Cover of The Medical Profession and Human Rights reportRecommendations from The Medical Profession and Human Rights: handbook for a changing agenda


As is made clear throughout the report, many guidelines and protocols have been drawn up by national and international medical organizations as well as by medical groups who campaign on human rights issues.

The BMA recommends that such material be made widely available by their drafters in order to assist individual doctors and medical associations. Ideally, availability through media such as the Internet could assist national medical associations fulfill their role of providing appropriate guidance.
Torture
1. The BMA re-affirms its support for the Declaration of Tokyo and its condemnation of the practice of torture or other cruel, inhuman or degrading treatment. Doctors should neither participate in, nor advise or train others how to carry out torture. Professional associations must play a key role in supporting individual doctors who speak out against such abuses. Similarly where a national medical association itself is attacked for exposing human rights abuses, associations in other countries, including the World Medical Association, have a duty to provide support.

2. Evidence continues to confirm that torture and maltreatment are most likely to occur in places of detention. Medical disciplinary bodies should take a lead in good standard setting for members of the medical profession who work in places of detention. They should ensure the dissemination of codes, guidelines and relevant international statements. In many countries, doctors working with the prison and police services are unaware of internationally agreed standards because these have never been translated into their own language and disseminated. Medical associations and disciplinary bodies have a responsibility to ensure relevant ethical guidance is provided where this does not exist and should also urge employers to do so.

3. All places of detention should establish clear protocols for issues such as 'whistle-blowing'. These protocols need to make unambiguously clear the steps doctors should take upon discovering evidence of maltreatment, poor standards of care, corruption or other abuse. It should also be clear to whom the doctor should report. National governments should have ultimate responsibility for ensuring that such mechanisms exist and that there is adequate legal protection for whistle blowers and for alleged victims of abuse.

4. In instances where those in direct authority are complicit, or suspected of being complicit, in abuse, doctors and national medical associations should consider alternative reporting strategies. 'Alternative' medical reports can be produced by doctors who are not subject to direct state pressure and can reflect accurately the physical and psychological sequelae of torture. Reports can be directed to those who are not complicit in covering up abuse. Even alternative medical reports are not without risk both for the drafter and the torture survivor. In particular, medical associations should consider how doctors can be helped to access 'safe' reporting mechanisms within the context of their work and, where appropriate, should help doctors convey evidence of torture for investigation by the UN Special Rapporteur on Torture.

5. The 'Istanbul Protocol', drawn up by an alliance of health professionals, lawyers and human rights organizations provides detailed guidance about the investigation of torture, including such issues as the conduct of an examination, indications for referral and interpretation of findings. The BMA urges all medical bodies to endorse this guidance and draw its existence to the attention of doctors.

6. Disciplinary bodies should have effective mechanisms for addressing promptly any evidence of abuse by their members. Professional associations may be required to pass information which appears credible to agencies that have appropriate investigative procedures.

7. In order to facilitate accurate reporting of the cause of death of individuals in places of detention medical associations should ensure that clear guidance is published about the factors to be recorded on death certificates.

8. All organizations with an interest in human rights issues should be involved in campaigns for the prosecution of perpetrators of serious human rights violations, including health professionals who are complicit with and advise torturers. In effect, this means opposing impunity measures wherever they exist.

9. Medical and educational bodies should take steps to raise professional awareness of human rights. Medical schools should consider offering education in medical ethics and human rights and draw students' attention to the availability of reputable materials on web sites.

10. Medical associations can exercise political influence in resisting some of the indicators of impending periods of crisis, such as the suspension of basic rights including freedom of expression. Wherever possible, medical associations should also oppose the routine imposition of 'gagging clauses' in doctors' contracts of employment with government bodies.

Prison doctors
11. Many adverse factors seriously affect prison medical staff, ranging from lack of resources to the common practice in many countries of using prisons as 'dumping grounds' for marginalized and mentally ill people. National medical associations have a role in ensuring that their members working in this field obtain good working conditions, adequate resources and appropriate training and support.

12. Many prison doctors feel that they lack adequate practical guidance. Medical associations should raise awareness amongst members working in this field of relevant existing guidance such as that produced by the European Committee Against Torture and Penal Reform International. Guidance on specific health care issues, such as HIV/AIDS and prisons, have been produced by both the World Health Organization and the Council of Europe. National medical associations should publish guidance for their members on aspects of prison health care that give rise to ethical dilemmas or complaints.

13. Prisoners with medical conditions, including HIV or AIDS, should be medically treated in the same way as patients in the community with regards to both testing and treatment. There should be the same respect for patient confidentiality and the need for consent. In particular, prison staff should be provided with ongoing training in the preventive measures to be taken and the attitudes to be adopted regarding HIV positivity and should be given appropriate instructions concerning non-discrimination and confidentiality.

14. Prison doctors require specific training, including in some countries trans-cultural education, in order that they can address the often very specific needs of prisoner patients. Medical associations should work with national governments to ensure that such training is provided and properly resourced.

15. There is a major role for professional associations in providing an overview of prison medical services and minimizing the likelihood of abuses involving health professionals. A possible mechanism is through the establishment of a prison doctors' committee within the medical association to focus on the particular needs of prison doctors as well as providing general guidance.

16. Regular contact with doctors working in the community can prevent the professional isolation of prison doctors as well as helping create equivalent standards of health care in the prison environment as in the rest of society and encouraging personal professional development. Professional associations should help their members working in prisons to establish good working contacts with doctors within the local community.

17. Regular inspection of places of detention by independent external agencies is essential in all countries. Health care in prisons and other places of detention, should be subject to clinical audit in the same way as other areas of medicine.

Forensic doctors
18. Human rights organizations, such as Amnesty International, have frequently stated that the period in which torture is most common, and when detainees are most at risk, is immediately after arrest. Where doctors have access to detainees during this period, their role in protecting them is critical. The pressures on such doctors, however, are unfortunately great and they are frequently unprepared and unsupported. It is crucial that doctor have clear guidelines about their responsibilities and that workable strategies are in place to provide help. Professional associations can and must play a part in developing such guidelines.

19. Forensic medicine is one of the most important tools for human rights and monitoring organizations. Doctors who undertake forensic work should receive specialized training, including an awareness of international human rights' standards. Professional associations can and should provide assistance in the development of such training programmes.

20. Forensic services should be established with the goal of providing impartial evidence about crimes including human rights violations. Such services should be adequately funded and independent of police or other law-enforcement agencies.

21. Individuals detained by the police have the right to be medically examined by an experienced health professional. The BMA supports the view of the European Committee for the Prevention of Torture that forensic examinations should always be conducted out of the hearing of law enforcement officials. Further, they should be conducted out of the sight of such officials, unless the doctor concerned requests otherwise in a particular case.

22. Results of medical examinations as well as relevant statements by the detainee and the doctor's conclusions should be formally recorded by the doctor and made available to the detainee.

23. Post-mortem examinations should be carried by independent doctors, preferably experts in forensic pathology, on the bodies of all those who die in custody. The post-mortem report should state the cause, manner and time of death and account for all injuries on the body, including any evidence of torture. The family of the deceased should have the right to have a representative present at the autopsy and should have access to the post-mortem report on completion.

Capital and corporal punishment
24. The BMA welcomes the trend to limit the application of capital punishment. The BMA believes that active involvement of doctors in carrying out the death sentence is unethical. The BMA recommends that all medical associations should adopt resolutions condemning active medical involvement in application of this punishment.

25. In the BMA's opinion, certification of death is part of normal medical duties and that this extends to death by judicial execution. The BMA strongly recommends that, where judicial executions are carried out, certification of death should take place away from the site of execution and several hours after it so that there is no doubt about life being extinct.

26. The BMA does not consider that giving forensic medical evidence to help determine guilt or innocence at a capital trial is different in substance from giving evidence for such purposes at other trials and therefore believes that giving evidence of fact is non-problematic. The BMA remains concerned that medical speculation about future dangerousness might well be highly unreliable and lacking scientific basis and considers that doctors should not be involved in assessing whether a prisoner should be executed or not.

27. Some forms of corporal punishment inflict grave suffering or disability. Punishments such as amputation are not only cruel but seriously and permanently hinder individuals' ability to provide for themselves and for dependent relatives and so contribute to an under-class of destitute and marginalized people. The medical profession should not only oppose such punishments but exercise an educative influence over such policies which affect the health of society.

28. The BMA is opposed to doctors certifying people fit for corporal punishments or execution. It calls upon other associations to campaign to remove such requirements from legislation. In the meantime, the reality in many countries, however, is that the task cannot be avoided. If doctors play such a role, it is important that they, and their professional bodies, ensure that poor health of prisoners qualifies for commutation of such sentences rather than simply postponement.

29. The BMA opposes not only doctors assisting in executions and corporal punishments but any health professional using medical technology and skills to further the aims of inflicting physical damage on individuals and calls on medical associations worldwide to address this issue.

Abuse in research
30. It is clear that a combination of factors are necessary to reduce the possibility of abusive research, including the obligation of researchers not to rely solely on their own perception of the ethics or acceptability of projects they wish to pursue. All research must be subject to independent ethical review. Representatives of the public and research subjects should have a voice in deciding the acceptability or otherwise of research projects.

31. Medical associations should ensure the publication of clear ethical guidance on research which includes discussion of safeguards for vulnerable or mentally incapacitated research participants. Medical associations should require researchers to seek appropriate ethical review, even where it is not a legal requirement; this includes research carried out in closed institutions, such as the armed forces.

32. National medical associations should seek to ensure that complaints procedures exist which are accessible to the public and which include investigation of fraud and misconduct in research. Before research is undertaken, compensation arrangements must be in place to recompense any person inadvertently harmed by medical research. Medical journals should scrutinize the ethical aspects of studies submitted for publication, including the requirement for the consent of participants.

Medicine in armed conflict
33. A network of medical associations and human rights groups, including the BMA and the WMA have formally adopted a proposal for a UN Special Rapporteur on the Independence and Integrity of Health Professionals. The rapporteur would be charged with monitoring that health professionals are allowed to move freely and that patients have access to medical treatment, without discrimination on grounds of nationality or ethnic origin, in war zones or in situations of political tension. The BMA calls on medical associations who have not already done so to add their formal support to this proposal.

34. The BMA believes that reporting and denunciation of human rights violations in times of armed conflict is vital but requires careful thought and planning. Reports must be accurate and unbiased. They need to be directed to an organization or authority able to investigate and take effective action against perpetrators. Inaccurate reporting may lead to discrediting the source. Reporting that has not been thought through and discussed with victims may place both the reporter and victims at serious risk of reprisals.

35. National medical associations should ensure that their members are properly informed about their ethical and legal responsibilities to treat all patients impartially during situations of civil conflict or international war.

Doctors and weapons
36. A number of medical associations, including the BMA, the Commonwealth Medical Association and the WMA have endorsed the SIrUS project which attempts to draw up medical criteria based on wound ballistics which can be used to measure whether a weapon causes 'superfluous injury or unnecessary suffering' as provided by humanitarian law. Individual doctors and medical associations are encouraged to endorse this important project.

37. While doctors may have a legitimate role in reviewing the defensive capability of weapons, the BMA considers that doctors should not knowingly use their skills and knowledge for weapons' development. It objects to doctors' participation in weapons' development for the same reasons that it opposes doctors' involvement in the design and manufacture of torture weapons and more effective methods of execution: through their participation doctors are lending weapons a legitimacy and acceptability that they do not warrant. Doctors may consider that they are, in fact, reducing human misery through their involvement, but in reality the proliferation of weapons show this to be untrue. Doctors must also be aware that information they gather and knowledge they disseminate for legitimate medical and scientific reasons may be open to abuse and misuse by others.

38. Doctors should not be discouraged from collecting data on wound ballistics as accurately and objectively as possible. Indeed its collection is seen by many doctors as a prerequisite to improving triage and wound management. Ensuring an ethical and scientific review of military medical research is essential and could contribute to minimizing the ethical dilemmas. Such ethical review should examine whether the medical benefit from the research outweighs its possible use for weapon design.

The abuse of institutionalized patients
39. Professionals working in closed institutions for the mentally ill, the elderly and children may lack appropriate training to enable them to address the specific social and health needs of the residents/patients. Staff should be familiar with humane methods of dealing with disturbed or distressed patients and not rely on physical forms of restraint and sedation in order to manage patients' behaviour.

40. Contact with colleagues and support in the community are necessary to ensure that the staff working in closed institutions do not become too isolated. The BMA considers that it is highly desirable for staff to be offered training possibilities outside their establishments as well as secondment opportunities.

41. The BMA considers that in all countries institutions' treatment of residents/patients should be effectively monitored by an independent body. This body should be authorized to talk to patient's privately, receive directly any complaints from patients, their relatives and/or staff and make appropriate recommendations.

42. Closed institutions should develop an agreed policy on how to deal with allegations of abuse and neglect. Such policies should include mechanisms for health professionals to discuss any suspicion of abuse with an independent individual, at least initially, on a confidential basis. This independent person should be in position to advise as to the appropriate action that can be taken in the future.

43. Cases invariably arise in institutional settings where some method of restraint is necessary either to protect the individual or others from serious harm. In all circumstances, restraint should be the minimum necessary to attain the objective. Physical restraint should not be used purely to force compliance with staff instruction when there is no immediate risk to people or property. The BMA recommends that all institutions in which restraints are used develop formal policies as to their use. Such guidelines should outline proper procedures for monitoring and reviewing the type and frequency of restraints used. The guidance should also identify and encourage alternatives to the use of restraints.

44. The BMA notes with concern studies that reflect the over prescribing of sedatives and tranquillizers to the elderly and supports the recommendation of the Royal College of Physicians that national guidelines for the administration of medication in nursing and residential homes be reviewed, with the help of health and local authorities, sharing examples of good practice.

45. Doctors caring for the mentally ill in closed institutions should be encouraged to be aware of relevant national and international standards on ethics and human rights. In particular, those produced by WHO, the WMA, the European Committee for the Prevention of Torture and the UN.

Gender issues
46. Doctors have ethical obligations to ensure that medical treatments - especially irreversible or invasive procedure - are carried out for the patient's benefit. If coercion is suspected, doctors should try to ascertain the patient's own wishes and act in conformity with those, where possible. Procedures involving patients who lack capacity require special care and should only be provided when it is in the patient's best interests. Potentially controversial treatments, such as sterilization, tissue donation or invasive research, should be subject to independent external monitoring where the individual is not competent.

47. It has been suggested that national, regional and international medical organizations should consider developing a specialized Code of Ethics for Reproductive Health Providers, covering issues such as autonomy, individual choice and respect for personal integrity. The BMA considers that in areas of the world where reproductive rights seem to be under threat, this could be a helpful development.

48. Doctors and professional medical organizations can have a profound influence on attitudes and prejudices existing within the communities in which they work. Compliance with practices that help promote inequality and disadvantaging of girl children will be seen as endorsement of the attitudes that underpin them. Medical education must raise awareness of the possibilities for influencing society in a positive direction and reducing unfair gender discrimination. It must stimulate awareness of the damaging effects of cultural practices such as female genital mutilation.

49. As studies continue to document incidence of systematic violence, including mass rape, against civilians in war, the drive for establishing mechanisms for identifying and prosecuting perpetrators needs to be accompanied by sensitivity about the effects on victims of being drawn into the collection of evidence rather than just receiving treatment. For many, therapy involves gaining some sense of control over what has happened and, where possible, obtaining redress. Survivors also need to be able to safeguard their own privacy. Ways in which this can be achieved need further discussion and, particularly, require an input from experts in torture rehabilitation. An aim of such discussion should be the development of standard protocols at national level for the care and examination of rape victims.

50. Health professionals working in settings such as refugee camps should ensure that programmes have been established to address victims' past experience of rape and that there are mechanisms in place to prevent the future occurrence of sexual violence.

51. The BMA endorses the 1993 World Medical Association declaration condemning female genital mutilation and recommending actions for individual doctors and medical associations. These involve the provision of information to women men and children about its harms and risks, and impose a duty upon medical associations to stimulate awareness about the need for preventative legislation.

52. Effective mechanisms must be in place to ensure the protection of vulnerable populations against coercive family planning. Doctors and aid workers should be aware that in some jurisdiction, the monitoring bodies that exist to safeguard the rights of vulnerable individuals fail to do so.

53. Medical organizations should develop educational materials and guidelines to raise the awareness of doctors about the prevalence and indicators of domestic violence and child abuse. Guidance from professional bodies should set out steps for the care of victims and ways in which they can be encouraged and supported towards voluntary disclosure of it.

54. Doctors or medical organizations who have information about the abuse of women and children covered by international standards established by the United Nations should raise the matter with the relevant Special Rapporteur.

Doctors and asylum seekers
55. As the right to seek asylum is gradually being challenged in many countries the BMA considers that medical associations should object when individuals with a well-founded fear of persecution are sent back to situations of high risk.

56. Not all forms of torture result in physical scars. In some cases a medical report may confirm the claims made by an asylum applicant. It can take time and many interviews before incidences of torture or abuse are fully revealed, particularly where the abuse has been sexual in nature. Therefore, it is crucial that sufficient time is allowed to obtain crucial medical evidence that can be vital to the case of an asylum seeker alleging torture or ill-treatment in their country of origin. Doctors are encouraged to use existing guidance, such as the 'Istanbul Protocol', to investigate and document allegations of torture.

57. The BMA considers that evidence of torture should be identified at the earliest possible opportunity in order that such evidence can be used to supplement any claim for asylum, to prevent that individual from being detained if this is proposed and to ensure that the individual receives appropriate counselling, medical treatment and other rehabilitative support. The BMA calls on national governments to develop appropriate mechanisms to facilitate this.

58. Doctors should be careful not to discriminate against asylum seekers who seek to register with their practice and should ensure that administrators are aware of procedures for registering asylum seekers. The BMA has issued guidance for doctors on access to health care for asylum seekers in the UK which confirms that there is no requirement to demand the immigration status of an individual who is seeking to register at primary health care level.

59. The BMA supports training for all doctors who regularly treat asylum seekers, some of whom will be victims of torture, in order that they are able to address their particular health care needs. The BMA calls on national governments to develop training programmes with the help of specialist bodies such as the London-based Medical Foundation. National governments should ensure that there are sufficient support services for doctors who treat asylum seekers, including specialist rehabilitative and interpreting services.

60. The BMA considers that detention for asylum seekers should be used only in the most exceptional circumstances. The BMA is opposed to the immigration detention of asylum seekers in penal institutions.

61. The BMA supports the WMA resolution that physicians can not be compelled to participate in any punitive or judicial action involving refugees or to administer any non-medically justified diagnostic measure or treatment, such as the use of sedatives, to facilitate easy deportation from the country.

Rehabilitation of torture victims
62. The BMA strongly supports the development of social and health services for individuals who have been tortured and for their families who cope with the effects of torture and exile. We urge national medical associations in countries where such specialist rehabilitation centres exist to support this work, through publicity, material aid and any other means that they find appropriate. In addition, governments have a responsibility to devote sufficient resources to permit the mainstream health system to cope with the needs of this group.

63. While recognizing the important work undertaken by specialist rehabilitation centres the BMA would welcome more research into the different models for rehabilitation of survivors of torture in order that guidance can be provided on those that have proved the most effective.

64. The London-based Medical Foundation welcomes professional volunteers to treat torture survivors and their families and to prepare medical reports documenting evidence of torture in support of applications for asylum. The BMA urges its members to consider this valuable area of voluntary work.

Truth, justice and reparation
65. International law permits governments to punish torture and other crimes against humanity even in cases where neither victim nor perpetrator have links with the state. Medical associations interested in helping victims of torture obtain a hearing should seek appropriate advice from human rights organizations with expertise in this area.

66. Truth commissions that hear evidence but are unable to punish known perpetrators of human rights violations have been criticized for fostering the notion of impunity. The BMA opposes blanket immunity and considers that all perpetrators should be brought to justice. Nevertheless, the BMA recognizes that in circumstances where no other means of justice or redress are forthcoming .there are arguments for using such commissions to establish the truth and allow victims to have a hearing.

67. Allowing perpetrators to benefit from impunity can only lead to contempt for the law and to renewed cycles of injustice. Doctors and their professional associations should use their power to ensure that international tribunals, such as that for the former Yugoslavia and Rwanda, are effectively supported and their work monitored. Professional organizations should support mechanisms such as the International Criminal Court to try those guilty of serious breaches of humanitarian law.

68. It is the responsibility of national governments to uphold the law. National medical associations and disciplinary bodies have clear duties to determine the innocence or culpability of doctors against whom allegations of abuse are made. Where the national body is unable or unwilling to act on an alleged incident of abuse, or where the crime is of such a serious nature that the national mechanisms are incapable of action, there should be resort to an international criminal tribunal.

69. Victims of human rights abuses are entitled to redress, including medical and psychological care and rehabilitation for physical or mental damage. Wherever possible, medical organizations should support appropriate mechanisms to promote redress.

70. Perpetrators of abuse should be punished, including doctors who breach basic principles of ethics and human rights. The WMA has passed a resolution calling on national medical bodies to prevent doctors who have committed abuses from evading justice. The BMA supports the proposal for an international registry of doctors against whom there is evidence of participation in gross violations of human rights. Such doctors should not be able to achieve automatic licensing in the jurisdiction of any national medical licensing body without submitting to some review of the evidence against them.

Teaching ethics
71. The value of international consensus statements, such as the Declaration of Tokyo, is lost if they are not known to doctors. Ideally, such guidelines should be brought to the attention of medical students, particularly those who intend to work in settings where human rights violations might be encountered, such as prisons, police stations and other places of detention.

72. In many countries, forensic doctors, prison doctors and those employed in closed institutions are most likely to see evidence of abuse. Such specialists should have access to training in ethics and human rights standards, including safe reporting procedures and the powers of various monitoring mechanisms, such as the European Committee for the Prevention of Torture (CPT).

73. Training materials should address common practical dilemmas encountered in closed institutions and by doctors with dual responsibilities, including issues such as use of restraint, punishment, covert administration of drugs and use of solitary confinement.

74. Quality teaching materials should be available via media such as the Internet so that they can accessed by doctors and medical students who have no other means of learning about medical ethics.

75. Human rights organizations should consider making anonymised case examples and other materials available for undergraduate teaching in medical ethics and human rights.

76. Further consideration should be given to the production of non-culture specific, ethics and human rights training materials for health professionals. Such materials should be adaptable for use by medical groups or by doctors working in isolation from colleagues and other sources of advice.

© British Medical Association 2008

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