Topic 11: Rights-based approach to care

Connection with curriculum

This topic relates to the concept: Indigenous Rights

Analyse strengths and limitations in Intensive Care Medicine with reference to the United Nations Declaration of Human Rights and Indigenous Peoples and other human rights instruments in terms of equity for Aboriginal and Torres Strait Islander Peoples; Determine strengths and challenges in delivering healthcare in Intensive Care Medicine with respect to the social determinants of health; Devise strategies for diagnosing and treating Aboriginal and Torres Strait Islander patients in Intensive Care Medicine from the perspective of the social determinants of health.

Introduction
There are numerous international mechanisms that outline the human right to health and the ability to thrive. The right to practice culture is an Australian right, as is the right to family life in a form defined by one's own family. As well as morally and functionally vital, these rights are legally protected. The impact of colonisation on the health of Aboriginal and Torres Strait Islander Peoples has been significant, and it limits the protective effect of other rights and norms that should apply to everyone. Those who have not experienced the effects of colonisation may not realise how this effect erodes every avenue for taking advantage of one’s own rights, especially at vulnerable times of life, such as an ICU admission for oneself or family. This situation is indicative of the need to treat Aboriginal and Torres Strait Islander Peoples’ health as social justice and the litmus test of Australia’s social policy.

Self-determination is a process of choice to enable groups to feel safe and meet our human needs. This means three key things:

We have a choice in determining how our lives are governed and our development paths.
We participate in decisions that affect our lives.
We have control over our lives and future, including our economic, social and cultural development.

Select the headings below to read more.

The United Nations Declaration on the Rights of Indigenous Peoples (United Nations, 2007) is the most comprehensive articulation of the fundamental and inherent rights that all Indigenous Peoples have. It establishes a minimum standard for the survival, dignity and wellbeing of Indigenous Peoples.

The Declaration states that these rights derive from Indigenous Peoples’ “political, economic and social structures and from their cultures, spiritual traditions, histories and philosophies, especially their rights to their lands, territories and resources” (United Nations, 2007, p. 3).

The systems and structures of the health system must be accessible alongside the right to establish Indigenous led systems.

Indigenous Peoples’ unique rights help ensure that their culture continues to exist into the future. This includes their rights to speak and teach their native language and customs, to live on the land of their ancestors and to look after sacred sites.

Enabling the exercise of the inherent rights of Indigenous Peoples ensures the health and wellbeing of Indigenous Peoples. Where these rights are not able to be fully exercised, as is the current reality for Aboriginal and Torres Strait Peoples, health outcomes are negatively affected (United Nations, 2007). Intensive Care Medicine trainees and specialists can use their power as health professionals to advocate for the exercising of these rights.

Caution

The United Nations Declaration on the Rights of Indigenous Peoples (United Nations, 2007) focuses on individual rights. It is important to remember that Indigenous Peoples also have inherent rights, which pertain to their communities as a whole.
The Declaration was first adopted in 2007 and the only countries that voted against the Declaration were Australia, New Zealand, Canada and the United States. Australia eventually became a signatory in 2009, and Aotearoa New Zealand in 2010.

Self-Determination

The principle of self-determination has been described as the most fundamental of all human rights for Indigenous Peoples. Self-determination has particular significance for Indigenous Peoples worldwide, given their historical exclusion from decision-making through the experiences of colonisation, dispossession and paternalism.

The United Nations Declaration of the Rights of Indigenous Peoples (United Nations, 2007) defines self-determination as the right to autonomy and self-government, the right to determine one’s own political status freely and to pursue economic, social and cultural development.

Self-determination reflects the aspirations of Indigenous Peoples worldwide to participate effectively in decision-making that affects them and to be in control of their destinies under conditions of equality. Self-determination is an inherent right of Aboriginal and Torres Strait Islander Peoples. Aboriginal and Torres Strait Islander families and communities have the right to decide their futures.

It is important to recognise that any one definition or understanding should not constrain self-determination. Self-determination means different things to different communities.

Select the headings below to read more.

Without self-determination it is not possible for Indigenous Peoples to fully overcome the legacy and ongoing impacts of colonisation and dispossession (Phillips, 2015).

Indigenous-led evidence shows that for Indigenous populations, self-determination (when comprehensively enabled) is a significant factor in improving health and social outcomes (Australian Human Rights and Equal Opportunity Commission, 1997). Self-determination is comprehensively enabled when governments do more than merely grant Indigenous Peoples ‘permission’ to design and implement services. Supporting self-determination extends to recognising that Indigenous Peoples have the right to be free from unwarranted state interference and to respond appropriately to issues within their communities (Davis, 2019). It also requires governments and non-government agencies give up control and share resources and power (Australian Human Rights and Equal Opportunity Commission, 1997).

When Indigenous Peoples have control over health, this leads to both better care and better health (Dixon et al., 1998; Kalt et al., 2008; Lavoie et al., 2010; Moore et al., 1990; Waldram et al., 2006). The link between health and status is autonomy: what level of perceived and realised control people have on their lives (Dixon et al., 1998; Kalt et al., 2008; Lavoie et al., 2010; Moore et al., 1990; Waldram et al., 2006). People with greater perceived control over their lives tend to be healthier, while those with lower perceived control tend to be less healthy. Lower perceived life control contributes to negative health outcomes by influencing detrimental health behaviours (e.g., smoking, alcohol consumption, poor diet, physical inactivity) and the production of chronic stress. The link between perceived control and health has been established in relation to a wide variety of health afflictions, including heart, lung and kidney disease, diabetes, mental illness, suicide and deaths resulting from accidents and violence—the very same afflictions that are the leading causes of morbidity and mortality in Indigenous communities worldwide (Marmot, 2004; Murphy, 2014).

A story of incarceration by Dr Penny Stewart

A friendly, helpful grandmother was in Alice Springs hospital with prison restraints on and two guards watching her.

She was unable to have conversations in private with her family; she was restricted to the bed due to the restraints interfering with her rehabilitation.

Was she a violent threat? Was it for the safety of our staff and the prison officers that she was restrained? No, she had merely accumulated too many fines from her vehicle, which she could not pay. Fines for not registering the vehicle due to lack of funds and so, therefore, not surprisingly, could not pay the fines.

For 3 days, she was left in the ICU with the restraints on until a phone call to the person in charge. They realised it was not necessary and were able to relax the restrictions.

Aboriginal women, despite being only 2% of the women in Australia, represent 34% of the female prisoners. Often, they are in prison for issues relating to poverty rather than violence.

It is important always to ask whether the restraints are necessary. The usual protocols are followed; however, when you ask questions, then human empathy can be used to look at whether these protocols are necessary or harmful.