August 6, 1997

Introduction

Restraining patients (prisoners and/or detainees) raises complex ethical problems in two areas: (a) the mere restraining of an individual whose physical condition is poor and is in pain. Restraining an individual under these conditions may be considered “torture”, particularly if the restraining methods are inappropriate; (b) it is the physician’s duty to maintain the patient’s physical and mental health and to relieve his or her suffering while respecting the value of life. The physician is perceived as the patient’s confidant, not as a government authority. The problem arises when restraining is allowed during physical examination, as this will be interpreted as the physician’s siding with government authorities rather than with the patient.

After reviewing the issue we think that it is important to establish several principles with respect to the restraining of prisoners and detainees:

This paper refers to all security entities – army, police and prison authorities - although there are differences between them. From the physician's perspective there is no reason to differentiate between these entities.

Hospital Care:

1.     In general – patients are not to be restrained

The basic ground rule is that prisoners and detainees will be treated without being restrained and will not be treated in the presence of a security entity, unless there is a real danger of escape or if the individual or the medical team is in danger.

2.     The decision to restrain as a security consideration

The first rule with respect to restraining is that it has been determined that such restraint is a necessary measure.

• The initial decision to restrain belongs to the security entities and should be determined by them (army, police, prison authorities).
• Due to the harsh significance of a decision to restrain a patient, only an individual holding a senior level position shall have the mandate to make such a decision. Where it would be otherwise impossible to employ restraints, due to the need for urgent treatment and/or if an authorized high level official is not available, the decision of the security entity on site shall suffice, provided that it is clear that the decision will be authorized by a senior level entity as soon as possible.
• Before a decision is made regarding patient restraint, the security official shall receive an updated report about the patient’s physical condition, so that he or she can evaluate the need for restraints. For example, the more critical the injury, the lower the chances of escape.

3.  Employing restraints only where a suitable alternative is lacking

The second rule is that the decision to restrain a patient will only be authorized if a more suitable alternative for achieving the same goal is lacking.

• Thus, for example, restraining should not be used as an alternative to suitable personnel and medical staff.
• Hospitals treating detainees or prisoners on a regular basis should be encouraged to undertake changes to alter the security conditions by allocating a suitable budget for this purpose. For example, the hospital should consider providing a treatment room without windows or with a window that cannot be opened. Obviously, it is not feasible to request special conditions in cases where the provision of medical treatment to such individuals is rare.
   

4.   Ultimately, the decision to restrain a prisoner or a detainee is subject to medical discretion

It is the role of the police or the army to determine the need for and scope of restraining measures. Nevertheless, it is up to the physician to decide whether the restraints will harm the patient or delay the provision of appropriate treatment.

If the patient is in danger the physician’s decision shall override any other decision.

5.  Implementation of these principles

In order to implement the above-mentioned principles, it is imperative to formulate clear guidelines that will be made known and accessible to all security entities and to the medical team.

• The guidelines shall be clear and specific, such as guidelines to remove restraints during childbirth, etc.
• The guidelines shall be formulated such that they will reduce to a minimum the danger of harm to the patient. For example, they shall specify the use of suitable restraining measures (handcuffs, long chains, etc.).
• In formulating the guidelines, the utmost effort shall be made to maintain the patients’ dignity and privacy, as in, for example, a guideline to conceal the restraining measures as much as possible.
• Every hospital shall have at its disposal, in an accessible place, the necessary equipment for appropriate restraining, in order to avoid the need to use inappropriate measures.

Control and coordination

All security entities and the management of medical institutions shall jointly decide on contact persons who shall be responsible for coordination and consultation with respect to guideline implementation.

The guidelines and their implementation will be evaluated periodically by a coordinating committee of the Ministry of Health and the Ministry of Justice.
 

Note: notwithstanding the above, it is important to specify that physicians shall not be required to act contrary to their moral conscience.