Learning & Teaching Human rights in health care

Raising awareness and ways of implementation - a student project.

We were very fortunate to be able to conduct a three-semester project seminar at ASH Berlin on the topic „Human Rights in Health care. Raising Awareness and Possibilities of Implementation“. The idea for the seminar arose from the observation and our assessment that this important topic is still not sufficiently addressed in teaching and studies and that its great importance for practice is not sufficiently perceived. Although we had already reckoned with the complexity of the topic in advance, we were surprised again and again in the course of the seminar by the diversity of its aspects and the significance of very different dimensions. Participants of the seminar were students from the study program Health and Care Management as well as Gudrun Piechotta-Henze (Nursing Science), Tim Reiß (Philosophy) and Tim Huttel (Philosophy). In the first semester Claudia Mahler (Law, German Institute for Human Rights) supported us, so that an interdisciplinary cooperation could be realized throughout.


What are human rights?

„What actually are human rights?“ With this question we entered the topic of our project seminar. Everybody talks about human rights - but it is not so easy to explain what exactly we mean by this term. Before we got an overview of the different human rights - such as human rights to education or health - and what exactly they cover, we wanted to find out what idea underlies human rights as a whole - that is, what all human rights have in common. In doing so, we noticed that the term is used in two very different ways. On the one hand, we talk about human rights being certain basal rights that all people have and cannot lose, simply because they are human beings, not because they have certain characteristics or live in a certain country. Every human being has these rights, no matter where they live. On the other hand, we sometimes speak critically of people not having human rights or some of them in a particular country: In a dictatorship or a totalitarian state, the people who live there often do not have all the rights they are entitled to. We perceive this as a scandal, sometimes even as a monstrosity. Paradoxically, all people have human rights, but not all people have them. To avoid this ambiguity, we could say: The inhabitants of some countries do not have human rights, but they should have them. All people have these rights, but not everywhere and in every respect are these rights recognized, respected, guaranteed. The described ambiguity is, however, in some respects also the point of human rights: Whether someone is entitled to human rights does not depend for us on whether these are actually guaranteed in the legal system of the country in which she/he lives. In this sense, they were „pre-state“ rights or entitlements. At the same time, human rights should not only be accepted in theory and welcomed in Sunday speeches in every state, but should be legally recognized and guaranteed. Therefore, human rights are not „merely“ moral claims whose recognition depends on the good will of some other.


How are human rights legally protected?

After this introduction to the philosophy of human rights, we dealt with the main features of the legal dimension of the subject. We were very fortunate to be accompanied in the first semester by Dr. Claudia Mahler of the German Institute for Human Rights, whose extensive legal expertise we were able to draw upon. In addition to the Universal Declaration of Human Rights (1948), the most important documents for the development of today's human rights protection system are above all the two UN human rights covenants (1966): the Covenant on Civil and Political Rights and the Covenant on Economic, Social and Cultural Rights. We then went on to familiarize ourselves with the main features of international human rights protection - in particular the state reporting procedure within the UN framework. Rich material on this can be found on the website of the German Institute for Human Rights.


What does the human right to health include?

We have dealt particularly intensively - from a philosophical and legal perspective - with the human right to health. What exactly does it cover? Or in other words: What is the human right to health actually a right to? Obviously, there can be no right to health in the strict sense, because health cannot be guaranteed. However, access to health services can be legally guaranteed. But to what extent are these guaranteed by human rights - and thus also (at least legally) protected from being sacrificed to a political austerity dictate? As a central point we worked out: It is a constriction if the human right to health is understood exclusively with regard to access to medical care. After all, health and health opportunities also depend to a large extent on living conditions as a whole, from access to clean drinking water to educational opportunities and adequate housing. What becomes apparent here is the so-called „indivisibility“ of human rights: The individual human rights are interrelated in many ways - in our case, the right to health, for example, with the right to education, to adequate food and to housing.


Violence and violence prevention in nursing care

A perspective from the field of nursing science then led us to a topic that is of enormous importance for the protection of human rights in practice, but which is reluctantly talked about: Violence and violence prevention in care, especially violence against elders. Much more prevention services are needed to ensure the fullest possible protection of the people being cared for. Assaultive or even violent behavior often has to do with excessive demands. Caregivers have to work under conditions that make it difficult, and sometimes impossible, for them to act in a human rights-based manner in practice. In this context, we have dealt with phenomena such as „coolout“ or „moral distress“: When nurses experience that they cannot implement what they recognize as morally right in practice at all and are even forced - for example, due to time pressure - to provide care that does not meet their own professional and moral standards, this can lead to „moral desensitization“. This means that, out of self-protection, people either leave the profession, come to terms with the contradictions or become numb to them. This gave rise to the question: How does one deal with the fact that what is taught in nursing theory and in the ethics seminar can hardly be implemented in practice? This question about the meaning of ethical sensitization and human rights education in view of the conditions that currently prevail more often in current practice is itself again an ethical-moral problem. If a nursing strike is used to fight for better conditions that make appropriate and human rights-based care possible in the first place: Is it permissible to accept the possibility that the strike will cause harm to patients in the here and now, for example by postponing an operation? Another aspect that must not be forgotten is that human rights apply not only to patients, but also to nurses themselves. In this respect, the question of the appropriateness of certain activities and conditions in professional action must always play a role in the human rights assessment.


Anthropology and ethics are closely related: Images of age and the concept of person

In the second and third semester Tim Huttel (University of Rostock) supported us with his extensive philosophical expertise, especially in the field of ethics. We decided on a thematic focus, namely the human rights of the elderly. The project seminar and the extraordinarily conducive conditions it provided - also in terms of time - gave us the opportunity to delve into the topic in a depth that is unfortunately not usually possible in 'normal' university teaching. Among other things, we dealt with 'images of old age', i.e. with the ideas and also stereotypes that are socially associated with aging. Due to prejudiced attitudes, the resources and special abilities of older people are systematically underestimated, among other things. Age as a phase of life is also a topic of philosophical anthropology. Here we have become impressively aware of the close connection between image of humanity and basic ethical attitudes. A 'mentalistic' or 'cognitivistic' view of man equates a person with his brain or consciousness. With the loss of cognitive abilities - e.g. in connection with dementia - the person „disappears“. One can object to such a view of the human being: We are bodily embodied beings. Our bodies also have an individual life history. In addition to autobiographical memory, there is a body memory that is preserved for much longer. For example, people with dementia experience the familiarity of a spatial environment, even if they can no longer express this linguistically. Personal identity does not depend on the ability to form and articulate a reflected will.

This made it very clear to us how important it is to address such mostly unconscious images of people in order to adopt an appropriate and sensitive attitude towards those affected that perceives and values them as individual persons.

In addition to the theoretical work, the student participants designed and developed two teaching units: An introductory unit entitled „Human Rights in Health Care. Basic communication of contexts in (nursing) practice“ and a thematically in-depth teaching unit entitled „Human rights in health care. Elderly people and dementia“.[1] The two teaching units were then practically „tested“ by the students within the framework of a theory block in a Berlin nursing school. There was very positive feedback here, which we were all very pleased about. The students also found the change of role to being a teacher a very enriching experience.


Human rights and the common good

Finally, in the theory section of the third semester, we took a step back and asked ourselves: as important as the study of human rights is, are there perhaps also difficulties that arise from focusing on the concept of human rights? Is it helpful if every grievance in care and health care is addressed in terms of a human rights violation? Also, as we have learned, the conceptualization of individual rights has evolved historically, and there are alternative ways of thinking about ethical and moral issues. In thinking about these questions, we have been assisted in a special way by Tim Huttel, who is engaged in a research context on the concept of the common good. The concept of the common good tends to be something of a foreign body within liberal rights discourse. Is the common good more and different than the sum of the fulfillment of individual legal rights? Might there be an opportunity here to enrich the normative vocabulary with which we judge conditions and practices in health care? Are there ethical-moral dimensions and questions that can be better or more sharply presented with an alternative terminology than with recourse to human rights?


The protection of vulnerable groups in times of pandemic.

For the most part, however, the third semester was devoted to developing the podcasts that we would like to briefly introduce below. Since we have always dealt with the ethical-moral conflicts and dilemmas triggered by the Corona pandemic in addition to the scheduled seminar program, we were quickly able to agree on a thematic bracket: Protecting Vulnerable Groups in Times of Pandemic.

Samis Fröhlich's podcast „Curtailing the Right to Health through Structural Changes in Public Health Care“, addresses fundamental ethical issues in light of current upheavals and developments in the medical care structure. In the Corona pandemic, certain challenges and difficulties became particularly clear, which also characterize everyday life in the care system beyond the pandemic. In a conversation with a competent partner from the field, it becomes clear, among other things, that centralization in inpatient care has many ambivalent aspects. The hospital is not only a medical „repair store“, but also a place of public life that is an irreplaceable part of the social infrastructure, especially in rural areas. Medical and social components are often mutually dependent in the provision of care and therefore cannot be considered separately. An economistic understanding of health care fails to recognize that health and health care always have a psychosocial component. Medical facilities should also be places that enable the people working there to experience the meaningfulness of their own actions. If this possibility is lost - as happens under the primacy of economic objectives - it can lead to cynicism and indifference toward one's own work. Also and especially in the case of digitization in the healthcare sector, there is a danger that emotional aspects will not be sufficiently taken into account. The importance of hospitals and medical facilities is not limited to the fact that they are part of the public service - a term that is widely used today. Equally, as Samis Fröhlich puts it in a nutshell, they should be places of general interest.

Tina Kahlert's podcast  „What Happened to Us? Lockdown horror for children and youth during the Covid 19 pandemic“, takes a complementary look at the impact of the response on another vulnerable group, children and youth. In conversation with a competent partner who teaches physical education and English at a Berlin high school, it becomes clear which possibly human rights-violating burdens were placed on children and adolescents by the political measures taken to contain the Corona pandemic. In particular, the strict prohibition of sports and social activities at the beginning had serious consequences for the development and (especially mental) health of children and adolescents.

Jessica Kittendorf's podcast „Self-isolation and the Rights of Older People in the Corona Pandemic“, explores the extent to which the sometimes drastic measures taken to protect older people in the early days of the Corona pandemic violated the rights of the very people they were supposed to protect. The interview with Claudia Mahler of the German Institute for Human Rights provides a good overview of a whole series of both ethically and morally highly problematic measures during the Corona pandemic, some of which may even have violated fundamental rights: advice to self-isolate; in nursing homes, sometimes the ban on leaving the room; breakdown of social life in long-term inpatient facilities; decisions on protective measures without the involvement of the residents. In addition, the collective attribution of vulnerability is problematized in the course of the conversation, as well as the discussion about the UN Convention on the Rights of the Elderly and the possible establishment of age as an inadmissible discrimination criterion in Article 3 of the Basic Law.

By presenting the burdens and consequences of the Corona pandemic in a complementary way from the perspective of two different vulnerable groups, the two podcasts by Tina Kahlert and Jessica Kittendorf raise a difficult ethical and moral question that has not been formulated in this clarity before: To what extent may precautions taken to provide special protection for one vulnerable group (the elderly in need of support and care) be at the expense of another vulnerable group (children and adolescents)? Are there considerations that allow for a trade-off? Possibly, however, such a question cannot be answered, but belongs to an open discussion process that helps to take into account the associated disadvantages and suffering.


Human rights in health care and nursing

Further reading, films and podcast (compiled by Fulya Kilic, student, ASH Berlin, Health and Care Management program, B.Sc.)

Amnesty International (2021). Health rights. Prerequisite for limiting human rights. Retrieved 4/5/2023 from https://www.amnesty.ch/de/themen/coronavirus/dok/2021/voraussetzung-zur-einschraenkung-von-menschenrechten Aronson, P. & Mahler, C. (2016). Human rights in nursing practice. Challenges and solutions in nursing homes. Retrieved 3/15/2023 from https://www.institut-fuer-menschenrechte.de/publikationen/detail/analyse-menschenrechte-in-der-pflegepraxis Bonacker, M. & Geiger, G. (2018). Human rights in nursing: an interdisciplinary discourse between freedom and security. Barbara Budrich. https://doi.org/10.2307/j.ctvdf03vq Charter of the Rights of People in Need of Assistance and Care. Retrieved 05.04.2023 from www.bundesregierung.de/breg-de/service/publikationen/charta-der-rechte-hilfe-und-pflegebeduerftiger-menschen-733904 Charter for the care of seriously ill and dying people in Germany. Retrieved 05.04.2023 from https://www.dgpalliativmedizin.de/projekte/charta.html Derkaoui, S. (n.d.). What is ethics in care & why is it so important? What do ethical principles mean for your everyday life? Retrieved 4/5/2023 from https://www.medirocket.de/karrieremagazin/details/was-ist-ethik-in-der-pflege--warum-ist-sie-so-wichtig German Institute for Human Rights (2016). Human rights in nursing homes. How human rights can be anchored in care for the elderly. Retrieved on 05.04.2023 from https://www.institut-fuer-menschenrechte.de/publikationen/detail/menschenrechte-in-pflegeheimen Dibelius, O. & Piechotta-Henze, G. (Eds.). (2020). Human rights-based care. Plea for the respect and application of human rights in nursing. Hogrefe Verlag. https://doi.org/10.1024/85913-000 Emmer De Albuqurque Green et al . (2017). The importance of human rights in residential care for the elderly: what do professional nurses know about them? Retrieved 03/15/2023 from https://www.ksh-muenchen.de/fileadmin/user_upload/Forschungsprojekt_MenPflege_Publikation.pdf Frewer, A. & Bielefeldt, H. (Eds.). (2017). The human right to health: normative foundations and current discourses. Transcript Verlag. doi. org/10.14361/9783839434710-001 Hack, C. et al. (Eds.). (2019). Human rights in health care. From the hospital to the state level. Königshausen & Neumann. Helmrich, C . (2017). The constitutional complaints against the nursing emergency. Documentation and interdisciplinary analyses. Nomos. Knüppel, J. (2018). Health is a human right. Retrieved 4/5/2023 from https://www.dbfk.de/media/docs/download/DBfK-Aktuell/Gesundheit-ist-ein-Menschenrecht_web.pdf?sn=sn4ed852f08893018d8a7b03db4d5e52 Krennerich, M. (2020). Health as a human right. APuZ/Aus Politik und Zeitgeschichte. (Federal Agency for Civic Education). Retrieved on 05.04.2023 from https://www.bpb.de/shop/zeitschriften/apuz/weltgesundheit-2020/318302/gesundheit-als-menschenrecht/ Mahler, C. (2015). Human rights in care What policy must do to protect older people. German Institute for Human Rights. Retrieved 03/15/2023 from https://www.institut-fuer-menschenrechte.de/fileadmin/Redaktion/Publikationen/Policy_Paper_30_Menschenrechte_in_der_Pflege.pdf Nolte, S. (2016). Ethics: health is a human right. Retrieved 4/5/2023 from https://www.aerzteblatt.de/archiv/180283/Ethik-Gesundheit-ist-ein-Menschenrecht Pollmann, A. & Lohmann, G. (2012). Human rights. An interdisciplinary handbook. J.B. Metzler Riedel, A. (2017). Nursing ethics. Retrieved 4/5/2023 from https://www.bpb.de/themen/umwelt/bioethik/182461/pflegerische-ethik/ Riedel, A. & Lehmeyer, S. (2020). Ethics in health care. Springer. doi. org/10.1007/978-3-662-58685-3 Riedel, A. & Linde, A.-C. (2018). Ethical reflection in nursing. Concepts - values - phenomena. Springer. doi. org/10.1007/978-3-662-55403-6 Riedel, A. et al . (2022). Ethics education in nursing - structural features and didactic implications of nursing education. https://doi.org/10.1007/s00481-022-00709-7 Städtler-Mach, B. & Hermanns, K . (2012). Human rights in nursing. In: Mührel, E. & Birgmeier, B. (Eds.) Human rights and democracy. Perspectives for the development of social work as a profession and scientific discipline. Springer VS, Wiesbaden. https://doi.org/10.1007/978-3-531-19283-3_16 Welsh, C. et al . (Eds.). (2017). Autonomy and human rights at the end of life: Foundations, experiences, reflections from practice. Transcript Verlag. doi. org/10.14361/9783839437469-003 Center for Quality in Care. (2017). Rights of people in need of care. Retrieved 04/05/2023 from https://www.zqp.de/wp-content/uploads/ZQP_Report_RechtePflegebed%C3%BCrftiger.pdf Videos, Podcast Ethics | Elsevier Nursing Podcast. Retrieved 03/15/2023 from https://www.youtube.com/watch?v=qRz6cLPst80 Ethics in Nursing. Retrieved 03/15/2023 from https://www.youtube.com/watch?v=IjELYCmhXMg Human rights in focus. The rights of older people. Dr. Claudia Mahler, Institute for Human Rights. Retrieved 04/05/2023 from www.youtube.com/watch Nursing homes equals human rights adè (Abuses in German nursing homes). Retrieved 05.04.2023. from www.youtube.com/watch What is the Care Charter? | ZQP explanatory film. Retrieved 03/15/2023 from https://www.youtube.com/watch?v=SU187XwyIsE What is ethics in nursing practice? - An explainer video. Retrieved 03/15/2023 from https://www.youtube.com/watch?v=LTvXrkZnV7M




[1] Materials/PowerPoint slides are deposited on the homepage of Gudrun Piechotta-Henze: www.ash-berlin.eu/hochschule/lehrende/professor-innen/prof-dr-gudrun-piechotta-henze/