and be strictly regulated and limited to very exceptional cases for as short a time as possible.311 191. Additionally, it is essential to stress that the prohibition of torture and ill-treatment relates not only to the conduct of law enforcement agents or military personnel but also to medical personnel working in places such as detention facilities.312 Medical personnel must not play a role in torture, directly or indirectly, such as by examining and certifying the fitness of detainees for abusive interrogations, by being present or assisting during such interrogations or by providing any information to facilitate acts of torture or illtreatment.313 192. International bodies and experts such as the World Medical Association, the UN Special Rapporteur on torture and the IACHR have also recognized that the decision to force-feed detainees who are mentally competent and voluntarily take part in a hunger strike is unjustifiable, as it violates rules of ethics and the right to health, amongst other things.314 Force-feeding should never be used to pressure detainees to stop a hunger strike.315 Furthermore, force-feeding “accompanied by threats, coercion, force or use of physical restraints is a form of inhuman and degrading treatment”316 and may even amount to torture.317 311 Ibid., paras. 75, 89; UN Special Rapporteur on torture, Interim report to the General Assembly, A/63/175, op. cit., note 307, paras. 80, 83; UN CAT, Concluding observations on the combined third to fifth periodic reports of the United States of America, op. cit., note 107, para. 20. 312 UN Special Rapporteur on torture, Interim report to the General Assembly, A/63/175, ibid., para. 51. 313 Istanbul Protocol, Manual on the Effective Investigation and Documentation of Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment (New York and Geneva: United Nations Publication, 2004), paras. 52-53, <http://www.ohchr.org/documents/publications/training8rev1en.pdf>; UN Special Rapporteur on torture, Theo van Boven, Report to the Commission on Human Rights, ��General Recommendations of the Special Rapporteur on torture”, E/CN.4/2003/68, 17 December 2002, para. n, <http://www.ohchr.org/Documents/Issues/SRTorture/recommendations.pdf>; UN Special Procedures, “Situation of detainees at Guantánamo Bay”, op. cit., note 23, paras. 73-74. See, also, “Principles of Medical Ethics relevant to the Role of Health Personnel, particularly Physicians, in the Protection of Prisoners and Detainees against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment”, New York, 18 December 1982, <http://www.ohchr.org/EN/ProfessionalInterest/Pages/MedicalEthics.aspx>; “Declaration of Tokyo, Guidelines for Physicians Concerning Torture and other Cruel, Inhuman or Degrading Treatment or Punishment in Relation to Detention and Imprisonment”, World Medical Association, Tokyo, October 1975 (as revised in Divonne-les-Bains, May 2006), <http://www.wma.net/en/30publications/10policies/c18/>. 314 See, for instance, UN Special Procedures, “Situation of detainees at Guantánamo Bay”, ibid., paras. 80, 82: “The Declarations of Tokyo and Malta prohibit doctors from participating in force-feeding a detainee, provided the detainee is capable of understanding the consequences of refusing food. This position is informed by the fundamental principle, which recurs throughout human rights law, of individual autonomy. As well as the World Medical Association, the American Medical Association and many others have endorsed the Declaration of Tokyo (…). [T]reating a competent detainee without his or her consent - including force-feeding - is a violation of the right to health, as well as international ethics for health professionals.” See, also, “IACHR, UN Working Group on arbitrary detention, UN Rapporteur on torture, UN Rapporteur on human rights and counter-terrorism, and UN Rapporteur on health reiterate need to end the indefinite detention of individuals at Guantánamo Naval Base in light of current human rights crisis”, OHCHR website, op. cit., note 107. 315 “World Medical Association Declaration of Malta on Hunger Strikers”, World Medical Association, Malta, November 1991 (as revised in Pilanesberg, October 2006), para. 13, <http://www.wma.net/en/30publications/10policies/h31/>; “IACHR, UN Working Group on arbitrary detention, UN Rapporteur on torture, UN Rapporteur on human rights and counter-terrorism, and UN Rapporteur on health reiterate need to end the indefinite detention of individuals at Guantánamo Naval Base in light of current human rights crisis”, OHCHR website, ibid. 316 “Declaration of Malta on Hunger Strikers”, World Medical Association, ibid, para. 16. 317 The European Court of Human Rights has found a violation of the prohibition of torture where the existence of a medical necessity was not convincingly demonstrated by domestic authorities, the procedural safeguards were not complied with and the force-feeding procedure (prescribed by decree; with handcuffs, a mouth-widener and a special tube inserted into the food channel, and using force in the event of resistance) amounted to torture (ECtHR, Nevmerzhitsky v. Ukraine, Application No. 80