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August 2009, Volume 59, Issue 8

Opinion and Debate

Torture and Doctors: An Ethical Dilemma?

Amin A. Muhammad Gadit  ( Discipline of Psychiatry, Memorial University of Newfoundland, St. John's, NL, Canada. )

'Torture' as a term has now assumed public health importance in the present era. With the current law and order situation in Pakistan and the high-handedness of law enforcing agencies, one comes across the number of horrendous examples of physical torture let alone mental and emotional torture. The United Nations1 has adopted a declaration against torture in 1975 through its General Assembly aiming at making its struggle more effective against torture and other cruel, inhuman or degrading treatment or punishment throughout the world. A number of countries in the world are signatories to it. Despite this campaign, media reports from all over the world are depicting painful accounts of torture and Pakistan is no exception to it. Irony of the fact is that the physicians are many a times witness or participants to the torture. The World Medical Association (WMA) has issued guidelines for the medical doctors in the form of its Declaration of Tokyo2 which is being reproduced for a quick reference for the medical doctors dealing with such a situation:   1. "The physician shall not countenance, condone or participate in the practice of torture or other forms of cruel, inhuman or degrading procedures, whatever the offense of which the victim of such procedures is suspected, accused or guilty, and whatever the victim's beliefs or motives, and in all situations, including armed conflict and civil strife. 2. The physician shall not provide any premises, instruments, substances or knowledge to facilitate the practice of torture or other forms of cruel, inhuman or degrading treatment or to diminish the ability of the victim to resist such treatment. 3. When providing medical assistance to detainees or prisoners who are, or who could later be, under interrogation, physicians should be particularly careful to ensure the confidentiality of all personal medical information. A breach of the Geneva Conventions shall in any case be reported by the physician to relevant authorities. The physician shall not use nor allow to be used, as far as he or she can, medical knowledge or skills, or health information specific to individuals, to facilitate or otherwise aid any interrogation, legal or illegal, of those individuals. 4. The physician shall not be present during any procedure during which torture or any other forms of cruel, inhuman or degrading treatment is used or threatened. 5. A physician must have complete clinical independence in deciding upon the care of a person for whom he or she is medically responsible. The physician's fundamental role is to alleviate the distress of his or her fellow human beings, and no motive, whether personal, collective or political, shall prevail against this higher purpose. 6. Where a prisoner refuses nourishment and is considered by the physician as capable of forming an unimpaired and rational judgment concerning the consequences of such a voluntary refusal of nourishment, he or she shall not be fed artificially. The decision as to the capacity of the prisoner to form such a judgment should be confirmed by at least one other independent physician. The consequences of the refusal of nourishment shall be explained by the physician to the prisoner. 7. The World Medical Association will support, and should encourage the international community, the National Medical Associations and fellow physicians to support, the physician and his or her family in the face of threats or reprisals resulting from a refusal to condone the use of torture or other forms of cruel, inhuman or degrading treatment"  With the aforementioned declaration in view, it has been reported that medical complicity with abuse and torture of prisoners is roughly prevalent in 100 countries. This has been reported by the survived victims and from other sources.3 The WMA has since updated the Declaration of Tokyo in 2006 further clarifying the role of medical practitioners in this respect. According to reports,4 a number of doctors have participated in torture to prisoners, concealed the facts in their medical reports and refrained from reporting such incidents. The worst examples are generally quoted from Abu Ghraib prison in Iraq and the Guantanamo Bay Detention Centre where physicians were quoted as accomplices to the inhuman practices of torture. Vesti P and Lavik NJ5  raised a number of issues in this regard, like the doctors who participated in torture in some ways were under the notion that such a situation was sanctioned by law. Obviously, medical ethics went behind the strong connotations of law. During Nazi era, medical ethics was practically non applicable. The famous case of Steve Biko brought forward the awareness about this aspect of medical professional. They argue about Islamic punishment and in this context, participation of doctors especially during the whipping procedure. Role and involvement of doctors in the witnessing and certification of capital punishments, detention in isolation and abuse of psychiatry are matters for concern. Interesting observations were made by Grodin M and Annas G6 about physicians' vulnerability in becoming perpetrators. This is possibly because of compartmentalization, tendencies towards sadism and voyeurism, healing through hurting, repressing awareness of violence, use of science to objectify violence, tendency to justify and rationalize, impersonal medical detachment and narcissistic sense of superiority. Reviewing the guidelines in the declaration, it appears that the doctors should refrain from any such practices.  Reverting back to the local scenario in Pakistan, there appears to be no data on this subject, there aren't any specific guidelines by the Pakistan Medical and Dental Council (PMDC) or by the Pakistan Medical Association (PMA). Anecdotal reports say that doctors do get involved in such practices under obligation of the law. In some instances 'duty to treat' had lead doctors in to a number of complications when the patient happened to be a criminal or terrorist. Issuance of clean certificates for 'custody deaths', witnessing and assuring tolerance capacity for people being flogged publicly, collusion in covering up non-accidental deaths and being a part of  capital punishment procedure are worth-mentioning. What should be done under trying circumstances? Should the doctor refuse the law enforcing agencies to participate in torture of any form? Should 'duty to treat' be fulfilled at any cost? Should there be a law to protect doctors?  Are the current ethics committees well-versed with this issue?  Let's work on this.

References

1.United Nations. Convention against torture and other cruel, inhuman or degrading treatment or punishment. (Online) 1997. Cited 2009 Apr 13. Available from URL: http://www.hrweb.org/legal/cat.html. 
2.World Medical Association (WMA). The World Medical Association Declaration of Tokyo. Guidelines for Physicians Concerning Torture and other Cruel, Inhuman or Degrading Treatment or Punishment in Relation to Detention and Imprisonment. Online 2003. (Cited 2009 Apr 8). Available from URL: http://www.wma.net/e/policy/c18.htm. 
3.Medical News Today. Medical Ethics and Torture: Revising the Declaration of Tokyo. Online 2009. (Cited 2009 Apr 8). Available from URL: http://www.medicalnewstoday.com/articles/136488.php. 
4.Lifton RJ. Doctors and Torture. N Engl J Med 2004; 351: 415-6. 
5.Vesti P, Lavik NJ. Torture and medical profession: a review. J Med Ethics 1991; 17: 4-8. 
6.Grodin M, Annas G. Physicians and Torture: lessons from Nazi doctors. International Review of the Red Cross 2007; 89: 635-54.
 

Journal of the Pakistan Medical Association has agreed to receive and publish manuscripts in accordance with the principles of the following committees: