Torture and doctors’ dual obligationBMJ 2015; 350 doi: https://doi.org/10.1136/bmj.h589 (Published 03 February 2015) Cite this as: BMJ 2015;350:h589
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Medical participation in torture is the very antithesis of good medical practice. Yet, despite the role of medical practice - to prevent, palliatate or cure illness or disability - being manifestly explicit, the BMJ editorial 'Torture and doctors’ dual obligation' focuses on how some doctors are at risk of inadvertantly colluding with, or participating in, torture.
In 1994 I reported doctors’ participation and leadership in Rwanda's most brutal of genocides (2) . When Colin Murray Parkes and I described the psychological, social and emotional influences that rendered perpetrators susceptible to the genocidal ideology, medical ethics were an irrelevance(3). Torture, rape and murder are considered such heinous crimes they can amount to crimes against humanity worthy of prosecution by the International Criminal Court. Genocide and torture are considered so egregious they are policed by individual UN Conventions which, uniquely, incorporate universal justisdiction obliging every country to prosecute any alleged perpetrator crossing their border.
The authors' laudable intentions would be better served by insisting that all alleged perpetrators are prosecuted so the victims can gain redress, and by requiring all doctors be subject to mandatory education in human rights so as to gain an appropriate perspective upon the intrinsic worth and value of each patient.
Torture and doctors’ dual obligation. Sheather J, Beynon R, Davies T et al. BMJ 2015;350:h589
Rwanda 1994: a report of the genocide. p 33-7 Doctors for Human Rights. 1994. http://phall.members.gn.apc.org/RwandaReport.pdf
3. Responses to Terrorism: Can psychosocial approaches break the cycle of violence? Parkes C. p 118-132. Routledge, London 2014
Competing interests: No competing interests
In recent years, colleagues and I have examined several hundred asylum seekers who gave histories of torture, and had congruent scars and/or psychological damage, but who were subjected to discretionary administrative detention in Immigration Removal Centres (IRCs). Many were seriously, avoidably, and unlawfully harmed. Our experience accords with numerous reports by the Prisons Inspectorate (1). Many of us would agree with Sheather et al (2): “New approaches are therefore required to support health professionals confronted with violation of detainees.”
Recent practice has caused such severe re-traumatisation of numerous vulnerable individuals that they have required hospitalisation for psychosis. In seven others, courts have held that detention constituted inhuman and degrading treatment (3). The Home Office probably spends some £10M annually compensating unlawful immigration detention (4) and attendant legal costs.
These recurrent failures have complex causes.
- Doctors employed in detention centres have little time or training to document those vulnerable individuals who should not be detained according to Home Office policy and the law through the “Rule 35” process (5). Many of these doctors feel caught between their duties to their patients and those to their ultimate employers, the Home Office, eg conflicting loyalties. Yet they issued some 1500 or more Rule 35 reports last year.
- Home Office caseworkers who take decisions to detain, usually formulaically reject these reports as “not independent evidence” of torture.
- These factors intersect. When a report is rejected by a caseworker, the latter must send a “reasons for refusal” letter to the detainee and the doctor. According to detention service orders (4), the doctor should read and where appropriate respond to the refusal letter, setting out their reasoning. This rarely happens.
All doctors have another duty: to work within their competence or to refer a colleague to address patients’ clinical needs. This fundamental injunction is one of the GMC’s Duties of a Doctor (6). It is being universally ignored. Accordingly, in addition to the damage to patients, the doctors themselves are at risk.
As colleagues, we owe them practical assistance and support in complying with their undoubtedly difficulties. Medact (via our Preventing Torture working group) is establishing a forum for doctors working in IRCs to contact and interact with colleagues who have expertise in the documentation of clinical stigmata of torture. We hope the BMA, GMC, NHS England and professional indemnity bodies will support this initiative.
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1) HMIP Inspection Reports for IRCs https://detentionforum.wordpress.com/resources-and-links/resources-and-i...
2) Sheather J et al. Torture and doctors' dual obligations. BMJ 2015;350:h589
3) Grant-Peterkin H et al. Inadequate mental healthcare in immigration removal centresBMJ 2014;349:g6627
4) Detention Service Order 17/2012. Application of Detention Centre Rule 35. https://www.gov.uk/government/uploads/system/uploads/attachment_data/fil...
5) Good Medical Practice, para 15c. General Medical Council. 2013. http://www.gmc-uk.org/guidance/good_medical_practice/apply_knowledge.asp
Competing interests: Frank Arnold has examined more than 200 survivors of torture during or after their detention in the UK. He is sometimes paid for doing so and producing expert evidence to the courts.