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The Role of Doctors in Investigation, Prevention and Treatment of Torture

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The Role of Doctors in Investigation, Prevention and Treatment of Torture REVIEW The role of doctors in investigation, prevention and treatment of torture Helen McColl1 • Kamaldeep Bhui2 • Edgar Jones3 1Liaison Psychiatry, Sussex Partnership Foundation Trust, Hove BN3 1AS, UK 2Wolfson Institute for Preventive Medicine, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London EC1 M6BQ, UK 3King’s Centre for Military Research, Kings College, London SE5 9RJ, UK Correspondence to: Kamaldeep Bhui Email: [email protected] DECLARATION Summary Doctors may assess and treat torture survivors; some may document Competing interests crucial evidence of torture in medico-legal reports. However, there is a Helen McColl is a lack of education on torture and related ethical and legal issues at Medical Advisor for undergraduate and postgraduate level and many doctors are not aware of Medical Justice opportunities to work with organisations for the prevention of torture. This Funding paper defines Torture, describes methods used, and sets out the human None rights instruments and codes of ethical practice that mandate efforts to prevent torture. Medical complicity in torture is discussed and the need for Ethical approval national and international medical associations to prevent torture by both Not applicable supporting doctors and recognising and tackling medial complicity. The Guarantor paper offers guidance for assessing and documenting torture, and for Helen McColl providing health care for survivors of torture. Contributorship All authors helped construct, edit and Introduction of torture in medicolegal reports (MLR). refine the paper However, there is a lack of education on torture whilst HM led on Torture continues to be a subject of media head- and related ethical and legal issues at undergradu- writing the first and lines; this year was the 10th anniversary of the ate and postgraduate level and many doctors are final draft. All first prisoners arriving at Guantanamo, and not aware of opportunities to work with organiz- 4 authors contributed torture in countries such as Libya continues ations for the prevention of torture. This paper clinical and to be widely condemned. Amnesty International defines torture, describes methods used, and sets research expertise; reported that at least 81 world governments out the human rights instruments and codes of 1 educational skills; practiced torture in 2008. The International Reha- ethical practice that mandate efforts to prevent bilitation Council for Torture Victims (IRCT) indi- torture. Medical complicity in torture is discussed, and made use of cated that torture is practiced in more than half of as is the need for national and international expertise in work all countries in the world.2 However, many cases medical associations to prevent torture by both with refugees and of torture do not hit the headlines, for example, supporting doctors and recognizing and tackling ethnic minorities torture stories from asylum seekers in the UK medial complicity. The paper offers guidance for (HM, KB), often go unheard. Even the UK Border Agency’s assessing and documenting torture, and for pro- international conflict detention of victims of torture and trafficking viding healthcare for survivors of torture. It does (EJ, KB), war studies was criticized earlier this year in the Vine report.3 not address controversies around the status of (EJ) and inequalities In the UK, doctors may assess and treat torture post-traumatic stress disorder (PTSD) as a legiti- survivors; some may document crucial evidence mate diagnosis and what evidence supports 464 J R Soc Med 2012: 105: 464–471. DOI 10.1258/jrsm.2012.120100 The role of doctors in investigation, prevention and treatment of torture and human rights specific treatment for torture survivors, as these (HM, KB). issues have been the subject of previous reviews.5,6 Box 1 Definitions of torture Acknowledgements None Methods ‘Any act by which severe pain or suffering, whether physical or mental, is intentionally inflicted on a person for such purposes as obtaining from him or a third person The purpose of this clinical review is to inform information or a confession, punishing him for an act he or a doctors of the international guidelines and legis- third person has committed or is suspected of having lation on how to deal with torture victims and committed, or intimidating or coercing him or a third person, or for any reason based on discrimination of any issues related to torture more generally. The kind, when such pain or suffering is inflicted by or at the article is therefore based on the best known inter- instigation of or with the consent or acquiescence of a public national guidelines that were used by HM whilst official or other person acting in an official capacity’ (UNCAT). working with victims of torture, taking account the experiences of KB and EJ on wider issues ‘The deliberate, systematic or wanton infliction of physical or mental suffering by one or more persons acting alone or of torture, culture and war studies. We ident- on the orders of any authority, to force another person to ified by Google the website of the key organis- yield information, to make a confession or for any other ations that aim to prevent and protect against reason’ (WMA). torture: United Nations, International Committee UNCAT- United Nations Convention Against Torture and of the Red Cross, Amnesty International, World Other Cruel, Inhuman or Degrading Treatment or Medical Assocation, International Rehabilitation Punishment Council for Victims of Torture, Freedom from WMA - World Medical Association Torture, Physicians for Human Rights, Medical Justice, MEDACTand REDRESS. We also searched Pubmed and Google Scholar for guidelines related the past 40 years’ and said ‘several studies have to torture. We included information, reports and shown that coercive interrogation or torture also articles that provide direct guidance on what increases the risk of false confessions, since doctors should do to assess and to protect vulner- people will often say anything just to make it able populations. stop’.7,8 Definitions, methods and Torture is a global public health functions of torture issue It is important to establish a definition of torture so In many circumstances torture is used against that estimates about prevalence, preventive groups of persons or an entire population actions and the treatment of the consequences for destructive purposes. The consequences of of torture inform a coherent response (Box 1). torture can be long-term physical and mental inju- Torture can be used to destroy dignity, gain infor- ries, with profound effects social and physical mation, draw a confession, create fear and punish. functioning. Imprisonment and related ill-health Knowledge of common torture methods is useful can contribute to loss of education and occupation for doctors (Box 2), although methods are over the life-course. Some survivors of often region specific (see www.amnesty.org.uk torture become internally or externally displaced for reports). Torture is commonly justified on the persons, for example, asylum seekers. A recent basis of security and safety; to gain information meta-analysis showed torture and other poten- to prevent terrorist attacks and so prevent casual- tially traumatic events are endemic in countries ties. However, there is little evidence that torture affected by ongoing conflict and that torture is actually leads to the disclosure of accurate infor- associated with mental disorder. The results sup- mation that can be used to protect the safety ported the moderating effects of the environment; or security of populations, or prevent threats internally or externally displaced populations had against the state. An American governmental higher rates of PTSD than those permanently report concluded ‘there had been almost no resettled.9 In another meta-analysis of refugee empirical research into interrogation methods in mental health, it was also found that contextual J R Soc Med 2012: 105: 464–471. DOI 10.1258/jrsm.2012.120100 465 Journal of the Royal Society of Medicine Instruments include the Universal Declaration of Box 2 Human Rights, the Geneva Conventions and the Torture methods and sequelae United Nations Convention against Torture and Other Cruel, Inhuman or Degrading Treatment or Blunt trauma: beating, kicking, ‘falanga’ (beating of the soles of the feet repeatedly) dragging along the ground, Punishment (UNCAT). UNCAT defines the obli- whipping and nail removal gations of governments to prevent torture and to Positional torture: suspension, forced positions and prosecute those responsible for the crime, to twisting of limbs provide training and education for professionals, Electric shocks and burns: use of acids, electrical and to ensure generous redress and rehabilitation instruments and cigarettes for victims of torture. As of March 2012 the con- Asphyxiation: use of chemicals, water boarding vention had 150 parties.11 (immobilization, inhalation of water, forced suffocation The Optional Protocol to the Convention against leads the person to experience a situation similar to drowning) and hangings Torture and other Cruel, Inhuman or Degrading Treat- Penetrating and crush injuries: stab and gunshot wounds, ment or Punishment, or OPCAT, builds on the breaking digits UNCAT. OPCATobliges nations to set up indepen- Sexual: rape, humiliation and direct trauma to genitalia dent preventive mechanisms. These examine the treatment of people in detention and make Amputation of digit or limbs recommendations to government authorities
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