should be used preferably in all situations where disclosure of the patient’s identity is non-essential. This may be the case, for example, in the collection of data about patterns of torture or maltreatment. Dilemmas arise where health professionals are pressured or required by law to disclose identifiable information which would be likely to put patients at risk of harm. In such cases, the fundamental ethical obligations are to respect the autonomy and best interests of the patient, to do good and avoid harm. This supersedes other considerations. Doctors should make clear to the court or the authority requesting information that they are bound by professional duties of confidentiality. Health professionals responding in this way are entitled to the support of their professional association and colleagues. In addition, during periods of armed conflict, international humanitarian law gives specific protection to doctor-patient confidentiality, requiring that doctors do not denounce people who are sick or wounded.65 Health professionals are protected in that they cannot be compelled to disclose information about their patients in such situations. protected and promoted. Nurses and doctors are expected to act as an advocate for their patients, and this is made clear in statements such as the World Medical Association’s Declaration of Lisbon and the International Council of Nurses’ statement on the Nurse’s Role in Safeguarding Human Rights.63 64. The World Medical Association’s Declaration of Lisbon specifies the duty for doctors to obtain voluntary and informed consent from mentally competent patients to any examination or procedure. This means that individuals need to know the implications of agreeing and the consequences of refusing. Before examining patients, health professionals must, therefore, explain frankly the purpose of the examination and treatment. Consent obtained under duress or as a result of false information being given to the patient is invalid, and doctors acting on it are likely to be in breach of medical ethics. The graver the implications of the procedure for the patient, the greater the moral imperative to obtain properly informed consent. That is to say, where examination and treatment are clearly of therapeutic benefit to individuals, their implied consent by cooperating in the procedures may be sufficient. In cases where examination is not primarily for the purposes of providing therapeutic care, great caution is required in ensuring that the patient knows and agrees to this and that it is in no way contrary to the individual’s best interests. As previously stated, examination to ascertain whether an individual can withstand punishment, torture or physical pressure during interrogation is unethical and contrary to the purpose of medicine. The only ethical assessment of a prisoner’s health is one designed to evaluate the patient’s health in order to maintain and improve optimum health, not to facilitate punishment. Physical examination for evidential purposes in an inquiry requires consent that is informed in the sense that the patient understands factors such as how the health data gained from the examination will be used, how they will be stored and who will have access to them. If these and other points relevant to the patient’s decision are not made clear in advance, consent to examination and recording of information is invalid. 3. D. Health professionals with dual obligations 66. Health professionals have dual obligations, in that they owe a primary duty to the patient to promote that person’s best interests and a general duty to society to ensure that justice is done and violations of human rights prevented. Dilemmas arising from these dual obligations are particularly acute for health professionals working with the police, military, other security services or in the prison system. The interests of their employer and their non-medical colleagues may be in conflict with the best interests of the detainee patients. Whatever the circumstances of their employment, all health professionals owe a fundamental duty to care for the people they are asked to examine or treat. They cannot be obliged by contractual or other considerations to compromise their professional independence. They must make an unbiased assessment of the patient’s health interests and act accordingly. Confidentiality 1. 65. All ethical codes, from the Hippocratic oath to modern times, include the duty of confidentiality as a fundamental principle, which also features prominently in the World Medical Association’s declarations, such as the Declaration of Lisbon. In some jurisdictions, the obligation of professional secrecy is seen as so important that it is incorporated into national law. The duty of confidentiality is not absolute and may be ethically breached in exceptional circumstances where failure to do so will foreseeably give rise to serious harm to people or a serious perversion of justice. Generally, however, the duty of confidentiality covering identifiable personal health information can be overridden only with the informed permission of the patient.64 Non-identifiable patient information can be freely used for other purposes and Principles guiding all doctors with dual obligations 67. In all cases where doctors are acting for another party, they have an obligation to ensure that this is understood by the patient.66 Doctors must identify themselves to patients and explain the purpose of any examination or treatment. Even when doctors are appointed and paid by a third party, they retain a clear duty of care to any patient whom they examine or treat. They must refuse to comply with any procedures that may harm patients or leave them physically or psychologically vulnerable to harm. They must ensure that their contractual terms allow them professional independence to make clinical judgements. Doctors must ensure that any person in custody has access to any medical examination and treatment needed. Where the detainee is a minor or a vulnerable adult, doctors have additional duties to act as an advocate. Doctors retain a 63 65 Article 16 of Protocol I (1977) and article 10 of Protocol II (1977), additional to the Geneva Conventions of 1949. 66 These principles are extracted from Doctors with Dual Obligations (London, British Medical Association, 1995). Adopted in 1983. Except for common public health requirements, such as the reporting by name of individuals with infectious diseases, drug addiction, mental disorders, etc. 64 14