Editorials

Doctors and torture

Acting collectively doctors can support each other in protecting victims

Torture and other human rights abuses have been common throughout history. For many centuries, for example, judges in France could order torture of prisoners to obtain information. In the American civil war deserters were branded, and even today branding may be part of a sentence in Iraq. But these abuses have rarely reached public perception and understanding. Asylum seekers reaching the United Kingdom from Kurdish Iraq or Bosnia have faced hostile accusations of being "economic refugees," not deserving of emotional, social, and economic support. Kosovo may have changed that. Increasingly knowledge of abuses is recorded by us all as we watch our television screens. The stories told of torture and of executions were simple, coherent, and compellingand reinforced by pictures from recent discoveries: the torture chamber in a school basement and mass graves. This type of reporting has been a trend for some time and has added impact to undercover reportage of human rights abuses in Turkey and Israel. The rapid appearance of pictures on the internet further broadens news coverageand provides access to the world's media for repressed minorities. This public awareness is a new phenomenon; in time we will see whether it produces change. For now, those who monitor abuses believe that torture and violations of human rights are becoming more common and, in many countries, institutionalised.

Do doctors have a special role, an extraordinary responsibility? It is received wisdom among experts in human rights that doctors have an important role in looking for, detecting, documenting, and prosecuting the crime of torture. Doctors see escaped or discharged prisoners and often also see those who are still in detention. They are in a position to observe the signs of physical torture, and indeed of psychological abuse. Doctors who work in places where systematised abuse is common, such as prisons and interrogation centres, are likely to see and link patterns of injury. Doctors who examine cadavers will see the sequelae of physical abuse. Doctors are also essential to legitimising the effects of torture on survivors and their families and communities. Though our knowledge of how to treat survivors is improving, services are not uniformly excellent and research is difficult. Rehabilitation treatment cannot ethically be denied to torture survivors, but the search for an evidence based framework for diagnosis and treatment is under way.

A secondary factor is that doctors are among the most privileged and respected members of society. While not invulnerable to state oppression, they are often affected less than other citizens. Education, relative wealth, and societal position make it easier for doctors to speak out. And, as members of a cohesive profession, they have the opportunity to group together for mutual protection and support. The World Medical Association, set up in the aftermath of the Nuremberg trials to ensure that doctors never again abused patients in the way the Nazis did, codified its advice on torture in the Declaration of Tokyo of 1975. It urges doctors "even under threat" to use their skills only to heal and comfort.¹

If all of this is received wisdom in the human rights community why do so many doctors and medical associations stay silent in the face of torture? Is it partly because those interested in the issue choose to work through specialist human rights groups? Or is it a reflection of the dangers that activists often face? Ignorance is often a factor: doctors do not know about the standard minimum rules for the treatment of prisoners and assume that abuse is the norm in all jurisdictions.² At the same time many doctors share the prejudices of their communities: abuses against criminals are less likely to be reported than those against "political" prisoners.

When the BMA wrote its first report on torture in 1986,³ signalling a continuing commitment to human rights, we were welcomed with astonishment. Human rights groups had never thought that national medical associations would be active in their field. The BMA is not alone: the national medical associations of Denmark, India, and Turkey, among others, see their role as placing human rights on the agenda of every doctor.⁴ This interest is also shown by the multidisciplinary efforts to set standards in gathering evidence of torture, the so called Istanbul protocol.

Individual doctors who speak out do so at personal risk. They may damage their careers, as Dr Simon Danson did when reporting on abuses in Barlinnie prison in 1995.⁵ They run the risk of being the next victim. Too often, external observers ignore these dangers. The support of a medical association and the support it receives from other associations and from the World Medical Association demonstrate that the targeting of doctors will not go ignored. Concerted action obtained the release of doctors imprisoned for treating suspected terrorists in Peru and might be responsible for the leniency of sentences given to doctors in Turkey who refuse to hand over medical records from rehabilitation centres to the authorities.

Doctors who blow the whistle must know that there is someone who will ratify their action. They need to know that governments will recognise the responsibility of doctors to treat all patients regardless of political beliefs or activities. Doctors need somewhere to lodge medical and forensic reports safely. A special United Nations rapporteur on violations of medical neutrality would build confidence.

The language of human rights is obtuse, and experts quote international laws and declarations which intimidate the uninitiated; there are jealousies about the impact that newly involved doctors can haveespecially with the media. And few medical associations have the BMA's resources, including expertise in the relevant law. But by working together, not least in the World Medical Association, we have an opportunity to unite doctors and change forever the pictures we see on our television screens.

Vivienne Nathanson, head of professional resources and research group. 

BMA, London WC1H 9JP