89 The role of medical personnel in places of detention Examples of ethical dilemmas However, despite these guidelines, ethical dilemmas may remain that healthcare professionals must be aware of and that must be dealt with individually based on an ethical analysis, particularly with regard to patients’ consent and medical confidentiality. One example is a case where the prison doctor becomes aware of signs of ill-treatment or even torture of an inmate and the inmate does not consent to the case being reported for fear of reprisals. On the one hand, medical confidentiality and patient consent rules have to be strictly followed, but, on the other hand, everything must be done to prevent ill-treatment and torture. Even international documents provide different guidance: The European Committee for Prevention of Torture and Inhuman or Degrading Treatment or Punishment (CPT) recommends reporting such cases even without the consent of the victim whereas the Istanbul Protocol15 and the WMA in its 2007 Resolution on the Responsibility of Physicians in the Documentation of Torture and Inhuman or Degrading Treatment or Punishment16 recommend seeking solutions that promote justice without breaching the individual‘s right to confidentiality and weighing the risk and potential danger to that individual patient against the benefits to the general prison population and the interests of society in preventing the perpetuation of abuse. Therefore, healthcare professionals should be aware of the overlapping and, in part, conflicting roles both victims/patients and doctors may have in cases of alleged ill-treatment: the victim is patient and plaintiff and often the only witness, whereas the doctor must assume the roles of the treating healthcare professional and the evaluating expert, roles with different and possibly conflicting duties of confidentiality. Another often quoted and extremely challenging example concerning patient consent is healthcare for hunger strikers in prison, leading to the following dilemma for care providers: what is more important: sanctity of life or a patient’s autonomy? Although the WMA Malta Declaration17 provides good guidance, the course of action taken after a patient loses his/her capacity to decide ultimately rests with the individual treating physician. Dual loyalty and how to mitigate the risks In order to expediently handle these ethical dilemmas, it is essential that healthcare professionals can act without any undue influence and intervention from third parties in relation to their sole task; the health and well-being of the inmates based on professional and clinical independence, i.e. without the ethical conflict of dual loyalty. Dual loyalty has been defined as the clinical role conflict between professional duties to a patient and obligations, express or implied, real or perceived, to the interests of a third party.18, 19 15 Office of the United Nations High Commissioner for Human Rights: The Istanbul Protocol http://www.ohchr.org/Documents/ Publications/training8Rev1en.pdf 16 WMA Resolution on the Responsibility of Physicians in the Documentation of Torture and Inhuman or Degrading Treatment or Punishment www.wma.net/policies-post/wma-resolution-on-the-responsibility-of-physicians-in-the-documentation-anddenunciation-of-acts-of-torture-or-cruel-or-inhuman-or-degrading-treatment 17 WMA Declaration of Malta on Hunger Strikers www.wma.net/policies-post/wma-declaration-of-malta-on-hunger-strikers 18 Physicians for Human Rights and School of Public Health and Primary HealthCare University of Cape Town, Health Sciences Faculty. Dual loyalty and human rights in health professional practice. Proposed guidelines and institutional mechanisms. March 2002. http://physiciansforhumanrights.org/library/report-dualloyalty-2006.html. 19 Pont J, Stöver H, Wolff H: Dual Loyalty in Prison Health Care. American Journal of Public Health 102:475-480, 2012 http://ajph. aphapublications.org/doi/10.2105/AJPH.2011.300374