral non-starter.  It wouldn’t even be heroic.  It’d be stupid.

I suppose that all doctors could leave the country to protest there… but that’d leave an injured man (and everyone else) without any medical attention at all.  This is also a non-starter.

Iacopino’s appeal to professional ethical standards seems to assume that they’re the be-all and end-all of moral decisionmaking; and those standards themselves, as he presents them, appear to reflect a rather naive view of the world.  Importantly, they suggest that we live in a world with no genuine moral dilemmas: in which things are straightforwardly right and wrong, and that’s that.  But we don’t.  Even if it turns out that medics should distance themselves from the Badawi case after all, it’s not nearly as straightforward as we might prefer.  If it were, the problem would never have arisen in the first place.  To pretend that there is no problem, as Iacopino does, is to sacrifice real ethics on the altar of codes of practice.

Keeping your hands clean because you don’t approve of the reasons why your patient is covered in blood… well, you can’t justify that by making vague statements about ethics – especially when your view of ethics goes no further than codes of practice.