Policy Tag: Degrading Treatment

Adopted by the 68th General Assembly, Chicago, United States, October 2017
and reaffirmed with minor revisions by the 221st WMA Council Session, Berlin, Germany, October 2022

 

PREAMBLE

The WMA Declaration of Tokyo strictly forbids physicians to countenance, condone or participate in the practice of torture or other forms of cruel, inhuman or degrading treatment and requires them to respect the confidentiality of medical information.

The United Nations Principles of Medical Ethics Relevant to the Role of Health Personnel, Particularly Physicians, in the Protection of Prisoners and Detainees Against Torture and Other Cruel, Inhuman, or Degrading Treatment or Punishment prohibits health personnel from “participation in, complicity in, incitement to or attempts to commit torture or other cruel, inhuman or degrading treatment or punishment”.

Since 2011, in at least eleven countries, physicians have participated in forced anal examinations of men and transgender women who are charged with consensual same-sex conduct.

The UN Special Rapporteur on Torture has described forced anal examinations as a form of torture or cruel, inhuman and degrading treatment that is “medically worthless” due to the lack of scientific validity of the tests.

Furthermore, in its Statement on Anal Examinations in Cases of Alleged Homosexuality, the Independent Forensic Expert Group, composed of forensic medicine specialists from around the world, has determined that “the examination has no value in detecting abnormalities in anal sphincter tone that can be reliably attributed to consensual anal intercourse”.

The WMA is deeply disturbed by the complicity of physicians in these non-voluntary and unscientific examinations, including the preparation of medical reports that are used in trials to convict men and transgender women of consensual same-sex conduct.

In accordance with its Statement on Body Searches of Prisoners, the WMA reminds that forced examinations are not ethically acceptable and physicians must not perform them.

The ability of persons in custody to provide free and informed consent is limited. Even when consent is given, physicians should refrain from undertaking procedures that are scientifically unfounded, discriminatory and potentially incriminating.

 

RECOMMENDATIONS

 Recognizing that persons who have undergone forced anal exams have described them as painful, humiliating, and amounting to sexual assault and recalling that physicians should never engage in acts of torture or other forms of cruel, inhuman or degrading treatment, the WMA:

  1. Calls on its Constituent Members, physicians and other health professionals, to stand firmly against participation in forced anal examinations because they are medically invalid;
  2. Urges its Constituent Members to issue written communications prohibiting their members from participating in such examinations;
  3. Urges its Constituent Members to educate physicians and other health professionals about the unscientific and futile nature of forced anal exams and the fact that they are a form of torture or cruel, inhuman and degrading treatment;
  4. Calls on the World Health Organization to make an official statement opposing forced anal examinations to prove same-sex sexual activity as unscientific and unethical in violation of medical ethics.

 

 

 

Adopted by the 64th General Assembly, Fortaleza, Brazil, October 2013 and
reaffirmed with minor revisions by the 224th WMA Council, Kigali, Rwanda, October 2023

 

PREAMBLE

The World Medical Association notes with grave concern the continued use of torture in many countries throughout the world.

The WMA reaffirms its total condemnation of all form of torture, and other cruel, inhuman or degrading treatment or punishment, as defined by the United Nations Convention Against Torture (CAT, 1984). Torture is one of the gravest violations of international human rights law and has devastating consequences for victims, their families and society as a whole. Torture causes severe physical and mental injuries and is a crime absolutely prohibited under international law.

The WMA reaffirms its policies adopted previously, namely:

The medical evaluation is an essential factor in pursuing the documentation of torture and the reparation of victims of torture. Physicians have a critical role to play in gathering information about torture, documenting evidence of torture for legal purposes, as well as supporting and rehabilitating victims.

The WMA recognizes the adoption, in December 2012, by the UN Committee Against Torture of the General Comment on the Implementation of article 14 of Convention against Torture relating to the right to reparation of victims of torture. The General Comment outlines the right of rehabilitation as an obligation on States and specifies the scope of these services. The WMA welcomes in particular:

  • The obligation of State parties to adopt a “long-term and integrated approach and ensure that specialized services for the victim of torture or ill treatment are available, appropriate and promptly accessible”, without making access to these services dependent on the victim pursuing judicial remedies [1].
  • The recognition of the right of victims to choose a rehabilitation service provider, be it a State institution, or a non-State service provider, which is funded by the State.
  • The recognition that State parties should provide torture victims with access to rehabilitation programs as soon as possible following an assessment by qualified independent healthcare professionals.
  • The references to measures aimed at protecting health and legal professionals who assist torture victims, developing specific training on the Istanbul Protocol for health professionals, and promoting the observance of international standards and codes of conduct by public servants, including medical, psychological and social service personnel [2].

The WMA notes that since the adoption of the General Comment on the Implementation of article 14, important developments have taken place in the practice of rehabilitation and in monitoring State compliance with their obligations:

 

RECOMMENDATIONS

  1. The WMA emphasizes the vital function of reparation for victims of torture and their families in rebuilding their lives and achieve redress and the important role of physicians in rehabilitation.
  2. The WMA encourages its member associations to work with relevant agencies – governmental and non-governmental – acting for the reparation of victims of torture, in particular in the areas of documentation and rehabilitation, as well as prevention, and to use the revised Istanbul Protocol and the global rehabilitations standards in doing so.
  3. The WMA encourages its members to support agencies that are under threat of – or subjected to – reprisals from state parties due to their involvement in the documentation of torture, rehabilitation and reparation of torture victims.
  4. The WMA calls on its members to use their medical experience to support torture victims in accordance with article 14 of the UN Convention against Torture, including by helping them to become active agents in their own rehabilitation process through survivor explicit programs.
  5. The WMA calls on its member associations to support and facilitate data collection at the national level, using established indicators for the right to rehabilitation, to monitor the implementation of the State’s obligation to provide rehabilitation services.

 

[1] Paragraph 13 of the General Comment
[2] Paragraph 18 of the General Comment
[3] Global Impact Data – IRCT

Adopted by the 182nd WMA Council Session, Tel Aviv, Israel, May 2009

WHEREAS:

Reports worldwide have alluded to deeply unsettling practices by health professionals, including direct participation in the infliction of ill-treatment, monitoring specific methods of ill-treatment, and participation in interrogation processes;

THEREFORE, the WMA

  1. Reaffirms its Declaration of Tokyo: Guidelines for Physicians Concerning Torture and other Cruel, Inhuman or Degrading Treatment or Punishment in Relation to Detention and Imprisonment, which prohibits physicians from participating in, or even being present during, the practice of torture or other forms of cruel, inhuman or degrading procedures, and urges National Medical Associations to inform physicians and governments of the Declaration and its contents.
  2. Reaffirms its Declaration of Hamburg: Support for Medical Doctors Refusing to Participate in or to Condone the use of Torture or other Forms of Cruel, Inhuman or Degrading Treatment.
  3. Reaffirms its Resolution: Responsibility of Physicians in the Denunciation of Acts of Torture or Cruel or Inhuman or Degrading Treatment of Which they are Aware.
  4. Urges national medical associations to speak out in support of this fundamental principle of medical ethics and to investigate any breach of these principles by association members of which they are aware.

Adopted by the 43rd World Medical Assembly, St. Julians, Malta, November 1991
and editorially revised by the 44th World Medical Assembly, Marbella, Spain, September 1992
and revised by the 57th WMA General Assembly, Pilanesberg, South Africa, October 2006
and revised by the 68th WMA General Assembly, Chicago, United States, October 2017

 

PREAMBLE

1.      Hunger strikes occur in various contexts but they mainly give rise to dilemmas in settings where people are detained (prisons, jails and immigration detention centres). They are usually a form of protest by people who lack other ways of making their demands known. In refusing nutrition for a significant period, prisoners and detainees may hope to obtain certain goals by inflicting negative publicity on the authorities. Short-term food refusals rarely raise ethical problems. Prolonged fasting risks death or permanent damage for hunger strikers and can create a conflict of values for physicians. Hunger strikers rarely wish to die but some may be prepared to do so to achieve their aims.

2.      Physicians need to ascertain the individual’s true intention, especially in collective strikes or situations where peer pressure may be a factor. An emotional challenge arises when hunger strikers who have apparently issued clear instructions not to be resuscitated reach a stage of cognitive impairment. The principle of beneficence urges physicians to resuscitate them but respect for individual autonomy restrains physicians from intervening when a valid and informed refusal has been made. This has been well worked through in many other clinical situations including refusal of life saving treatment. An added difficulty arises in custodial settings because it is not always clear whether the hunger striker’s advance instructions were made voluntarily and with appropriate information about the consequences.

PRINCIPLES

3.      Duty to act ethically. All physicians are bound by medical ethics in their professional contact with vulnerable people, even when not providing therapy. Whatever their role, physicians must try to prevent coercion or maltreatment of detainees and must protest if it occurs.

4.      Respect for autonomy. Physicians should respect individuals’ autonomy. This can involve difficult assessments as hunger strikers’ true wishes may not be as clear as they appear. Any decisions lack moral force if made by use of threats, peer pressure or coercion. Hunger strikers should not forcibly be given treatment they refuse. Applying, instructing or assisting forced feeding contrary to an informed and voluntary refusal is unjustifiable. Artificial feeding with the hunger striker’s explicit or necessarily implied consent is ethically acceptable.

5.      ‘Benefit’ and ‘harm’. Physicians must exercise their skills and knowledge to benefit those they treat. This is the concept of ‘beneficence’, which is complemented by that of ‘non-maleficence’ or primum non nocere. These two concepts need to be in balance. ‘Benefit’ includes respecting individuals’ wishes as well as promoting their welfare. Avoiding ‘harm’ means not only minimising damage to health but also not forcing treatment upon competent people nor coercing them to stop fasting. Beneficence does not necessarily involve prolonging life at all costs, irrespective of other determinants.

Physicians must respect the autonomy of competent individuals, even where this will predictably lead to harm. The loss of competence does not mean that a previous competent refusal of treatment, including artificial feeding should be ignored.

6.      Balancing dual loyalties. Physicians attending hunger strikers can experience a conflict between their loyalty to the employing authority (such as prison management) and their loyalty to patients. In this situation, physicians with dual loyalties are bound by the same ethical principles as other physicians, that is to say that their primary obligation is to the individual patient. They remain independent from their employer in regard to medical decisions.

7.      Clinical independence. Physicians must remain objective in their assessments and not allow third parties to influence their medical judgement. They must not allow themselves to be pressured to breach ethical principles, such as intervening medically for non medical reasons.

8.      Confidentiality. The duty of confidentiality is important in building trust but it is not absolute. It can be overridden if non-disclosure seriously and imminently harms others. As with other patients, hunger strikers’ confidentiality and privacy should be respected unless they agree to disclosure or unless information sharing is necessary to prevent serious harm. If individuals agree, their relatives and legal advisers should be kept informed of the situation.

9.      Establishing trust. Fostering trust between physicians and hunger strikers is often the key to achieving a resolution that both respects the rights of the hunger strikers and minimises harm to them. Gaining trust can create opportunities to resolve difficult situations. Trust is dependent upon physicians providing accurate advice and being frank with hunger strikers about the limitations of what they can and cannot do, including situations in which the physician may not be able to maintain confidentiality.

10.    Physicians must assess the mental capacity of individuals seeking to engage in a hunger strike. This involves verifying that an individual intending to fast is free of any mental conditions that would undermine the person’s ability to make informed health care decisions. Individuals with seriously impaired mental capacity may not be able to appreciate the consequences of their actions should they engage in a hunger strike. Those with treatable mental health problems should be directed towards appropriate care for their mental conditions and receive appropriate treatment. Those with untreatable conditions, including severe learning disability or advanced dementia should receive treatment and support to enable them to make such decisions as lie within their competence.

11.    As early as possible, physicians should acquire a detailed and accurate medical history of the person who is intending to fast. The medical implications of any existing conditions should be explained to the individual. Physicians should verify that hunger strikers understand the potential health consequences of fasting and forewarn them in plain language of the disadvantages. Physicians should also explain how damage to health can be minimised or delayed by, for example, increasing fluid and thiamine intake. Since the person’s decisions regarding a hunger strike can be momentous, ensuring full patient understanding of the medical consequences of fasting is critical. Consistent with best practices for informed consent in health care, the physician should ensure that the patient understands the information conveyed by asking the patient what he or she understands.

12.    A thorough examination of the hunger striker should be made at the start of the fast including measuring body weight. Management of future symptoms, including those unconnected to the fast, should be discussed with hunger strikers. Also, the person’s values and wishes regarding medical treatment in the event of a prolonged fast should be noted. If the hunger striker consents, medical examinations should be carried out regularly in order to determine necessary treatments. The physical environment should be evaluated in order to develop recommendations for preventing negative effects.

13.    Continuing communication between the physician and hunger strikers is essential. Physicians should ascertain on a daily basis whether individuals wish to continue a hunger strike and what they want to be done when they are no longer able to communicate meaningfully. The clinician should identify whether the individual is willing, in the absence of their demands being met, to continue the fast even until death. These findings must be appropriately recorded.

14.    Sometimes hunger strikers accept an intravenous solution transfusion or other forms of medical treatment. A refusal to accept certain interventions must not prejudice any other aspect of the medical care, such as treatment of infections or of pain.

15.    Physicians should talk to hunger strikers in privacy and out of earshot of all other people, including other detainees. Clear communication is essential and, where necessary, interpreters unconnected to the detaining authorities should be available and they too must respect confidentiality.

16.    Physicians need to satisfy themselves that food or treatment refusal is the individual’s voluntary choice. Hunger strikers should be protected from coercion. Physicians can often help to achieve this and should be aware that coercion may come from the authorities, the peer group, or others, such as family members. Physicians or other health care personnel may not apply undue pressure of any sort on the hunger striker to suspend the strike. Treatment or care of the hunger striker must not be conditional upon suspension of the hunger strike. Any restraint or pressure including but not limited to hand-cuffing, isolation, tying the hunger striker to a bed or any kind of physical restraint due to the hunger strike is not acceptable.

17.    If a physician is unable for reasons of conscience to abide by a hunger striker’s refusal of treatment or artificial feeding, the physician should make this clear at the outset, and must be sure to refer the hunger striker to another physician who is willing to abide by the hunger striker’s refusal.

18.    When a physician takes over the case, the hunger striker may have already lost mental capacity so that there is no opportunity to discuss the individual’s wishes regarding medical intervention to preserve life. Consideration and respect must be given to any advance instructions made by the hunger striker. Advance refusals of treatment must be followed if they reflect the voluntary wish of the individual when competent. In custodial settings, the possibility of advance instructions having been made under pressure needs to be considered. Where physicians have serious doubts about the individual’s intention, any instructions must be treated with great caution. If well informed and voluntarily made, however, advance instructions can only generally be overridden if they become invalid because the situation in which the decision was made has changed radically since the individual lost competence.

19.    If no discussion with the individual is possible and no advance instructions or any other evidence or note in the clinical records of a discussion exist, physicians have to act in what they judge to be in the person’s best interests. This means considering the hunger strikers’ previously expressed wishes, their personal and cultural values as well as their physical health. In the absence of any evidence of hunger strikers’ former wishes, physicians should decide whether or not to provide feeding, without interference from third parties.

20.    Physicians may rarely and exceptionally consider it justifiable to go against advance instructions refusing treatment because, for example, the refusal is thought to have been made under duress. If, after resuscitation and having regained their mental faculties, hunger strikers continue to reiterate their intention to fast, that decision should be respected. It is ethical to allow a determined hunger striker to die with dignity rather than submit that person to repeated interventions against his or her will. Physicians acting against an advanced refusal of treatment must be prepared to justify that action to relevant authorities including professional regulators.

21.    Artificial feeding, when used in the patient’s clinical interest, can be ethically appropriate if competent hunger strikers agree to it. However, in accordance with the WMA Declaration of Tokyo, 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 decision, he or she shall not be fed artificially. Artificial feeding can also be acceptable if incompetent individuals have left no unpressured advance instructions refusing it, in order to preserve the life of the hunger striker or to prevent severe irreversible disability.  Rectal hydration is not and must never be used as a form of therapy for rehydratation or nutritional support in fasting patients.

22.    When a patient is physically able to begin oral feeding, every caution must be taken to ensure implementation of the most up to date guidelines of refeeding.

23.    All kinds of interventions for enteral or parenteral feeding against the will of the mentally competent hunger striker are “to be considered as “forced feeding”. Forced feeding is never ethically acceptable. Even if intended to benefit, feeding accompanied by threats, coercion, force or use of physical restraints is a form of inhuman and degrading treatment. Equally unacceptable is the forced feeding of some detainees in order to intimidate or coerce other hunger strikers to stop fasting.

THE ROLE OF NATIONAL MEDICAL ASSOCIATIONS (NMAS) AND THE WMA

24.    NMAs should organize and provide educational programmes highlighting the ethical dimensions of hunger strikes, appropriate medical approaches, treatments, and interventions. They shall make efforts to update physicians’ professional knowledge and skills.

NMAs should work to provide mechanisms for supporting physicians working in prisons/jails/immigration detention centers, who may often find themselves in conflict situations and, as stated in the WMA Declaration of Hamburg, shall support any physicians experiencing pressure to compromise their ethical principles.

NMAs have a responsibility to make efforts to prevent unethical practices, to take a position and speak out against ethical violations, and to investigate them properly.

25.    The World Medical Association will support physicians and NMAs confronted with political pressures as a result of defending an ethically justifiable position, as stated in the WMA Declaration of Hamburg.

Portuguese translation

Adopted by the 54th WMA General Assembly, Helsinki, Finland, September 2003,
revised by the 58th WMA General Assembly, Copenhagen, Denmark, October 2007,
editorially revised by the 179th WMA Council Session, Divonne-les-Bains, France, May 2008
and by the 71st WMA General Assembly (online), Cordoba, Spain, October 2020

 

PREAMBLE

The dignity and value of every human being are acknowledged globally and expressed in numerous distinguished ethical codes and codifications of human rights, including the Universal Declaration of Human Rights. Any act of torture or cruel, inhuman or degrading treatment constitutes a violation of these codes and is irreconcilable with the ethical principles that lie at their core. These codes are listed at the end of this Statement (1).

However, in the medical professional codes and legal texts, there is no consistent and explicit reference to an obligation upon physicians to document cases and denounce acts of torture or cruel, inhuman or degrading treatment of which they become aware or witness.

The careful and consistent documentation and denunciation of torture or cruel, inhuman or degrading treatment by physicians contributes to the human rights of the victims and to the protection of their physical and mental integrity. The absence of documentation and denunciation of these acts may be considered as a form of tolerance thereof.

Because of the psychological sequelae from which they suffer, or the pressures brought upon them, victims are often unable or unwilling to formulate by themselves complaints against those responsible for the torture or cruel, inhuman and degrading treatment and punishments they have undergone.

By ascertaining the sequelae and treating the victims of torture, either early or late after the event, physicians witness the effects of these violations of human rights.

The WMA recognizes that in some circumstances, documenting and denouncing acts of torture may put the physician, and those close to him or her, at great risk. Consequently, doing so may have excessive personal consequences.

This statement relates to torture and other cruel, inhuman and degrading treatment and punishments as referred by the United Nations Convention against torture, excluding purposely the role of physicians in detention appraisal addressed in particular by the UN Standard Minimum Rules for the Treatment of Prisoners (Mandela rules).

 

RECOMMENDATIONS

The WMA recommends that its constituent members:

  1. Promote awareness among physicians of The Istanbul Protocol, including its Principles on the Effective Investigation and Documentation of Torture and Other Cruel, Inhuman or Degrading Treatment. This should be done at the national level.
  2. Promote training of physicians on the identification of different methods of torture and cruel, inhuman and degrading treatment and punishments, to enable them to provide high quality medical documentation that can be used as evidence in legal or administrative proceedings.
  3. Encourage professional training to ensure that physicians include assessment and documentation of signs and symptoms of torture or cruel, inhuman and degrading treatment and punishments in the medical records, including the correlation between the allegations given and the clinical findings.
  4. Work to ensure that physicians carefully balance potential conflicts between their ethical obligation to document and denounce acts of torture or cruel, inhuman and degrading treatment and punishments and a patient’s right to informed consent before documenting torture cases.
  5. Work to ensure that physicians avoid putting individuals in danger while assessing, documenting or reporting signs of torture and cruel, inhuman and degrading treatment and punishments.
  6. Promote access to immediate and independent health care for victims of torture or cruel, inhuman and degrading treatment and punishments.
  7. Support the adoption of ethical rules and legislative provisions:
  • Aimed at affirming the ethical obligation on physicians to report and denounce acts of torture or cruel, inhuman and degrading treatment and punishments of which they become aware; depending on the circumstances, the report or denunciation should be addressed to the competent national or international authorities for further investigation.
  • Addressing that a physician’s obligation to document and denounce instances of torture and cruel, inhuman and degrading treatment and punishments may conflict with their obligations to respect patient confidentiality and autonomy.
  • Physicians should use their discretion in this matter, bearing in mind paragraph 69 of the Istanbul Protocol (2).
  • cautioning physicians to avoid putting in danger victims who are deprived of freedom, subjected to constraint or threat or in a compromised psychological situation when disclosing information that can identify them.
  • Work to ensure protection of physicians, who risk reprisals or sanctions of any kind due to the compliance with these guidelines.
  • Provide physicians with all relevant information on procedures and requirements for reporting torture or cruel, inhuman and degrading treatment and punishments, particularly to national authorities, non-governmental organizations and the International Criminal Court.
  1. The WMA recommends that the constituent members’ codes of ethics include the physician’s obligations concerning documentation and denunciation of acts of torture and cruel, inhuman and degrading treatment and punishments as they are stated in this document.

 

(1) Codes and codifications:

  1. The Preamble to the United Nations Charter of 26 June 1945 solemnly proclaiming the faith of the people of the United Nations in the fundamental human rights, the dignity and value of the human person.
  2. The Preamble to the Universal Declaration of Human Rights of 10 December 1948 which states that disregard and contempt for human rights have resulted in barbarous acts which have outraged the conscience of mankind.
  3. Article 5 of the Universal Declaration of Human Rights which proclaims that no one shall be subjected to torture or cruel, inhuman or degrading treatment.
  4. The United Nations Standard Minimum Rules for the Treatment of Prisoners (the Nelson Mandela Rules), Adopted by the First United Nations Congress on the Prevention of Crime and the Treatment of Offenders, held at Geneva in 1955, and approved by the Economic and Social Council by its resolutions 663 C (XXIV) of 31 July 1957 and 2076 (LXII) of 13 May 1977, revised and adopted by the General Assembly on 17 December 2015.
  5. The American Convention on Human Rights, which was adopted by the Organization of American States on 22 November 1969 and entered into force on 18 July 1978, and the Inter-American Convention to Prevent and Punish Torture, which entered into force on 28 February 1987.
  6. The Declaration of Tokyo, Adopted by the 29th World Medical Assembly, Tokyo, Japan, October 1975 Editorially revised by the 170thWMA Council Session, Divonne-les-Bains, France, May 2005 and the 173rdWMA Council Session, Divonne-les-Bains, France, May 2006.
    Revised by the 67th WMA General Assembly, Taipei, Taiwan, October 2017.
  7. The Declaration of Hawaii, adopted by the World Psychiatric Association in 1977.
  8. The Principles of Medical Ethics Relevant to the Role of Health Personnel, Particularly Physicians, in the Protection of Prisoners and Detainees Against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment, adopted by the United Nations General Assembly on 18 December 1982, and particularly Principle 2, which states: “It is a gross contravention of medical ethics… for health personnel, particularly physicians, to engage, actively or passively, in acts which constitute participation in, complicity in, incitement to or attempts to commit torture or other cruel, inhuman or degrading treatment…”.
  9. The Convention Against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment, which was adopted by the United Nations General Assembly on December 1984 and entered into force on 26 June,1987.
  10. The European Convention for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment, which was adopted by the Council of Europe on 26 June 1987 and entered into force on 1 February 1989.
  11. The WMA Declaration of Hamburg, adopted by the World Medical Association in November 1997 during the 49th General Assembly, and reaffirmed with minor revision by the 207th WMA Council session, Chicago, United States, October 2017 calling on physicians to protest individually against ill-treatment and on national and international medical organizations to support physicians in such actions.
  12. The Istanbul Protocol (Manual on the Effective Investigation and Documentation of Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment), adopted by the United Nations General Assembly on 4 December 2000.
  13. The Convention on the Rights of the Child, which was adopted by the United Nations on 20 November 1989 and entered into force on 2 September 1990.
  14. The World Medical Association Declaration of Malta on Hunger Strikers, adopted by the 43rd World Medical Assembly Malta, November 1991and amended by the WMA General Assembly, Pilanesberg, South Africa, October 2006, and revised by the 68th WMA General Assembly, Chicago, United States, October 2017.

(2) Istanbul Protocol, paragraph 69: “In some cases, two ethical obligations are in conflict. International codes and ethical principles require the reporting of information concerning torture or maltreatment to a responsible body. In some jurisdictions, this is also a legal requirement. In some cases, however, patients may refuse to give consent to being examined for such purposes or to having the information gained from examination disclosed to others. They may be fearful of the risks of reprisals for themselves or their families. In such situations, health professionals have dual responsibilities: to the patient and to society at large, which has an interest in ensuring that justice is done and perpetrators of abuse are brought to justice. The fundamental principle of avoiding harm must feature prominently in consideration of such dilemmas. Health professionals should seek solutions that promote justice without breaking the individual’s right to confidentiality. Advice should be sought from reliable agencies; in some cases, this may be the national medical association or non-governmental agencies. Alternatively, with supportive encouragement, some reluctant patients may agree to disclosure within agreed parameters.”

Adopted by the 49th WMA General Assembly, Hamburg, Germany, November 1997,
reaffirmed by the 176th WMA Council Session, Berlin, Germany, May 2007
And reaffirmed with minor revision by the 207th WMA Council session, Chicago, United States, October 2017

PREAMBLE

1.     On the basis of a number of international ethical declarations and guidelines subscribed to by the medical profession, physicians throughout the world are prohibited from countenancing, condoning or participating in the practice of torture and other cruel, inhuman or degrading treatment or punishment for any reason.

2.     Primary among these declarations are the World Medical Association’s International Code of Medical Ethics, Declaration of Geneva, the Declaration of Tokyo (1975), the Resolution on the Responsibility of Physicians in the Documentation and Denunciation of Acts of Torture or Inhuman or Degrading Treatment (2003) and the Resolution on Physician Participation in Capital Punishment(1981); as well as the Standing Committee of European Doctors’ Statement of Madrid (1989); the Nordic Resolution Concerning Physician Involvement in Capital Punishment; and, the World Psychiatric Association’s Declaration of Hawaii.

3.     However, none of these declarations or statements addresses explicitly the issue of what protection should be extended to physicians if they are pressured, called upon, or ordered to take part in torture and other cruel, inhuman or degrading treatment or punishment. Nor do these declarations or statements express explicit support for, or the obligation to protect, doctors who encounter or become aware of such procedures.

RESOLUTION

4.     The World Medical Association (WMA) hereby reiterates and reaffirms the responsibility of the organised medical profession:

4.1  To encourage physicians to honour their commitment as physicians to serve humanity and to resist any pressure to act contrary to the ethical principles governing their dedication to this task;

4.2  To support physicians experiencing difficulties as a result of their resistance to any such pressure or as a result of their attempts to speak out or to act against such inhuman procedures; and,

4.3  To extend its support and to encourage other international organisations, as well as the constituent members of the World Medical Association (WMA), to support physicians encountering difficulties as a result of their attempts to act in accordance with the highest ethical principles of the profession.

4.4  To encourage physicians to report and document any acts of torture and other cruel, inhuman or degrading treatment or punishment they are aware of.

5.     Furthermore, in view of the continued employment of such inhumane procedures in many countries throughout the world, and the documented incidents of pressure upon physicians to act in contravention to the ethical principles subscribed to by the profession, the WMA finds it necessary:

5.1  To protest internationally against any involvement of, or any pressure to involve, physicians in acts of torture and or other forms of cruel, inhuman or degrading treatment or punishment;

5.2  To support and protect, and to call upon its constituent members NMAs to support and protect, physicians who are resisting involvement in such inhuman procedures or who are documenting and reporting these procedures, or who are working to treat and rehabilitate victims thereof, as well as to secure the right to uphold the highest ethical principles including medical confidentiality;

5.3  To publicize information about and to support physicians reporting evidence of torture and to make known proven cases of attempts to involve physicians in such procedures; and,

5.4  To encourage its constituent members to take action so that physicians are held accountable before the law in case of complicity in acts of torture and other cruel, inhuman or degrading treatment or punishment;

5.5  To encourage its constituent members to ask corresponding academic authorities to teach and investigate in all schools of medicine and hospitals the consequences of torture and its treatment, the rehabilitation of the survivors, the documentation of torture, and the professional protection described in this Declaration.