Istanbul Protocol Model Medical Curriculum

As the Istanbul Protocol makes clear, the absence of physical and/or psychological evidence in a medical evaluation does not rule-out the possibility that torture or ill-treatment was inflicted.

The Istanbul Protocol was developed to prevent torture and ill-treatment and to promote accountability. Governments must ensure that its official representatives do not engage in misuse or misrepresentation of the Istanbul Protocol to exonerate police who are accused of abuses or for any other purpose, as has been noted in a recent report by Physicians for Human Rights (PHR):^[1]

Recent statements by Mexican authorities to the press^[2] relating to the highly publicized case of Víctor Javier García Uribe, alias ‘El Cerillo’, demonstrate a fundamental misunderstanding of the purpose, nature and limitations of the Istanbul Protocol (Manual on the Effective Investigation and Documentation of Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment). The Istanbul Protocol is not a diagnostic test or tool that can be used to assure, with certainty, the presence or absence of torture, nor is it a U.N. treaty or instrument that can be ratified by member States as has been suggested by Governor José Reyes Baeza.^[3]

The Istanbul Protocol is a set of guidelines for the effective investigation and documentation of torture and ill-treatment. When used appropriately, these international standards help forensic experts to assess the degree to which medical findings correlate with the individual allegation of abuse and to effectively communicate the findings and interpretations to the judiciary or other appropriate authorities. As the Istanbul Protocol makes clear, the absence of physical and/or psychological evidence in a medical evaluation does not rule-out the possibility that torture or ill-treatment was inflicted.

Such misrepresentation of the Istanbul Protocol may explain why, in the PHR study, the majority of the forensic physicians working for the Federal Attorney General’s Office wrongly equated the lack of forensic findings with “proof” that the alleged torture and ill-treatment did not occur.

^[1]Forensic Documentation of Torture and Ill-treatment: An Assessment of the Implementation Process of the Istanbul Protocol Standards. Moreno A, Iacopino V. Physicians for Human Rights. December, 2008. pp. 94 and 114.

^[2] Rubén Villalpando, Rechaza PGJE de Chihuahua Tortura a Supuesto Asesino, JORNADA, Aug. 12, 2005 (“La Procuraduría General de Justicia del Estado (PGJE) confirmó que Víctor García Uribe, El Cerillo, no fuesometido a tortura en noviembre de 2001 para que se confesara culpable de asesinar a 11 mujeres, de acuerdo los criterios periciales del Protocolo de Estambul.”)[The Office of the State Attorney General confirmed that according to the expert opinion based on the Istambul Protocol, Víctor García Uribel, alias the Match, was not subjected to torture with the purpose of forcing a confesion of the 11 women murdered in November 2001]; Protocolo de Estambul no halla evidencias de tortura vs Cerillo, DIARIO , Aug. 12, 2005.

^[3] “Al afirmar que la aplicación del Protocolo de Estambul no está en entredicho, el gobernador José Reyes Baeza, indicó que ‘siempre las detenciones de cualquier presunto responsable estarán sujetas al respeto irrestricto de los derechos humanos, y con ello evitar el señalamiento, la inquietud y la molestia por parte de la comunidad, en torno a este tipo de detenciones’.” [“Confirming that there was no question about whether an evaluation according to the Istambul Protocol had been performed, the Governor José Reyes Baeza, said that ‘detentions are always subject to the utmost respect for the human rights of the person, thus avoiding questioning, uncertainty and anger within the community around such type of detentions’.”], available at www.nortedeciudadjuarez.com [1], (last visited August 17, 2005).

As the Istanbul Protocol makes clear, the absence of physical and/or psychological evidence in a medical evaluation does not rule-out the possibility that torture or ill-treatment was inflicted. The Istanbul Protocol was developed to prevent torture and ill-treatment and to … Continue reading →

Ensuring procedural safeguards for detainees is essential in conducting effective medical investigation and documentation of torture and ill-treatment. Failure to ensure such safeguards may, in fact, result in the possibility of administrative and/or criminal santions againse the medical expert responsible for forensic documentation of torture and ill-treatment. The Istanbul Protocol provides a series of guidelines to ensure procedural safeguards for medical evaluations of detainees alledging torture and ill-treatment as follows:

Forensic medical evaluations of detainees by all clinicians should be conducted in response to official written requests by public prosecutors or other appropriate officials. Requests for medical evaluations by law enforcement officials are to be considered invalid unless they are requested by written orders of a public prosecutor. Detainees themselves, their lawyer or relatives, however, have the right to request a medical evaluation to seek evidence of torture and ill-treatment. The detainee should be taken to the forensic medical examination by officials other than soldiers and police since torture and ill-treatment may have occurred in the custody of these officials and, therefore, that would place unacceptable coercive pressures on the detainee or the physician not to effectively document torture or ill-treatment. The officials who supervise the transportation of the detainee should be responsible to the public prosecutors and not to other law enforcement officials. The detainee’s lawyer should be present during the request for examination and post-examination transport of the detainee. Detainees have the right to obtain a second or alternative medical evaluation by a qualified physician during and after the period of detention.

Each detainee must be examined in private. Police or other law enforcement officials should never be present in the examination room. This procedural safeguard may be precluded only when, in the opinion of the examining doctor, there is compelling evidence that the detainee poses a serious safety risk to health personnel. Under such circumstances, security personnel of the health facility, not the police or other law enforcement officials, should be available upon the medical examiner’s request. In such cases, security personnel should still remain out of earshot (i.e. be only within visual contact) of the patient. Medical evaluation of detainees should be conducted at a location that the physician deems most suitable. In some cases, it may be best to insist on evaluation at official medical facilities and not at the prisoner jail. In other cases, prisoners may prefer to be examined in the relative safety of their cell, if they feel the medical premises may be under surveillance, for example. The best place will be dictated by many factors, but in all cases, investigators should ensure that prisoners are not forced into accepting a place they are not comfortable with.

The presence of police officers, soldiers, prison officers or other law enforcement officials in the examination room, for whatever reason, should be noted in the physician’s official medical report. The presence of police officers, soldiers, prison officials or other law enforcement officials during the examination may be grounds for disregarding a “negative” medical report. The identity and titles of others who are present in the examination room during the medical evaluations should be indicated in the report. Medico-legal evaluations of detainees should include the use of a standardized medical report form.

The original, completed evaluation should be transmitted directly to the person requesting the report, generally the public prosecutor. When a detainee or a lawyer acting on his or her behalf requests a medical report, they must be provided with the report. Copies of all medical reports should be retained by the examining physician. A national medical association or a commission of inquiry may choose to audit medical reports to ensure that adequate procedural safeguards and documentation standards are adhered to, particularly by doctors employed by the State. Reports should be sent to such an organisation, provided the issues of independence and confidentiality have been addressed. Under no circumstances should a copy of the medical report be transferred to law enforcement officials. It is mandatory that a detainee undergo a medical examination at the time of detention and an examination and evaluation upon release.^[1] Access to a lawyer should be provided at the time of the medical examination. An outside presence during examination may be impossible in most prison situations. In such cases, it should be stipulated that prison doctors working with prisoners respect medical ethics, and they must be capable of carrying out their professional duties independently of any third party influence. If the forensic medical examination supports allegations of torture, the detainee should not be returned to the place of detention, but rather should appear before the prosecutor or judge to determine the detainee’s legal disposition.^[2]

^[1] See the United Nations Standard Minimum Rules for the Treatment of Prisoners (chap. I, sect. B).

^[2] “Health care for prisoners: implications of Kalk’s refusal”, TheLancet, vol. 337 (1991), pp. 647-648.

Ensuring procedural safeguards for detainees is essential in conducting effective medical investigation and documentation of torture and ill-treatment. Failure to ensure such safeguards may, in fact, result in the possibility of administrative and/or criminal santions againse the medical expert responsible … Continue reading →

The rules of medical ethics and medical professional codes do not allow for discrimination in the provision of health care to prisoners and detainees. Individuals under arrest or any form of detention must have access to a standard of health care and services, and compassionate care, which are equivalent to that of the surrounding general population. This applies to health professionals who work directly in prisons or other detention centres, and equally to health professionals working in the national health services to whom prisoners may be referred. One consequence of neglect of detainee is that they learn to mistrust doctors, leading to them to avoid seeking medical help after imprisonment.^[1] There may be other reasons for prisoners not to trust the prison doctor. Doctors working in prisons are often underpaid, ill-considered by their superiors, and receive no training on prison health issues. As a result they are not very motivated in performing their jobs, which leads the prisoners to mistrust their services. Prison doctors in situations where torture is a reality will also be, rightly or wrongly, seen as accomplices of “the system” and also be mistrusted.

Hunger strikes are a particularly difficult situation for doctors to deal with. Most fasting prisoners do so for two or three weeks, and those on strikes rarely suffer any harm. As they go on longer, the risks to the hunger striker increase. In an ideal situation, an independent doctor will have explained the risks of prolonged hunger strike, and taken instructions on what the person wants to happen if he or she ceases to be capable of rational thought. This should happen in an environment where the patient’s confidentiality can be respected, and where he or she can be protected from undue pressure from political colleagues. In cases where prison doctors have been following hunger strikers before and during the fast, and know what the patients’ positions and convictions are, physicians should respect the principles stated in the Declaration of Malta on hunger strikes. This declaration allows physicians to act in the best perceived interests of their patients, while respecting autonomy. If a physician is called upon to take care of a hunger striker already in a comatose state, he or she will have no choice and will have to provide reanimation. A physician should not rely on what amounts to “hearsay” in such cases. The opinions of the immediate family should be taken into consideration, but are not paramount. Neither the opinions of the authorities nor those of the patient’s political colleagues should be given any weight.

^[1] Smidt-Nielsen K. The participation of health personnel in torture. Torture, 1998; 8(3):91-94.

The rules of medical ethics and medical professional codes do not allow for discrimination in the provision of health care to prisoners and detainees. Individuals under arrest or any form of detention must have access to a standard of health … Continue reading →