INTRODUCTION

This report, prepared at the request of the Truth and Reconciliation Commission in South Africa, examines the role that health professionals played in helping or hindering the promotion of human rights during the apartheid period and considers the legacy of apartheid for health care in South Africa. The report shows the variety of ways in which the culture and legal structure of apartheid continue to influence practices within the health sector and have left a system of institutions in the government and in the professions that are ill-equipped to prevent abuses. Accordingly, the report explores ways to develop a health system and assure professional standards of behavior in South Africa consistent with international human rights and ethical norms. It also recommends ways to nurture a culture that supports health and human rights within the health professions, official regulatory bodies, and community-based organizations. Additionally, the report considers how to hold perpetrators of violations accountable for their actions.

Under international human rights and humanitarian law, as well as codes of professional medical ethics, health professionals have a responsibility to protect and promote all human rights. Human rights violations have devastating health consequences, and protecting and promoting human rights also contribute to providing the conditions for health and well-being. Members of the health professions have considerable opportunities to fulfill these duties: they may be among the first witnesses of violence and human rights violations. They may care for persons injured during civil unrest. They may be called upon to provide medical care to victims of torture or to investigate suspicious deaths in custody. They themselves may experience violations of human rights because of their personal or professional beliefs or activities. And they may practice in health care institutions that systematically discriminate against people who are members of certain racial or ethnic groups.

During apartheid, health professionals in South Africa had the unenviable challenge of working in a system that attempted to subordinate their ethical and human rights responsibilities to political decisions about appropriate health care for each legally defined racial group. While some health professionals acted with great courage and conviction to uphold ethical standards, the majority did not. Many health professionals acted to reinforce apartheid even when not legally required to do so.

A. Background of the Report

In late 1996, the South African Truth and Reconciliation Commission (TRC) invited the Science and Human Rights Program (the Program) of the American Association for the Advancement of Science (AAAS) to participate in their evaluation of human rights violations in the health care sector. The invitation reflected the TRC's appreciation of earlier AAAS work on health and human rights in South Africa and ongoing collaboration between the Science and Human Rights Program and the TRC. In 1987, the Program sponsored the research and published a study entitled Turning a Blind Eye? Medical Accountability and the Prevention of Torture in South Africa¹, which documented the failure of district surgeons to protect the health of their detainee patients and prevent their being tortured and abused by prison authorities. In 1989, AAAS conducted a medical mission of inquiry to South Africa by sending a six-member delegation, representing four U.S. medical and scientific organizations, to examine health and human rights issues. The team's report, Apartheid Medicine: Health and Human Rights in South
Africa,² examined how legal structures and the culture of apartheid resulted in massive human rights violations by individuals and institutions in the health care sector. Since January 1996, the Program has been providing scientific and professional assistance to the TRC Research Department.

To fulfill the TRC's request, AAAS assembled a consultative team, including the U.S.-based non-governmental organization (NGO) Physicians for Human Rights (PHR), as co-sponsor. Other participating NGOs include the Committee for Health in Southern Africa (CHISA), and the American Nurses Association (ANA). Appendix A provides a list of the members of the consultative team and their affiliations.

The consultative team undertook the following tasks as contributions to the TRC medical sector review:

1. It suggested a series of themes to frame specific questions for those making submissions to the TRC health sector hearings; these themes were forwarded to the TRC in March 1997.

2. It prepared a preliminary submission for the TRC's health sector hearings based on the research published in Turning a Blind Eye? and Apartheid Medicine, augmented by more recently published data. This submission specifically focused on international human rights and ethical standards and the failure of district surgeons to perform their duties in compliance with agreed-upon national and international codes of human rights law and professional ethics.

3. Members of the team attended the TRC health sector hearings in June 1997 and made a presentation based on their preliminary submission.

4. Staff of AAAS and PHR and members of the team conducted more than 100 interviews with health professionals, academics, government officials, representatives of community organizations and others, to be better able to develop recommendations to the TRC on overcoming the legacy of apartheid era abuses and fostering a human rights culture in the health care sector. In March 1997, staff members of AAAS and PHR visited South Africa to begin the interview process. Building on this initial work, ten members of the team each spent between ten days and six weeks in South Africa during June and July 1997 to undertake site visits, conduct interviews, and collect publications, unpublished papers, and documents.

This report represents the product of these efforts. It has seven chapters. The remainder of the introduction considers international human rights standards protecting health and the right to health and physicians' responsibilities under international medical codes and South African law. The second chapter provides a brief overview of the nature of the apartheid system and its impact on the health sector. The third chapter examines patterns of apartheid era human rights abuses. The fourth chapter undertakes an analysis of various aspects of the health sector under the apartheid system, including professional associations, professional regulatory bodies, the education and training of physicians, the role of district surgeons, forensic practices, and the military. The fifth chapter assesses the underlying causes of human rights violations in the health sector. The sixth chapter presents a series of recommendations on reforms relating to professional ethics, professional discipline, health system regulation, monitoring, the human rights component of professional education and training, the role of district surgeons, and forensic services. Recommendations for legislative changes are included. Finally, as a delegation from the United States, we thought it appropriate to examine the implications of our work for our own country, and the report concludes by doing so.

B. Health and Human Rights: The Role
of Health Professionals

The TRC's mandate is to determine "as complete a picture as possible of the causes, nature and extent of the gross violations of human rights…including the antecedents, circumstances, factors and contexts of such violations" and to compile "a report providing as comprehensive account as possible of the activities and findings…and which contains recommendations of measures to prevent the future violations of human rights."³ In addition, the TRC must "make recommendations to the President with regard to the creation of institutions conducive to a stable and fair society and the institutional, administrative and legislative measures which should be taken or introduced in order to prevent the commission of violations of human rights."⁴ Gross violations include killing, abduction, torture, and severe ill-treatment.

In order to understand the causes and nature of such gross violations of human rights, we believe that it is important to consider the manner in which the apartheid system affected all rights, both those rights categorized as civil and political rights and those labeled as economic, social and cultural rights. In considering the apartheid context in which health professionals functioned, it is relevant to take the following factors into account:

1. Gross violations are greatly facilitated by legal abridgments of the rights to free expression, association, movement and due process;
2. Grievous discrepancies in economic and social status, education, housing, work opportunities, access to health services, basic nutrition and public health programs in and of themselves constitute severe ill-treatment;

3. Systematic violations of economic, social and cultural rights represent a fundamental disregard for the inherent dignity of fellow members of the human family and thus may be antecedent causes of civil and political rights violations;

4. Enforcement of discrepancies in economic, social and cultural rights depends largely on abridgment of civil and political rights; and

5. Moral disengagement by perpetrators of violence often hinges on the view that their victims are somehow less human than they are because of the political culture under which they live.

Systematic disparities in economic, social and cultural rights represent a form of structural violence that had become so ingrained in South African society that the relationship between these human rights violations and more "gross violations" of human rights deserves special attention. The AAAS's Apartheid Medicine report documents disparities in equity and access to health care, education, and health status, as well as segregation in medical education and the delivery of health services.

Throughout history, society has charged healers with the duty of understanding and alleviating causes of human suffering. In the past century, the world has witnessed ongoing epidemics of armed conflicts and violations of international human rights, epidemics that have devastated and continue to devastate the health and well-being of humanity. As we enter the twenty-first century, the nature and extent of human suffering has compelled health providers to redefine their understanding of health and the scope of their professional interests and responsibilities.

Health professionals have a responsibility to protect and promote all human rights. This is the case not only because human rights violations have devastating health consequences, but because protecting and promoting human rights (civil, political, economic, social and cultural) may be the most effective means to providing the conditions for health and well-being.

However, health professionals throughout the world have been ill-equipped to address suffering caused by armed conflicts and human rights abuses. Medical and health concerns in the twentieth century have dealt almost exclusively with the diagnosis, treatment and prevention of disease. Traditional disease concerns often fail to recognize the physical, psychological and social health consequences of violations of human rights and humanitarian law. In contemporary medical practice, rational and empirical traditions that form the basis of scientific thought largely reduce the complex phenomenon of suffering to the concern of disease: its diagnosis, treatment and prevention. By decontextualizing suffering and neglecting the social conditions that affect health and well-being, health providers marginalize their roles in society.

Furthermore, medical codes of ethics tend to focus narrowly on the provider-patient relationship, thereby neglecting the institutional context in which health professionals function. Principles of bioethics, such as beneficence, non-maleficence, confidentiality, autonomy and informed consent aim to regulate the conduct of physicians in their encounters with individual patients. They do not, however, generally address interference with health care and well-being by the state.

In South Africa, as in the United States and other countries, narrow conceptualizations of health and the ethical responsibilities of health professionals have contributed greatly to silence and inaction in the face of the suffering caused by human rights violations. Although some progressive health professionals in South Africa worked for the protection and promotion of human rights during apartheid, most did not.

Increasingly, health professionals are recognizing the importance of protecting and promoting human rights as necessary preconditions for individual and community health. When health is defined as "complete physical, mental and social well-being, and not just the absence of disease or infirmity,"⁵ health professionals recognize an ethical responsibility to protect and promote human rights in order to provide the conditions for health and well-being. In this regard, progressive health professionals in South Africa who have worked for the protection and promotion of human rights have made important contributions to establishing a culture of human rights in the health sector. However, human rights concerns have not yet been formally integrated into the curricular studies of health professionals. Health professionals in South Africa and around the world face immense challenges in addressing human rights concerns and engaging in human rights education. The extent of human rights violations, the complexity of their causes, and enormity of their consequences make for extraordinarily difficult and emotionally challenging work. Despite such challenges, evolving international standards demand that health professionals adopt adherence to human rights as a fundamental component of health care.

C. Health and International Human Rights Law

Beginning with the Universal Declaration of Human Rights, adopted by the United Nations General Assembly in 1948, the international community has drafted a series of instruments that recognize the inherent dignity and the equal and inalienable rights of all members of the human family. The Universal Declaration, broadly considered to be a common standard of achievement for all peoples and nations, enumerates some two dozen specific rights to which all persons are entitled without distinction of any kind, such as race, color, sex, language, religion, political or other opinion, national or social origin, property, birth or other status. Two fundamental protections are the right to life, liberty and security of person (article 3) and the right to freedom from discrimination (article 7). Other civil and political rights that are articulated include freedom from torture and cruel, inhuman, or degrading punishment (article 5), freedom from arbitrary arrest and detention (article 9), and the right to a fair trial (article 10). In addition, the text of the Universal Declaration sets forth a series of social and economic rights, among them, that "everyone has a right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing, and medical care and necessary social services" (article 25).⁶

The principles enumerated in the Universal Declaration are further developed in a series of human rights conventions. States that ratify these instruments and thereby become states parties are legally bound by their provisions. Well over 130 countries have ratified the two most important of these instruments: the International Covenant on Civil and Political Rights and the International Covenant on Economic, Social and Cultural Rights.

Among its provisions, the International Covenant on Civil and Political Rights incorporates protections for the right to life, security of the person, and freedom to seek, receive, and impart information, all of which are relevant to the health care sector.⁷ In addition, Article 7 of the International Covenant on Civil and Political Rights incorporates protections
against torture and cruel, inhuman or degrading treatment or punishment.⁸ These latter provisions are further amplified in the Convention Against Torture and Other Cruel Inhuman or Degrading Treatment or Punishment. Among its protections, Article 10 instructs states parties to ensure that education and information regarding the prohibition against torture are fully included in the training of medical personnel.⁹

Of the major international human rights instruments, the International Covenant on Economic, Social and Cultural Rights provides the fullest and most definitive conception of the right to health. Article 12 of the International Covenant on Economic, Social and Cultural Rights "recognizes the right of everyone to the enjoyment of the highest attainable standard of physical and mental health."¹⁰ To achieve this goal, it mandates states parties to undertake the following steps:

a) The provision for the reduction of the stillbirth-rate and of infant mortality and for the healthy development of the child;

b) The improvement of all aspects of environmental and industrial hygiene;

c) The prevention, treatment and control of epidemic, endemic, occupational and other diseases;

d) The creation of conditions which would assure medical service and medical attention to all in the event of sickness.¹¹

Also relevant to the health sector, under the terms of the International Convention on the Elimination of All Forms of Racial Discrimination, states parties undertake to prohibit and eliminate racial discrimination in all its forms and to guarantee, without distinction as to race, color, national or ethnic origin, the enjoyment of the right to public health and medical care.¹² The Convention on the Elimination of All Forms of Discrimination Against Women directs states parties to take all appropriate measures to eliminate discrimination against women in the field of health care and to ensure equality of access to health care services, including those related to family planning, pregnancy, confinement and the post-natal period, granting free services where necessary.¹³ Similarly, the Convention on the Rights of the Child extends provisions of the right to health enumerated in the International Covenant on Economic, Social and Cultural Rights to children and mandates that states parties take appropriate measures to diminish infant and child mortality; ensure the provision of necessary medical assistance and health care to all children, with emphasis on the development of primary care; combat disease and malnutrition; provide clean drinking water; and combat the dangers and risks of environmental pollution.¹⁴

D. International Medical Codes of Ethics

International medical ethical principles unequivocally provide that physicians, nurses, and other health professionals have the professional duty of care to patients. This applies to the treatment of detainees regardless of whether a health professional has an obligation to a third party such as a state institution. This section reviews three aspects of medical ethics often violated under apartheid, especially in the care of detainees: health professionals' duties regarding torture, the non-discriminatory provision of medical care, and confidentiality.

1. Physicians' duties regarding torture

Under circumstances where doctors are employed by the government or a third party, they retain a duty (1) to provide care to the patients they examine or treat, (2) not to participate in torture in any way, and (3) to document acts of torture, and cruel, inhuman or degrading treatment. The Convention Against Torture, 1984, defines torture as:

…any act by which severe pain or suffering, whether physical or mental, is intentionally inflicted on a person for such purposes as obtaining from him or a third person information or a confession, punishing him for an act he or a third person has committed or is suspected of having committed, or intimidating or coercing him or a third person for any reason based on discrimination of any kind, 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.¹⁵

The duties and obligations are clear: physicians must not collaborate in any way with state-sponsored torture.

The obligations of physicians treating prisoners and detainees are set forth under the Principles of Medical Ethics Relevant to the Role of Health Personnel, Particularly Physicians, in the Protection of Prisoners and Detainees Against Torture and Other Cruel, Inhuman, or Degrading Treatment or Punishment.¹⁶ These Principles specifically address the obligations of physicians under internationally accepted standards of medical ethics. The Principles are intended to prevent any direct or indirect participation by physicians in torture:

Principle 2: It is a gross contravention of medical ethics, as well as an offense under applicable international instruments, for health personnel, particularly physicians, to engage, actively or passively, in acts which constitute participation in, complicity in, incitement to or attempts to commit torture or other cruel, inhuman or degrading treatment or punishment.

Principle 3: It is a gross contravention of medical ethics for health personnel, particularly physicians, to be involved in any professional relationship with prisoners or detainees the purpose of which is not to solely evaluate, protect or improve their physical and mental health.

The Declaration of Tokyo¹⁷ not only prohibits physician complicity in torture, but also calls for complete clinical independence in caring for the person for whom the physician is responsible, and support for doctors who face threat of reprisals resulting from a refusal to condone the use of torture:

Article 1: The doctor shall not countenance, condone or participate in the practice of torture or other forms of cruel, inhuman, or degrading procedures.

Article 2: The doctor shall not provide any premises, instruments, substances or knowledge to facilitate torture or other forms of cruel, inhuman, or degrading treatment.

Article 3: The doctor shall not be present during any procedure during which torture or other forms of cruel, inhuman or degrading treatment is used or threatened.

Article 4: A doctor must have complete clinical independence in deciding upon the care of a person for whom he or she is medically responsible. The fundamental role is to alleviate the distress of his or her fellow men, and no motive, whether personal, collective or political shall prevail against this higher purpose.

Article 5: Where a prisoner refuses nourishment and is considered by the doctor as capable of forming an unimpaired and rational judgment concerning the consequences of such a voluntary refusal of nourishment, he or she shall not be fed artificially. The decision as to the capacity of the prisoner to form such a judgment should be confirmed by at least one other independent doctor. The consequences of the refusal of nourishment shall be explained by the doctor to the prisoner.

Article 6: The WMA will support, and should encourage the international community, the national medical associations and fellow doctors, to support the doctor and his or her family in the face of threats or reprisals resulting from a refusal to condone the use of torture or other forms of cruel, inhuman, or degrading treatment.

The Standard Minimum Rules for the Treatment of Prisoners and Procedures for the Effective Implementation of the Standard Minimum Rules¹⁸ place many obligations upon physicians who come into contact with prisoners. The prison medical officer has the obligation to report to the director of the institution whenever he or she considers that a prisoner's physical or mental health has been or will be injuriously affected by continued imprisonment or by the conditions of imprisonment. He or she has the obligation also to report any cruel, inhuman or degrading punishments, as these are completely prohibited. It is further indicated that where it is beyond the competence of those in charge to alter the adverse conditions, the medical officer should then submit his or her own report to a higher authority for action. Physicians who examine detainees are, for the purposes of the Declaration, considered to be prison medical officers.

Article 25 (2): The medical officer shall report to the director whenever he considers that a prisoner's physical or mental health has been or will be injuriously affected by continued imprisonment or by any condition of imprisonment.

2. Non-discriminatory provision of medical care

The fundamental principles of non-maleficence articulated in the Hippocratic Oath and similar pledges clearly establish the physician's role as healer of human suffering and the professional responsibility to do no harm.¹⁹ These concepts are reinforced by the Declaration of Geneva, which states that: "I will maintain the utmost respect for human life from its beginning even under threat... I will not use my medical knowledge contrary to the laws of humanity...[and]... I will not permit considerations of religion, nationality, race, party politics, or social standing to intervene between my duty and my patient."²⁰

Furthermore, the International Code of Medical Ethics provides that: "A physician shall give emergency care as a humanitarian duty..."²¹ The World Medical Association's Regulations in Time of Armed Conflict²² states that: "Under all circumstances, every person, military or civilian, must receive promptly the care he needs without consideration of sex, race, nationality, religion, political affiliation or any other similar criterion....[and that]…The fulfillment of medical duties and responsibilities shall in no circumstance be considered an offense."

3. Confidentiality

International standards of medical ethics uniformly call upon physicians to maintain confidentiality as a fundamental obligation to patients and to disclose information only with the patient's consent. When a doctor is required by the state or another third party to release information, the patient must be informed before the examination.

The World Medical Association has, in various codes of conduct for health professionals, stated the physician's obligation to maintain confidentiality:

Regulations in Time of Armed Conflict: "A
physician shall preserve absolute confidentiality on all he knows about his patient even after the patient has died."²³

Declaration of Geneva: "I will respect the secrets which are confided in me, even after the patient has died."²⁴

International Code of Medical Ethics: "A physician shall respect the rights of patients, of colleagues, and of other health professionals, and shall safeguard patient confidences."

Breaches in medical confidentiality may be justified on the basis of compelling health concerns such as the spread of infectious disease or safety of the public. Codes of conduct for health professionals prescribe safeguards for confidentiality. The World Medical Association's Regulation in Time of Armed Conflict states "The physician must never be prosecuted for observing professional secrecy."²⁵

4. The nurse's role in safeguarding human rights

The International Council of Nurses has adopted a number of statements to implement its endorsement of the Universal Declaration of Human Rights, the most comprehensive of which is "The Nurse's Role in Safeguarding Human Rights," which dates from 1983.²⁶ It emphasizes the responsibility of nurses to safeguard human rights in normal work situations as well as in times of political upheaval and war. According to the text, whenever abuse of patients, nurses, or others is witnessed or suspected, "[N]urses have a responsibility in these situations to take action to safeguard the rights of those involved." The statement advises that while nurses have an individual responsibility, they often can be more effective when they approach human rights issues corporately. When implementing this responsibility, the individual "nurse initiating the actions requires knowledge of human rights, moral courage, an adequate plan of action and a commitment and determination to see that the necessary follow-up does occur." Additionally, the statement emphasizes that health care is a right for all individuals and that nurses must ensure that adequate treatment is provided, within available resources, in accordance with nursing ethics. Going beyond a narrow definition of professional responsibility, the statement directs national nurses' associations to participate in the development of health and social legislation relative to patients' rights and all related topics.

5. Nurses and torture

A statement on nurses and torture was adopted at the meeting of the Council of National Representatives of the International Council of Nurses (ICN) in May 1989. Recognizing that violations of human rights have become more pervasive and that scientific discoveries have brought about more sophisticated forms of torture and methods of resuscitation, the text specifies that the nurse shall not countenance, condone, or voluntarily participate in:

· Any deliberate, systematic or wanton infliction of physical or mental suffering or any other form of cruel, inhuman or degrading procedure by one or more persons acting alone or on the orders of any authority, to force another person to yield information, to make a confession or for any other reason.

· Any treatment which denies to any person the respect which is his/her due as a human being.²⁷

6. The nurse's role in the care of detainees and prisoners

The International Council of Nurses Code for Nurses states that the fundamental responsibility of the nurse is to those people who require nursing care. To that end, it mandates the nurse to take appropriate action to safeguard the individual whose care is endangered by a co-worker or any other person.²⁸

A directive on the "Nurse's Role in the Care of Detainees and Prisoners" was adopted at a meeting of the Council of National Representatives of the International Council of Nurses in Singapore in August 1975.²⁹ This statement condemns the use of interrogation procedures for detainees and prisoners of conscience that result in ill effects on the person's mental and physical health. It directs that "[N]urses having knowledge of physical or mental ill-treatment of detainees and prisoners must take appropriate action including reporting the matter to appropriate national and/or international bodies." The statement prohibits nurses employed in prison health services from assuming the functions of prison security personnel, such as body search procedures for security reasons. It also specifies that nurses only participate in clinical research carried out on prisoners if the freely given consent of the patient has been secured based on an explanation and full understanding of the nature and risk of the research.

NOTES

¹ Rayner, Mary. Turning a Blind Eye? Medical Accountability and the Prevention of Torture in South Africa. Washington, D.C.: American Association for the Advancement of Science, 1987.

² American Association for the Advancement of Science. Apartheid Medicine: Health and Human Rights in South Africa. AAAS: Washington, D.C. 1990.

³ Promotion of National Unity and Reconciliation Act 1995, § 3(1)(d).

⁴ Promotion of National Unity and Reconciliation Act 1995, § 3(1)(d).

⁵ World Health Organization. "Preamble to the Constitution," The First Ten Years of the World Health Organization. Geneva: WHO, 1958, p. 11. Also see World Health Organization Declaration of Alma Alta. Geneva: WHO, 1978.

⁶ U.N. General Assembly. Third Session. Official Records. Universal Declaration of Human Rights. Pursuant to General Assembly Resolution 217 A (III), UN Doc.A/810, 1948.

⁷ U.N. General Assembly. Twenty-first Session. Official Records. International Covenant on Civil and Political Rights, articles 6, 7, 9, and 10. Pursuant to General Assembly Resolution. 2200A (XXI), Supp. No.16, art.47, UN Doc. A/6316, 1976. Hereinafter "CCPR".

⁸ Id.,. Art. 10.

⁹ U.N. General Assembly. Official Records. Convention Against Torture and Other Cruel, Inhuman, or Degrading Treatment or Punishment. Adopted and open for signature, ratification, and accession by United Nations General Assembly. Pursuant to Resolution 39/46, 1984. Hereinafter "Convention Against Torture".

¹⁰ U.N. General Assembly. Twenty-first Session. Official Records, Supplement 16. International Covenant on Economic, Social and Cultural Rights. Article 12, p. 49, UN Dpc.A/6316, 1966. Hereinafter "CESCR."

¹¹ Ibid.

¹² U.N. General Assembly. Official Records. International Convention on the Elimination of All Forms of Racial Discrimination. Pursuant to 2100 A (XX) of 21 December 1965, 660 UNTS. 195 (entered into force 4 Jan., 1969). Article 5(e)(iv). Hereinafter "Convention Against Racial Discrimination."

¹³ U.N. General Assembly. Thirty-fourth Session. Official Records. Supplement 46. Convention on the Elimination of All Forms of Discrimination Against Women. Pursuant to Resolution 34/180, A/34/46, 1980, Art. 12 (1). Reprinted in 19 I.L.M. 33, 1980. Hereinafter "CEDAW".

¹⁴ U.N. General Assembly. Forty-fourth session. Official Records. Supplement 49. Convention on the Rights of the Child. Pursuant to Resolution 25GAIV, A/RES/44/25 (1989), Art. 24.

¹⁵ The Convention Against Torture. Twenty-Five Human Rights Documents. New York: Center for the Study of Human Rights, Columbia University, 1994, p. 148.

¹⁶ "Principles of Medical Ethics Relevant to the Role of Health Personnel, Particularly Physicians, in the Protection of Prisoners and Detainees against Torture and Other Cruel, Inhuman, or Degrading Treatment or Punishment." Adopted by the United Nations General Assembly in 1982, in Ethical Codes and Declarations Relevant to the Health Professions. London: Amnesty International, 1994, p. 50-53.

¹⁷ Id., p. 9. From World Medical Association. "Declaration of Tokyo," 1975.

¹⁸ Id., p. 89-104. From "Standard Minimum Rules for the Treatment of Prisoners and Procedures for the Effective Implementation of the Standard Minimum Rules. Adopted by the United Nations, 1955; amended 1977.

¹⁹ Id., p. 42. From "The Hippocratic Oath."

²⁰ Id., p. 4. From World Medical Association. "Declaration of Geneva," 1948, 1968, 1983.

²¹ Id., p. 5-6. From World Medical Association. "International Code of Medical Ethics," 1949, 1968, 1983.

²² World Medical Association. "Regulations in Time of Armed Conflict."

²³ Ibid.

²⁴ "Declaration of Geneva."

²⁵ Ibid and World Medical Association. "Regulations in Time of Armed Conflict."

²⁶ International Council of Nurses. "The Nurse's Role in Safeguarding Human Rights." Adopted by representatives of the International Council of Nurses meeting in Brazil in June 1983 and last reviewed in 1991. From Amnesty International, 1994, p. 27-29.

²⁷ International Council of Nurses. "Nurses and Torture." Adopted by National Representatives of the International Council of Nurses in Seoul in May 1989 and reviewed in 1991. From Amnesty International, 1994, p. 30-31.

²⁸ International Council of Nurses. Code for Nurses. Geneva, ICN. Adopted 1973, reaffirmed in 1989.

²⁹ International Council of Nurses. "The Nurses Role in the Care of Detainees and Prisoners." Adopted at the meeting of National Representatives of the International Council of Nurses in Singapore in August 1975 and last reviewed in 1991. From Amnesty International, 1994, p. 24-26.