The Practical Guide to Humanitarian Law

« Calling things by the wrong name adds to the affliction of the world. » Albert Camus.

Medical Ethics

Codes of ethics are designed to protect the quality and independence of a particular profession, such as medicine, journalism, or law. They are recognised and protected by national and international law. Given the power that doctors have over the life and death patients, and over their physical and mental health, professional medical ethics have developed since ancient times, most notably with the famous Hippocratic Oath.

Over time, these rules were reinforced to limit the involvement of doctors in extreme and totalitarian forms of social control and political violence. The Second World War, for example, revealed the involvement of doctors in the politics of torture and eugenics. The political misuse of psychiatric internment and treatment as a tool of mind and body control has also been established in coercive political environments. Far from being an isolated phenomenon attributable to barbarism or dictatorship, studies and historical practice have shown that the misuse of medical knowledge and personnel is a constant temptation notably in situations of detention and armed conflict. The involvement of military and civilian doctors in acts of torture and degrading treatment inflicted on detainees in the context of the “war on terror” and other counterterrorism armed conflicts have been a further step in raising awareness of the nature and extent of the phenomenon.

This has led to the adoption of additional international rules that go beyond the usual national framework of medical ethics in order to deal with particular situations of vulnerability and the ethical dilemmas they pose. These rules have two complementary objectives: to protect the integrity of the patient from abuse by the doctors, and to protect the autonomy of doctors’ decision from social, political or military pressure.

In addition to the general framework of international medical ethics (I), specific international rules reinforce and protect medical ethics in situations of armed conflict (II) and detention (III). Specific ethical rules have also been developed for medical research (see infra, box on ethical rules in the field of medical research) and for situations in which a doctor is faced with the dual obligation of defending the individual interests of the patient against other collective or security requirements.

The proper and ethical management of dual or conflicting obligations is governed by specific rules and guidelines which apply in particular to the management of the medical confidentiality in the context of national reporting requirements (infra, box on medical confidentiality and/or national mandatory reporting system) and to the ethical involvement of doctors against torture (III.1).

Sanctions for breaches of medical ethics can take various forms (V). Adherence to the general rules of medical ethics is usually monitored by professional medical organisations, which are responsible for investigating possible breaches and imposing disciplinary sanctions including the withdrawal of the right to practise medicine. Such decisions give rise to compensation for victims in civil courts.

Some serious breaches of medical ethics may also constitute criminal offenses that can be prosecuted in national or international criminal courts. This is particularly the case in situations of complicity in ill-treatment and torture. In situations of armed conflict, some breaches of medical ethics rules may also amount to war crimes.

Medical dutiesMedical PersonnelTortureWar crimes/Crimes against humanityWounded and sick

I. General International Rules of medical ethics

There is no international convention binding on States that regulates the content of medical ethics in times of peace. This issue is regulated within the framework of national and international health professional associations.

The content of different national codes of medical ethics may differ, but the fundamental principles are similar in all countries. They are articulated around four main ethical principles known as: Beneficence (to the patient), Non-maleficence (do no harm to the patient), Autonomy (of the patient) and Justice (fairness). Informed consent, truth-telling, and confidentiality flow directly from these four morals obligations on the part of doctors that are unreserved and universally accepted. They form the framework within which moral principles are translated into a set of moral duties and virtues of the doctor, reflected in the Hippocratic Oath. They also provide guidance in specific situations where the practical implementation of other potentially competing principles or legal requirements must be reconciled.

As such they frame the various dimensions of medical ethics, which includes reference to deontological rules, moral duties, virtues, and consequences of medical behaviour.

The World Medical Association (WMA) drafted and adopted an International Code of Medical Ethics (ICoME) in November 1983, as amended in 2006 and 2022, which sets out the consensus on fundamental principles of medical ethics. This document complements national rules and those contained in earlier international texts, such as:

•The Nuremberg Code of 1947, concerning medical ethics and in particular, experimentations on human beings;

•The Geneva Declaration of 1948 which solemnly proclaims the Physician’s Pledge; •Specific rules of international humanitarian law (IHL) governing medical action in situations of armed conflict, notably the right of the wounded and sick to be treated without discrimination in accordance with medical ethics and strengthened medical rules (the Geneva Conventions of 1949 and its Additional Protocols of 1977); •Specific international rules governing the medical actions in the context of detention.

The latest ICoME, adopted by the WMA in 2022 demonstrates the broad consensus achieved by WMA members representing over 10 million doctors worldwide. Its principles provide a strong international and intercultural content to the language of medical ethics shared by doctors and patients around the world with different moral and cultural perspectives. The 2022 update illustrates the strengthening of some fundamental and uncontroversial principles and the need to discuss and add new rules to better frame other more controversial and contentious principles. The 2022 ICoME consist of a preamble and 40 paragraphs divided into: 12 general principles (paras. 1-12 of the ICoME); 17 Duties towards the patient (paras. 13-29 of the ICoME); 3 Duties towards doctors, health professionals, students, and other personnel (paras. 30-33 of the ICoME); 5 Duties towards society (paras. 34-38 of the ICoME) and 2 Duties as member of the medical profession (paras. 39-40 of the ICoME).

The preamble clarifies that national ethical, legal, and regulatory norms and standards as well as international norms and standards, shall not diminish the doctor’s commitment to the ethical principles set forth in this Code. It thus establishes the primacy of the principle of the autonomy of medical personnel in the face of laws or regulations or requirements that are contrary to the rules of medical ethics adopted by professionals at the international level.

Among the various principles some are of greater importance in the context of humanitarian action, where the relation imbalance between doctor and patient is exacerbated and the national legal framework for the protection of human rights is unreliable.

  • Obligation of care : The obligation to provide competent, timely and compassionate medical care to those who needs it without discrimination based on age, illness, creed, ethnic origin, gender, nationality, political affiliation, race, culture, sexual orientation, social status, or any other factor, is linked to the obligation to respect life and to consider emergency care as a humanitarian duty. (paras. 1 and 2 of the ICoME). This ethical obligation can also be found in criminal law in the offence of failing to assist a person in danger. The duty to provide medical care obliges the doctors to act in the exclusive interest of the patient.
  • Respect of patients’ informed consent and principle of patient autonomy and dignity (paras. 13 and 15-19 of the ICoME): This principle is key to maintaining the confidence of patients and the public in their relationship with doctors. (para. 37 of the ICoME). The obligation to inform the patient and to obtain and respect his or her consent before any act of care is of paramount importance in protecting the balance in the relationship between doctor and patient and in ensuring that the patient’s dignity is respected. This obligation puts into perspective the power that the doctor has over the patient. Although the doctor must always act in the best interest of the patient, he or she cannot substitute himself for the patient and decide what the patient wants. This duty is well defined in most national laws and gives rise to compensation in the courts. The implementation of respect for the patient’s informed consent has been given some additional guidance to adapt to situations where the patient has limited capacity to understand and make a fully informed decision. In such a case the doctor must involve the patient’s trusted representative, if available, to make decisions in accordance with the patient’s preferences if they are known or can reasonably be inferred. If the patient’s preferences cannot be ascertained, the doctor must make decisions in the patient’s best interests and in compliance with all other ethical rules (paras. 16-19 of the ICoME). The 2022 ICoME also clarified that patient consent is required at every stage of medical care and can be withheld by the patient at any time. (para. 15 of the ICoME).

When the patient cannot give consent for medical or legal reasons (minors or unconscious patients) or when consent cannot be freely given (prisoners), the doctor is responsible for the ethical nature of the decision and the medical act. Ethical criteria may go beyond or be contrary to legal or administrative requirements. The management of these dual obligations is the responsibility of the doctor and is governed by specific ethical principles ( infra , sections II and III).

  • Medical confidentiality : According to the Geneva Declaration of 1948, the duty of medical secrecy is an ethical imperative that binds the doctor to the patient even after the patient’s death. However, in the formulation chosen by the ICoME in 2006, this duty had lost its absolute character and was therefore amended in 2022 to regain its strict value. The 2006 ICoME stated that it is consistent with medical ethics to disclose confidential information if the patient consents or if there is a dangerous, real, and imminent danger to the patient or to others and this danger can only be removed by a breach of confidentiality. This wording was too confusing with the mandatory reporting system in some national legislations for listed medical cases such as gunshot wounds and intentional violence, including sexual violence or abuse of minors, as well as serious communicable diseases.

In such cases, the transmission of information normally protected by medical confidentiality is made to judicial or police authorities and is justified by considerations of judicial protection of the patient, public order, and the fight against impunity. This case is the one that departs most from the principle of medical confidentiality. It has to be seen if such reporting is only intended to relieve the doctor of his or her duty of confidentiality towards the patient, while maintaining his or her duty to act in the best interest of the patient and within the ethical framework of consent for those patients who are unable to decide. If so, the reporting framework protects the doctor from lawsuit by the patient or the patients’ representative. If not, the mandatory reporting conflict with ethical duties and may result in criminal sanctions by the State against the doctor who, on ethical grounds, refuses to report to the authorities. This risk exists in some controversial domestic laws. Comparative analysis of national legislation on mandatory reporting in has shown that it can have a negative impact on access to health care and the ethical medical management of victims of violence, including in situations of armed conflict. Doctors can claim benefit from international ethical rules supporting his or her refusal to act in breach of medical confidentiality against the patient’s consent and/or interest.

To limit this risk, the ICoME revised version of 2022 has tightened the wording and content of the medical confidentiality rule. It still applies after a patient has died. Specific potential justifications for breaching confidentiality are limited to “exceptional cases, when disclosure is necessary to safeguard a significant and overriding ethical obligation” (para. 22 of the ICoME). The justification no longer refers broadly to a threat to the patient or others which may be covered by domestic legal obligations. The doctor’s decision can only be based on ethical grounds, not on legal compliance.

Where reporting requirements are based on a public health justification, they are usually intended for health authorities and are carried out in a way that can maintain the anonymity of the patient. Such medical reporting may comply with international medical ethics as provided by ICoME (paras. 37 and 38 of the ICoME).

The principle of medical confidentiality/secrecy may be complicated by dual obligations on the part of the doctor, which can only be resolved on the basis of other ethical criteria ( infra , section III.2 b and box on medical confidentiality). If disclosure of certain information may cause harm to the patient, the doctor has an ethical obligation to respect confidentiality and to act in the patient’s best interest. If non-disclosure may cause great harm to another person, the doctor must still obtain the patient’s consent.

In all cases, the doctor must inform in advance the patient of the nature and extent of any disclosure obligations and obtain consent for such interaction (para. 23 of the ICoME). Exceptional ethical cases are those where the best interests of the patient may differ from the decision and consent of the patient’s representative, or where consent is not possible.

Most national laws allow such ethical autonomy for the decision of the doctor. Many jurisdictions allow, rather than require, doctors to report cases. The main purpose of this is to protect the doctor from complaint by the patient or patient representative in such cases, and there are no sanctions against doctors who fail to report a case. Other national laws restrict the ethical autonomy of doctors. It is therefore important for doctors to be able to refer to international professional standards of medical ethics in the face of such conflicting national norms.

  • Act in the best interest of the patient: The obligation to act in the best interest of the patient implies the obligation to refer the patient to a competent person when the medical case exceeds one’s own professional capacity. It is also forbidden to provide treatment whose negative effects outweigh the therapeutic benefits. This obligation also regulates the possibility of overriding consent and prohibits medical experimentation unless it is in the direct interest of the patient, the balance of risks and expected benefits is positive and the patient’s free and informed consent has been secured (para. 14 of the ICoME).

The 2022 version of the ICoME include an additional explicit ethical obligation that medical personnel shall never participate in or facilitate acts of torture or other cruel, inhuman, or degrading practices and punishments (para. 10 of the ICoME). It is particularly important to frame ethical medical behaviour in countries where doctors are required by law to participate in the monitoring of repressive State procedures.

It also expands the ethical framework of conscientious objection by doctors to include the impact on patients with conflicting conscientious beliefs. It affirms that the doctor’s conscientious objection to a lawful medical procedure may be exercised only if the individual patient is not harmed or discriminated against and if the patient’s health is not endangered (para. 29 of the ICoME).

These international ethical principles are intended to be incorporated into national codes of ethics for health professionals to harmonise and safeguard the quality and independence of medical care against external interference and pressure (paras. 39-40). They are also sometimes incorporated into national laws, making them legally binding.

Doctors may practise medicine in the country in which they are registered with the college of physicians. Except for first aid acts (known as Samaritan acts), the practice of medicine in a foreign country is only permitted in accordance with the rules of that country. Doctors working abroad, notably in humanitarian settings, are still subject to the ethics of the medical order to which they belong, and the laws of the country in which they are working.

The WMA has also adopted several specific declarations on respect for medical ethics in situations of detention and torture ( infra , section III) and in the field of medical research and patient’s rights). They are complementary to other international or convention rules that focus on the professional regulation of doctors.

The WMA has adopted the following statement on medical research and patients’ rights:

•The WMA Declaration of Helsinki adopted in 1964 and last amended in 2013 on ethical principles for medical research involving human subjects, as amended in 1975, 1983, 1989, 1996, 2000, 2002, 2004, 2008 and 2013 ( infra , box on ethical rules in the field of medical research);

•The WMA Declaration of Taipei adopted in 2002 on ethical considerations regarding health databases and biobanks;

•The WMA Declaration of Lisbon on the Rights of the Patient, adopted in 1981 and amended in 1995 and reaffirmed in 2005 and 2015.

Ethical Rules in the Field of Medical Research

The Nuremberg Code of 1947 sets out the basic principles of medical ethics in relation to medical research. The Code contains 10 principles, including the need to obtain the consent of the patient participating in the research (art. 1), the possibility for the patient to withdraw from the research at any time (art. 9), and the obligation of the researcher to assess the risks involved in the research and to ensure that the patient suffers no physical harm (arts. 4-7).

These rules have been strengthened to cover situations of armed conflict and detention. Principle 22 of the “Body of Principles for the Protection of All Persons under Any Form of Detention or Imprisonment,” adopted by the UN General Assembly (resolution 43/173) in December 1988, provides that “[n]o detained or imprisoned person shall, even with his consent, be subjected to any medical or scientific experimentation which may be detrimental to his health.”

This provision is also clarified in the context of international armed conflicts by Additional Protocol I of 1977 to the Geneva Conventions, which provides that it is prohibited to subject detainees or persons deprived of their liberty to physical mutilations, to medical or scientific experiments or to removal of tissues or organs for transplantation unless such acts are justified by the state of health of the person concerned and are in accordance with generally accepted medical standards which would be applied in similar medical circumstances to persons who are nationals of the Party conducting the procedure and who are in not in any way deprived of their liberty (API, art. 11).

The WMA Declaration of Helsinki, adopted in 1964 and amended several times (last revision in October 2013), completes the ethical rules applicable for medical research involving human subjects. The Declaration set out 35 principles, including the following: the welfare of the patient must take precedence over all other interests (Principle 6); the research must be thoroughly described in a research protocol (Principle 14); such a protocol must be submitted to an independent ethics committee (Principle 15); and the researcher has an obligation to obtain the informed consent of the patient (Principle 24). Furthermore, it is imperative that no ethical, legal, or regulatory mandate, whether on a national or international level, undermines or removes any of the safeguards for research participants outlined in the Declaration. (Principle 10).

The Taipei Declaration adopted by the WMA in 2002 addressed ethical considerations related to health databases, big data and biobanks. It is intended to cover the collection, storage and use of identifiable patient data and biological material for purposes beyond individual patient care. It adapts ethical rules to specific ethical dilemmas and risks related to, inter alia, breaches of medical confidentiality, patient informed consent free from pressure, conflicts of interest, patient access to benefit sharing in medical research.

The Universal Declaration on Bioethics and Human Rights adopted by UNESCO in 2005, provides a basic ethical and legal framework for medical research and practice in this field. It is complemented by a World health Organization (WHO) initiative to promote a Global network of WHO Collaborating Centres for bioethics.

International regulations governing medical research are less stringent than some national regulations, particularly in Western countries. This allows organisations conducting medical research in certain countries to apply minimum rules and standards of protection. In such cases, two criteria apply. The first concerns the actual freedom of the patient to give consent, including the absence of pressure on his or her right to care if he or she refuses. The second criterion concerns the balance between the direct benefits and the foreseeable risks to the patient. In order to ensure the application of safeguards, international and European legislation provides for a double obligation to respect the legal and ethical rules applicable in the country where the research is carried out and in the country of origin of the researchers carrying out the research.

In addition to the WMA, there are several international and regional associations representing the various health professions, such as the World Psychiatric Association and the International Council of Nurses. At the regional level, there is the Islamic Organisation for Medical Sciences and the Federation of Islamic Medical Associations which discuss the ethical rules appropriate to their activities or mandates. For example, the Islamic Code of Medical and Health Ethics, also known as the Kuwait Declaration, was adopted in 1981 by the First International Conference on Islamic Medicine. It was revised and expanded in 2004 by the Islamic Organisation for Medical Sciences.

DetentionWounded and sick persons

II. Rules of medical ethics Applicable in Situations of Armed Conflict

International humanitarian law (IHL) contains numerous provisions to safeguard medical ethics in situations of armed conflict or detention, where the independence of doctors may be compromised by the parties to the conflict. These rules affirm the legal and ethical imperative to provide medical care to all wounded and sick without discrimination including those associated with the enemy (1). They affirm the autonomy of medical services and personnel, their protection from military interference and their immunity from punishment (2). They require strict respect for medical ethics and confidentiality (3).

☞ The overall protection afforded by IHL grants to the medical mission in times of armed conflict is linked to respect for the principles of medical ethics. Thanks to the Geneva Conventions, the rules of medical ethics have become binding norms of IHL and are now part of customary international humanitarian law (CIHL). This means that national rules or military orders that would violate these principles cannot be imposed on medical personnel under any circumstances. The obligation to respect medical ethics protects doctors from pressure by security or military forces to participate in acts of torture or ill-treatment of the wounded and sick in situations of armed conflict or of detainees and persons deprived of their liberty.

The 1949 Geneva Conventions and their 1977 Additional Protocols, as well as CIHL stipulate that no one may be punished for carrying out medical activities compatible with medical ethics, regardless of the circumstances and the persons benefiting from their actions (API, art. 16(1), APII, art. 10(1); CIHL Rule 26).

Any act that is inconsistent with medical ethics or that endangers the physical or mental health of an individual, as well as any deliberate refusal to provide the necessary care to a wounded or sick person, may constitute a war crime (GCI, art. 50, GCII, art. 51, GCIII, art. 130, GCIV; art. 147 and API, art. 11; CIHL Rule 156).

In situations of armed conflict, IHL establishes the imperative to protect the wounded and sick, and to provide them with medical care without discrimination and without delay in accordance with medical ethics. This requirement has been at the heart of IHL since the First Geneva Convention of 1864. IHL does not give a precise definition of the content of medical ethics, but several articles refer to the protection of the medical mission, which is organised along two lines. The first requires the protection and care of the wounded and sick and prohibits any act not in accordance with medical ethics (1). Serious violations of these fundamental rules of medical ethics and duties may amount to war crimes (2). The second protects the independence and autonomy of doctors, who in turn must defend the ethical, neutral, and impartial character of medical structures, units, and activities (3). Doctor’s independence is supported in particular by enhanced protection of medical secrecy (4).

1. Obligation to care for and to protect the wounded and sick

The protection of the medical mission in armed conflict is one of the most important elements of customary and conventional IHL. Historically, the adoption of the first Geneva Convention in 1864 under the auspices of Henry Dunant was intended to regulate the medical care of the wounded and sick on the battlefield. Under IHL, no one can be intentionally left without medical assistance or care.

Withholding assistance or discriminating in providing medical care is strictly prohibited. Common article 3 to the four Geneva Conventions—applicable in all circumstances and at all times, stipulates that the wounded and sick must be collected and cared for and treated with humanity and dignity and without discrimination as to race, religion, belief, gender, birth, wealth, or other similar criteria. This obligation was reinforced in 1977 by the two Additional Protocols to the Geneva Conventions applicable to international (API) and non-international (APII) armed conflicts. These Protocols state that all wounded, sick and shipwrecked persons, regardless of which party to the conflict they belong to, must be respected, and protected. This means that treating the wounded and sick of the enemy is not only mandatory but neutral under IHL and cannot be considered an unfriendly or hostile act. The wounded and sick are considered under IHL as hors de combat (out of combat) and must in all circumstances be treated humanely and given, to the fullest extent practicable and with the least possible delay, the medical care and attention required by their condition. No distinction may be made between them on grounds other than medical ones (API, art. 10, APII, art. 7).

CIHL Rule 110 recalls that the wounded and the sick have the right to access medical care, without distinction on any grounds other than medical ones. This rule applies in both international and non-international armed conflicts.

With regards to the prohibition of discrimination in the provision of medical care, the ICoME affirms that doctor must practice medicine without bias or discriminatory conduct based on non-medical criteria. It states that doctors have a twofold duty: prioritising individual patient care in accordance with medical standards and contributing to societal well-being. They must provide unbiased care, addressing patients’ health needs without discrimination based on various factors. (paras. 1 and 2 of the ICoME) This Code is not binding on States as such, but its legal value in situations of armed conflict is upheld by the obligation to respect medical ethics, as provided for in IHL and CIHL.

2. Grave Breaches of IHL

To support the medical obligation to care for all wounded and sick without discrimination, IHL includes related breaches in the category of grave breaches of IHL amounting to war crimes, which can be prosecuted under the Rome Statute of the International Criminal Court (ICC) or in domestic courts under the system of universal jurisdiction.

Intentional killing, torture, or inhuman treatment, including biological experiments, and wilful causing of great suffering or serious injury to body or health, committed against persons protected by the Geneva Conventions, including the wounded and sick, are grave breaches of IHL (GCI, art. 50). This criminal prohibition was further specified in 1977 by article 11 of Additional Protocol I, which provides that:

“1. The physical or mental health and integrity of persons who are in the power of the adverse Party or who are interned, detained or otherwise deprived of liberty [for reasons related to the conflict] shall not be endangered by any unjustified act or omission. Accordingly, it is prohibited to subject the persons described in this Article to any medical procedure which is not indicated by the state of health of the person concerned and which is not consistent with generally accepted medical standards which would be applied under similar medical circumstances to persons who are nationals of the Party conducting the procedure and who are in no way deprived of liberty.

  1. It is, in particular, prohibited to carry out on such persons, even with their consent: (a) physical mutilations; (b) medical or scientific experiments; (c) removal of tissue or organs for transplantation, except where these acts are justified in conformity with the conditions provided for in paragraph 1.
  2. Exceptions to the prohibition in paragraph 2(c) may be made only in the case of donations of blood for transfusion or of skin for grafting, provided that they are given voluntarily and without any coercion or inducement, and then only for therapeutic purposes, under conditions consistent with generally accepted medical standards and controls designed for the benefit of both the donor and the recipient.” Intentional withholding of care has also been added to the grave breaches listed in the same article, which provides that: “Any wilful act or omission which seriously endangers the physical or mental health or integrity of any person who is in the power of a Party other than the one on which he depends and which either violates any of the prohibitions in paragraphs 1 and 2 or fails to comply with the requirements of paragraph 3 shall be a grave breach of this Protocol.”(API, art 11(4)).

These grave breaches of IHL constitute war crimes subject to national or international criminal prosecution, whether committed in international or non-international armed conflicts (arts. 8(2)(a)(ii) and (iii); 8(2)(b)(x) and (xxi); 8(2)(c)(i), (ii) and 8(2)(e)(vi) of the Rome Statute).

Indeed, Common article 3, which applies to non-international armed conflicts, prohibits violence to life and person, in particular murder of all kinds, mutilation, cruel treatment and torture, but also outrages upon personal dignity, in particular against the wounded and the sick. Violations of Common article 3 have been recognised by international jurisprudence as grave breaches of IHL and war crimes.

These prohibitions, along with the requirement to protect the wounded and sick, are now part of CIHL, which applies in both international and non-international armed conflicts. CIHL Rule 90 confirms the prohibition of torture, cruel or inhuman treatment, and outrages upon personal dignity. Rule 92 confirms that “mutilation, medical or scientific experiments or any other medical procedure not indicated by the state of health of the person concerned and not consistent with generally accepted medical standards are prohibited.” These rules apply in both international and non-international armed conflicts.

TortureWar crimes/Crimes against humanity

3. Protection of the doctor’s independence and medical activities

IHL establishes clear rules to protect the independence of medical personnel in the conduct of their medical activities, and thus their ability to respect and defend medical ethics against external pressures. These rules are considered customary and the corresponding rules of CIHL apply to both international and non-international armed conflicts:

•Medical and religious personnel must be respected and protected. They must be given all available assistance to carry out their duties and must not be compelled to perform tasks incompatible with their humanitarian mission (API, art. 15, APII, art. 9(1));

•CIHL Rules 25 and 28 confirm the obligation to respect and protect medical personnel and medical units and services in all circumstances;

•“In the performance of their duties medical personnel may not be required to give priority to any person except on medical grounds” (APII, art. 9(2)). •“Under no circumstances shall any person be punished for having carried out medical activities compatible with medical ethics, regardless of the person benefiting there from” (API, art. 16(1), APII, art. 10(1));

•Persons engaged in medical activities shall not be compelled to perform acts or to carry out work contrary to the rules of medical ethics, other rules designed for the benefit of the wounded and sick, or other provisions of IHL, nor shall they be compelled to refrain from acts required by such rules (API, art. 16(2), APII, art. 10(2)); •CIHL Rule 26 confirms these provisions and states that “punishing a person for performing medical duties compatible with medical ethics or compelling a person engaged in medical activities to perform acts contrary to medical ethics is prohibited.”

These rules were solemnly reaffirmed by the UN Security Council (UNSC) in resolution 2286, adopted in 2016 in the wake of attacks on hospitals. This is particularly important with regard to respect for medical confidentiality by doctors and the rule of non-punishment ( infra , section 4).

The rules governing medical secrecy and the principle of doctor-patient confidentiality in times of international or internal conflict are explained in the next section.

4. Enhanced Medical Confidentiality

Respect for medical confidentiality is a fundamental rule of medical ethics that applies at all times ( supra , section I). However, it is reinforced to take account of the particular vulnerability of patients and their greater need for protection in situations of armed conflict and detention. In peacetime, medical confidentiality may be limited by forensic obligations under national law. These may require doctors to report to the authorities certain infectious diseases or cases of violence, such as gunshot victims, victims of sexual violence and children who have been abused/mistreated. However, the rules of IHL, and in particular those relating to the duty to respect medical ethics, place the principle of medical secrecy above any other conflicting rules. Therefore, medical secrecy can only be lifted by the doctor if three cumulative ethical conditions are met: (1) it is in the best interest of the patient, (2) it does not cause harm to the patient, and (3) it is done with the patient’s informed and free consent.

Even in the case of prosecution of the most serious crimes, the ICC’s Rules of Procedure and Evidence protect medical confidentiality and do not consider admissible information obtained in breach of that confidentiality to be admissible unless the patient consents (Rule 73 of the ICC Rules of Procedure and Evidence ).

Medical confidentiality and/or national mandatory reporting system

The Hippocratic Oath already bound doctors to secrecy: “all that may come to my knowledge in the exercise of my profession or outside of my profession or in daily commerce with men, which ought not to be spread abroad, I will keep secret and will never reveal.”

•Medical secrecy is protected at all times by the ICoME

•Medical confidentiality is protected by IHL.

In situations of armed conflict, medical personnel caring for the sick and wounded must strictly respect doctor-patient confidentiality and must not disclosed protected medical information to adverse/hostile authorities (API, art. 16(3)). In fact, medical information provided to the authorities can be used against patients, as a means of pressure, and to deny some wounded and sick people access to medical care.

•In situations of internal disturbance or armed conflict, the ethical rules of medical secrecy take precedence over any conflicting obligations under national law. A doctor may not disclose information if it is not in the direct interest of the patient and if such disclosure may be harmful to the patient.

•Only the law can regulate the limited restrictions on the principle of medical secrecy. A simple order or regulation issued by a military or administrative authority does not authorise a doctor to breach his or her duty of medical confidentiality. •Furthermore, whatever the legal arguments put forward, no sanctions can be taken against a doctor who refuses to lift medical confidentiality in times of armed conflict, even if national law requires the reporting of protected medical information’s in the case of gunshot wounds and other violence, including sexual violence. (API, art 16(1); APII, art 10(1) to (4) and CIHL Rule 26)

•The current international agreement seeks to resolve the potential conflict and dilemma between medical ethics and the national legal obligation to report medical information by recognising an absolute ethical prohibition on disclosure of such information unless it is in the patient’s interest and with the patient’s consent.

•The primacy of medical ethics is recognised in international documents such as the 2016 UNSC resolution 2286, the 2022 version of the WMA ICoME, and the ICRC 2020 initiative on (guidance on) the humanitarian impacts of mandatory reporting on access to health care.

•However, despite international rules protecting medical confidentiality, in practice health workers are often left to deal with conflicting national rules.

In situations of international armed conflicts, IHL establishes medical secrecy vis-à-vis the opposing party to the armed conflict as an absolute principle. It provides that no person engaged in medical activities shall be compelled to divulge any information concerning the wounded and sick who are or have been under his or her care so long as the medical person considers that such information might prove harmful to the patients concerned or to their families. This applies regardless of the person requesting the information belongs to the opposing party to the armed conflict or to the medical person’s own party, except in cases provided for the person’s national law. However, there is only one exception: the rules concerning the obligation to communicable diseases must be respected (API, art. 16(3)).

In situations of non-international armed conflict, the non-state party to the conflict is not entitled to the same rights than the State. Nevertheless, IHL recalls that only the law can limit the principle of medical secrecy. Additional Protocol II of 1977 states that “the professional obligations of persons engaged in medical activities regarding information which they may acquire concerning the wounded and sick under their care shall, subject to national law, be respected.” (APII, art. 10(3)). It also affirms that “subject to national law, no person engaged in medical activities may be penalized in any way for refusing or failing to give information concerning the wounded and sick who are, or who have been, under his care.” (APII, art. 10(4)).

In armed conflict, whether international or non-international, respect for medical ethics takes precedence over other provisions of national law. Indeed, as the final authority on the matter, IHL provides that under no circumstances may any person be punished for carrying out medical activities in conformity with medical ethics, regardless of the person benefiting from them. (API, art. 16(1), APII, art. 10(1)).

However, in a situation of non-international armed conflict, the apparent contradiction remaining in article 10 of Additional Protocol II between the possibility (art.10(4)) and the absolute prohibition (art.10(1)) to punish doctors who refuse to disclose medical secrets on the basis of respect for medical ethics has created a great deal of legal and practical uncertainty and reluctance among medical personnel. This legal uncertainty has a practical impact on the safety, trust, and access of victims of violence to ethical and effective medical care. It is further exacerbated by the diversity of domestic national frameworks as demonstrated by a legal opinion on the obligation of health care professionals to report gunshot wounds published in 2019 by the Swiss Institute of Comparative Law and the ICRC. This legal experts’ report is based on a study of different provisions on confidentiality and disclosure contained in the national legislation of 22 countries.

It concluded that the only generalisation that can be drawn from the comparative study is that the existence of an obligation of doctor-patient confidentiality is essentially universal. However, the experts note that there is little consistency across countries in their national legislation- in terms of the form, content, scope, limitations or even the existence of norms regarding the duty to report and its interplay with the duty of confidentiality. The experts also found that there is little clarity on how to balance competing norms and that no country provides for or has a specific procedure for resolving these conflicts. They confirmed that the obligation to report may conflict with both the duty of confidentiality and the duty to treat. Very few countries have taken a clear position on the fact that emergency medical treatment takes precedence over reporting requirements and that police may not interfere with medical treatment or even approach a gunshot victim without the permission of the doctor. Very few countries have also incorporated the immunity of doctors from punishment and sanction provided for in IHL into their national law. In 2020, a joint report by the British Red Cross and the ICRC on mandatory reporting of sexual violence in armed conflict came to a similar conclusion. It argues that while mandatory reporting may be well-intentioned to combat impunity, prevent future crimes and protect victims, it is potentially inconsistent with international law and medical ethics and creates legal and ethical dilemmas for health care providers. It has also been found that mandatory reporting of sexual violence can impede access to health care and expose both victims and health care workers to further harm.

The legal and ethical management of these dual and conflicting medical duties is at the hearth of the protection of medical activities, particularly in situations of non-international armed conflict. Indeed, in such conflicts, the provision of medical care to the wounded and sick associated with non-state armed groups falls within a dangerous legal mix between IHL and national criminal domestic law. What constitutes a legal and ethical duty of medical personnel under IHL may be criminalised under national law, particularly regarding the provision of medical care and reporting, if the non-state armed group is classified as terrorist.

This risk was at the core of the debates leading to the adoption of UNSC resolution 2286 in 2016 to stop the wake of various attacks carried out on hospitals.

The resolution recalled the applicable rules of IHL regarding to the non-punishment of any person for carrying out medical activities in accordance with medical ethics. It also reaffirmed the duty to ensure that persons engaged in medical activities are not compelled to perform work contrary to the rules of medical ethics or other medical rules for the benefit of the wounded and sick. This language clarifies some controversial interpretations regarding the dual duty of doctors to respect medical confidentiality within the limits of national obligations regarding mandatory reporting of victims of violence and gunshot wounds. The resolution made no reference to national law and mandatory reporting, but rather recalled that doctors cannot act contrary to ethical rules and the best interests of the patient. It adhered to the most protective provisions of IHL in this area and recalled the non-punishment of any person who performs medical activities in accordance with medical ethics without submitting this non-punishment conditional on compliance with domestic legislation.

Reminders of respect for the most progressive IHL and medical ethics frameworks at the highest level of the UN organisation do not solve the practical problems created by restrictive national legislation. It does, however, it creates more space and legitimacy to challenge and limit their negative impact on medical care in situations of armed conflict.

III. Rules of Medical Ethics Applicable in Situations of Detention

The active or passive participation of medical personnel in acts of torture or degrading treatment of persons detained or otherwise deprived of their liberty is a practice that has been revealed in many circumstances. This participation increases the victim’s sense of powerlessness and fear and enhance the effectiveness of torture in its aim of destroying any individual or group capacity for physical or moral resistance and prolonging pain without causing death.

Specific rules of ethics have been developed to limit the exposure and increase the resistance of medical personnel to various form of pressure from security or military forces. Numerous studies have also shown that medical personnel are ill-equipped both professionally and psychologically, to refuse to participate in practices that the authorities consider to be outside their sphere of responsibility. Some doctors believe that they are no longer in a therapeutic relationship with the patient but in a technical interaction with the authorities, and that therefore the rules of medical ethics do not apply. In some countries, however, national laws may require doctors to supervise procedures such as the death penalty, physical mutilation, repressive interrogation of prisoners, or forced feeding of hunger-striking prisoners.

This situation has led the WMA to develop specific ethical guidance on this issue in special documents such as:

•The WMA Declaration of Tokyo, also known as the “Guidelines for Medical Doctors concerning Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment in relation to Detention and Imprisonment,” adopted in 1975 and revised in 2005, 2006 and 2016;

•The Tokyo declaration forbid doctors to countenance, condone, or participate in the practice of torture or other forms of cruel inhuman or degrading procedures, whatever the offence of which the victim of such proceeding is suspected, accused or guilty, and whatever the victim’s belief or motives, and in all situations, including armed conflict and civil strife;

•The WMA Declaration of Hamburg Concerning Support for Medical Doctors Refusing to Participate in, or to Condone, the Use of Torture or Other Forms of Cruel, Inhuman, or Degrading Treatment, adopted in 1997 reaffirmed in 2007 and again with minor revision in 2017.

The WMA Declaration of Tokyo has been joined by declarations from other medical organisations:

•The 1977 Declaration of Hawaii from the World Psychiatric Association (WPA) (updated in 1983);

•The 1996 Madrid Declaration and seven general guidelines of WPA reaffirmed in 1999, 2002, 2005 and in 2011 and which has now been superseded by the 2020 WPA Code of Ethics;

•The 1975 Position statement of the International Council of Nurses (ICN) on the Nurse’s Role in the Care of Detainees and Prisoners (replaced in 1998 by another position statement of the same name, which was then revised in 2006 and 2011).

In 2022, the WMA decided to include this topic as a standing ethical duty in the revised ICoME: “[P]hysician must never participate in or facilitate acts of torture, or other cruel, inhuman, or degrading practices and punishment” (para.10).

These ethical norms and the preamble to the ICoME that national ethical, legal and regulatory norms and standards should not diminish the commitment of doctors to the ethical principles set forth in the ICoME, place great pressure on doctors working in countries where national legislation requires doctors to engage in coercive practice. However, the WMA decided that the value of providing an international professional standard of medical ethics allows for debate against conflicting national norms.

In addition to the WMA Declarations, this ethical issue is governed by IHL and two majors United Nations regulations, which takes into account the broader context of State responsibility.

Doctors’ involvement in interrogation and ill-treatment can take many forms, most of which are indirect. Such participation may include surveillance, observation, assistance, communication of medical information, administration of medication not justified by the patient’s state of health and without his or her consent, falsification of medical records or death certificates, or the provision of medical care that allows the prolongation of torture. It was therefore necessary to clarify the rules concerning the active or passive participation of medical personnel in acts of torture and to regulate the ethical content of the obligations of doctors towards detained patients.

In 1982, the United Nations codified the basic principles of medical ethics applicable in situations of detention (1). These rules supplement those provided by IHL to frame the conditions for the exercise of medical mission with respect to prisoners of war and other persons deprived of their liberty in connection with an international or non-international armed conflict. They also supplement the Standard Minimum Rules for the Treatment of Prisoners adopted by the United Nations in 1977 (Economic and Social Council resolutions 663 C (XXIV) of 31 July 1957 and 2076 [LXII] of 13 May 1977), which already contained numerous rules relating to the rights of detainees and the practice of medical mission in places of detention. However, these rules were mainly addressed to States and did not delineate the boundaries of medical ethics and individual responsibility of medical personnel for such violations. In 1974, the adoption of the Istanbul Protocol by the United Nations provided direct guidance to medical personnel in the ethical management of situations of torture and ill-treatment (2). It emphasises the ethics of the therapeutic relationship as opposed to other forms of medical presence and proposes guidelines for the ethical management of dilemmas arising from the dual and conflicting obligations of doctors under national law.

Detention </content/article/3/detention>__ ▸ Torture

1. 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

These principles were adopted by consensus by the UN General Assembly on 18 December 1982 (Resolution 37/194). They go beyond the principles of medical ethics set out in the Nuremberg Code of 1947, which was limited to regulating medical experimentation on detainees. They supplement the rules governing the exercise of the medical mission in situations of armed conflict, which prohibit the active or passive participation of doctors in acts of torture and cruel, inhuman, or degrading treatments of detainees. Finally, they reinforce the general rules of medical ethics by adapting them to the specific risks associate with detention.

•They set out six fundamental principles from which there can be no derogation for any reason, including public emergency (Principle 6).

•They reaffirm the rule of non-discrimination and equality of medical treatment, whatever the status of the patient: “[h]ealth personnel, particularly physicians, charged with the medical care of prisoners and detainees have a duty to provide them with protection of their physical and mental health and treatment of disease of the same quality and standard as is afforded to those who are not imprisoned or detained.” (Principle 1).

•They clarify the content of the individual responsibility of the care provider inactive or passive involvement in ill-treatment. (Principle 2).

They affirm that the passive or active participation of the doctor in torture and cruel or inhuman treatment is established as soon as the role of the medical personnel is shown to have an objective other than that of assessing, protecting or improving the physical or mental health of the persons concerned. (Principle 3).

“It is a gross contravention of medical ethics, as well as an offence 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 2).

“It is a 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 solely to evaluate, protect or improve their physical and mental health” (Principle 3).

“It is a contravention of medical ethics for health personnel, particularly physicians: (a) to apply their knowledge and skills in order to assist in the interrogation of prisoners and detainees in a manner that may adversely affect the physical or mental health or condition of such prisoners or detainees and which is not in accordance with the relevant international instruments; (b) to certify, or to participate in the certification of, the fitness of prisoners or detainees for any form of treatment or punishment that may adversely affect their physical or mental health and which is not in accordance with the relevant international instruments, or to participate in any way in the infliction of any such treatment or punishment which is not in accordance with the relevant international instruments.” (Principle 4).

Additionally, “[i]t is a contravention of medical ethics for health personnel, particularly physicians, to participate in any procedure for restraining a prisoner or detainee unless such a procedure is determined in accordance with purely medical criteria as being necessary for the protection of the physical or mental health or the safety of the prisoner or detainee himself, of his fellow prisoners or detainees, or of his guardians, and presents no hazard to his physical or mental health.” (Principle 5).

2. Manual on the Effective Investigation and Documentation of Torture and Other Cruel, Inhuman, or Degrading Treatment or Punishment

Under the name of the Istanbul Protocol, endorsed by the former United Nations High Commissioner for Human Rights on 9 August 1999 (latest revision in 2022), this Manual provides guidelines to help health care professionals faced with torture and ill-treatment to deal with ethical dilemmas. It also recalls the obligations of doctors in documenting torture and ill-treatment and the prohibition on participating in this type of treatment.

a. Ethics of the therapeutic relationship

The Manual confirms that the only ethical relationship between prisoners and health professionals is one designed to assess, protect and improve the health of prisoners. Assessing the health of prisoners to facilitate punishment or torture is clearly contrary to medical ethics. For the purposes of this Manual, “participation in torture” includes assessing a person’s ability to withstand ill-treatment; being present at, supervising or inflicting ill-treatment; resuscitating persons for the purpose of further ill-treatment or providing medical treatment immediately before, during or after torture on the instructions of those likely to be responsible for it; providing professional knowledge or personal health information about individuals to torturers; and deliberately neglecting evidence and falsifying reports, such as autopsy reports and death certificates.

This document recalls the three fundamental obligations of the doctor: (1) to provide compassionate care by considering only the patient’s best interests, (2) to respect the patient’s informed consent, and (3) to respect medical confidentiality and to do no harm to the patient.

The Manual outlines the dilemmas associated with the obligations of the medical personnel to the patient on the one hand, and to society on the other, and provides guidelines for dealing with these ethical dilemmas.

b. Ethical Management of the Dilemmas arising from Dual Obligations

The Manual notes that doctors are often faced with conflicting obligations, which they must arbitrate on the basis of ethical principles. For example, there is a conflict between the duty to provide care and the duty not to participate in ill-treatment, or between the duty of medical confidentiality owed to the patient and the duty to disclose medical information to the authorities. The document clarifies the principles that can help medical personnel manage these dual obligations.

First and foremost, it states that the absolute prohibition of harm to the patient is the only ethical criterion that can be used to resolve ethical dilemmas relating to the lifting or maintenance of medical confidentiality. It also affirms that when the dilemma is between an ethical obligation and a legal obligation, such as the obligation to disclose confidential information about a patient, the ethical rule must always prevail. Conversely, when the dilemma is between two different ethical obligations, the principle of avoiding any risk to the patient should prevail. This is evident, for example, in the doctor’s obligation to respect medical confidentiality, but also to protect the patient by alerting the authorities about his or her state of health condition and disclosing confidential information when it is in the patient’s best interest to do so. The Manual recalls that the doctor must never base his or her ethical decision solely on obedience to a legal requirement. In making his or her decision, the doctor must weigh the risk to the patient of alerting the authorities to ill-treatment in places of detention under their control. This includes, in particular, pressure from the authorities to obtain information and personal medical records on the patients concerned, or to restrict the doctor’s autonomy and the patient’s access to care. Ultimately, the ethical principle of confidentiality towards the patient overrides any legal obligation to report.

With regards to dilemmas arising from the nature of the doctor-patient relationship, the Manual points out that when a doctor does not intervene at the patient’s request or in the context of a therapeutic relationship guided by the patient’s best interests, he or she must inform the patient of the nature of the mission and of the constraints of confidentiality. The doctor must explain the reasons for the examination or treatment. The patient must remain free to consent or not.

If the doctor is acting at the request of a third party, such as a penitentiary administration, the military or a security actor, he or she must refuse any order that could harm the physical or mental health of the patient and ensure that the patient always has access to the necessary care. The doctor must also defend the independence and impartiality of diagnosis and medical decisions. Finally, the doctor must ensure that the confidentiality of medical information gathered in the course of his or her work is not broken without the consent and information of the patient.

IV. Recourse and Sanctions for Violations of Medical Ethics

Certain violations of medical ethics may fall within the definition of international crimes, particularly with regard to the prohibition of participating in or aiding and abetting acts of torture, war crimes or crimes against humanity. The Additional Protocols to the Geneva Conventions have also extended the list of grave breaches of IHL to include acts and omissions that intentionally impair the state of health of protected persons in situations of armed conflict (API, art. 11(4), APII, art. 5(2)(e). These criminal offenses may be prosecuted before national courts of any country in accordance with the principle of universal jurisdiction contained in the United Nations Convention against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment (arts. 2 and 5) and the Geneva Conventions (GCI–II, arts. 49, 50; GCII, art. 129 and GCIV, arts. 146 and 147; API, art. 85(1)), as well as for war crimes and crimes against humanity as defined in the Rome Statute of the ICC. Depending on the case, the jurisdiction of the ICC can also be invoked.

Medical professionals who act contrary to medical ethics can also be prosecuted by national disciplinary bodies (colleges of physicians). These authorities cannot impose criminal sanctions, but they can deprive doctors of their right to practise medicine. The purpose of these sanctions is to protect society from acts contrary to good professional practice. However, in situations where medical personnel are involved in abusive State practices, such as the ill-treatment or torture of prisoners, national disciplinary authorities tend to regard this as a political rather than an ethical issue to be dealt with by national courts. This was the decision of the College of Physicians of California in 2005, when it refused to investigate the case of a doctor responsible for treating prisoners at Guantanamo. The issue had already been raised earlier, concerning the ethical or non-ethical nature of doctors’ involvement in the application of the death penalty by lethal injection. In the latter case, however, the ethical question is, in time of peace, separate from the criminal question of participation in acts of torture, since the definition of the Convention against Torture excludes suffering resulting from the execution of a criminal sentence pronounced by a regular court.

Given the difficulty for national medical associations to deal with the specific issue of doctors’ involvement in torture and ill-treatment of prisoners, it has been suggested that this matter be delegated to an international professional body, such as the World Medical Association, or that a new body be created specifically to deal with this issue. Such a step would arguably not weaken national or international criminal jurisdictions, which are still not very active in these matters, but on the contrary would stimulate reflection and ethical decision-making within the medical field.

DetentionIll treatmentMedical dutiesMedical personnelMedical servicesTortureWorld Health OrganizationWounded and sick persons

@ World Medical Association: World Psychiatric Association:

International Council of Nurses:

Islamic Organization for Medical Sciences: Federation of Islamic Medical Associations: International Council of Nurses: Commonwealth Medical Association:

**For Additional Information:

Amnesty International,*Ethical Codes and Declarations Relevant to the Health Professions: An Amnesty International Compilation of Selected Ethical and Human Rights Texts and Other International Standards , Fifth edition, London: Amnesty International, 2009. Available at

Beauchamp T., Childress J., Principles of biomedical ethics , 8th ed., New York, NY: Oxford University Press, 2019.

Bonnie, Richard J., “Political abuse of psychiatry in the Soviet Union and China: Complexities and Controversies”, The Journal of the American Academy of Psychiatry and the Law , February 2002, vol. 30: 136-144. Available at

Borchelt, Gretchen, “Break Them Down: Systematic Use of Psychological Torture by US Forces”, Report, Physicians for Human Rights , Cambridge, 2005. Available at

British Medical Association, The Medical Profession and Human Rights: Handbook for a Changing Agenda, London: Zed Books in association with BMA and New York: Palgrave, St. Martins Press, 2001, 562 pages.

British Red Cross, Forced to report: The humanitarian impact of mandatory reporting on access to health care for victims/survivors of sexual violence in armed conflict and other emergencies , April 2020, 44 pages. Available at

Grodin, Michael and Annas, George, “Physicians and Torture: Lessons Learned from the Nazi Doctors.”, International Review of the Red Cross , vol. 89, no. 867 (September 2007): 635-654.

Gunn, M. J. and McCoubrey, H., “Medical Ethics and the Laws of Armed Conflict.”, Journal of Armed Conflict Law , vol. 3, no. 2 (December 1998): 133-161.

Human Rights Watch, The Legacy of psychiatric abuse in the USSR , 1990. Available at

International Committee of the Red Cross (ICRC), Reporting gunshot wounds, Study provides insights on health staff practices revolving reporting gunshot wounds , 9 December 2019. Available at

Forced to report: Mandatory reporting of sexual violence in armed conflict , 8 July 2020. Available at

**Islamic Organization for Medical Sciences, “The Islamic Code of Medical Ethics”, 1981.


Miles, Steven H., “Abu Ghraib: Its Legacy for Military Medicine”, Lancet Medical Journal , vol. 364, no. 9435, (August 2004): 725-729.

Parsa-Parsi, Ramin, W., Gillon, Rannan and Wiesing, Urban, “The revised International Code of Medical Ethics: an exercise in international ethical self-regulation”, Journal of Medical ethics , 24 July 2023. Available at

Pérez-Sales, Pau, « La version 2022-révisée du Protocole d’Istanbul: kit d’orientation pour les personnes en situation d’urgence », Torture Journal , vol. 32, no. 3, p. 3-15, September 2022. Available at’Istanbul_kit_d’orientation_pour_les_personnes_en_situation_d’urgence

Swiss Institute of Comparative Law and ICRC, Legal Opinion on the Obligation of Health Care Professionals to Report Gunshots Wounds ; 2019, 120 pages. Available at

The Constitution Project’s Task Force on Detainee Treatment, “The Role of Medical Professionals in Detention and Interrogations Operations.”, Chapter 6, in The Report of the Constitution Project’s Task Force on Detainee Treatment , 2013, Washington, D.C., 203-242. Available at

United Nations Educational, Scientific and Cultural Organization (UNESCO), Universal declaration on bioethics and human rights , 19 October 2005. Available at

United Nations Human Rights Office of the High Commissioner (OHCHR) , Istanbul Protocol, Manual on the Effective Investigation and Documentation of Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment , New York and Geneva, 2022. Available at

“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”, General Assembly Resolution 37/194 , 18 December 1982. Available at

United Nations Office on Drugs and Crime (UNODC), Standard Minimum Rules for the Treatment of Prisoners, Adopted by the First United Nations Congress on the Prevention of Crime and the Treatment of Offenders , Geneva, 1955. Approved by the Economic and Social Council, Resolutions 663 C (XXIV), 31 July 1957, and 2076 (LXII), 13 May 1977. Available at

Van Voren, Robert, “Political Abuse of Psychiatry: An Historical Overview”, Schizophrenia Bulletin , January 2010, vol. 36, no.1, p. 33-35.

Viñar, Marcelo N., “Civilization and Torture: Beyond the Medical and Psychiatric Approach.”, International Review of the Red Cross , vol. 89, no. 867, (September 2007): 619-633.

World Health Organization, Global network of WHO collaborating centres for bioethics , 3 December 2021, Available at

World Medical Association, “Declaration of Tokyo” – Guidelines for physicians concerning torture and other cruel, inhuman or degrading treatment or punishment in relation to detention and imprisonment , 2016. Available at: policies-post/wma-declaration-of-tokyo-guidelines-for-physicians-concerning-tortureand-other-cruel-inhuman-or-degrading-treatment-or-punishment-in-relation-todetention-and-imprisonment/

Geneva Declaration of 1948: Physician’s pledge , Available at

International Code of Medical Ethics , October 2006. Available at

International code of medical ethics , October 2022. Available at

Medical Ethics Manual , 3rd ed., 2015. Available at

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