Module 2: Istanbul Protocol Standards for Medical Documentation of Torture and Medical Ethics

1. The Istanbul Protocol can best be described as:
   1. The duties of states to ensure the effective investigation and documentation of torture and ill treatment
   2. Guidelines for the effective investigation and documentation of torture and ill treatment
   3. International Legal obligations of states to respect The intentional infliction of severe mental or physical pain or suffering
   4. International standards that enable medical and legal experts to prove or disprove allegations of torture and ill treatment
2. The guidelines contained in the Istanbul Protocol are not designed to be fixed; rather, they represent an elaboration of the minimum standards contained in the Istanbul Principles and should be applied in accordance with a reasonable assessment of available resources.
   1. True
   2. False
3. The Istanbul Protocol has been recognised by UN and regional human rights bodies as the international standard for the effective investigation and documentation of torture and ill treatment.
   1. True
   2. False
4. A forensic medical evaluator should avoid conveying empathy during evaluations of alleged torture victims because it may compromise his or her objectivity in the collection of physical and psychological evidence.
   1. True
   2. False
5. Although there may be considerable variability in the psychological effects of torture and ill-treatment, the effects are often profound and result in long-term psychological disability.
   1. True
   2. False
6. According to the Istanbul Protocol, what are the most common psychological problems that torture victims suffer from?
   1. There are no common psychological problems
   2. Posttraumatic stress disorder (PTSD) and depression
   3. Paranoia
   4. Sexual dysfunction
7. Physical evidence of trauma is always of greater legal value than psychological evidence.
   1. True
   2. False
8. In addition to providing medical evidence of torture and ill treatment, the Istanbul Protocol can be used to exonerate police who are accused of torture and ill treatment of detainees.
   1. True
   2. False
9. Which of the following are procedural safeguards for detainees?
   1. Police may be in the presence of the detainee when s/he is being examined
   2. The detainee’s lawyer should be present during the request for examination
   3. Prisoners should be examined at the most convenient location
   4. A copy of the examination should not, under any circumstances, be transferred to law enforcement officials
   5. Requests for medical evaluations by police should be considered valid
10. If the forensic medical examination supports allegations of torture, the detainee should not be returned to the place of detention.
    1. True
    2. False
11. The presence of police, security forces, and/or other third parties during the examination may be grounds for disregarding a negative medical report.
    1. True
    2. False
12. The term “medical ethics” refers to the moral framework that each health professional is bound to in their work.
    1. True
    2. False
13. The use of hoods or blindfolds during any contact between a detainee and a health professional is absolutely unacceptable under any circumstances.
    1. True
    2. False
14. Which of the following is not a provision under the World Medical Association’s 1975 Tokyo Declaration?
    1. Doctors shall not be present during any procedure during which torture is used
    2. The doctor shall not countenance, condone or participate in the practise of torture or other forms of cruel, inhuman or degrading procedures
    3. The doctor’s fundamental role is to alleviate the stress of his or her fellow man and no motive whether personal, collective, or political shall prevail against this higher purpose
    4. None of the above
15. Which of the following is not an example of a role that a health professional may play in the participation of torture and ill treatment?
    1. A health professional might be asked to resuscitate a torture victim after he/she has become unconscious
    2. A health professional might provide certain instruments to the torturers/perpetrators
    3. A health professional might be asked to falsify or misrepresent a medical report
    4. A health professional might perform a medical evaluation in order to assess that the victim will be able to withstand torture
    5. A health professional might provide confidential medical information to interrogators
    6. All of the above
16. Which of the following are essential elements of informed consent?
    1. Mental competence
    2. Full disclosure regarding risks and benefits
    3. The individual understands the information provided
    4. Consent is voluntary and not coerced in any way
    5. The individual provides verbal or written authorization of consent
    6. All of the above
17. When health professionals are pressured or required by law to disclose information to third parties about patients without consent, they should make clear to any authority requesting information that they are bound by professional duties of confidentiality.
    1. True
    2. False
18. Under which of the following circumstances would it be appropriate for a physician to feed a hunger striker?
    1. When the physician’s moral beliefs compel him or her to do so
    2. If the hunger striker is already in a comatose state and no prior directives have been established
    3. Immediate family members insist on feeding after the hunger striker became comatose, even though the attending physician documented that the detainee was competent, rational and understood the risk of his actions
    4. None of the above
19. The ethical duties of medical personnel do not apply in non-clinical encounters with detainees, such as interrogation.
    1. True
    2. False
20. Effective medical and legal investigations of torture and ill treatment requires obtaining the following essential information?
    1. Identity of the victim
    2. Identity of the perpetrators
    3. Description of how the individual came into the hands of the perpetrators
    4. Description of the location where the abuse took place
    5. Description of the form of abuse
    6. Possible witnesses
    7. All of the above

The Istanbul Protocol can best be described as: The duties of states to ensure the effective investigation and documentation of torture and ill treatment Guidelines for the effective investigation and documentation of torture and ill treatment International Legal obligations of … Continue reading →

Health professionals, whether working in places of detention, called to visit a police station or other place of detention, or working in national health services, may well be presented with detainees to examine in the presence of security forces. The reasons for such examination may include a statutory initial medical examination upon arrival in a place of detention, complaint of illness or ill-treatment by a detainee, or routine referral for medical treatment. When faced with a detainee, the health professional must apply their usual ethical principles in any assessment and treatment. The detainee must give informed consent to any examination, procedure or treatment, and this should include an explanation of who will have access to any findings, and how these findings may be used. Informed consent requires that the consenting individual:

• Is mentally competent
• Receives full disclosure of information, i.e. risks vs. benefits
• Understands the information provided
• Gives his/her consent voluntarily
• Provides authorisation for his/her consent

Two further points of particular importance in the examination of detainees must be highlighted: the maintenance of medical confidentiality and the use of restraints (such as handcuffs) on detainees. Medical ethics dictates that consultations and the information gained therein should be confidential between the doctor and the patient. In the case of prisoners, the security forces (police, military or prison guards) will often maintain that they must remain present during any consultation, the most common reason being that it is for the protection of the health professionals. In some circumstances, the security personnel might insist that the detainee remain in restraints (handcuffs, ankle-cuffs) and even with a hood or blindfold during the consultation. Thus there is an immediate conflict between security and medical concerns.

As stated above, health professionals have a duty to observe their usual ethical practise in their treatment of detainees. In brief, there can be no blanket rule that dictates that all detainees are dangerous and merit, in all circumstances, the presence of security personnel and/or restraints. If escape is an issue, health professionals can conduct consultations with the security personnel outside the door, or as a less acceptable alternative, with the door open and the personnel out of range of hearing. Further, security concerns can be addressed by conducting the consultation in a room that has only one entrance, and either no windows or barred windows.

The routine use of restraints during medical consultation or treatment is also contrary to medical ethics and international standards on treatment of prisoners. Health professionals must not accept such practises. Restraints not only interfere with the proper diagnosis, management and treatment of patients, but they also run contrary to the inherent dignity of all human beings. The only possible acceptable justification for use of restraints is as a last resort when there is substantiated reason to believe that this particular detainee presents an immediate and current violent threat to himself or others. Health professionals can and should question the use of restraints if they have reason to doubt such a risk exists. In the exceptional circumstances that restraints are used, they should be as minimal as possible.

The use of hoods or blindfolds during any contact between a detainee and health professionals is absolutely unacceptable under any circumstances. The use of hoods or blindfolds has in itself been found to be a form of ill-treatment. In the health setting hoods or blindfolds not only impair any meaningful contact with the patient, they also prevent the identification of any health professionals and may thus add to a perception of impunity in any cases of ill-treatment.

Health professionals, whether working in places of detention, called to visit a police station or other place of detention, or working in national health services, may well be presented with detainees to examine in the presence of security forces. The … Continue reading →

Health professionals should also be wary of any attempts (from officials) to ask them to administer treatment or medication that are not aimed at benefiting the physical or mental health of the patient, but only at assisting an interrogation or the management of a patient or detainee.

The individual need not be in prison, or in detention at all, to be tortured. Health professionals must be aware that they might be considered responsible for ill-treatment in settings where patients do not have freedom of movement, for example, those detained under mental health legislation or in facilities for the elderly. Inappropriate use of medical treatment, such as overuse of sedatives, may also be ill-treatment.

For information on the role of medical personnel in torture by the United States in its “War on Terror,” see: http://www.uctv.tv/search-details.asp?showID=15575 [1], a presentation by: Vincent Iacopino MD, PhD, Physicians for Human Rights, in the Global Health and Human Rights series, offered by the UCSF Mini Medical School for the Public, October 23, 2008.

Health professionals should also be wary of any attempts (from officials) to ask them to administer treatment or medication that are not aimed at benefiting the physical or mental health of the patient, but only at assisting an interrogation or … Continue reading →

It is a principle of ethical practise that patients must understand what is happening to them and consent to it. This is extremely important in working with torture survivors who have been in the situation of having no control over any aspect of their lives. It is essential that they do not feel powerless in the subsequent clinical setting. This is particularly true of medico-legal work in which the documentation will be in the public domain. As stated above, for consent to be valid, the patient must understand how the data gained from the examination will be used, how it will be stored and who will have access to it.

While all statements emphasise the obligation to act in the best interests of the individual being examined or treated, this presupposes that health professionals know what the patient’s interests are. A fundamental idea in modern medical ethics is that patients are the best judges of their own interests. This requires that health professionals should normally give precedence to the competent adult patient’s wishes. Where the patient is unconscious or otherwise incapable of giving valid consent, health professionals must make a judgement about how that person’s best interests can be protected and promoted. Nurses and doctors are expected to act as advocates of their patients’ well-being and this is made clear in professional statements.

Conflicts arise where health professionals are pressured or required by law to disclose information to third parties about patients without consent. This may include an obligation to report torture or serious crimes (possibly including torture itself). A health professional may receive an allegation of torture on the patients’ understanding that they are only seeking treatment and that the information will not be disclosed to others for fear of reprisals or other reasons. The health professional must contemplate the risks to the patient, and indeed to themselves, in disclosing such information, and the potential benefits to society as a whole (e.g. potentially avoiding further harm to others), before acting. Whatever decision is reached, the health professional should endeavour to gain consent. In such cases, the fundamental ethical obligations to respect autonomy and to act in the best interests of the patient are more important than other considerations. Health professionals should make clear to any authority requesting information that they are bound by professional duties of confidentiality. Health professionals responding in this way are entitled to the support of their professional association and colleagues.

The Geneva Conventions give particular protection to doctor-patient confidentiality in periods of international armed conflict, for example, requiring that doctors should not be compelled to disclose information about their patients to the opposing side.

It is a principle of ethical practise that patients must understand what is happening to them and consent to it. This is extremely important in working with torture survivors who have been in the situation of having no control over … Continue reading →

The security of the individual who may complain of or show signs of ill-treatment is closely related to the issues of consent and confidentiality described above. In examining or treating these individuals, the health professional must keep in mind the security of both the patient and him or herself. Often, the patient may have the impression that the health professional can provide an element of physical protection, and even prevent further arrest or ill-treatment. This sense of protection may be even more commonplace when health professionals visit the individual while they are still detained (particularly if it is a visit by an international team) since it is assumed that the fact of having access to the place of detention invests them with greater powers.

The security of the individual extends to how any information collected is used or to whom it is divulged. Clearly the release of any information is governed by the issues of consent and of confidentiality since identifiable information may itself lead to recriminations for the individual, or their family, or indeed the health personnel. Health professionals thus have a duty to ensure that individuals are aware of the limits of their ability to protect them, and must ensure that no information is released or passed on that may put interviewees at risk. All documentation must be stored safely.

The security of the individual who may complain of or show signs of ill-treatment is closely related to the issues of consent and confidentiality described above. In examining or treating these individuals, the health professional must keep in mind the … Continue reading →

Health professionals may at times have concerns that other health professionals might be participating directly or indirectly in the torture or other ill-treatment of individuals. The appropriate course of action in such cases can depend on the particular circumstances, for instance, whether the concerned health professional is working within the same institution as those he or she suspects; whether he or she is a local practitioner or part of an international visiting team; and the assessment of level of risk that may be involved in various courses of action. In some cases, a private discussion with trusted colleagues may be enough to clarify and bring about positive change. In other cases, there may be a need to turn (sometimes discreetly) to outside bodies, national or international (such as medical associations or human rights bodies), in order to seek advice.

Health professionals may at times have concerns that other health professionals might be participating directly or indirectly in the torture or other ill-treatment of individuals. The appropriate course of action in such cases can depend on the particular circumstances, for … Continue reading →

Health professionals who encounter any of the above situations, and have concerns on how to act, can seek information and support from a variety of bodies, national and even international, who may be able to provide more specific guidance. If there are ethics bodies within the police, military or prison medical services, then this could be one avenue for support. Such bodies, however, may be unable to work impartially, or the health professional may feel that turning to these bodies could present a risk of personal security to him or herself or the patient. Other bodies the health professional could perhaps turn to include national medical associations, national human rights bodies, or, if these are not available, relevant international bodies, in particular the World Medical Association (WMA).

Health professionals who encounter any of the above situations, and have concerns on how to act, can seek information and support from a variety of bodies, national and even international, who may be able to provide more specific guidance. If … Continue reading →

Country-specific national legislation and regulations relevant to medical documentation vary considerably and are beyond the scope of this Curriculum. Instructors who use the Model Curriculum should consider adding country-specific information:

• Rights, obligations and restrictions of the physician according to national legislation concerning the preparation of forensic report
  • criminal procedures
  • administrative procedures
  • disciplinary procedures
• Possible consequences of false reports for the patient and for the physician
• Best practise of medical reporting and its impact in practise
• Legal status of alternative (non-governmental) reports
• The problem of dual obligation
• Ethical and legal responsibilities of the physician according to the above mentioned international codes
• The similarities and differences between the international (ethical and legal) and national codes
• Qualification of health professionals to conduct psychological and physical evaluations
• The differences between national legislation and practise
• Regulations that apply specifically to gender-based violence against women

Country-specific national legislation and regulations relevant to medical documentation vary considerably and are beyond the scope of this Curriculum. Instructors who use the Model Curriculum should consider adding country-specific information: Rights, obligations and restrictions of the physician according to national … Continue reading →