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Medical B oard Hearings for P hysicians who Torture : Aims, Rules, Punishments. . Steven Miles, MD University of Minnesota miles001@umn.edu. From Nuremberg 1946 to London 2013. A Brief History. Nuremburg Nazi Doctors Trial, 1946-1947. 23 defendants 7 death by hanging

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Medical B oard Hearings for P hysicians who Torture : Aims, Rules, Punishments.


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    1. Medical Board Hearings for Physicians who Torture: Aims, Rules, Punishments. Steven Miles, MD University of Minnesota miles001@umn.edu

    2. From Nuremberg 1946 to London 2013 A Brief History

    3. Nuremburg Nazi Doctors Trial, 1946-1947 • 23 defendants • 7 death by hanging • 9 prison terms, 10 yrs to life, • 7 acquitted.

    4. Physicians Sanctioned for War Crimes / Torture 1975-2013 Yugoslavia UK Greece Pakistan Bangladesh Brazil Sri Lanka Guyana Rwanda Chile Uruguay SanctionedHearingOpen Medical Board Domestic Court International Court Died during crim trial SouthAfrica Argentina Combinations signify multiple events for one person

    5. To Remember and Atone To Punish To Prevent Domestically and Internationally Aims Of Medical Board Sanctions

    6. To Remember and Atone

    7. To Punish 21 December 2012 Army doctor struck off over death of Iraqi detainee Baha Mousa after failed resuscitation when he was severely beaten by soldiers. Dr. Keilloh showed 'repeated dishonesty' in claiming not to have seen injuries. Dr. Derek Keilloh was struck off the medical register today over the death of Iraqi detainee Baha Mousa.

    8. To Deter Torture • Physicians • Belong to civil society. • Have professional ethics binding them to the well being of patients. • Belong to prestigious and somewhat protected domestic and international communities. • Are in every prison. • Should serve as human rights monitors. • Medical Boards by asserting, enforcing ethics, • Inform physicians of their duty • Let torturing regimes realize that not all the prison “eyes’ belong to them. • Create a domestic and international message to deter torture.

    9. Physician or Soldier? Rules to Evaluate Unprofessional Conduct Punishments Designing Medical Board Hearings

    10. Physician or Soldier?

    11. Domestic Professional Associations World Medical Association United Nations Rules to Evaluate Unprofessional Conduct

    12. United Nations Convention Against Torture, Cruel, Inhuman, and Degrading Treatment UN Principles Protection of Persons under Detention UN Principles Medical Ethics 1956 1946 1948 1975 1980 1984 1988 1997 2007 Clinical Societies Policies WMA Declaration of Geneva No Licenses MDs fleeing prosecution Declaration of Tokyo Regulations in Armed Conflict Duty of MDs to Document and Denounce

    13. Authoritative Rules For Medical Boards to use to Evaluate professional Conduct Do authoritative professional rules exist?Can the rules be transparently applied? Local Medical Society Codes World Medical Association United Nations

    14. Convention Against Torture Torture: any act by which severe pain or suffering, whether physical or mental, • is intentionally inflicted on a person • when such pain or suffering is inflicted by or at the instigation of or with the consent or acquiescence of a public official or other person acting in an official capacity. • does not include pain or suffering arising only from, inherent in or incidental to lawful sanctions.

    15. UN Principles for Protection of All Persons under Any Form of Detention or Imprisonment “Cruel, Inhuman and Degrading Treatment or Punishment:” • should be interpreted so as to extend the widest possible protection against abuses, whether physical or mental, including the holding of a detained or imprisoned person in conditions which deprive him, temporarily or permanently of the use of any of his natural senses, such as sight or hearing, or of his awareness of place and the passing of time.

    16. UN Principles of Medical Ethics It is a gross contravention of medical ethics, for physicians, to [1] engage, actively or passively, in acts which constitute participation in, complicity in, to commit torture or other cruel, inhuman or degrading treatment or punishment, … [2] be involved in any relationship with prisoners or detainees the purpose of which is not solely to evaluate, protect or improve their physical and mental health, …

    17. UN Principles of Medical Ethics It is a gross contravention of medical ethics, for physicians, to [3] apply their knowledge and skills in order to assist in the interrogation of prisoners … in a manner that may adversely affect the physical or mental health or condition of such prisoners … ; certify, or to participate in the certification of the fitness of prisoners … for any treatment or punishment that may adversely affect their physical or mental health [4] participate in any procedure for restraining a prisoner … unless such a procedure is determined in accordance with purely medical criteria as being necessary for the protection of the physical or mental health or the safety of the prisoner or detainee himself … and presents no hazard to his physical or mental health.

    18. Geneva Convention • No prisoner of war may be subjected to physical mutilation or to medical or scientific experiments of any kind which are not justified by the medical treatment of the prisoner concerned and carried out in his interest. • The burial or cremation of a prisoner of war shall be preceded by a medical examination of the body. • Death certificates shall be forwarded as rapidly as possible to the Prisoner of War Information Bureau. • The death certificates shall show particulars of identity, and the date and place of death, the cause of death, the date and place of burial and all particulars necessary to identify the graves.

    19. Oath of Geneva - 1948 I will not make use of my medical knowledge contrary to the laws of humanity.

    20. Declaration of Tokyo -1975 • Torture is the deliberate, systematic or wanton infliction of physical or mental suffering by persons acting alone or on the orders of authority,. • The doctor • shall not countenance, condone or participate in torture or cruel, inhuman or degrading procedures in any situations, including armed conflict and civil strife. • shall not provide any premises, instruments, substances or knowledge to facilitate the practice of torture or other forms of cruel, inhuman or degrading treatment or to diminish the ability of the victim to resist such treatment. • shall not be present when torture or other forms of cruel, inhuman or degrading treatment are used or threatened.

    21. Regulations in Times of Armed Conflict and Other Situations of Violence • Medical ethics in times of armed conflict is identical to medical ethics in times of peace. • Physicians’ primary obligation is to their patients in all their professional activities, • Physicians should adhere to international conventions on human rights and WMA declarations on medical ethics. • Privileges and facilities afforded to physicians and other health care professionals in times of armed conflict and other situations of violence must never be used other than for health care purposes.

    22. Regulations in Times of Armed Conflict and Other Situations of Violence Physicians must in all circumstances: • Provide health care for anyone taken prisoner; • Advocate for regular physician visits to prisoners; • Advocate and provide effective and impartial care without reference to discrimination or enemy status • Give special consideration to the greater vulnerability of women and children in armed conflict and other situations of violence; • Respect the right of a family to know the fate and whereabouts of a missing family member whether or not that person is dead;

    23. Regulations in Times of Armed Conflict and Other Situations of Violence It is unethical for physicians to: • Give advice or perform prophylactic, diagnostic or therapeutic procedures that are not justifiable for the patient's health care; • Weaken the physical or mental strength of a human being without therapeutic justification; • Employ scientific knowledge to imperil health or destroy life; • Employ personal health information to facilitate interrogation; • Condone, facilitate or participate in the practice of torture or any form of cruel, inhuman or degrading treatment.

    24. Regulations in Times of Armed Conflict and Other Situations of Violence Physicians should, to the degree possible: • Refuse to obey an illegal or unethical order; • As an exception to professional confidentiality, physicians should denounce acts of torture or cruel, inhuman or degrading treatment; • Keep adequate health care records; • Give consideration to how health care personnel might mitigate violence in question, for example by reacting to violations of international human rights law. • Physicians have a duty to press governments for the provision of the infrastructure that is needed for health, including drinkable water and adequate food and shelter.

    25. WMA Code of Medical Ethics 1949 “The following practice is deemed unethical: • any act or advice which could weaken physical or mental resistance of a human being.” “A doctor should certify or testify only to that which he has personally verified.”

    26. Documentation and Denunciation of Acts of Torture or Cruel or Inhuman or Degrading Treatment NATIONAL MEDICAL ASSOCIATIONS should • Attempt to ensure that physicians include assessment and documentation of symptoms of torture or ill-treatment in the medical records using the necessary procedural safeguards to prevent endangering detainees.

    27. Declaration of Madrid • There are aspects in the history of psychiatry and in some totalitarian political regimes that increase psychiatrists’ vulnerabilities to be abused in the sense of having to acquiesce to inappropriate demands to provide inaccurate psychiatric reports that help the system, but damage the interests of the person being assessed. • Psychiatrists shall not take part in any process of mental or physical torture, even when authorities attempt to force their involvement in such acts. World Psychiatric Association

    28. Hippocratic Oath- 500BC In a pure and holy way, I will guard my life and my art and science. I will use regimens for the benefit of the ill in accordance with my ability and my judgment, but from [what is] to their harm or injustice I will keep [them]. Into as many houses as I may enter, I will go for the benefit of the ill, while being far from all voluntary and destructive injustice, If I render this oath fulfilled, may it be to me to be held in good repute among all human beings for time eternal. If, however, I transgress, the opposite of these.

    29. Rule-based Medical Board Hearings • Authoritative rules can be found in • The Codes of the World Medical Association • National medical association codes • United Nations. • Such rules provide a clear authority for opinions on professional misconduct. • Are straightforward and transparent to apply.

    30. Revoke License Suspend License Restrict to public (non-military hospital) Censure (Medical boards cannot imprison) Punishments

    31. Remove license

    32. Suspend license

    33. Restrict license to public service hospitals

    34. Statements of Censure

    35. Steven Miles MD University of Minnesota miles001@umn.edu Slides available on Request