5.2 Issues regarding prison medicine in solitary confinement units What are ‘dual loyalties’ and where can health professionals seek support and advice? A physician shall owe his/her patients complete loyalty and all the scientific resources available to him/her (WMA International Code of Medical Ethics, 1949). A situation of dual loyalty arises when health professionals face “simultaneous obligations, expressed or implied, to a patient and a third party”73. Health professionals working in prisons will almost inevitably face situations where they are asked or expected to suspend their clinical judgement in favour of other considerations or to contribute to processes and procedures that are not driven by therapeutic purposes. Codes of ethics make it clear that the duty owed to the patient takes precedence over any other obligation, and that health professionals must act in the best interest of their patients at all times. Many of the issues outlined in the following sections, such as whether to certify someone fit for punishment, or the right to access healthcare, are examples of such dual loyalties. Clearly, as in any medical practice, there will be situations in which health professionals will have to judge whether their primary obligation to the care of the individual patient might have to be overridden in order to protect that individual, other prisoners, or staff. Again, their actions should be guided primarily by their function as health professionals, above that of their status as employees of a prison, police force or the military, but therein lies the very essence of “dual loyalties”. Health professionals should strive to retain a professional independence, and thereby to retain the trust and confidence of their prisoner-patient. Physicians seeking advice on ethical dilemmas can approach both their national medical association and the World Medical Association74 (www.wma.net). Nursing professionals can approach their national nursing association as well as the International Council of Nurses, the body which provides ethical guidance to nurses (International Council of Nurses www.icn.ch). Do health professionals have any role in certifying a prisoner ‘fit’ to undergo disciplinary measures, including solitary confinement? In exactly the same manner as any health professional working in the community, the primary duty of the health professional working inside a prison is to protect, promote and improve the health of their patients. Naturally, when working in an environment whose over-arching aim is security, the health professional must follow the rules and procedures necessary for the safe and lawful running of the institution, but their role as health professionals must not be subordinated to this purpose. Their ethical duties remain the same as if they were working in the community but, as we shall see below, with the various constraints that working in a place of deprivation of liberty brings. 58 Sourcebook on solitary confinement: The role of health professionals in segregation units