ESSEX PAPER 3: INITIAL GUIDANCE ON THE INTERPRETATION AND IMPLEMENTATION OF THE UN NELSON MANDELA RULES Full Clinical Independence Rule 25(2) underscores the full clinical independence of the health-care service. This reflects the range of international standards and norms providing for the clinical independence of health professionals working in prisons.223 Rule 24(2) provides that health-care services should be ‘organised in close relationship to the general public health administration’. When read together with Rule 25(2), the Essex Group recalled international standards and norms that require the general public health administration to be the entity to employ the prison health-care staff rather than the prison director in order to safeguard clinical independence.224 The Essex Group also noted that as provided in Rule 27(2), the prison administration must have no influence or go against the decisions of the health-care team. The Rule underscores that decisions ‘may only be taken by the responsible healthcare professionals and may not be overruled or ignored by non-medical prison staff’. This is in line with medical ethics including the World Medical Association’s Declaration of Tokyo225 which states that: A physician must have complete clinical independence in deciding upon the care of a person for whom he or she is medically responsible. The physician’s fundamental role is to alleviate the distress of his or her fellow human beings, and no motive, whether personal, collective or political, shall prevail against this higher purpose’.226 Equivalence of Care Rule 24 of the Nelson Mandela Rules emphasises that health-care in prison should be equivalent to that in the community as the right to the highest attainable standard of health under the International Covenant on Economic, Social and Cultural Rights applies throughout the state without distinction. Those in the community and in prisons have a right to the highest attainable standard of health-care based on assessed individual needs and the state is required to meet the obligation to the outside community and in prisons. Rule 24 requires the organization of health- UN Principles of Medical Ethics, the Bangkok Rules, the UN Rules for the Protection of Juveniles Deprived of their Liberty adopted by General Assembly resolution 45/113 on 2 April 1991, the Background Paper for the Trencin Statement on Prisons and Mental Health 2007 (the Trencin Statement), the Council of Europe Committee of Ministers’ Recommendation No. R (98) 7 Concerning the Ethical and Organisational Aspects of Health Care in Prison 8 April 1998, and Principle X of the Principles and Best Practices on the Protection of Persons Deprived of Liberty in the Americas (2008) indicate international acceptance of such obligations. The provision of health-care services operated with full clinical independence has also been established in the Proposed Guidelines & Institutional Mechanisms A Project of the International Dual Loyalty Working Group Guidelines for Prison, Detention and Other Custodial Settings (Dual Loyalty Guidelines) and in the 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 1975, Rev. October 2016, available at: http://www.wma.net/en/30publications/10policies/c18/ (WMA Declaration of Tokyo) 223  WHO, Good governance of prison health in the 21st century. In this document WHO suggests that in order for prisons to meet international human rights standards and to contribute to better public health the best organisational solution is that “health ministries should provide and be accountable for health care services in prisons and advocate healthy prison conditions.” See also Commentary to Recommendation REC(2006)2 of the Committee of Ministers to member states on the European Prison Rules. Strasbourg, Council of Europe (2005) available at: http://www.coe.int/t/dghl/ standardsetting/prisons/E%20commentary%20to%20the%20EPR.pdf. It reads (at p.17): “Organisation of prison health care. Rule 40. The most effective way of implementing Rule 40 is that the national health authority should also be responsible for providing health care in prison, as is the case in a number of European countries. (…). This will not only allow for a continuity of treatment but will also enable prisoners and staff to benefit from wider developments in treatments, in professional standards and in training.” (Commentary to Recommendation REC(2006)2) 224  WMA Declaration of Tokyo 225  Principle 5 226  Penal Reform International and the Essex Human Rights Centre | 63