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Proposed Guidelines for Practice in Difficult Settings
Guidelines for Prison, Detention and Other Custodial Settings
problem of dual loyalty and human rights is particularly challenging
for health professionals who are responsible for providing health
care services to prisoners. On the one hand, such professionals
are subject to professional ethics and mores governing their conduct;
on the other, they work within institutions primarily concerned
with state and/or public security. It is inevitable that these dual
obligations will at times seem to be, or actually will be, opposed
to each other.
professionals working in prisons often willingly and knowingly comply
with policies that violate one or more aspects of medical ethics,
and may even participate in drawing up separate codes of ‘medical
ethics’ specifically for use in such institutions. Others
may be unsure of how to cope with situations where their ethical
responsibility to the patient seems to be in conflict with state
or prison policies and practices. They tend to be passive participants
in unethical practices, rather than willing perpetrators of ethical
some situations, subordination of patient interests to the requirements
of the state undeniably serves legitimate purposes. For example,
a prison health professional who becomes aware of sexual or other
abuse among prisoners themselves may in certain cases have to intervene
and breach confidentiality in order to protect others from harm.
Under some circumstances, particularly when public health is at
risk, a health professional may have to consider betraying confidentiality
for the wider public interest, for example, in combating contagious
diseases. More frequently, however, elevating the interests of the
state over those of the patient leads to violations of that patient’s
human rights. As noted above, in Chile, as well as in other South
American countries, physicians participated in torture under orders
from the military; in South Africa, as well as in many other countries,
prison health professionals routinely failed to record or report
torture and abuse of political detainees.
international codes and declarations address (directly and indirectly)
the responsibilities and obligations of prison health professionals.
The fact that such health professionals still find themselves facing
apparently irresolvable ethical dilemmas, or even acting unethically,
indicates the complexity of these situations, for which existing
codes may be inadequate or incomplete. This set of guidelines intends
to reinforce the principles already stated in existing codes and
declarations, while specifically addressing the dual loyalty concerns
experienced by health professionals working in prisons and other
Dual Loyalty Working Group has thus attempted to address the almost
inevitable ethical conflict that will confront prison health professionals,
by developing guidelines that build on and add to existing codes,
and by suggesting ways in which institutional support mechanisms
can be strengthened.
The following guidelines apply to health professionals who are responsible
for providing health care services to persons in custody, whatever
their legal situation — whether they are awaiting trial or
already sentenced, detainees being held without charge or in any
other form of custody. The rules apply wherever the health professional
is called upon to provide medical treatment or any other form of
medical expertise, whether that be in a prison itself, a police
station, a holding cell, a health care facility or any other place
where people are held in custody.
In addition to being required to adhere to the principles outlined
in relevant World Medical Association, World Health Organization,
United Nations, and other guidelines, health professionals who are
responsible for providing health care services to those in custody
should follow the following guidelines.
The health professional should act in the best interests of his
or her patient at all times.
Commentary: While this precept may seem to conflict with
others, it is the basis for medical ethics outlined in such documents
as the World Medical Association’s Declaration of Geneva and
International Code of Medical Ethics, as well as other declarations
such as the Malta Declaration on Hunger Strikes. It must continue
to be the primary goal of health professionals caring for prisoners,
even in situations of dual loyalty. Acting in the best interests
of patients does not necessarily preclude taking steps to prevent
harms to, or violations of the rights of other parties, where the
health professional has information that could prevent such harms.
However, the Guideline does imply that actions that are not in the
interest of the patient should be considered only within a framework
of exceptions described in General Guideline
The health professional is responsible for ensuring physical and
mental health care (preventive and promotive) and treatment, including
specialized care when necessary; ensuring follow-up care; and facilitating
continuity of care— both inside and outside of the actual
custodial setting— of convicted prisoners, prisoners awaiting
trial, and detainees who are held without charge/trial.
Health professionals face an ethical conflict when they are called
upon to limit or deny care to prisoners, as well as when they are
called upon to engage in or passively accept practices that harm
the physical and mental health of the patient. This guideline makes
clear the responsibility of the health professional to provide care,
regardless of outside pressures, and to advocate for the health
interests of the patient. This guideline goes beyond Principle 1
laid out in the UN Principles of Medical Ethics Relevant to the
Role of Health Personnel in the Protection of Prisoners, which states
that health personnel have a duty to “provide [prisoners]
with protection of their physical and mental health and treatment
of disease of the same quality and standard…afforded to those
who are not imprisoned or detained.” It is recognized that
not all health professionals will be able to ensure follow-up and
continuity of care outside the custodial setting, but to the extent
they can, they should.
The health professional must be ensured, and must insist on, unhindered
access to all those in custody.
Health professionals may unknowingly deny care to prisoners when
custodial officials deny them access to prisoners, often to manipulate
which prisoners get care. This practice may be undertaken for a
variety of reasons, including corruption, harassment or enforced
discrimination. This guideline makes clear the health professional’s
responsibility to ensure his or her duties are not neglected or
impeded because of the actions of prison officials.
The health professional should examine a detained or imprisoned
person as soon as possible after incarceration, and thereafter should
provide medical care and treatment to such persons whenever necessary,
and consistent with the principle of informed consent for such treatment.
This guideline, building on Guideline 3, ensures
that health professionals are able to provide care to all prisoners
within the custodial setting, especially ones who may have experienced
abuse. This guideline reinforces Principle 24 of the UN Body of
Principles for the Protection of All Persons Under Any Form of Detention
or Imprisonment. Furthermore, even though incarcerated, prisoners
do not lose their right as patients to be consulted on any treatments
they receive consistent with the principle of informed consent.
The health professional must regularly inspect and report on sanitary,
living and general health conditions to the custodial authority
and an independent medical authority; and should, when necessary,
advocate for better custodial conditions with custodial authorities
and/or an independent medical authority.
Health professionals in prison settings face an ethical conflict
when their duty is to protect the health of the prisoners, yet the
material and/or psychological living conditions of those prisoners,
whether through lack of resources or deliberate neglect on the part
of prison authorities, make that impossible. In such cases, health
professionals can uphold the best interests of their patients by
reporting on sanitary and living conditions. This guideline is more
specific than those of other medical codes, which do not address
the responsibility of health professionals to monitor living conditions
The health professional should report to the custodial authorities
and, where appropriate, to an independent medical authority any
situation in which he or she becomes aware of allegations or evidence
that those in custody are being subjected to torture or cruel, inhuman
or degrading treatment. The health professional must, however, weigh
this action against any reprisal or further punishment to the prisoner
that may result. When appropriate, the health professional should
gain the consent of the prisoner before making such a report.
This guideline builds on current principles barring complicity in
torture outlined in the UN Principles of Medical Ethics and the
WMA’s Declaration of Tokyo, but goes further by calling on
health professionals to report the abuses they may witness. When
there is potential for reprisal, however, health professionals must
take care to report only to those who will not misuse the information.
Bearing in mind Guideline 1, they should take into
account the need to protect the safety of the patient. This guideline
requires that there be strong institutional mechanisms to support
the health professional who blows the whistle, including an independent
medical authority and a supportive national medical association.
The health professional should certify only that which he or she
has personally verified; should not falsify evidence and should
ensure that complete and accurate medical records are kept for all
Health professionals are often called upon by the state, or another
powerful third party, to omit, falsify, or disguise crucial information
in medical records. The WMA International Code of Medical Ethics
holds that health professionals should certify only what they have
personally verified, but it and others do not address the specific
problem of omitting or falsifying information for the benefit of
a party that does not have the best interest of the patient in mind.
This guideline goes further than existing codes in addressing this
omission brought on by dual obligations. The guideline requires
strong institutional mechanisms to support the health professional
who maintains complete and accurate records as well as to support
his or her patients.
The health professional should abstain from participating, actively
or passively, in any form of torture.
This guideline is basic to medical ethics and is supported by international
human rights covenants, as well as by the WMA Declaration of Tokyo
and by the UN International Code of Medical Ethics. A health professional
passively participates by permitting his or her clinical findings
or treatment to be used by authorities to aid the process of torture.
The health professional should not provide any means or knowledge
to facilitate the practice of torture or cruel, inhuman, or degrading
treatment or punishment; should not authorize, approve, or participate
in punishment of any form, in any way, including being present when
such procedures are being used or threatened.
Health professionals, while they may not participate directly in
torture or punishment, may be called upon to participate indirectly,
by providing instruments to facilitate torture, by using medical
knowledge to monitor torture, or by authorizing punishment. This
indirect participation includes examinations to declare an individual
“fit” for caning, shackles, solitary confinement or
any other type of abuse, and dietary restrictions. It also includes
being present while the punishment is being administered, for example,
observing caning, or examining a patient in solitary confinement
to declare him or her “fit” for continuation of the
punishment. This guideline does not prevent a health professional
from providing necessary medical care to an individual in solitary
confinement; nor does it prevent a health professional from intervening
to seek removal of a prisoner from solitary confinement on medical
The health professional should not participate in capital punishment
in any way, or during any step of the process. This includes an
examination immediately prior to execution and one conducted after
the execution has been carried out.
Health professional participation in capital punishment continues
to occur, despite the World Medical Association’s resolution
prohibiting physician participation and the many codes that prohibit
physician involvement in other cruel, inhuman, and degrading treatment.
Health professionals are called upon to participate in a range of
activities – from preparing intravenous lines for lethal injection
to certifying the death of executed prisoners. This guideline goes
beyond existing codes to hold that health professionals should not
participate in any part of the process, including the certification
of death. We are aware, however, that in some countries, prisoners
facing execution may prefer to have death certified by a health
professional to ensure, for example, that organs for donation are
not removed prior to death or that the individual is not buried
alive. In these situations, the health professional should obtain
explicit informed consent from the prisoner who is to be executed,
stipulating that he or she wishes that health professional to certify
death. Strong institutional mechanisms are needed to support health
professionals in these positions, as many countries’ laws
require that health professionals do participate.
The health professional should respect medical confidentiality;
should insist on being able to perform medical duties in the privacy
of the consultation, with no custodial staff within earshot; should
divulge information strictly on a need-to-know basis, when it is
imperative to protect the health of others.
Confidentiality is a cornerstone of medical ethics and is upheld
in the WMA’s Declaration of Geneva, among other codes. Yet
health professionals are often called upon to divulge patients’
confidential medical information to authorities, or may perform
examinations with authorities present, constraining the extent to
which a patient can speak openly with the healthcare provider. When
the health of other prisoners is at stake, however, the health professional
has an obligation to balance their needs with the confidentiality
due the patient, for instance, in circumstances of contagious disease
or prisoner-to-prisoner abuse. When confidentiality in such circumstances
is breached, care should be taken not to disclose any information
beyond that which is needed for the asserted purpose. Such balancing
of cases should be openly discussed with peer supervisors from medical
authorities/bodies outside of the custodial setting in order to
guard against abuses.
The health professional should have the unquestionable right to
make independent clinical and ethical judgements without untoward
Health professionals in prison settings are often called upon to
subordinate their sound medical judgment in order to support conclusions
or outcomes favorable to the state. This includes situations of
falsifying or omitting information, but it also includes recommending
treatment or action that is not in the best interest of the patient,
for example, allowing an ill patient to be transferred when the
transfer will lead to further harm, or not hospitalizing an ill
patient because authorities believe he is a security threat. Existing
codes call for complete clinical independence. This guideline reinforces
those codes and further requires that health professionals actively
insist on and be granted this right. There may, however, be situations
where legitimate restrictions are put on the health professional’s
independent judgment. For instance, a physician may be asked to
prescribe medication from an essential drug list, with medicines
not on the list requiring particular motivation. In such instances,
the physician may legitimately accept the restriction, if it is
indeed for the greater benefit of the larger community— as
long as that restriction does not bring harm or untoward consequences
to the patient.
The health professional should not perform any medical duties on
shackled or blindfolded patients, inside or outside the custodial
setting. The only exception should be in circumstances where, in
the health professional’s judgment, some form of restraint
is necessary for the safety of the individual, the health professional
and/or others, and treatment cannot be delayed until a time when
the individual no longer poses a danger. In such circumstances,
the health professional may allow the minimum restraint necessary
to ensure safety.
Health professionals in prisons are often expected to ignore or
passively accept the physical restraints imposed on their patients.
Many codes outline the duty of health professionals not to participate
in any form of restraint except when medically determined to be
necessary for the health of the patient and others (UN Principles
of Medical Ethics, UN Minimum Rules for the Treatment of Prisoners,
UN Principles for the Protection of Persons with Mental Illness).
This Guideline goes beyond the others by permitting only a narrow
exception, that health professionals should not treat a patient
in restraints unless an urgent situation requires immediate action
that cannot be performed safely without restraints — and even
then with the minimum possible restraints.
The health professional should not perform medical duties or engage
in medical interventions for security purposes.
Health professionals should never engage in medical interventions
that are not in the individual’s therapeutic interests, even
when requested to do so by authorities for security purposes. Principle
3 of the UN Principles of Medical Ethics states that the purpose
of the professional relationship must be “solely to evaluate,
protect or improve … physical and mental health [of prisoners
and detainees].” For individuals in psychiatric hospitals,
the UN Principles for the Protection of Persons with Mental Illness
and the Improvement of Mental Health Care state that medication
“shall only be used for therapeutic or diagnostic purposes
and shall never be administered as a punishment or for the convenience
The health professional should not participate in police acts like
body searches or the imposition of physical restraints unless there
is a specific medical indication for doing so or, in the case of
body searches, unless the individual in custody specifically requests
that the health professional participate. In such cases, the health
professional will ascertain that informed consent has been freely
given, and will ensure that the prisoner understands that the health
professional’s role becomes one of medical examiner rather
than that of clinical health professional.
This guideline follows from Guideline 14. The
World Medical Association’s Statement on Body Searches holds
that health professionals should participate in body cavity searches
as they have the medical knowledge and skills to ensure that the
prisoner is not harmed. The BMA and others, however, assert that
such participation makes the doctor a wielder of force, which contravenes
basic medical ethics. The British Medical Association holds that
only if the doctor can ascertain true informed consent should he
or she perform the search. This guideline goes beyond the WMA Statement
and the BMA policy to say that the prisoner must request the participation
of the health professional. Any breach of confidentiality will concern
only the search and no other confidential medical information that
the prisoner may confide to the health professional.
The health professional should, if prepared to treat a hunger striker,
respect the rights and freedom of choice of a detained hunger striker
regarding medical intervention and intravenous feeding without the
intervention of a third party whose primary interest may not be
the patient’s welfare.
Health professionals treating detained hunger strikers are challenged
to uphold the sanctity of life while respecting the rights and choices
of their patients. The WMA Declaration of Malta addresses this issue
far more thoroughly than it is within the scope of this document
to do. For the purpose of guidance in cases involving dual loyalty,
where authorities may pressure health professionals to force feed
hunger strikers, the health professional must not submit to the
wishes of a third party whose primary interest may not be the patient’s
The health professional should not engage or participate in any
form of human experimentation amongst prisoners, unless the research
will provide significant health and other benefits for prisoners
and facilitate promotion of their human rights.
The Working Group is aware that this is a controversial issue and
that some existing guidelines do allow for research on prisoners,
provided that voluntary informed consent is given. It is the view
of the Working Group that true “voluntary informed consent”
is almost impossible to obtain in the prison setting, because of
the various overt and covert factors which govern the relationship
between prisoner, prison staff and health professional. There may
however, be some particular circumstances when research with prisoners
may provide significant health and other benefits and facilitate
promotion of their human rights. The Group acknowledges, moreover,
that research issues are not strictly part of its mandate; it would
thus welcome further discussion with and guidance from those directly
involved in the ethics of research.
B) Guidelines on Health Care for Refugees and Immigrants
States often explicitly discriminate against refugees and immigrants.
As countries seek to restrict the entry of refugees, they also limit
state welfare services, including health care. Even in countries
with strong traditions of state services, refugees are often denied
equal access to health care. State policies restricting entry to
the country and restricting access to care can bring about severe
dual conflicts for health professionals.
codes of the UN and the WMA focus on the health of vulnerable groups
such as torture victims, prisoners, the mentally ill, the mentally
retarded, the handicapped and women. However they contain no provisions
on refugees. Some human rights treaties address rights of refugees
to health services. Article 24 of the UN Convention on the Rights
of the Child states that every child has a right “to the highest
degree of health and to access to health care” and calls on
all states to assure that no child is prevented from access to health
care institutions. Article 22 clarifies that refugee children have
the same rights.
European Convention on Social Rights recognizes, in Article 11,
everybody’s right on protection of health, and calls on states
to remove the causes of health hazards, to create health counseling
and education facilities and to prevent epidemic diseases. The attachment
to the Convention (item 2) holds that refugees must be treated as
favorably as possible and in no case less favorable than defined
in the preceding articles of the Convention.
the health professional, guidelines are needed in two circumtances:
in the evaluation of claims for asylum and in state restrictions
on access to health care.
The following guidelines apply to health professionals who are responsible
for providing health care services to refugees or immigrants and
for evaluating claims for asylum. In the latter case, reference
should also be made to the Guidelines for Forensic
1. The health professional should recognize that refugees and immigrants
have a human right to equal access to health care.
The health professional should be guided by two fundamental human
rights principles, that everyone has the right to the highest attainable
standard of health and that health services should be made available
on a non-discriminatory basis. When state policies limit access
to health care, either through legal requirements or limitations
on reimbursement for services, the individual health professional
should not acquiesce.
is unreasonable, however, to place the full responsibility for equal
health care of refugees on individual health professionals facing
legal or financial impediments to equal care however. Most often
collective action will be required. For example, the British Medical
Association’s guidelines for refugee health care demand that
doctors offering an extended range of services to this group of
patients get additional payments. Medical organizations can also
organize voluntary medical services for this group.
Health professionals should not report immigrants who lack legal
status to government authorities.
state has the responsibility for immigration matters and law enforcement.
It is not part of the health professional’s function to participate
in law enforcement activities, and the health professional should
resist where a breach of confidentiality amounts to a violation
of human rights that could result in incarceration, prosecution,
deportation or all three.225 In immigration
and refugee matters, where there exists no likelihood of harm to
a third party in the absence of disclosure, the principle of confidentiality
and of making health services available to people in need should
take precedence over the state’s interest in using health
professionals to assist in enforcement of immigration laws. Health
professionals must therefore decline to report undocumented immigrant
to state authorities. It may be particularly difficult for health
professionals working in state institutions or on a government payroll
to resist pressures to report. Strong institutional mechanisms must
be in place to support them.
Health professionals should not disclose information gained in the
course of treatment of refugees to state authorities.
Doctors may face pressure from immigration authorities to disclose
information about patients for planning, administrative, law enforcement
and other purposes. Disclosing confidential information in these
circumstances, however, can have potentially severe human rights
consequences for the patient. By contrast, assuring refugees and
immigrants that confidentiality will be respected will also aid
the therapeutic mission, since it can gain trust from refugees and
immigrants who may be very anxious and reluctant to give information
on their health background and may be fearful of examination. Fears
that information disclosed to a health professional may reach authorities
should be addressed directly.
the health professional is engaging in examination for state authorities
for purposes other than treatment, the health professional must
clearly disclose the purpose of the examination and the limits on
confidentiality to the person being examined.226
Proper counseling should be given to the patients regarding the
uses of the information obtained by state immigration authorities.
Health professionals should not participate in medical examinations
on behalf of the state for the purpose of determining a refugee’s
eligibility for entry into the country except in cases where public
health and preventive measures are needed to counter the risk of
epidemic. Screening or testing is only permitted with prior informed
consent. In case of repatriation the results of medical assessments
and necessary treatment programs should be provided to the refugee.
In some countries immigration authorities rely on medical techniques
such as X-ray or dental screening to seek to determine the age of
the refugee or immigrant. They may also engage in examinations purporting
to engage in “fitness to travel” when forced repatriation
is likely. These examinations are often superficial and misused
and rarely include an assessment of the overall health of a refugee
e.g. a psychotrauma caused by war atrocities or other kinds of violence.
This high potential for serious abuse should lead health professionals
to avoid participation.
Health professionals should insist that medical services for refugees
and immigrants, and examinations for determination of status include
Health care services usually do not provide interpreters. They rely
upon relatives or friends (often children) for translation. This
practice violates medical confidentiality and the principle of neutrality.
The enormous stakes for the individual in cases of examinations
also supports the need for interpreters.
Health professionals acting as evaluators in asylum procedures and
court procedures should be aware of potential dual loyalty conflicts
if providing treatment to refugees as well.
Although this separation of function would provide the greatest
protection of the human rights of refugees, in practice it is rare,
either because there are few health professionals with specialized
knowledge in transcultural medicine, refugee health and refugee
trauma, or because the state does not take adequate steps to avoid
role conflicts. Health professionals should urge that the separation
of function be instituted.
Guidelines for Health Professionals in the Workplace
Health professionals frequently provide a range of services at the
workplace to employed persons. Such services may include direct
clinical care such as periodic health examinations, curative and
rehabilitative care, preventive education, and health promotion
interventions directed at high-risk individuals. In addition, health
professionals at the workplace are frequently called on to provide
services where the primary motivation is neither therapeutic nor
clinical, but evaluative. These may further a legitimate administrative
or institutional purpose. For example, medical personnel are frequently
called upon to provide medical reports in support of compensation
claims, to evaluate a candidate’s fitness for a particular
job, or to provide expert opinion on the sickness record of a particular
employee in the context of a perceived absenteeism problem. At other
times, health professionals have the responsibility of conducting
measurements of potential hazards to workers’ health as part
of industrial hygiene programs.227
such circumstances, the health professional is subject to expectations
from a third party, usually an employer. At the same time, the health
professional has ethical obligations towards his or her patient.
As a result, he or she is faced with the problem of dual or divided
loyalty conflicts at the workplace may be exacerbated by potential
conflict generated by adversarial employer-employee relations.228
Usually such conflicts arise out of a contractual relationship between
the health care provider and the company, which is also the employer
of the worker-patient. Conflicts also arise vis-à-vis non-business
employers, however, for instance, workers’ trade union, or
the government safety department, which may seek confidential information
for purposes of addressing a perceived health hazard at a workplace.
presence of a dual loyalty conflict at the workplace does not inevitably
result in violation of workers’ rights. It can, however, if
inadequately managed. Health professionals may, for instance, subordinate
independent therapeutic judgment in order to promote an objective
of the employer, thus placing workers at further risk of injury.
The Dual Loyalty Working Group has attempted to address such ethical
conflicts by drawing on recognized human rights standards in developing
guidelines which build on and add to existing ethical codes.
These Guidelines apply to health professionals responsible for providing
occupational health services to employed persons. Occupational health
service provision is taken to cover the full range of preventive,
promotive, curative and rehabilitative services for persons at the
workplace, and includes both direct health care and occupational
hygiene services. These Guidelines are a particular application
of the Guidelines for Forensic Health Professionals
and apply to clinical care as well as to health professionals’
non-clinical obligations, such as monitoring workers to meet statutory
Health professionals responsible for providing occupational
health services should adhere to the following guidelines, in addition
to the principles outlined in relevant national and international
professional ethical codes.
Health professionals should exercise independent judgment229
in their clinical management and non-clinical assessment of the
This is a particular application of General
Guideline 4. Generally, independent judgment requires the health
professionals to act in the best interests of patients at all times
and ensure that occupational health service provision remains focused
on the promotion of the health of the workforce, regardless of the
role (therapeutic or non-therapeutic) he or she is asked to play.
Cost may be regarded as a legitimate consideration if the occupational
health service is seeking to identify the most cost-effective way
to attain a health objective. However, it is not ethically acceptable
to subordinate independent judgment to cost considerations nor to
trade off a health objective as too costly to achieve based upon
a company’s concerns solely to minimize costs or maximize
party requests for clinical judgments that benefit their interests
are, in the occupational setting, common but misguided. Requests
to limit sickness absenteeism, or favor a particular conclusion
in a medical assessment should not influence the clinical judgment
of the health professional. Occupational health professionals should
not be party to the misuse of a clinical examination as a means
to dismiss workers.
requests from third parties pose irreconcilable ethical and human
rights conflicts, the occupational health professional should consider
withdrawing his or her services, as long as this does not disadvantage
the patient unreasonably. Occupational health professionals should
avoid any judgments, advice, or activities that may endanger trust
in their integrity and impartiality. Treating all workers in a non-discriminatory
manner, basing judgments on scientific knowledge and technical competence,
and respecting diversity and equity at the workplace will help to
establish a relationship of trust and confidence in the health professional
among all stakeholders.
Even when acting in a non-therapeutic role in relation to the patient,
such as that of independent evaluator, a health professional cannot
ignore the ethical obligations to the individual patient, to which
he or she would be subject in a typical clinical encounter.230
Even when acting in a non-therapeutic role, such as assessing employees
for purposes of fitness for work, disability, or compensation, the
health professional must conduct the assessment in a manner that
complies with ethical and human rights norms.
the health professional should inform the patient before the assessment
that he or she is acting in a non-therapeutic role and should make
sure the patient understands the implications of this role. This
gives the worker-patient the opportunity to take responsibility
for choosing another health care provider or refusing the examination.
the employee consents to the examination, the health professional
should conduct the examination with respect for the patient’s
dignity and autonomy, using his or her independent judgment and
knowledge of the workplace to reach a considered assessment of the
worker’s fitness. The findings of the examination and tests
and the contents of the report should be discussed with the worker
prior to submitting the report, which, again, should only contain
details relevant to the purpose of the examination.
note is that in assessing employees with recurrent absence due to
illness, the role of the health professional is to provide advice
to both the employer and the employee. Other than providing advisory
information, however, the health professional should not be involved
in absenteeism control, which is the job of management.231
Health professionals should maintain confidentiality of medical
information, and not disclose clinical information not directly
germane to the purpose of evaluation.232
No medical information about a worker should be revealed to a third
party, including employers, without the express consent of the worker
concerned unless the following apply. 1) Revealing such information
is clearly in the interests of the worker concerned; 2) The information
required is germane to the specific determination of the worker’s
fitness for the job, and is consonant with the precise requirements
of the job; 3) Release is required by overwhelming public health
considerations and is mandated by law.
medical information obtained in the course of periodic or pre-placement
examination should not be revealed to an employer except to the
extent it is relevant to the worker’s fitness to do the job
and any limitation of function. Thus, for example, medical tests
should only be permitted as part of a fitness examination if they
are relevant to the requirements of the job. On the other hand,
the health professional should reveal anonymous group data from
biological monitoring, as part of his or her responsibility to bring
any workplace risks to the attention of management.233
Health professionals must release information regarding workplace
hazards to affected workers or the appropriate authorities, where
definable harm – either existing or threatened – to
the worker-patient, other workers, or third parties outweighs the
right of the company and of the patient to privacy.
As in normal practice, health professionals are obligated to share
the results of medical testing and examinations with the worker-patient,
and to counsel the patient on the implications of such findings.
Health professionals may come under pressure to omit certain information
from reports that have statutory or financial implications for the
employer, so as to protect the company from legal or financial liability.
Under no circumstances, however, should such considerations induce
the health professional to alter his or her judgment in determining
the best course of action with regard to hazard or risk communication
for the worker-patient or worker-patients.234
Guideline 12 requires that health professionals report violations
of human rights that interfere with their ability to comply with
their duty of loyalty to patients to appropriate authorities. Where
wider knowledge about the existence of hazards or of occupational
disease or disability in a workplace may help to reduce health risks
to workers, the health professional has a responsibility to act
upon such information to the best of his or her capacity.235
The health professional’s action should be aimed at ensuring
that communication of the data prompts removal or control of such
hazards. The first step is to inform workplace management, stressing
the need for timely remedial action. If attempts to address the
hazard through routine management channels fail, the health professional
should ‘blow the whistle’ on the existence of such hazards
to an appropriate body (professional, employer, governmental, trade
union, or other) that can take action to remedy the hazard. These
considerations also apply where a health professional is aware of
hazards posed to families of workers or to neighboring communities
as a result of workplace processes.
often invoke commercial secrecy to prevent disclosure of information
about hazardous workplace conditions. This appeal is unjustified,
however. The specific hazard posing a health risk rarely reveals
proprietary agents or processes. Even where it might do so, considerations
relating to the prevention of disease and disability should take
precedence over commercial secrecy. As mentioned above, in such
a circumstance, the occupational health professional should urge
the company to release the information. If this fails, he or she
should “blow the whistle” and consider resorting to
court action to secure legal protection. Occupational health professionals
should, as a preventive measure, make sure that health considerations
override secrecy clauses in their employment contracts.
an occupational health professional may identify information relating
to the fitness of a worker that places fellow workers or third parties
at risk of harm or injury. In such circumstances, the health professional
is justified in breaking confidentiality, but only after he or she
has counseled the patient carefully and sought the patient’s
informed consent, and such counseling does not itself compel voluntary
Health professionals should ensure that any audit or regulatory
monitoring undertaken to ascertain risks to workers, their families,
or the neighboring community, is undertaken with the highest standard
of scientific integrity.
The inspection or monitoring of workplaces for potential hazards
(such as dust or chemicals), whether by outside agencies or by in-house
professionals, is critically important to detect the presence of
conditions that may threaten the health of workers, their families,
or the neighboring community. It is well recognized that advance
knowledge of such inspections often prompts management to clean
up the workplace in advance of the inspections.
professionals should avoid participating in actions designed to
create a false impression of safe conditions at the workplace, and
should draw any such action to the attention of inspecting authorities.
If possible, the health professional should prevent selective monitoring
from taking place, rather seeking to ensure that representative
monitoring provides a true picture of the extent of any workplace
hazards. Similarly, where possible, the health professional should
maintain medical and environmental monitoring records intact, accessible
for statutorily mandated inspection.
Health professionals should support other occupational health professionals
facing conflicts arising from dual loyalty conflicts.
health professionals have collegial obligations to fellow professionals
facing pressure to compromise ethical standards. Not only is this
obligation part of one’s professional identity, but it is
also necessary to strengthen the ability of the profession collectively
to establish ethical and human rights norms and standards that protect
others. Experience has shown that such support from peers is among
the most powerful counters to pressures on occupational health professionals
to abandon ethical principles. See General
Guideline 15 and Institutional Mechanisms.
Health professionals should identify and declare any conflicts of
interests before helping disseminate research findings or formulate
policy for the control of occupational health hazards.
Occupational health professionals should seek to disseminate existing
health and safety knowledge, support research to identify and control
new hazards, and publish such findings.236
Additionally, they should participate in policy formulation for
the promotion of workers’ health and the control of occupational
hazards, through serving on expert committees, regulatory reviews,
and other policy structures. In doing so, however, they should be
explicit about the existence of any conflict of interests, for instance,
financial, that may burden independence.237
Declaration of existing or potential conflicts of interests establishes
transparency in research dissemination and policy formulation.
Guidelines for Health Professionals Engaged in Forensic Evaluations
The job of a forensic health professional is to document, obtain,
preserve or interpret evidence. Forensic health professionals are
often called upon to engage in evaluations for courts or administrative
bodies. In criminal cases, forensic health professionals238
may be asked to evaluate whether a person is criminally responsible
for his or her conduct, whether a person is competent to stand trial,
and even whether an element of an offense has been established,
e.g., intoxication. Forensic health professionals may also examine
victims of crimes, e.g., rape or assault victims, for the purpose
of gathering evidence. In civil cases, they may engage in evaluations
in divorce, child custody, disability benefits, workers’ compensation
and other cases.239 In applications
for political asylum, health professionals may be asked to establish
medical evidence of torture. Health professionals engaged in treatment
may also be called upon to provide evidence about a person to a
court or other adjudicative body. For instance, a physician may
be asked to provide information about a person’s medical condition
in connection with an application for social benefits.240
these functions are designed to assist the state in gathering and
presenting evidence to decision-making bodies, rather than to assist
or treat the person subject to evaluation. As a health professional,
however, the evaluator retains a duty to respect the human rights
of the person being evaluated and to adhere to ethical standards
of the profession, including the duty to inform the person about
the nature and objectives of the examination.
exists an inevitable tension between a health professional’s
role as forensic evaluator contributing to the development of evidence
in a legal proceeding and his or her role as a health professional
with a duty of loyalty to the individual241.
This tension is magnified when loyalty to the state or a third party
contradicts medical ethics and implicates the human rights of the
person being evaluated, e.g., medical evaluations for corporal punishment.
The health professional cannot resolve this tension by claiming
that the evaluative role frees him or her from ethical duties to
the individual being evaluated.242
Rather, the tension must be resolved by performing the evaluative
role consistent with the human rights of the individual.
rights standards have been established regarding the health professional’s
role in torture and participation in the death penalty.243
More general standards for forensic evaluations, however, are needed.
The following guidelines apply to health professionals engaged in
forensic evaluations on behalf of the state or other third party.
They apply wherever the forensic professional is called upon to
evaluate – whether in a criminal setting or a civil setting.
Additional, more particularized guidelines have been drafted for
evaluations of refugees and asylum seekers as well as evaluations
in the workplace. These guidelines do not apply to forensic evaluators
retained by the person, for example, for his or her criminal defense.
The judgment of the forensic medical evaluator must be completely
independent of influence by the state or other third parties.
The single most serious threat to the human rights of individuals
being evaluated comes from forensic medical evaluators who fashion
medical judgment to serve state or powerful third-party interests.
Although the function of the medical evaluator may result in findings
that are not in the interests of the individual (e.g., to support
a criminal conviction or to support the denial of benefits), the
medical evaluator must never distort documentation or tailor findings
to achieve outcomes desired by state or private actors on whose
behalf the professional is making the evaluation, no matter how
worthy the evaluator believes these outcomes to be. These distortions
can occur by making findings or interpretations that are not supported
by the facts, or by refraining from making or failing to disclose
fully findings that are warranted by the facts.
this guideline appears self-evident, there are many examples of
medical evaluators permitting their allegiance to a state or state
policies to distort their findings, either by making determinations
favorable to the state or, more commonly, by failing to make or
disclose findings. In doing so, medical evaluators become complicit
in the violation of the human rights of the person being evaluated.
For example, German doctors examining Bosnian refugees, seeking
to support a government interest in excluding the refugees from
the country, failed to include evidence of Post-Traumatic Stress
Disorder in their reports despite ample evidence of its existence.244
In Turkey, health professionals failed to record evidence of torture
or abuse in detention.245 In South
Africa, medical cover-ups were very clearly documented in the “Gluckman
The medical evaluator should disclose to the person being evaluated
the purpose of the evaluation, the fact (where applicable) that
the examination is not confidential with respect to the entity seeking
the evaluation, and the findings. In the event the evaluatee is
mentally incompetent to understand the purposes and findings, disclosure
should be made to the person authorized to act on the evaluatee’s
behalf. Individuals being evaluated should also be informed of any
oversight mechanisms that exist.
Any individual examined by a health professional has legitimate
reason to expect that the information will be used for the benefit
of that individual, not for some other purpose, and will be held
in confidence. It is therefore incumbent upon the health professional
engaged in a forensic evaluation to explain when these assumptions,
valid in other circumstances, do not apply.
of the purpose of the examination and the findings is required by
the human right to due process of law. It is also the responsibility
of the institution to give a hard copy of the forensic evaluation
to the individual being evaluated, his personal doctor outside the
institution and/or another individual (family member) chosen by
In any report, the medical evaluator should explain the reasons
for his or her conclusions and indicate where the evidence is insufficient
to support certainty concerning these conclusions. The medical evaluator
should indicate or make note of alternative interpretations of his
or her findings.
In many cases, the findings of the evaluator lend themselves to
alternative explanations. In other cases, the findings are themselves
equivocal. Medical evaluators working for prosecutors or other state
agents are often under pressure to provide an interpretation of
findings that is most favorable to the state. The forensic health
professional should resist these pressures and instead provide his
or her best judgment about the proper interpretation of findings,
including the limitations of the findings. This can often be accomplished
by providing alternative explanations of the findings in the report
that the health professional believes are supportable.
Forensic evaluators cannot ignore the obligation to treat a person
in distress and must take steps either to offer treatment or to
refer the person to another clinician for therapy when the person’s
This guideline is consistent with the principle that a health professional
does not forego the therapeutic role and concomitant obligations
simply because the professional’s skills are used in a particular
instance for evaluation. The health professional should offer emergency
treatment when qualified to do so and in all cases make an appropriate
referral for medical care when the person’s condition warrants.
A forensic evaluator should not include clinical information about
the person being evaluated that is not germane to the purpose of
The forensic evaluator may ascertain that the information he or
she obtains from the history, physical and additional examination
of the evaluatee includes matters that are irrelevant for the party
on whose behalf he or she performs the forensic evaluation. This
clinical information is within the boundaries of professional confidentiality.
The forensic medical evaluator must not engage, directly or indirectly,
in practices that aid or support torture or cruel or inhuman treatment
Health professionals should absolutely not participate in evaluations
whose purpose or effect is to facilitate torture or cruel or inhuman
treatment. Such participation extends not only to engaging in acts
that themselves amount to torture or cruel or inhuman treatment,
but also to evaluations that can help the torturer determine the
individual’s “suitability” for torture, ability
to withstand torture, or medical condition as a session of torture
continues. A health professional can, of course, provide medical
attention to a victim of torture where treatment does not amount
to a de facto involvement in an interrogation to allow continued
The forensic health professional should not participate in evaluations
incident to legally sanctioned executions and corporal punishment.
International norms against medical participation in legally-sanctioned
executions are well-established.248
Evaluations used for executions include competency for execution
and certification of death. With respect to corporal punishment,
the Convention Against Torture and Other Cruel, Inhuman and Degrading
Treatment or Punishment excludes pain or suffering arising from
lawful sanctions from the definition of torture, but the Declaration
of Tokyo prohibits physician participation even if the person is
guilty of an offense. Accordingly, health professionals should not
participate in assessments of medical condition before corporal
punishment or in monitoring medical condition during the course
of and after punishment.
guidelines prohibit indirect as well as direct participation, since
furthering the infliction of pain without therapeutic purpose and
the taking of life249 violate a health
professional’s duty. For example, a forensic medical professional
may be asked to assess a person’s “suitability”
or competence or tolerance for torture, isolation, or aversive treatment,
without actually participating in the event. But the assessment
is a crucial dimension of the process and thus is prohibited.
The forensic health professional who, while acting in an evaluative
role, witnesses (the sequelae of) torture and cruel, inhuman and
degrading treatment or punishment, should proactively report these
Forensic reports are commonly produced upon request of certain parties,
for example, the prosecution. Forensic medicine is in this respect
a reactive or responsive discipline. However, the health professional
may witness torture or other abuses, which should be reported even
when there is no request for forensic reporting. Examples are child
abuse, domestic violence, torture, and police abuse.
E) Guidelines for Military Health Professionals
Health professionals working in institutions that serve state interests,
where human rights are easily at risk, are most likely to be confronted
with dual loyalty conflicts. Among these, military health professionals
face unique conflicts. They must navigate their way between very
different and sometimes antagonistic or even irreconciliable goals:
on the one hand, to preserve life, attend to the sick, and reduce
suffering (the obligation of the health professional), and on the
other, to support killing and inflicting harm on the enemy (the
obligation of the military officer or soldier).
long as the interests of the patient and the military organization
are in line with each other, dual loyalty conflicts can be avoided.
As one military physician put it: “What’s good for the
patient is good for the military, and you want a fit, happy troop.”
But even in peacetime the two objectives may conflict. The military
health professional is a member of civil society’s health
professions subject to ethical and human rights standards and goals.
As such, the military health professional attends to the soldier
who is sick, wounded, or in need of other medical attention and
who, like any other patient, seeks the expertise, counseling, and
support of his doctor or nurse in privacy and confidentiality. Indeed,
this medical function is protected by international humanitarian
law, which forbids warring parties from interfering or obstructing
efforts by medical personnel to care for the sick and wounded, regardless
the military’s point of view, however, even treatment goals
can be subordinated or reinterpreted to reinforce military objectives.
For example, usual principles of triage demand that in medical emergencies
health professionals attend to the most seriously injured first.
But in battle the commander may compel the physician to attend first
to soldiers with less severe wounds as a means to return them to
battle quickly and maximize force strength; meanwhile the most seriously
injured suffer or may die. Similarly, treatment of sick or traumatized
soldiers in both physical and mental health may differ from standard
civilian protocols in order to serve military purposes, for example,
preparing the soldier as soon as possible for new battle engagements
rather than seeking the best long term outcome for the patient.
Soldiers are often not entitled to exercise informed consent regarding
medication and vaccines. Indeed, even interventions to promote the
health and well being of soldiers are designed to further the fitness
of troops for battle or other military tasks.
more extreme circumstances, the ethical medical role can be even
more severely compromised. A military health professional may be
requested to declare troops fit for engagement even when they are
not. The health professional may be called upon to participate or
advise in interrogation of suspects of terrorism, insurgency, or
espionage to an extent that may amount to torture or cruel and inhuman
treatment, to prepare (and be present at) executions, or to administer
pharmaceutical substances or vaccines to soldiers (own or enemy)
without medical justification. He or she may be called on to participate
in biological, chemical or pharmaceutical research and experimentation
where civilian protocols, regulations and supervision are reduced
or absent. When such research takes place in secrecy – often
for legitimate reasons of national security – the military
health professional may be required or asked to yield to security
interests and forego medical ethical principles and professional
codes of conduct.
dual loyalty conflicts place the health professional in an untenable
position. In some of the above examples the practitioner is put
in a situation where the underlying conduct violates human rights.
In other cases the health professional may be called upon to support
a violation of the laws of war, such as supporting acts of violence
against a civilian population. Further, during engagements and missions,
military health professionals are likely to witness human rights
violations on the battle field or in peace-enforcing actions. Yet
their duty to report these violations may be inconsistent with the
perceived needs of the combat unit.
dual loyalty problem may arise in jurisdictions where military service
is voluntary and members of the armed forces are generally held
to have voluntarily waived some of their rights by choosing to join
the armed services. As patients, they take some responsibility in
advance for deciding the extent to which they are willing to “give
up” their rights, including, for example, the right to doctor-patient
confidentiality. However, this agreement does not mean all of a
military patient’s rights are neccessarily waived and health
care providers should therefore not exceed what is “necessary”
in any disclosure. Indeed, it is debatable whether the waiving of
rights by conscripts could be reasonably accepted as voluntary.
professionals engaged in peacekeeping face other dual loyalty conflicts.
In such operations, military health professionals confront the medical
needs of civilian populations in the area of their assignment; yet
they may be subject to rules and regulations preventing them from
providing professional assistance to these civilians.
health professionals – being members of the troops and placed
in the hierarchical chain of command250
– thus face an extraordinary set of medical-ethical and human
rights conflicts. The following Guidelines are meant to address
these conflicts. The Guidelines follow the World Medical Association’s
Regulations in Time of Armed Conflict in insisting that the health
professional in the military is bound by the same standards of practice
as civilian health professionals.
The following Guidelines apply to military doctors and other military
health professionals, both in times of combat and in peacekeeping
and peace-enforcing operations. These guidelines apply both to the
individual health professional and to the military institutions
and civil authorities and organizations related to the services
of the military health professional.
The military health professional’s first and overruling identity
and priority is that of a health professional.
Although this guideline appears self-evident, many military organizations
teach physicians that they are officers or soldiers first and physicians
second. As such, they are supposed to make their medical skills
available exclusively for military purposes. In some countries,
such as France, the military physician is trained in a separate
miltary medical school, rather than trained as a military doctor
after graduating from civilian medical school. Even where such training
takes place, the primacy of the medical function should always be
reinforced, even if there exist circumstances where the needs of
the military prevail over the needs of the soldiers.
Civilian medical ethics apply to military health professionals as
they do to civilian practitioners.
The starting point for the conduct of military health professionals
should be the ethical and human rights standards of civilian professionals,
with exceptions only for absolutely essential military purposes.
These exceptions should be reviewed on a regular basis. Where deviations
from normative (“regular”) medical ethics are proposed,
such deviations should be subject to careful review and oversight
by a suitable structure such as a medical ethical commission with
membership that includes an adequate number of civilian health professionals
skilled in ethical issues.
medical ethics includes the obligation to obtain informed consent
for treatment. The health professional should consider his or her
relationship to the individual under treatment or evaluation as
comparable to a civilian health professional-patient relationship
rather than as part of a military hierarchy. In considering modes
of treatment, a health professional should engage in the same kinds
of dialogue with a patient about medical procedures as he or she
would in civilian practice. Adherence to civilian informed consent
practice does not imply that there will never be circumstances where
consent is not required, but rather that the same standards should
apply as in civilian health practice. For example, compulsory vaccinations
should only be administered without consent in the military to the
extent that such vaccinations can be administered in the absence
of consent in civilian practice. Even though joining the armed forces
may imply ‘voluntary’ waiving of some patient rights,
this does not relieve the health professional of responsibility
to apply general rules of obtaining informed consent.
The military health professional should adhere to the principle
of confidentiality in a manner consistent with practice in civil
Many military organizations consider the health professional as
part of the chain of command who must thus disclose information
concerning patients to his or her commanding officer, whether that
officer is a health professional or not. This blanket abrogation
of the confidentiality principle is not always necessary to achieve
military objectives, however. Information about a person’s
medical condition may be needed to make a determination for fitness
to serve, but this function is no different from fitness to work
determinations in the civilian employment context (except that soldiers
are not permitted to withhold consent and leave the position). Military
health professionals can provide their opinions and disclose their
medical judgments about fitness for duty, extent of disability (and
projected length of disability), or required restrictions in a soldier’s
scope of responsibilities without providing detailed medical information
and without sharing the information with personnel not directly
involved in the assignment decision. The information disclosed should
be made known to the soldier.
confidential information simply on the basis of command interests
should, as in civilian society, be regarded as unethical behavior.
Exceptions to this general rule should be reviewed by a mechanism
similar to that applicable in civilian life as described in General
Guidelines 7 and 8.
The military health professional is a member of the national and
international health professionals’ community.
In many, if not most, countries the military medical community identifies
itself with the military rather than with the larger medical community.
This identification may be due in part to training and organzation,
but it is also psychological. Military health professionals sometimes
feel that they are not an accepted part of the civilian medical
society. In other circumstances they do not separate their role
from that of the military generally. The supremacy and priority
of the military health professional’s identity as a professional
can be promoted by this Guideline as well as by the membership of
military health professionals in national and international associations.
The military health professional should treat the sick and wounded
according to the rules of medical needs and triage.
The Geneva Conventions require medical attention according to usual
medical practice for persons outside of combat, whether civilians
or wounded enemy soldiers. Thus, a guideline requiring adherence
to the usual rules of triage should not be controversial. Because
this principle is so often breached, it warrants repetition.
international human rights and humanitarian law and international
professional codes of conduct support the responsibility to follow
the rules of triage. The military health professional should ensure
on the basis of a pre-engagement agreement that he or she will be
able to treat civilians of his or her “own side” and
civilians and military (POW and otherwise) of the “enemy side”
or those caught in between, with the understanding that medical
need and triage be the exclusive criteria for selection. A similar
guideline should apply in peacekeeping operations where emergency
medical care is needed.251
the usual rules of triage should apply with respect to soldiers
within a health professional’s own unit. As indicated above,
the military’s goal in returning the maximum number of wounded
soldiers to battle as quickly as possibly often results in different
rules of triage than those applied in civilian life. In the military
context, the least wounded may receive treatment first, while treatment
for the most seriously wounded is delayed. The delay in treatment
increases the risk of death to the more severely wounded. This practice
should be considered unacceptable.
Health professionals should not participate in research or development
of chemical or biological weapons (CBW) that could be used for purposes
of killing, disabling, torturing or in any way harming human life.
Military health professionals may be called upon to apply their
specific expertise for offensive chemical and biological weapons
research. Such projects to develop weapons of mass destruction against
civilian populations are often shielded by formal or informal secrecy
and immunity. Military health professionals have participated in
horrific chemical and biological weapons experimentation252
on human beings, hidden behind a wall of secrecy and immunity. This
guideline prohibits such participation because it is fundamentally
inconsistent with human rights.
research involving methods to protect human beings from the effects
of CBW weapons, or with materials that could directly or indirectly
contribute to CBW weapons, must be subject to systems of ethical
review and scrutiny. Such systems of ethical review and scrutiny,
even when conducted in secrecy due to national security concerns,
should have built into them mechanisms for civilian participation
in the oversight of research.
The military health professional should refrain from direct, indirect
and administrative forms of cooperation in torture and cruel, inhuman
and degrading treatment and punishment at all times, including in
wartime and during interrogation of prisoners.
The Guideline prohibiting civilian health professionals from participating
in cruel and unusual treatment and punishment applies to military
health professionals as well. Military health professionals have
been called upon to assist in interrogation of prisoners and, in
some cases, domestic dissidents. Despite their military status,
however, these professionals are bound by existing prohibitions
on medical participation in torture and cruel and inhuman treatment.
Special attention should be given to practices such as certifying
fitness of individuals to undergo intensive forms of interrogation,
to be punished for non-cooperation, or to be subjected to medical
and/or pharmaceutical ‘treatment’ after such interrogations
The military health professional should refrain from direct, indirect,
preparatory and administrative participation in capital punishment,
both within the military court martial system and elsewhere.
Many countries that have abandoned capital punishment for criminal
offenses permit its use in military courts. In such cases the military
health professional is likely to be involved when he or she is requested
to declare the sentenced prisoner fit for execution. International
codes prohibiting the participation of medical personnel in capital
punishment and contain no exceptions for the military setting. It
is never justified for health professionals to participate, directly
or indirectly, in capital punishment.
Military health professionals should report violations of human
rights that interfere with their ability to comply with their duty
of loyalty to patients to appropriate authorities and report human
rights violations perpetrated by their own troops as well as by
Military health professionals should maintain their independence
and report human rights violations as civilian health professionals
do (see General Guideline 12). The military
health professional should especially take steps to report violations
of the Geneva Conventions.
health professional should not engage or participate in any form
of human experimentation among members of military services unless
the research will provide significant health and other benefits
for miltary personnel and facilitate promotion of their human rights.
It is the view of the Working Group that true “voluntary informed
consent” is extremely difficult to obtain in the military
setting, because of the various overt and covert factors which govern
the relationship between military personel, their chain of command
and the health professional. There may however, be some particular
circumstances when research with military personnel may provide
significant health and other benefits and facilitate promotion of
their human rights. The Working Group acknowledges, moreover, that
research issues are not strictly part of its mandate; we would thus
welcome further discussion with and guidance from those directly
involved in the ethics of research.
II. Dimensions of the Problem
III. Proposed General Guidelines
IV. Proposed Guidelines for Difficult
V. Institutional Mechanisms