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A follow-up investigation on the quality of medical documents from examinations of Basque incommunicado detainees
Forensic Science International 182 (2008) 57–65
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A follow-up investigation on the quality of medical documents from examinations of Basque incommunicado detainees The role of the medical doctors and national and international authorities in the prevention of ill-treatment and torture Benito Morentin a,*, Hans D. Petersen b,c, Luis F. Callado d, M. Itxaso Idoyaga e, J. Javier Meana d a
Section of Forensic Pathology, Basque Institute of Legal Medicine, Barroeta Aldamar 10, planta – 1, E-48001 Bilbao, Bizkaia, Spain International Department, Rehabilitation and Research Centre for Torture victims, Copenhagen, Denmark c Department of Medicine, Sygehus Nordsjælland, Frederikssund, Denmark d Department of Pharmacology, University of the Basque Country, Leioa, Bizkaia, Spain e Torturaren Aurkako Taldea, Bilbao, Spain b
A R T I C L E I N F O
A B S T R A C T
Article history: Received 14 November 2007 Received in revised form 27 September 2008 Accepted 2 October 2008 Available online 7 November 2008
According to the United Nations and the European Committee for the Prevention of Torture (CPT), torture and ill-treatment continues to be a problem during incommunicado detentions in Spain. CPT has visited Spain and published recommendations for improvements of preventive medical examinations. However, no scientific assessment of the impact of such recommendations exists. The objectives of this study were to assess the quality of documents from preventive medical examinations and the prevalence of alleged ill-treatment and compare findings with similar data from a previous study. Documents issued by state employed doctors describing medical examination of Basques held incommunicado during 2000–2005 were reviewed. The analysis covered allegations of ill-treatment and existence and quality of information essential for medical appraisal of allegations of ill-treatment. The material was collected by a non-governmental organisation. Of 425 documents concerning 118 persons, 85% had no formal structure and the format recommended by CPT was never used. None of 127 documents, concerning 70 persons with allegations of ill-treatment had an overall conclusion on the likelihood of ill-treatment. Twelve to 68% of necessary data were totally missing, and only 13–38% of existing information was sufficient. There was significant variation between the reporting of individual doctors, but in general the quality was unacceptable, although somewhat higher than in the previous study. The prevalence of allegations of ill-treatment was as high as previously. There were more reports of psychological ill-treatment and procedures of forced physical exhaustion, but fewer reports of beatings. In conclusion, there was no indication that the conditions of incommunicado detainees have improved substantially over the past 15 years and the standard of medical reporting was unacceptable. The Spanish authorities should give clear objectives and guidelines for medical examinations of detainees. An independent forensic specialist with the overall academic responsibility for preventive medical examinations of detainees should be employed to supervise state employed doctors. The present article shows the necessity for harmonization of medical practice in documentation of torture. ß 2008 Elsevier Ireland Ltd. All rights reserved.
Keywords: Ill-treatment Torture Police custody Forensic medicine Prevention
1. Introduction Medical examination is one of the best ways to obtain evidence of torture. In this way, medical doctors are in many countries
* Corresponding author. Tel.: +34 94 4016731; fax: +34 94 4016985. E-mail address: [email protected] (B. Morentin). 0379-0738/$ – see front matter ß 2008 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.forsciint.2008.10.002
employed by the state to perform regular examinations of detainees in police stations. However, the quality of such work has been questioned [1–5]. In a previous study, we concluded, that the quality of medical documents issued in Spain in the years 1991– 1994, describing routine examinations of detainees held incommunicado, was very low [4]. During the recent years there has been an increasing interest in ensuring that the practice of security forces towards inmates is up
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to the standard given in national law and international conventions. However, as far as we know, there has been no scientific research on the impact of measures of prevention of torture. The European Committee for the Prevention of Torture (CPT) is one of the most advanced organisations to prevent violations of the rights of detainees. From 1996 to 2003, the CPT has published seven reports from Spain describing visits to closed institutions carried out in the period 1991–2001 [6–12]. The CPT has repeatedly recommended several measures to improve the deficient reporting by forensic doctors. Thus, these reports suggest to include: (a) description of state of health and any allegations of ill-treatment; (b) the doctor’s objective medical findings based on a thorough examination; and (c) the doctor’s conclusions in the light of (a) and (b). In 1997, the Spanish Government published a standardised form for the recording of findings of forensic doctors, but it did not include allegations of ill-treatment and the doctor’s conclusions [13]. We wanted to examine whether national efforts and international visits to detention centres would be reflected in changes in the prevalence of allegations of ill-treatment of detainees held incommunicado (considered to imply the greatest risk of illtreatment), and in the quality of medical reports from examinations of detainees. Thus, the aim of this study was to appraise the quality of medical forensic documents from 2000 to 2005 and to compare these findings and the prevalence of allegations of ill-treatment with similar findings from our previous study [4]. 2. Material and methods The antiterrorist Justice Court, Audiencia Nacional (AN), is a special tribunal located in Madrid. The Spanish antiterrorist legislation allows for incommunicado detention for a period of 5 days. Forensic doctors employed by the AN (FDAN) examine detainees in the central police stations in Madrid on a daily basis, and again in the AN on the day they are presented in court. In provincial police stations, the medical examinations are usually carried out by forensic doctors of local institutions (FDLI). With the consent of the ex-detainees, we had access to 425 documents concerning medical examinations of 118 persons held incommunicado under the antiterrorist legislation in the period April 2000 to July 2005. The documents have been collected by a non-governmental organisation, Torturaren Aurkako Taldea (TAT). They represent all the documents from the studied period obtained by TAT. The TAT lawyers have obtained these documents by way of the judicial files containing the denunciations of torture. In accordance with the Helsinki Declaration, all persons gave informed consent to the TAT to study their documents [14]. Our analysis of the documents covered:
the structure of form (document) used, according to the CPT or the Spanish Government’s recommendations [6–13]; the degree of co-operation from the detainee to the anamnesis and physical examination; the existence and sufficiency of information about allegations of ill-treatment; the existence and sufficiency of information about subjective state of health; the extent of a physical examination; clinical findings indicating exposure to recent violence; the existence and quality of conclusions as to age or origin of any recent lesion; the presence of a conclusion about any allegation of ill-treatment.
We assumed that the examinee co-operated to the examination, unless the doctor stated explicitly that (s)he did not. If ill-treatment was alleged, there should be a reasonable description of presence or absence of symptoms that are common after such violence. In case of alleged beatings, these should be described as to region of the body and whether instruments, fists or open hands were used. All detainees should have the whole surface of the body examined, and when beatings were alleged there should be a description of the regions allegedly hurt. Conclusions on the age and origin of the lesions were assessed according to international standards [15–18], and classified as acceptable, unacceptable, insufficient as to premises, or questionable when not possible to fit into the first three groups.
We compared the pattern of reporting of the FDAN and the FDLI; the reporting from central police stations and from the AN; and the reporting of individual doctors. In the comparison between the two study periods [4], we used similar indicators, emphasising lack of relevant information. In our previous study we assessed the quality of 318 medical documents concerning 100 Basque detainees held incommunicado in Spain during the period 1991–1994 [4]. All these documents were revised to define their structure; likewise, their descriptions of ill-treatment were revised because the previous study focused on physical ill-treatment. There were 6 documents with allegations of psychological ill-treatment without allegations of physical ill-treatment. Thus, the number of documents with allegations of ill-treatment was 77 instead of 71, which was the value given in the published paper [4]. The statistical method used was x2 test, when necessary with Yates’ correction and Fisher’s exact test.
3. Results For the period 2000–2005, our material comprised 425 documents concerning 118 persons in the age group 19–55 years, median 26 years. Eighty-nine (75%) were men. Five FDAN issued 345 of the documents, 288 in central police stations and 57 in the AN. Twenty four FDLI issued 74 documents and 6 documents were issued by police doctors. None of the forensic documents we had access to was issued by a doctor of the detainee’s choice or by a non-state employed doctor. 3.1. The structure of the documents There was no formal structure in 363 (85%) documents. Dr. A (FDAN) used sheets, apparently self-made, with two or three headings (‘‘history’’, ‘‘examination’’ ‘‘conclusion and observations’’) in 44 (60%) of his reports. The remaining ones were without headlines. A similar structure was used by one FDLI on 8 occasions. Nine FDLI used in 10 examinations a formal format in line with the directives of the Spanish Government from 1997. Three of these documents included a subheading ‘‘ill-treatment’’ and a space for evaluation of injuries. Ninety-three documents were handwritten, 14 being only partially readable. One document by a FDLI was supplemented by photographical documentation of lesions. Two other FDLI documents included body drawings with indications of lesions. In one case of alleged electrical shocks with visible lesions, a hospital dermatologist undertook an examination that included photo documentation [19]. 3.2. The content of the documents (Table 1) Lack of co-operation to the history of exposure to ill-treatment and subjective state of health were 9 and 12%, respectively. To the physical examination, lack of co-operation was total in 178 (42%) and partial in 40 documents (9%). In 256 documents there was some information about presence or absence of exposure to alleged ill-treatment. In 127 of these documents the doctors quoted the examinees to have been illtreated. In another 129 documents, the examinee was quoted to deny ill-treatment. The terminology to describe treatment was ambiguous in 40 documents. Physical violence, mainly beatings was alleged in 66 documents. Information about symptoms related to ill-treatment was not indicated in 45 documents. This information was considered to be sufficient only in 11% of the 127 documents alleging ill-treatment. In the 66 documents with allegations of beatings, this information was assessed to be sufficient in 33% (Table 1). There was some information on subjective state of health in 280 documents. Presence of one or more symptoms was described in 187 documents. The symptoms most commonly described were
B. Morentin et al. / Forensic Science International 182 (2008) 57–65 Table 1 Basic information from the documents in 2000–2005 period. n (%) Data about ill-treatment Exposure to ill-treatment Lack of co-operation of the detainee described Not indicated data by the forensic doctor Ambiguous terminology Documents reporting ill-treatment Documents denying ill-treatment
n = 425 documents 37 (9%) 92 (22%) 40 (9%) 127 (30%) 129 (30%)
Symptoms related to alleged ill-treatment Not relevant information Not indicated data by the forensic doctor Documents with sufficient information Documents with insufficient information
n = 127 documents 22 (17%) 45 (35%) 14 (11%) 46 (36%)
Localisation of beatings in documents with allegations of beatings Not relevant information Not indicated data by the forensic doctor Documents with sufficient information Documents with insufficient information
n = 66 documents
Data about subjective state of health Lack of co-operation of the detainee described Not indicated data by the forensic doctor Type of information in documents with some information Documents describing presence of one or more symptoms Documents describing absence of symptoms Quality of the information Documents with sufficient information Documents with insufficient information Quality of the history of ill-treatment Lack of co-operation of the detainee described Documents with sufficient information Documents with insufficient information Data about physical examination Present information about if the whole body was examined Total lack of co-operation of the detainee described Partial lack of co-operation of the detainee described Not indicated data by the forensic doctor Yes Information about presence/absence of signs of recent violence Total lack of co-operation of the detainee described Not indicated data by the forensic doctor Documents describing presence of signs of recent violence Documents describing absence of signs of recent violence Explicit description of region allegedly beaten in documents with allegations of beatings Not relevant information Not indicated data by the forensic doctor Documents describing presence of signs of recent violence Documents describing absence of signs of recent violence
4 (6%) 11 (17%) 22 (33%) 29 (44%) n = 425 documents 49 (12%) 96 (23%)
187 (44%) 93 (22%) 143 (34%) 137 (32%) n = 425 documents 49 (12%) 128 (30%) 248 (58%)
n = 425 documents 178 (42%) 40 (9%) 140 (33%) 67 (16%) n = 425 documents 178 (42%) 30 (7%) 137 (32%) 80 (19%)
n = 66 documents 13 (20%) 20 (30%) 19 (29%)
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them. In documents with allegations of beatings of a particular region (n = 53), an explicit description of the region allegedly beaten was given in 33 cases, with marks indicating exposure to violence in 19. Lesions caused by handcuffs (n = 29) were not classified as indications of exposure to violence. In none of the documents the doctor indicated a request for blood tests, e.g. muscular enzymes. Our assessment of the overall sufficiency of the documents is shown in Fig. 1. Only 5% of the 425 documents had sufficient information about exposure to ill-treatment, subjective state of health and physical examination. This percentage was 3% for the documents with allegations of ill-treatment, and that figure would be nil if the presence of an acceptable conclusion would be included as a criterion. Sixteen doctors gave 64 conclusions on age and/or origin of recent signs of violence in 42 documents. There were 40 conclusions on the age; in 7 documents the lesions were appraised to have been acquired during the detention, the remaining before or during the apprehension. There were 24 conclusions on origin. In none of the 15 documents with allegations of physical illtreatment and a conclusion on origin, the doctor inferred that the lesions were compatible with allegations of ill-treatment apart from what took place in connection with a violent detention. Seventeen documents (40%) with a history of ill-treatment and clinical signs of recent violence were short of a conclusion. Only 25 of the conclusions (39%) on age or origin were acceptable; 25% were unacceptable, 27% insufficient as to premises, and 9% were questionable. All documents were short of a conclusion as to the likelihood of statements of ill-treatment. 3.3. The comparison of the reporting of FDAN and FDLI (Fig. 2) Lack of co-operation to the history of exposure to ill-treatment was a little more frequent, while lack of co-operation to the physical examination was remarkably more frequent in the FDAN documents. Omission of information about ill-treatment and signs of recent violence was more frequent in FDLI documents. However, the prevalence of allegations of ill-treatment was the same for the two groups of doctors. The percentage of documents with sufficient information was significantly higher in FDAN group for exposure to ill-treatment and subjective state of health. Conversely, sufficiency of information about symptoms related to ill-treatment was lower in FDAN (Fig. 2). Ambiguous terminology of ill-treatment was only found in documents of the FDAN, n = 40 (12% of all the documents of the FDAN) (P < .01). The comparison of documents issued in central police stations and in the AN by the FDAN revealed no difference for any of the studied variables.
14 (21%)
pain (n = 82), anxiety (n = 51), malaise (n = 25), and headache (n = 17). Our appraisal of the quality of this information is shown in Table 1. Examinations of the whole body were sparse (32% of the documents with full co-operation; 43% in documents with allegations of ill-treatment). Two hundred and seventeen documents (88% of the documents with full or partial co-operation) had some information about presence or absence of signs of recent violence. Physical findings indicating recent exposure to violence were described in 137 of
3.4. Comparison of documents by individual doctors from the AN (Fig. 3) The information in the documents of Dr. A was more often insufficient than that of Dr. B and C. Moreover, Dr. A reported illtreatment and recent signs of violence significantly less often than the others. Dr. B made fewer examinees co-operate to the history of exposure to ill-treatment and subjective state of health than the others. The documents of Dr. C had fewer omissions and were more sufficient than those of the other doctors.
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Fig. 1. Overall sufficiency of the documents.
3.5. Comparison between the periods 1991–1994 [4] and 2000–2005 The rate of documents with a formal or semiformal structure was 15% in the 2000–2005 sample and 2% in 1991–1994 (n = 318 documents) (P < .0001). The percentage of documents with allegations of ill-treatment was as high in 2000–2005 as in 1991–1994 (30% vs. 24%). Forced physical exercise and/or keeping an awkward body position for an extended period of time was alleged far more often in 2000– 2005 (P < .0001). Threats were alleged in 29 documents, and other psychological ill-treatment in 44 documents in 2000–2005, being significantly more frequent than in 1991–1994 (Table 2). Beatings and more sophisticated methods like suffocation procedure, electrical shocks, or burns were alleged more often in 1991– 1994. However, the difference was only significant for the allegations of beatings. The detainees co-operated significantly less frequently to the physical examination in the present study (58% vs. 89%) (Table 3). On the other hand, recent signs of violence were described more frequently in documents from those who cooperated to the examination in the present study.
The percentage of documents with missing information was significantly more prevalent in the first than in the second period for subjective state of health and examination of the whole body. On the contrary, the percentage of missing information for presence/absence of signs of violence was significantly higher in the second period. This data reflects the much lower rate of co-operation to the physical examination. Lack of conclusions on age and origin of lesions was more prevalent in the first than in the second study period (Table 4). Fewer conclusions as to age and/or origin of lesions were considered acceptable in the first study (1:26) than in the second (25:64) (P < .0005). 3.6. Data about detainees The documents quoting the examinees to have been ill-treated concerned 70 of the 118 detainees (59%) in the period 2000–2005. This percentage was slightly higher than in the period 1991–1994 (46%), but without statically significant differences. Physical findings indicating recent exposure to violence were described in documents concerning 54 subjects (46%) in the period
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Fig. 2. Comparison of the documents reported by FDAN (white columns; n = 345 documents) and FDLI (black columns; n = 74 documents). The six documents issued by police doctors were not included in the comparison. The percentages for ‘‘lack of co-operation’’ were calculated in relation to the total number of documents in their own group. The percentages for ‘‘not indicated information’’, ‘‘information sufficient’’ and ‘‘information present’’ were calculated in relation to the number of documents in which the detainee cooperated and the information was considered as relevant in their own group. *P < .05; **P < .01; ***P < .001.
2000–2005, the same percentage was observed in the period 1991–1994. 4. Discussion The documents of this study and the previous one were collected in the same way by the same human rights organisation. Considering that about 793 persons from the Basque Country were held under the antiterrorist legislation in 2000–2005 and that 486 (61%) of them alleged ill-treatment [20–24], our material represents, as in the first study, approximately 15% of all the Basque detainees who have been examined by state employed forensic doctors. We therefore assume that the two samples are comparable and since 59% of the present examinees alleged ill-treatment, we assume that they to some extent are representative for the whole
of the Basques who have been detained under the antiterrorist legislation. We had no access to other sources of information about the remaining approx. 85% of the Basques detained under the antiterrorist legislation. Moreover, registers containing information relevant for comparison with our study population hardly exist. Thus, no comparison can be made between the characteristics of those included and those not included in our study and we cannot rule out selection bias. This consideration reflects a general problem in epidemiologic studies of Human Rights violations: access to relevant information is limited. The prevalence of allegations of ill-treatment was higher – although not to a significant level – in the second than in the first study period. It could be argued that the level of fear among the detainees has decreased over the years between the two study periods, reflecting an improvement in their conditions, and
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Fig. 3. Comparison of the documents reported by individual doctors of the FDAN (n = 345 documents): Dr. A (white columns; n = 73 documents); Dr. B (black columns; n = 112 documents; Dr. C (hatched columns; n = 123 documents). The percentages for ‘‘lack of co-operation’’ were calculated in relation to the total number of documents in their own group. The percentages for ‘‘not indicated information’’, information sufficient’’ and ‘‘information present’’ were calculated in relation to the number of documents in which the detainee cooperated and the information was considered as relevant in their own group. *P < .05; **P < .01; ***P < .001.
Table 2 Documents with allegations of ill-treatment and types of alleged ill-treatment. Study period
1991–1994 period
2000–2005 period
P
Physical violence including beatings Suffocation with plastic bag, ‘‘la bolsa’’ Electrical shocks Procedures of physical exhaustion Psychological ill-treatment including threats
n = 77/318 (24%) 60 (78%) 24 (31%) 6 (8%) 5 (6%) 13 (17%)
n = 124/425 (30%) 66 (52%) 27 (21%) 2 (2%) 53 (43%) 61 (48%)
P < .0005 ns ns P < .0001 P < .0005
Total number and % of documents with allegations of ill-treatment. Methods with a frequency lower than 5% were excluded. ns: not statistically significant.
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Table 3 Data about physical examination. Study period
1991–1994
2000–2005
P
Full and partial co-operation to clinical examination Number of documents where information about signs of violence was not indicated Number of documents that described presence of signs of recent violence
283/318 79/283 (28%) 101/283 (36%)
247/425 30/247 (12%) 137/247 (59%)
P < .0001 P < .0001 P < .0001
Data are expressed as absolute values and percentages related to the number of documents obtained from subjects that collaborated in the physical examination.
Table 4 Information that was totally missing in the documents. Study period
1991–1994
2000–2005
All documents
(n = 318)
(n = 425)
Exposure to ill-treatment Subjective state of health Statement that the whole body was examined Physical examination
136 170 302 114
169 145 358 208
Data related to conclusions Overall conclusion on alleged ill-treatment A conclusion on age and/or origin of recent signs of violence
74 (96%) 72 (74%)
(43%) (53%) (95%) (36%)
(40%) (34%) (84%) (49%)
127 (100%) 25 (36%)
P
ns P < .0001 P < .0001 P < .0005
ns P < .0005
Missing information refers to data that were not present in the document, either due to lack of co-operation of the detainee, not indicated data by the forensic doctor or ambiguous terminology used in the document.
encouraging the ex-detainees to mention ill-treatment to the examining doctor during the detention period. However, this possibility is in contradiction with the much higher prevalence of allegations of psychological abuses incl. threats. Moreover, we noted that other forms of alleged ill-treatment have changed. In particular, we found it noteworthy that allegations physical exhaustion procedures were much more common in the second period (43% vs. 6%, P < .0001). Unless it is presupposed that a very high fraction of all the Basque detainees were instructed to falsely claim that they were ill-treated with a few specific procedures, our findings – in concordance with other reports [4,6–12,20–25] – indicate that illtreatment is frequent in some detention centres in Spain. We have analyzed the documents on their own premises, i.e. they are the doctors’ account, and the doctors have reported the detainees’ allegations of ill-treatment. The vast majority of documents were insufficient as to key elements in the appraisal of exposure to ill-treatment, but in spite of this, most of the documents with allegations of ill-treatment contained some information about ensuing symptoms and/or clinical signs of recent violence in agreement with the history of illtreatment. Thus, in general we find the detainees’ statements credible, although the premises often were insufficient and not in all cases substantiated by physical signs of violence. This assessment is in agreement with the reports from CPT and the Special Rapporteur on Torture of the UN in that torture and illtreatment continue to be a serious problem for Basques detained under the antiterrorist legislation [6–12,25]. The documents in general had serious and systematic shortcomings according to international standards [6–12,17,18]. Thus, they reflected insufficient and inadequate medical examinations aimed, among other things, at safeguarding the rights of the detainees. Accordingly, experiences from other countries with serious political conflicts show that safeguards exclusively based on intervention of state appointed forensic doctors do not function [1–5]. Other important findings were firstly the doctors’ omission of using a formal protocol in line with the recommendations of the CPT. Even the insufficient format of the Spanish Government was used only in a few cases. Thus, the forensic doctors work with little consideration to the directives of the Ministry and the recom-
mendation of the CPT. We think that the lack of a formal protocol is a crucial point and would explain many of the shortcomings of the documents and the differences among doctors in their reporting. Secondly the complete lack of conclusions as to the likelihood of alleged ill-treatment; the many omission of conclusions on age and origin of recent lesions; and the low quality of such conclusions when present. The doctors are part of a safeguarding system. The medical examination is supposed to represent a possibility for the detainee to have a professional assessment of his testimony about ill-treatment and a safeguard for police officers against false accusations. The document should give clear premises and an opinion/conclusion as to the likelihood of any allegations of illtreatment. The low quality of the documents and the complete lack of overall conclusions indicate that the doctors did not take on this responsibility. This failure in medical documentation of torture can be due to several factors: omission of using a formal protocol, lack of directives about their role as safeguards for the rights of the detainees, absence of application of elementary diagnostic procedures, lack of qualified professional supervision, lack of harmonization of medical practice and lack of expertise training plans or interchanges programs. In special situations some experts have pointed out that dual loyalty can be a factor related to the failure of the medical profession in the prevention of the human rights of the detainees [26,27]. One FDAN has stated in court that 10–15 min is sufficient to take the history of a detainee and carry out a thorough clinical examination without using a formal protocol. On such conditions it is not surprising that the quality of the documents in general was very defective. The doctors clearly need a formal protocol as a mandatory checklist. However, the protocol should also represent the objectives of medical examinations given by the involved ministries. Our findings show that the doctors need directives about their role as safeguards for the rights of the detainees, and the existing ministerial format for examinations does not fulfill this. There was some variation in the quality of the reporting of individual items by the two groups of doctors, underlining the need for a protocol, but the overall quality was equally low for the two groups. However, a remarkable finding was the much lower number of detainees who co-operated fully to the physical
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examination of the AN doctors. The characteristics for the two groups of detainees – number of allegations of ill-treatment, presence of symptoms and signs – did not differ markedly. An explanation for this highly significant difference in compliance could be dissimilarity of ‘‘the local medical cultures’’. FDAN’s own description of his professional conduct, cf. above, indicates lack of commitment and would not induce confidence from the detainees and thereby encourage compliance. Moreover, lack of privacy during the medical examination could be an important factor to diminish confidence towards the doctors. In a statement in court, a police officer testified, that the door to the office where the medical examinations took place as a rule was kept open [28]. This fact is absolutely contrary to the recommendations of the CPT [6–12]. Such factors could explain the observed difference and could reflect a way for some doctors to avoid having opinions on recent signs of violence. When comparing the two study periods, we note that in the present study period, the doctors accomplished fewer clinical examinations. However, they described recent signs of violence in more documents, in spite of the fact that fewer examinees alleged exposure to physical violence. We think that this finding reflects better standard of physical examination and reporting. This interpretation is corroborated by the observation that significantly fewer documents in the present study were short of a description of whether the examination revealed presence or absence of signs of violence. Nevertheless, practically all documents with allegations of ill-treatment were far from fulfilling international standards [6–12,17,18]. Most importantly, the number of allegations of ill-treatment in the present study was as high as in the previous study period [4]. However, the pattern of alleged ill-treatment has changed; methods that are dangerous (suffocation) and leave marks, which may be detected at a clinical examination (beatings) have to a certain extent been replaced by other methods. In this light we find it remarkable that the forensic doctors never indicated in the documents with allegations of forced physical exercise the need for an examination of muscle enzymes in serum. As described from Spain, this examination would be a valuable supplement to the clinical examination of a detainee who alleges exposure to such procedures [29]. In our opinion this omission indicates that doctors carry out their duties without any formal instructions in how to apply elementary diagnostic procedures for proper documentation of physical ill-treatment, including serum analysis and photo documentation, i.e., they lack qualified professional supervision.
5. Conclusion As it has been previously pointed out concerning other fields of forensic medicine – such as medico-legal autopsy [30] and attending detainees in police custody [31] – the present article shows the necessity for harmonization of medical practice in documentation of torture. We found serious and systematic shortcomings of the documents of the present study. Thus, in general, the doctors have failed in their role as safeguards of the rights of the detainees. Furthermore, we see no ground to believe, that the conditions of the inmates have improved substantially over the past 15 years, notwithstanding that CPT has visited Spain many times in that period and given recommendations for changes. We point to two sets of main reason for this: (a) The Ministry of Justice has not made it clear to the forensic doctors that part of their role is to detect and report possible infractions of Human Rights. In contrast, the Ministry has not
followed up to ensure that the forensic doctors comply with its – insufficient – instructions for medical examinations of detainees. (b) The doctors work without a formal protocol, and they are not supervised as to the quality of their work and reporting. We still believe that doctors with forensic expertise have an important role to safeguard the rights of detainees. However, to fulfill this role, they must carry out examinations according to a sufficient protocol. They must be independent, and they must first and foremost be concerned about their patients, work with commitment, have their professional skills updated, and be supervised. In 2006, Spain ratified the Optional Protocol to the Convention against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment (OPCAT). The OPCAT has two pillars: an international visiting mechanism with a mandate very similar to that of CPT, but with fewer resources, and a national preventive mechanism that, in many countries, shall replace already existing visiting bodies. The observed lack of substantial improvements over more than a decade with many visits of the CPT and the effort of national preventive bodies should defer the Spanish Government from, in the future, relying only on the preventive effect of the OPCAT. The responsible ministries should rethink the structure and function of existing safeguards of Human Rights in detention centres— parallel to the implementation of the OPCAT. Changes should in our opinion include the mandatory use of a sufficient medical examination format and employment of independent chief forensic doctors, preferably from the universities, with the overall academic responsibility for the medical examinations carried out in detention centres. Acknowledgements We are grateful to the staff of Torturaren Aurkako Taldea, Bilbao for the permission to analyze the documents from the archives of the organisation, for collecting the consents of the ex-detainees, and for logistic assistance; and to authorised interpreter Stina Thurø, the Rehabilitation and Research Centre for Torture Victims, Copenhagen, Denmark, for her linguistic revision of the draft manuscript. References [1] M. Heisler, A. Moreno, S. DeMonner, A. Keller, V. Iacopino, Assessment of torture and ill treatment of detainees in Mexico: attitudes and experiences of forensic physicians, JAMA 289 (2003) 2135–2143. [2] C. Reis, A.T. Ahmed, L.L. Amowitz, A.L. Kushner, M. Elahi, V. Iacopino, Physician participation in human rights abuses in southern Iraq, JAMA 291 (2004) 1480– 1486, Erratum in: JAMA 291 (2004) 2316. [3] V. Iacopino, M. Heisler, S. Pishevar, R.H. Kirschner, Physician complicity in misrepresentation and omission of evidence of torture in post detention medical examinations in Turkey, JAMA 276 (1996) 396–402. [4] H.D. Petersen, B. Morentin, L.F. Callado, J.J. Meana, M.I. Idoyaga, Assessment of the quality of medical documents issued in central police stations in Madrid, Spain: the doctor’s role in the prevention of ill-treatment, J. Forensic Sci. 47 (2002) 293– 298, Erratum in J. Forensic Sci. 47 (2002) 928. [5] C. Perera, Review of initiatives adopted for effective documentation of torture in a developing country, J. Clin. Forensic. Med. 13 (2006) 288–292. [6] European Committee for the prevention of torture and inhuman or degrading treatment or punishment (CPT), Report to the Spanish Government on the visit to Spain carried out by the European Committee for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment (CPT) from 1 to 12 April 1991. CPT/Inf (96) 9 [EN] (Part 1)—Publication Date: 5 March 1996, http:// www.cpt.coe.int/documents/esp/1996-09-inf-eng-1.htm, accessed January 30, 2007. [7] European Committee for the prevention of torture and inhuman or degrading treatment or punishment (CPT), Report to the Spanish Government on the visit to Spain carried out by the European Committee for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment (CPT) from 10 to 22 April 1994
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[17] H.D. Petersen, O.V. Rasmussen, Medical appraisal of allegations of torture and the involvement of doctors in torture, Forensic Science International 53 (1992) 97– 116. [18] D. Forrest, B. Knight, G. Hinshelwood, J. Anand, V. Tonge, A guide to writing medical reports on survivors of torture, Forensic Science International 76 (1995) 69–75. [19] L. Danielsen, O.V. Rasmussen, Dermatological findings after alleged torture, Torture 16 (2006) 108–127. [20] Torturaren Aurkako Taldea (TAT). Torture in the Basque Country, TAT annual report 2001, Bilbao 2002, http://www.stoptortura.com/liburuC.php, accessed January 30, 2007. [21] Torturaren Aurkako Taldea (TAT). Torture in the Basque Country, TAT annual report 2002, Bilbao 2003. [22] Torturaren Aurkako Taldea (TAT). Torture in the Basque Country, TAT annual report 2003, Bilbao 2004. [23] Torturaren Aurkako Taldea (TAT). Torture in the Basque Country, TAT annual report 2004, Bilbao 2005. [24] Torturaren Aurkako Taldea (TAT). Torture in the Basque Country, TAT annual report 2005, Bilbao 2006. [25] United Nations, Economic and Social Council, Report of the Special Rapporteur on the question of torture. Civil and political rights, including the question of torture and detentions. Visit to Spain, E/CN.4/2004/56/add.2, 2004, http://www. unhchr.ch/Huridocda/Huridoca.nsf/(Symbol)/E.CN.4.2004.56.Add.2.En?Opendoc ument, accessed January 30, 2007. [26] J.A. Singh, American physicians and dual royalty obligations in the ‘‘war on terror’’, BMC Med. Ethics 4 (2003) 4 http://www.biomedcentral.com/I4726939/4/4. [27] Editorial. How complicit are doctors in abuses of detainees? Lancet 364 (2004) 637–638. [28] United Nations. Economic and Social Council, Report of the Special Rapporteur on the question of torture. Civil and political rights, including the question of torture and detention. Addendum. Follow-up to the recommendations made by the Special Rapporteur. Visits to Azerbaijan, Brazil, Cameroon, Chile, Me´xico, Romania, The Russian Federation, Spain, Turkey, Uzbekistan, and Venezuela, E/CN.4/ 2006/6/Add.2,2006, http://daccessdds.un.org/doc/UNDOC/GEN/G06/119/12/ PDF/G0611912.pdf?OpenElement, accessed January 30, 2007. [29] P.M. Garamendi, Rabdomiolisis tras actividad fı´sica extenuante. A propo´sito de un caso. Cuad Med Forense 11 (2005) 183–189, http://www.scielo.isciii.es/scie lo.php?script=sci_arttext&pid=S1135-76062005000300002&Ing=es&nrm=iso, accessed January 30, 2007. [30] B. Brinkmann, Harmonization of medico-legal autopsy rules. Committee of Ministers. Council of Europe, Int. J. Leg. Med. 113 (1999) 1–14. [31] P. Chariot, P. Martel, M. Debout, Guidelines for doctors attending detainees in police custody: a consensus conference in France, Int. J. Leg. Med. (2007) (Epub ahead of print).
Contents lists available at ScienceDirect
Forensic Science International journal homepage: www.elsevier.com/locate/forsciint
A follow-up investigation on the quality of medical documents from examinations of Basque incommunicado detainees The role of the medical doctors and national and international authorities in the prevention of ill-treatment and torture Benito Morentin a,*, Hans D. Petersen b,c, Luis F. Callado d, M. Itxaso Idoyaga e, J. Javier Meana d a
Section of Forensic Pathology, Basque Institute of Legal Medicine, Barroeta Aldamar 10, planta – 1, E-48001 Bilbao, Bizkaia, Spain International Department, Rehabilitation and Research Centre for Torture victims, Copenhagen, Denmark c Department of Medicine, Sygehus Nordsjælland, Frederikssund, Denmark d Department of Pharmacology, University of the Basque Country, Leioa, Bizkaia, Spain e Torturaren Aurkako Taldea, Bilbao, Spain b
A R T I C L E I N F O
A B S T R A C T
Article history: Received 14 November 2007 Received in revised form 27 September 2008 Accepted 2 October 2008 Available online 7 November 2008
According to the United Nations and the European Committee for the Prevention of Torture (CPT), torture and ill-treatment continues to be a problem during incommunicado detentions in Spain. CPT has visited Spain and published recommendations for improvements of preventive medical examinations. However, no scientific assessment of the impact of such recommendations exists. The objectives of this study were to assess the quality of documents from preventive medical examinations and the prevalence of alleged ill-treatment and compare findings with similar data from a previous study. Documents issued by state employed doctors describing medical examination of Basques held incommunicado during 2000–2005 were reviewed. The analysis covered allegations of ill-treatment and existence and quality of information essential for medical appraisal of allegations of ill-treatment. The material was collected by a non-governmental organisation. Of 425 documents concerning 118 persons, 85% had no formal structure and the format recommended by CPT was never used. None of 127 documents, concerning 70 persons with allegations of ill-treatment had an overall conclusion on the likelihood of ill-treatment. Twelve to 68% of necessary data were totally missing, and only 13–38% of existing information was sufficient. There was significant variation between the reporting of individual doctors, but in general the quality was unacceptable, although somewhat higher than in the previous study. The prevalence of allegations of ill-treatment was as high as previously. There were more reports of psychological ill-treatment and procedures of forced physical exhaustion, but fewer reports of beatings. In conclusion, there was no indication that the conditions of incommunicado detainees have improved substantially over the past 15 years and the standard of medical reporting was unacceptable. The Spanish authorities should give clear objectives and guidelines for medical examinations of detainees. An independent forensic specialist with the overall academic responsibility for preventive medical examinations of detainees should be employed to supervise state employed doctors. The present article shows the necessity for harmonization of medical practice in documentation of torture. ß 2008 Elsevier Ireland Ltd. All rights reserved.
Keywords: Ill-treatment Torture Police custody Forensic medicine Prevention
1. Introduction Medical examination is one of the best ways to obtain evidence of torture. In this way, medical doctors are in many countries
* Corresponding author. Tel.: +34 94 4016731; fax: +34 94 4016985. E-mail address: [email protected] (B. Morentin). 0379-0738/$ – see front matter ß 2008 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.forsciint.2008.10.002
employed by the state to perform regular examinations of detainees in police stations. However, the quality of such work has been questioned [1–5]. In a previous study, we concluded, that the quality of medical documents issued in Spain in the years 1991– 1994, describing routine examinations of detainees held incommunicado, was very low [4]. During the recent years there has been an increasing interest in ensuring that the practice of security forces towards inmates is up
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to the standard given in national law and international conventions. However, as far as we know, there has been no scientific research on the impact of measures of prevention of torture. The European Committee for the Prevention of Torture (CPT) is one of the most advanced organisations to prevent violations of the rights of detainees. From 1996 to 2003, the CPT has published seven reports from Spain describing visits to closed institutions carried out in the period 1991–2001 [6–12]. The CPT has repeatedly recommended several measures to improve the deficient reporting by forensic doctors. Thus, these reports suggest to include: (a) description of state of health and any allegations of ill-treatment; (b) the doctor’s objective medical findings based on a thorough examination; and (c) the doctor’s conclusions in the light of (a) and (b). In 1997, the Spanish Government published a standardised form for the recording of findings of forensic doctors, but it did not include allegations of ill-treatment and the doctor’s conclusions [13]. We wanted to examine whether national efforts and international visits to detention centres would be reflected in changes in the prevalence of allegations of ill-treatment of detainees held incommunicado (considered to imply the greatest risk of illtreatment), and in the quality of medical reports from examinations of detainees. Thus, the aim of this study was to appraise the quality of medical forensic documents from 2000 to 2005 and to compare these findings and the prevalence of allegations of ill-treatment with similar findings from our previous study [4]. 2. Material and methods The antiterrorist Justice Court, Audiencia Nacional (AN), is a special tribunal located in Madrid. The Spanish antiterrorist legislation allows for incommunicado detention for a period of 5 days. Forensic doctors employed by the AN (FDAN) examine detainees in the central police stations in Madrid on a daily basis, and again in the AN on the day they are presented in court. In provincial police stations, the medical examinations are usually carried out by forensic doctors of local institutions (FDLI). With the consent of the ex-detainees, we had access to 425 documents concerning medical examinations of 118 persons held incommunicado under the antiterrorist legislation in the period April 2000 to July 2005. The documents have been collected by a non-governmental organisation, Torturaren Aurkako Taldea (TAT). They represent all the documents from the studied period obtained by TAT. The TAT lawyers have obtained these documents by way of the judicial files containing the denunciations of torture. In accordance with the Helsinki Declaration, all persons gave informed consent to the TAT to study their documents [14]. Our analysis of the documents covered:
the structure of form (document) used, according to the CPT or the Spanish Government’s recommendations [6–13]; the degree of co-operation from the detainee to the anamnesis and physical examination; the existence and sufficiency of information about allegations of ill-treatment; the existence and sufficiency of information about subjective state of health; the extent of a physical examination; clinical findings indicating exposure to recent violence; the existence and quality of conclusions as to age or origin of any recent lesion; the presence of a conclusion about any allegation of ill-treatment.
We assumed that the examinee co-operated to the examination, unless the doctor stated explicitly that (s)he did not. If ill-treatment was alleged, there should be a reasonable description of presence or absence of symptoms that are common after such violence. In case of alleged beatings, these should be described as to region of the body and whether instruments, fists or open hands were used. All detainees should have the whole surface of the body examined, and when beatings were alleged there should be a description of the regions allegedly hurt. Conclusions on the age and origin of the lesions were assessed according to international standards [15–18], and classified as acceptable, unacceptable, insufficient as to premises, or questionable when not possible to fit into the first three groups.
We compared the pattern of reporting of the FDAN and the FDLI; the reporting from central police stations and from the AN; and the reporting of individual doctors. In the comparison between the two study periods [4], we used similar indicators, emphasising lack of relevant information. In our previous study we assessed the quality of 318 medical documents concerning 100 Basque detainees held incommunicado in Spain during the period 1991–1994 [4]. All these documents were revised to define their structure; likewise, their descriptions of ill-treatment were revised because the previous study focused on physical ill-treatment. There were 6 documents with allegations of psychological ill-treatment without allegations of physical ill-treatment. Thus, the number of documents with allegations of ill-treatment was 77 instead of 71, which was the value given in the published paper [4]. The statistical method used was x2 test, when necessary with Yates’ correction and Fisher’s exact test.
3. Results For the period 2000–2005, our material comprised 425 documents concerning 118 persons in the age group 19–55 years, median 26 years. Eighty-nine (75%) were men. Five FDAN issued 345 of the documents, 288 in central police stations and 57 in the AN. Twenty four FDLI issued 74 documents and 6 documents were issued by police doctors. None of the forensic documents we had access to was issued by a doctor of the detainee’s choice or by a non-state employed doctor. 3.1. The structure of the documents There was no formal structure in 363 (85%) documents. Dr. A (FDAN) used sheets, apparently self-made, with two or three headings (‘‘history’’, ‘‘examination’’ ‘‘conclusion and observations’’) in 44 (60%) of his reports. The remaining ones were without headlines. A similar structure was used by one FDLI on 8 occasions. Nine FDLI used in 10 examinations a formal format in line with the directives of the Spanish Government from 1997. Three of these documents included a subheading ‘‘ill-treatment’’ and a space for evaluation of injuries. Ninety-three documents were handwritten, 14 being only partially readable. One document by a FDLI was supplemented by photographical documentation of lesions. Two other FDLI documents included body drawings with indications of lesions. In one case of alleged electrical shocks with visible lesions, a hospital dermatologist undertook an examination that included photo documentation [19]. 3.2. The content of the documents (Table 1) Lack of co-operation to the history of exposure to ill-treatment and subjective state of health were 9 and 12%, respectively. To the physical examination, lack of co-operation was total in 178 (42%) and partial in 40 documents (9%). In 256 documents there was some information about presence or absence of exposure to alleged ill-treatment. In 127 of these documents the doctors quoted the examinees to have been illtreated. In another 129 documents, the examinee was quoted to deny ill-treatment. The terminology to describe treatment was ambiguous in 40 documents. Physical violence, mainly beatings was alleged in 66 documents. Information about symptoms related to ill-treatment was not indicated in 45 documents. This information was considered to be sufficient only in 11% of the 127 documents alleging ill-treatment. In the 66 documents with allegations of beatings, this information was assessed to be sufficient in 33% (Table 1). There was some information on subjective state of health in 280 documents. Presence of one or more symptoms was described in 187 documents. The symptoms most commonly described were
B. Morentin et al. / Forensic Science International 182 (2008) 57–65 Table 1 Basic information from the documents in 2000–2005 period. n (%) Data about ill-treatment Exposure to ill-treatment Lack of co-operation of the detainee described Not indicated data by the forensic doctor Ambiguous terminology Documents reporting ill-treatment Documents denying ill-treatment
n = 425 documents 37 (9%) 92 (22%) 40 (9%) 127 (30%) 129 (30%)
Symptoms related to alleged ill-treatment Not relevant information Not indicated data by the forensic doctor Documents with sufficient information Documents with insufficient information
n = 127 documents 22 (17%) 45 (35%) 14 (11%) 46 (36%)
Localisation of beatings in documents with allegations of beatings Not relevant information Not indicated data by the forensic doctor Documents with sufficient information Documents with insufficient information
n = 66 documents
Data about subjective state of health Lack of co-operation of the detainee described Not indicated data by the forensic doctor Type of information in documents with some information Documents describing presence of one or more symptoms Documents describing absence of symptoms Quality of the information Documents with sufficient information Documents with insufficient information Quality of the history of ill-treatment Lack of co-operation of the detainee described Documents with sufficient information Documents with insufficient information Data about physical examination Present information about if the whole body was examined Total lack of co-operation of the detainee described Partial lack of co-operation of the detainee described Not indicated data by the forensic doctor Yes Information about presence/absence of signs of recent violence Total lack of co-operation of the detainee described Not indicated data by the forensic doctor Documents describing presence of signs of recent violence Documents describing absence of signs of recent violence Explicit description of region allegedly beaten in documents with allegations of beatings Not relevant information Not indicated data by the forensic doctor Documents describing presence of signs of recent violence Documents describing absence of signs of recent violence
4 (6%) 11 (17%) 22 (33%) 29 (44%) n = 425 documents 49 (12%) 96 (23%)
187 (44%) 93 (22%) 143 (34%) 137 (32%) n = 425 documents 49 (12%) 128 (30%) 248 (58%)
n = 425 documents 178 (42%) 40 (9%) 140 (33%) 67 (16%) n = 425 documents 178 (42%) 30 (7%) 137 (32%) 80 (19%)
n = 66 documents 13 (20%) 20 (30%) 19 (29%)
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them. In documents with allegations of beatings of a particular region (n = 53), an explicit description of the region allegedly beaten was given in 33 cases, with marks indicating exposure to violence in 19. Lesions caused by handcuffs (n = 29) were not classified as indications of exposure to violence. In none of the documents the doctor indicated a request for blood tests, e.g. muscular enzymes. Our assessment of the overall sufficiency of the documents is shown in Fig. 1. Only 5% of the 425 documents had sufficient information about exposure to ill-treatment, subjective state of health and physical examination. This percentage was 3% for the documents with allegations of ill-treatment, and that figure would be nil if the presence of an acceptable conclusion would be included as a criterion. Sixteen doctors gave 64 conclusions on age and/or origin of recent signs of violence in 42 documents. There were 40 conclusions on the age; in 7 documents the lesions were appraised to have been acquired during the detention, the remaining before or during the apprehension. There were 24 conclusions on origin. In none of the 15 documents with allegations of physical illtreatment and a conclusion on origin, the doctor inferred that the lesions were compatible with allegations of ill-treatment apart from what took place in connection with a violent detention. Seventeen documents (40%) with a history of ill-treatment and clinical signs of recent violence were short of a conclusion. Only 25 of the conclusions (39%) on age or origin were acceptable; 25% were unacceptable, 27% insufficient as to premises, and 9% were questionable. All documents were short of a conclusion as to the likelihood of statements of ill-treatment. 3.3. The comparison of the reporting of FDAN and FDLI (Fig. 2) Lack of co-operation to the history of exposure to ill-treatment was a little more frequent, while lack of co-operation to the physical examination was remarkably more frequent in the FDAN documents. Omission of information about ill-treatment and signs of recent violence was more frequent in FDLI documents. However, the prevalence of allegations of ill-treatment was the same for the two groups of doctors. The percentage of documents with sufficient information was significantly higher in FDAN group for exposure to ill-treatment and subjective state of health. Conversely, sufficiency of information about symptoms related to ill-treatment was lower in FDAN (Fig. 2). Ambiguous terminology of ill-treatment was only found in documents of the FDAN, n = 40 (12% of all the documents of the FDAN) (P < .01). The comparison of documents issued in central police stations and in the AN by the FDAN revealed no difference for any of the studied variables.
14 (21%)
pain (n = 82), anxiety (n = 51), malaise (n = 25), and headache (n = 17). Our appraisal of the quality of this information is shown in Table 1. Examinations of the whole body were sparse (32% of the documents with full co-operation; 43% in documents with allegations of ill-treatment). Two hundred and seventeen documents (88% of the documents with full or partial co-operation) had some information about presence or absence of signs of recent violence. Physical findings indicating recent exposure to violence were described in 137 of
3.4. Comparison of documents by individual doctors from the AN (Fig. 3) The information in the documents of Dr. A was more often insufficient than that of Dr. B and C. Moreover, Dr. A reported illtreatment and recent signs of violence significantly less often than the others. Dr. B made fewer examinees co-operate to the history of exposure to ill-treatment and subjective state of health than the others. The documents of Dr. C had fewer omissions and were more sufficient than those of the other doctors.
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Fig. 1. Overall sufficiency of the documents.
3.5. Comparison between the periods 1991–1994 [4] and 2000–2005 The rate of documents with a formal or semiformal structure was 15% in the 2000–2005 sample and 2% in 1991–1994 (n = 318 documents) (P < .0001). The percentage of documents with allegations of ill-treatment was as high in 2000–2005 as in 1991–1994 (30% vs. 24%). Forced physical exercise and/or keeping an awkward body position for an extended period of time was alleged far more often in 2000– 2005 (P < .0001). Threats were alleged in 29 documents, and other psychological ill-treatment in 44 documents in 2000–2005, being significantly more frequent than in 1991–1994 (Table 2). Beatings and more sophisticated methods like suffocation procedure, electrical shocks, or burns were alleged more often in 1991– 1994. However, the difference was only significant for the allegations of beatings. The detainees co-operated significantly less frequently to the physical examination in the present study (58% vs. 89%) (Table 3). On the other hand, recent signs of violence were described more frequently in documents from those who cooperated to the examination in the present study.
The percentage of documents with missing information was significantly more prevalent in the first than in the second period for subjective state of health and examination of the whole body. On the contrary, the percentage of missing information for presence/absence of signs of violence was significantly higher in the second period. This data reflects the much lower rate of co-operation to the physical examination. Lack of conclusions on age and origin of lesions was more prevalent in the first than in the second study period (Table 4). Fewer conclusions as to age and/or origin of lesions were considered acceptable in the first study (1:26) than in the second (25:64) (P < .0005). 3.6. Data about detainees The documents quoting the examinees to have been ill-treated concerned 70 of the 118 detainees (59%) in the period 2000–2005. This percentage was slightly higher than in the period 1991–1994 (46%), but without statically significant differences. Physical findings indicating recent exposure to violence were described in documents concerning 54 subjects (46%) in the period
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Fig. 2. Comparison of the documents reported by FDAN (white columns; n = 345 documents) and FDLI (black columns; n = 74 documents). The six documents issued by police doctors were not included in the comparison. The percentages for ‘‘lack of co-operation’’ were calculated in relation to the total number of documents in their own group. The percentages for ‘‘not indicated information’’, ‘‘information sufficient’’ and ‘‘information present’’ were calculated in relation to the number of documents in which the detainee cooperated and the information was considered as relevant in their own group. *P < .05; **P < .01; ***P < .001.
2000–2005, the same percentage was observed in the period 1991–1994. 4. Discussion The documents of this study and the previous one were collected in the same way by the same human rights organisation. Considering that about 793 persons from the Basque Country were held under the antiterrorist legislation in 2000–2005 and that 486 (61%) of them alleged ill-treatment [20–24], our material represents, as in the first study, approximately 15% of all the Basque detainees who have been examined by state employed forensic doctors. We therefore assume that the two samples are comparable and since 59% of the present examinees alleged ill-treatment, we assume that they to some extent are representative for the whole
of the Basques who have been detained under the antiterrorist legislation. We had no access to other sources of information about the remaining approx. 85% of the Basques detained under the antiterrorist legislation. Moreover, registers containing information relevant for comparison with our study population hardly exist. Thus, no comparison can be made between the characteristics of those included and those not included in our study and we cannot rule out selection bias. This consideration reflects a general problem in epidemiologic studies of Human Rights violations: access to relevant information is limited. The prevalence of allegations of ill-treatment was higher – although not to a significant level – in the second than in the first study period. It could be argued that the level of fear among the detainees has decreased over the years between the two study periods, reflecting an improvement in their conditions, and
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Fig. 3. Comparison of the documents reported by individual doctors of the FDAN (n = 345 documents): Dr. A (white columns; n = 73 documents); Dr. B (black columns; n = 112 documents; Dr. C (hatched columns; n = 123 documents). The percentages for ‘‘lack of co-operation’’ were calculated in relation to the total number of documents in their own group. The percentages for ‘‘not indicated information’’, information sufficient’’ and ‘‘information present’’ were calculated in relation to the number of documents in which the detainee cooperated and the information was considered as relevant in their own group. *P < .05; **P < .01; ***P < .001.
Table 2 Documents with allegations of ill-treatment and types of alleged ill-treatment. Study period
1991–1994 period
2000–2005 period
P
Physical violence including beatings Suffocation with plastic bag, ‘‘la bolsa’’ Electrical shocks Procedures of physical exhaustion Psychological ill-treatment including threats
n = 77/318 (24%) 60 (78%) 24 (31%) 6 (8%) 5 (6%) 13 (17%)
n = 124/425 (30%) 66 (52%) 27 (21%) 2 (2%) 53 (43%) 61 (48%)
P < .0005 ns ns P < .0001 P < .0005
Total number and % of documents with allegations of ill-treatment. Methods with a frequency lower than 5% were excluded. ns: not statistically significant.
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Table 3 Data about physical examination. Study period
1991–1994
2000–2005
P
Full and partial co-operation to clinical examination Number of documents where information about signs of violence was not indicated Number of documents that described presence of signs of recent violence
283/318 79/283 (28%) 101/283 (36%)
247/425 30/247 (12%) 137/247 (59%)
P < .0001 P < .0001 P < .0001
Data are expressed as absolute values and percentages related to the number of documents obtained from subjects that collaborated in the physical examination.
Table 4 Information that was totally missing in the documents. Study period
1991–1994
2000–2005
All documents
(n = 318)
(n = 425)
Exposure to ill-treatment Subjective state of health Statement that the whole body was examined Physical examination
136 170 302 114
169 145 358 208
Data related to conclusions Overall conclusion on alleged ill-treatment A conclusion on age and/or origin of recent signs of violence
74 (96%) 72 (74%)
(43%) (53%) (95%) (36%)
(40%) (34%) (84%) (49%)
127 (100%) 25 (36%)
P
ns P < .0001 P < .0001 P < .0005
ns P < .0005
Missing information refers to data that were not present in the document, either due to lack of co-operation of the detainee, not indicated data by the forensic doctor or ambiguous terminology used in the document.
encouraging the ex-detainees to mention ill-treatment to the examining doctor during the detention period. However, this possibility is in contradiction with the much higher prevalence of allegations of psychological abuses incl. threats. Moreover, we noted that other forms of alleged ill-treatment have changed. In particular, we found it noteworthy that allegations physical exhaustion procedures were much more common in the second period (43% vs. 6%, P < .0001). Unless it is presupposed that a very high fraction of all the Basque detainees were instructed to falsely claim that they were ill-treated with a few specific procedures, our findings – in concordance with other reports [4,6–12,20–25] – indicate that illtreatment is frequent in some detention centres in Spain. We have analyzed the documents on their own premises, i.e. they are the doctors’ account, and the doctors have reported the detainees’ allegations of ill-treatment. The vast majority of documents were insufficient as to key elements in the appraisal of exposure to ill-treatment, but in spite of this, most of the documents with allegations of ill-treatment contained some information about ensuing symptoms and/or clinical signs of recent violence in agreement with the history of illtreatment. Thus, in general we find the detainees’ statements credible, although the premises often were insufficient and not in all cases substantiated by physical signs of violence. This assessment is in agreement with the reports from CPT and the Special Rapporteur on Torture of the UN in that torture and illtreatment continue to be a serious problem for Basques detained under the antiterrorist legislation [6–12,25]. The documents in general had serious and systematic shortcomings according to international standards [6–12,17,18]. Thus, they reflected insufficient and inadequate medical examinations aimed, among other things, at safeguarding the rights of the detainees. Accordingly, experiences from other countries with serious political conflicts show that safeguards exclusively based on intervention of state appointed forensic doctors do not function [1–5]. Other important findings were firstly the doctors’ omission of using a formal protocol in line with the recommendations of the CPT. Even the insufficient format of the Spanish Government was used only in a few cases. Thus, the forensic doctors work with little consideration to the directives of the Ministry and the recom-
mendation of the CPT. We think that the lack of a formal protocol is a crucial point and would explain many of the shortcomings of the documents and the differences among doctors in their reporting. Secondly the complete lack of conclusions as to the likelihood of alleged ill-treatment; the many omission of conclusions on age and origin of recent lesions; and the low quality of such conclusions when present. The doctors are part of a safeguarding system. The medical examination is supposed to represent a possibility for the detainee to have a professional assessment of his testimony about ill-treatment and a safeguard for police officers against false accusations. The document should give clear premises and an opinion/conclusion as to the likelihood of any allegations of illtreatment. The low quality of the documents and the complete lack of overall conclusions indicate that the doctors did not take on this responsibility. This failure in medical documentation of torture can be due to several factors: omission of using a formal protocol, lack of directives about their role as safeguards for the rights of the detainees, absence of application of elementary diagnostic procedures, lack of qualified professional supervision, lack of harmonization of medical practice and lack of expertise training plans or interchanges programs. In special situations some experts have pointed out that dual loyalty can be a factor related to the failure of the medical profession in the prevention of the human rights of the detainees [26,27]. One FDAN has stated in court that 10–15 min is sufficient to take the history of a detainee and carry out a thorough clinical examination without using a formal protocol. On such conditions it is not surprising that the quality of the documents in general was very defective. The doctors clearly need a formal protocol as a mandatory checklist. However, the protocol should also represent the objectives of medical examinations given by the involved ministries. Our findings show that the doctors need directives about their role as safeguards for the rights of the detainees, and the existing ministerial format for examinations does not fulfill this. There was some variation in the quality of the reporting of individual items by the two groups of doctors, underlining the need for a protocol, but the overall quality was equally low for the two groups. However, a remarkable finding was the much lower number of detainees who co-operated fully to the physical
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examination of the AN doctors. The characteristics for the two groups of detainees – number of allegations of ill-treatment, presence of symptoms and signs – did not differ markedly. An explanation for this highly significant difference in compliance could be dissimilarity of ‘‘the local medical cultures’’. FDAN’s own description of his professional conduct, cf. above, indicates lack of commitment and would not induce confidence from the detainees and thereby encourage compliance. Moreover, lack of privacy during the medical examination could be an important factor to diminish confidence towards the doctors. In a statement in court, a police officer testified, that the door to the office where the medical examinations took place as a rule was kept open [28]. This fact is absolutely contrary to the recommendations of the CPT [6–12]. Such factors could explain the observed difference and could reflect a way for some doctors to avoid having opinions on recent signs of violence. When comparing the two study periods, we note that in the present study period, the doctors accomplished fewer clinical examinations. However, they described recent signs of violence in more documents, in spite of the fact that fewer examinees alleged exposure to physical violence. We think that this finding reflects better standard of physical examination and reporting. This interpretation is corroborated by the observation that significantly fewer documents in the present study were short of a description of whether the examination revealed presence or absence of signs of violence. Nevertheless, practically all documents with allegations of ill-treatment were far from fulfilling international standards [6–12,17,18]. Most importantly, the number of allegations of ill-treatment in the present study was as high as in the previous study period [4]. However, the pattern of alleged ill-treatment has changed; methods that are dangerous (suffocation) and leave marks, which may be detected at a clinical examination (beatings) have to a certain extent been replaced by other methods. In this light we find it remarkable that the forensic doctors never indicated in the documents with allegations of forced physical exercise the need for an examination of muscle enzymes in serum. As described from Spain, this examination would be a valuable supplement to the clinical examination of a detainee who alleges exposure to such procedures [29]. In our opinion this omission indicates that doctors carry out their duties without any formal instructions in how to apply elementary diagnostic procedures for proper documentation of physical ill-treatment, including serum analysis and photo documentation, i.e., they lack qualified professional supervision.
5. Conclusion As it has been previously pointed out concerning other fields of forensic medicine – such as medico-legal autopsy [30] and attending detainees in police custody [31] – the present article shows the necessity for harmonization of medical practice in documentation of torture. We found serious and systematic shortcomings of the documents of the present study. Thus, in general, the doctors have failed in their role as safeguards of the rights of the detainees. Furthermore, we see no ground to believe, that the conditions of the inmates have improved substantially over the past 15 years, notwithstanding that CPT has visited Spain many times in that period and given recommendations for changes. We point to two sets of main reason for this: (a) The Ministry of Justice has not made it clear to the forensic doctors that part of their role is to detect and report possible infractions of Human Rights. In contrast, the Ministry has not
followed up to ensure that the forensic doctors comply with its – insufficient – instructions for medical examinations of detainees. (b) The doctors work without a formal protocol, and they are not supervised as to the quality of their work and reporting. We still believe that doctors with forensic expertise have an important role to safeguard the rights of detainees. However, to fulfill this role, they must carry out examinations according to a sufficient protocol. They must be independent, and they must first and foremost be concerned about their patients, work with commitment, have their professional skills updated, and be supervised. In 2006, Spain ratified the Optional Protocol to the Convention against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment (OPCAT). The OPCAT has two pillars: an international visiting mechanism with a mandate very similar to that of CPT, but with fewer resources, and a national preventive mechanism that, in many countries, shall replace already existing visiting bodies. The observed lack of substantial improvements over more than a decade with many visits of the CPT and the effort of national preventive bodies should defer the Spanish Government from, in the future, relying only on the preventive effect of the OPCAT. The responsible ministries should rethink the structure and function of existing safeguards of Human Rights in detention centres— parallel to the implementation of the OPCAT. Changes should in our opinion include the mandatory use of a sufficient medical examination format and employment of independent chief forensic doctors, preferably from the universities, with the overall academic responsibility for the medical examinations carried out in detention centres. Acknowledgements We are grateful to the staff of Torturaren Aurkako Taldea, Bilbao for the permission to analyze the documents from the archives of the organisation, for collecting the consents of the ex-detainees, and for logistic assistance; and to authorised interpreter Stina Thurø, the Rehabilitation and Research Centre for Torture Victims, Copenhagen, Denmark, for her linguistic revision of the draft manuscript. References [1] M. Heisler, A. Moreno, S. DeMonner, A. Keller, V. Iacopino, Assessment of torture and ill treatment of detainees in Mexico: attitudes and experiences of forensic physicians, JAMA 289 (2003) 2135–2143. [2] C. Reis, A.T. Ahmed, L.L. Amowitz, A.L. Kushner, M. Elahi, V. Iacopino, Physician participation in human rights abuses in southern Iraq, JAMA 291 (2004) 1480– 1486, Erratum in: JAMA 291 (2004) 2316. [3] V. Iacopino, M. Heisler, S. Pishevar, R.H. Kirschner, Physician complicity in misrepresentation and omission of evidence of torture in post detention medical examinations in Turkey, JAMA 276 (1996) 396–402. [4] H.D. Petersen, B. Morentin, L.F. Callado, J.J. Meana, M.I. Idoyaga, Assessment of the quality of medical documents issued in central police stations in Madrid, Spain: the doctor’s role in the prevention of ill-treatment, J. Forensic Sci. 47 (2002) 293– 298, Erratum in J. Forensic Sci. 47 (2002) 928. [5] C. Perera, Review of initiatives adopted for effective documentation of torture in a developing country, J. Clin. Forensic. Med. 13 (2006) 288–292. [6] European Committee for the prevention of torture and inhuman or degrading treatment or punishment (CPT), Report to the Spanish Government on the visit to Spain carried out by the European Committee for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment (CPT) from 1 to 12 April 1991. CPT/Inf (96) 9 [EN] (Part 1)—Publication Date: 5 March 1996, http:// www.cpt.coe.int/documents/esp/1996-09-inf-eng-1.htm, accessed January 30, 2007. [7] European Committee for the prevention of torture and inhuman or degrading treatment or punishment (CPT), Report to the Spanish Government on the visit to Spain carried out by the European Committee for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment (CPT) from 10 to 22 April 1994
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