Torture and doctors’ dual obligation
BMJ 2015; 350 doi: https://doi.org/10.1136/bmj.h589 (Published 03 February 2015) Cite this as: BMJ 2015;350:h589
- Julian Sheather, deputy head of ethics1,
- Rhian Beynon, communications manager2,
- Tom Davies, Stop Torture campaign manager 3,
- Kamran Abbasi, international editor4
- 1British Medical Association, London, UK
- 2Freedom from Torture, London, UK
- 3Amnesty International UK, London, UK
- 4The BMJ, London WC1H 9JR, UK
- Correspondence to: K Abbasi kabbasi{at}bmj.com
People held in detention are vulnerable. Complex physical and psychological health needs are compounded by loss of freedom that constrains detainees’ ability to assert their interests. The purpose of custodial institutions and environments is not therapeutic. Health professionals who look after detainees find themselves torn by divided loyalties: their primary obligation to patient wellbeing conflicts with their obligations to institutions and employers.1
Involvement of health professionals in torture is indisputable. A recent report by the US Senate Intelligence Select Committee confirmed that the line between medical care and interrogation was breached by the Central Intelligence Agency (CIA) during the “war on terror.”2 Health professionals supervised waterboarding sessions and cleared detainees for enhanced interrogation. Medical staff were involved in rectal feeding and hydration, which the CIA considered useful in overcoming detainees’ refusal of food and fluids despite no evidence of its benefit. Meanwhile in Saudi Arabia, a panel of medical experts has assessed whether blogger Raif Badawi is fit enough to be flogged.3
Figures from Amnesty International’s Stop Torture campaign show that torture was reported in 141 countries over the past five years.4 Torture has a central role in policing and public security operations across the globe. Perpetrators act with impunity, and medical professionals see many victims of torture in relation to their detention. This is despite international prohibitions regarding any non-therapeutic participation, or any use of medical skills and knowledge, by medical professionals in torture or interrogation.5
Documentation is important
Properly resourced and supported, independent health professionals can have an important role in preventing torture and holding those who torture to account. They can identify and support victims of torture, provide vital forensic evidence, and assist in reporting torture and other forms of abuse to the relevant authorities. Unfortunately, health professionals in these settings struggle to maintain their clinical and ethical independence when faced with coercive institutions.
Assessment and documentation of torture requires specialist forensic expertise; without this the claims of torture victims cannot be corroborated and appropriate care may not be delivered. But resource constraints or a lack of political will mean that such expertise is seldom available. Although documentation of torture can be traumatic for a survivor, a comprehensive medicolegal report on the physical and psychological effects of torture can provide important evidence towards a claim for political asylum. An inadequate medicolegal report makes an asylum claim hard to substantiate and may place victims at risk of further torture if they are sent home.
Up to 8000 torture victims pass through the UK immigration detention system each year.6 Detainees in immigration removal centres receive health checks because UK policy dictates that if there is independent evidence of torture people should be detained in these centres only in “very exceptional circumstances.” This safeguard is ineffective: a government audit reported that only 9% of medical reports of torture resulted in the detainee being released.7
Ensuring better support
Health professionals face a critical challenge. Moral disorientation generated by the competing demands of dual obligations contributes to the abuse of detainees. Hence, health professionals must be able to exercise independent clinical judgment. Dual obligations are hard to escape, but if they are properly understood and disclosed their effects can be diminished.
New approaches are therefore required to support health professionals confronted with violation of detainees. An international professional network can help overcome isolation, emotional fatigue, and institutional neglect. Training to identify and document torture, in line with international standards, should be compulsory for all health professionals who work with detainees who are at risk of, or who have survived, torture.8 Medical schools and universities also have an important role in establishing clear ethical standards, compliant with international law, that adequately prepare health professionals.9 Unless difficult systemic changes are made, states will continue to use torture with impunity.
Torture remains widely used despite evidence of its inability to gather reliable information. It is a complex, politically driven phenomenon that is used to terrify, punish, and intimidate. Health professionals cannot expect to eradicate torture themselves but can be independent witnesses, documenters, reporters, and healers to prevent violations of the fundamental human right to health of vulnerable people.
Notes
Cite this as: BMJ 2015;350:h589
Footnotes
This article arose from a meeting on doctors and torture held at the BMA on 20 January 2015. Kate Allen, John Chisholm, and Juliet Cohen reviewed earlier drafts.
Competing interests: We have read and understood BMJ policy on declaration of interests and declare Freedom from Torture provides rehabilitation and forensic documentation services for people who have been tortured.
More information on Amnesty International’s Stop Torture campaign is available at www.amnesty.org.uk/stoptorture. Information on Freedom from Torture can be found at www.freedomfromtorture.org. Details of the BMA’s human rights work can be found here: http://bma.org.uk/humanrights.
Provenance and peer review: Commissioned; not externally peer reviewed.