treatment11 – in cases of handcufng of prisoners during medical examina‑ tion and treatment. Alternative solutions can and should be found to reconcile legitimate security requirements with the principle of medical confdentiality. One possibility might be the installation of a call system, for a doctor to be in a position to rapidly alert prison ofcers in those exceptional cases when a prisoner becomes agitated or threatening during a medical examination.12 The fnal decision, on ethically questionable practices regarding the use of handcufs and interviews behind glass, should be left to the medical staf. Examination rooms should be secure, so they must be ftted out in such a way as to limit risks of escape; this also helps to meet security concerns. If and when the custodial staf are trusted to distribute medication to prison‑ ers, the medical staf should pre‑pack medication in dosette boxes. In order to preserve medical confdentiality, the staf distributing medication should not be aware of the names and dosage of the medication. Keeping prisoners’ medical fles is the responsibility of the doctor. In the event of transfer, the fle should be sent in a confdential way – using secure data transfer – to the doctors in the receiving establishment. Doctor–patient confdentiality as a cornerstone of medical ethics Respect for confdentiality is essential in ensuring an atmosphere of trust, which is necessary for the doctor–patient relationship; it should be the duty of the doctor to preserve such a relationship and to decide how to observe the rules of confdentiality in a given case. A prison doctor acts as a patient’s personal doctor. Prisoners should be able to approach the health‑care ser‑ vice on a confdential basis – for example, by means of a message in a sealed envelope. Prison ofcers should not seek to screen requests for consultation with a doctor. A difcult situation may arise when the patient’s decision conficts with the general duty of care incumbent on the doctor. This might happen when the patient is infuenced by personal beliefs (for example, refusal of a blood 11. Mouisel v. France 67263/01 and Tarariyeva v. Russia 4353/03. 12. CPT/Inf (2007)47. Medical ethics in prison Page 13