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II. RELEVANT ETHICAL CODES ISTANBUL PROTOCOL

should be taken to minimize the harm and offence others. A clinician who examines an alleged victim
to the patient that may arise from the disclosure. It who fears reprisals and refuses to consent to a clinical
is recommended that physicians should inform their evaluation, however, should not breach the primary
patients that confidentiality might be breached for their ethical duties of “do no harm” and respect for
own protection and that of any potential victim. The autonomy over the obligation to document and report.
patient’s cooperation should be enlisted if possible.
180. The clinician’s capacity to respect autonomy and
178. In applying this guidance to the context of clinical confidentiality establishes a foundation for trust that
evaluations of alleged or suspected cases of torture is essential in conducting an effective evaluation of
or ill-treatment, health professionals need to physical and psychological evidence of torture and
balance the duty of not harming the alleged victim ill-treatment. While the ethical obligations of clinicians
and that of preventing potential harm to others are the same in all encounters with patients and alleged
who may otherwise be subjected to unchecked victims, an individual’s ability to exercise free choice
torture practices. Before health professionals about the disclosure of information may depend on
consider the possibility of breaching confidentiality the circumstances of the evaluation. For example,
without the alleged victim’s consent, the health in therapeutic settings and medico-legal evaluations
professional should reasonably believe that: conducted by independent, non-governmental
clinicians at the request of the alleged victim, there
(a) Severe or life-threatening harm to others is are generally no mandatory reporting requirements.
reasonably certain to occur imminently (not only In such circumstances, individuals typically view
foreseeable and probable) if the health professional clinical evaluations of torture and ill-treatment to be
does not take action; in their best interests and the clinician’s capacity to
respect autonomy and confidentiality establishes a
(b) Disclosure of information will prevent the foundation for trust and, consequently, the disclosure
reasonably certain and imminent serious or life- of information. Documenting and reporting torture
threatening harm to others; and ill-treatment in such encounters is entirely
appropriate as long as informed consent is provided.
(c) The risk of reprisals to alleged victims is deemed to
be low by both the clinician and the alleged victim; 181. Although health professionals in State institutions
have the same ethical obligations as other health
(d) There is sufficient clinical evidence, such as professionals, in some State institutions, the
observed injuries and/or psychological distress, to conditions of their evaluations may make it difficult
warrant a suspicion of torture or ill-treatment; to establish trust with patients and alleged victims.
State employees, particularly forensic experts and
(e) Information can be provided to an independent those working with the police, military or other
body that will conduct a prompt, impartial and security services or in the prison system, often have
effective investigation into the circumstances. mandatory reporting requirements. In such settings,
individuals may have limited power and choice in the
179. Health professionals should seek all opportunities to evaluation and may not wish to speak openly about
ensure the alleged victim’s safety and that they will the alleged abuse for fear of reprisals against them
not be tortured again. Given these considerations, the or family members. The health professionals in these
circumstances under which health professionals may circumstances should, nevertheless, comply with their
breach the duty of confidentiality are limited. For ethical obligations and do their best to facilitate trust
example, clinicians who observe evidence of patterns and rapport with the patient/detainee. As stated in
of abuse may report anonymous information to an paragraphs 166–167 above, before beginning any
independent body if they can do so without triggering evaluation, the clinician must identify themselves,
reprisals against the torture victim. Clinicians working inform the individual of the purpose and content of
in prisons, places of detention, forensic institutions, the evaluation and disclose any mandatory reporting
and national (e.g. national human rights institutions requirements. Regulations may not permit the patient
and national preventive mechanisms) and international to refuse examination, but the patient has the option
monitoring bodies may be in a position to observe of choosing whether to cooperate with the evaluation
evidence of patterns of abuse and report anonymous and/or to disclose the cause of any injury. In such
information, thereby preventing potential harm to cases, the clinician must respect the patient’s decision,

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