ESSEX PAPER 3: INITIAL GUIDANCE ON THE INTERPRETATION AND IMPLEMENTATION OF THE UN NELSON MANDELA RULES The Essex Group noted that in order to ensure that this requirement is met in the prison context, training for all staff (particularly medical staff) on human rights and medical ethics will be needed242. Informed Consent and Autonomy Of particular importance to medical ethics and the right to the highest attainable standard of health is a strong understanding of informed consent and prisoner-patient autonomy as set out in Rule 32(1)(b). The Essex Group noted that prison authorities are under an obligation to make sure that informed consent is documented through a written procedure. As set out above, prisoner-patient autonomy and confidentiality are cornerstones of a trustful patient-doctor relationship. The absence of a trustful relationship may mean that prisoners may not feel comfortable revealing health conditions that could be of public health relevance. Where treatment is proposed, the principles of informed consent and patient autonomy mean that the prisoner must be able to refuse treatment if he or she does not wish to receive it.243 The information on the proposed treatment must be explained in a language that the prisoner understands. In the very narrowest of circumstances, the Essex Group noted that medical staff may act where the prisoner is unable to consent, for example, where the prisoner is unconscious and requires emergency treatment. However, following the Declaration of Lisbon, where clear prior wishes to the contrary have been expressed, even such emergency treatment is not permissible. This Declaration provides that, ‘if a legally entitled representative is not available, consent of the patient may be presumed, unless it is obvious and beyond any doubt on the basis of the patient’s previous firm expression or conviction that he/she would refuse consent to the intervention in that situation’.244 The experts recalled that no vaginal examination of women prisoners must be undertaken without consent and that virginity tests are prohibited explicitly by Rule 8 of the Bangkok Rules. WHO, Good governance of prison health in the 21st century reflects on State’s core obligations under the right to health according to General Comment No. 14 and concludes with regard to health staff’s professional and ethical conduct and their clinical independence (at p. 9) “(..) such an understanding of their role implies the necessity for all people working in prisons to be trained in and respect human rights and medical ethics”. The Norwegian Medical Association, in cooperation with the World Medical Association, has developed a web-based course Doctors Working in Prison: Human Rights and Ethical Dilemma. Oslo, Norwegian Medical Association, 2001, available at: http://www. wma.net/en/70education/10onlinecourses/20prison/ , or https://nettkurs.legeforeningen.no/enrol/index.php?id=39). See also UN Principles of Medical Ethics and the Council of Europe’s Manual on Prison health care and medical ethics (2015), available at: http://www.coe.int/t/dgi/criminallawcoop/Presentation/Documents/Publications_HealthCare_manual_Web_A5_E.pdf . 242  A WHO guide to the essentials in prison health, at 37- 38; UN General Assembly, Interim report of the Special Rapporteur on torture and other cruel, inhuman or degrading treatment or punishment, (28 July 2008) UN doc A/63/175, paras. 47, 74. 243  WMA Declaration of Lisbon on the Rights of the Patient (1981/Rev.2015), available at: http://www.wma.net/en/30publications/10policies/l4/, Principle 4 b. 244  Penal Reform International and the Essex Human Rights Centre | 67