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Part ~ Torture, Psychiatric Abuse, and the Ethics of Medicine INTRODUCTION Gerard Debreu Over the past two decades the systematic use of torture and psychiatric abuse have been sanctioned or condoned by more than one-thirc] of the nations in the United Nations, about half of mankind. They have shown no discrimination according to ideologies or to races. They have raised many questions that concern this academy and the Institute of Medicine. Some of those questions are of a scientific nature. What are the long-range physical and psychological consequences of torture and of psychiatric abuse? How can they be treated? How do the victims react when they are faced with excruciating pain or the loss of their mental integrity? How does a human being become a torturer? How does a society tolerate torture and the commitment of political dissidents to psychiatric hospitab? The first part of this symposium will deal with some of those issues, but it wiD also focus on ethical questions. Outstanding among them is the participation of physicians in both torture and psychi- atric abuse. The fact that men, women, and sometimes children are subjected to torture is an outrage. The outrage is greater when physicians, committed by their profession to healing and to relieving suffering, become active participants in inflicting pain and in abusing psychiatry for political purposes. 21

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Many members of the worldwide medical community have spo- ken and acted forcefully in their condemnation of those professional abuses and in their defense of human rights. Four of them are with us today. The three discussants, Drs. Helen Ranney, Albert Soinit, and Alfred Haynes, have all served as members of our Committee on Human Rights. Dr. Helen Ranney is chair of the Department of Medicine at the University of California at San Diego and Distinguished Physician at the Veterans Administration Medical Center in La JolIa. She will discuss torture, collusion of physicians in torture, and scientists and health professionals as victims of torture. Dr. Albert SoInit is Sterling Professor of Pediatrics and Psychi- atry at the Child Study Center at Yale University. He will discuss the basic tenets of psychiatric treatment of victims of torture and the abuses of psychiatry for political ends. Dr. Alfred Haynes is professor, Department of Community Medi- cine at the Charles R. Drew Postgraduate Medical School in Los Angeles. He will discuss the responsibility of scientists and medical personnel to condemn abuses and to provide support for those who speak out against or refuse to collude in torture and psychiatric abuse. Our guest speaker, Dr. Juan Cuts Gonzalez, Is a surgeon and president of the independent Medical Association of Chile. ~ hac] the privilege of meeting Dr. Gonzalez one morning in March 1985, when a human rights mission of the academy spent a week in Santiago. On that occasion, Dr. Gonzalez and his colleagues commanded the respect of our mission for their professionalism and thoroughness. They won our admiration for the courage with which they condemned the practice of torture and the collusion of physicians with torturers in their country. Gonzalez testified before the U.S. Congress on torture in Chile, and he accepted the Scientific Freedom and Responsibility Award for 1986 from the American Association for the Advancement of Science for the Colegio Medico de Chile. In 1986, he became the president of the National Civic Assembly in Chile, a group of representatives of professional, social, and community organizations and trade unions who oppose the Chilean government. When Dr. Gonzalez was arrested on July 11, 1986, with 15 other members of the board of the National Civic Assembly involved in the planning of the July 2d and ad general strike, the Committee

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23 on Human Rights and its correspondents, many of whom are in the audience today, took unmediate and repeated action in their behalf. Frank Press and Institute of Medicine President Samuel Thier publicly appealed for their release and for the release of other im- prisoned colleagues. Dr. Gonzalez was released on bad] on August 18, 1986, and acquitted in January 1987. ~ introduce him today with exceptional pleasure. TEE WORK OF THE MEDICAL ASSOCIATION OF ClIIIE Juan Luis Gonz6lez Ladies and gentlemen, dear friends. It would be easy to dismiss the problem of torture by saying that torturers are depraved psy- chotics. However, it is the view of the Medical Association of Chile, of which ~ am the president, that a society that allows torture to exist and to persist and become part of the system is a sick society. Thus, our association believes that the system of institutional- ized torture in Chile is ultimately the responsibility of the Chilean society. Torture became a frequent practice throughout Chile follow- ing the coup d'etat by General Pinochet in 1973. While formal reports of torture in a frightened society are few, such reports in Chile are compiled by the Vicaria de la Solidaridad of the Catholic church in Santiago and have come to the attention of the international community. Other groups, such as the Chilean Commission on Human Rights and the National Commission Against Torture, which was formed at the end of 1982, also assist in docu- menting torture and repression. Physicians are actively involved in these groups, and many have been the object of government reprisals. The National Commission Against Torture is chaired by a physi- cian, Dr. Pedro Castillo, who is also the national counselor of the Medical Association of Chile and a former prisoner of conscience of the National Academy of Sciences' Committee on Human Rights. Another physician, Dr. Ramiro Olivares of the Vicaria de la Solidari- dad, who has documented dozens of cases of torture, was arrested in May 1986. Although he was subsequently released, he was rearrested in December under the antiterrorism law and has been held without trial since then.7 7Dr. Olivares was released on bail from prison in late 1987. At the time of publication of this book, the charges against him had not been dropped.

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24 The Medical Association of Chile also receives many oral reports of torture; most of the victims are afraid to put them in writing While we investigate these reports and know that torture has beer a too! used by the government in Chile during the past 13 years, we are restricted by the government in our effort to find witnesses and verify the facts. It is within this societal context that the Medical Association of Chile has taken a strong position against torture, including the establishment, in November 1983, of a code of ethics with respect to torture. Within the last four years, there has been an awakening oi the national conscience in Chile that has become increasingly forceful. One consequence has been that by the end of 1981 the Medical Association of Chile had begun to elect its own officers. Prior to this, since General Pinochet came to power, such officers were appointed by the government to all the professional associations. These internal elections have allowed the struggle against tor- ture to take place within the association's institutional framework. The leaders, democratically elected in accordance with the historical traditions of professional associations, have assumed the responsibil- ity of increasing people's awareness of the system of torture and of working to stop its practice. For example, in an important effort to combat the participation of physicians in torture or cruel, inhumane, or degrading treatment of prisoners, the association incorporated into its ethical code a section specifically prohibiting the direct or indirect participation of physicians in such practices. The association's decision to denounce torture and the collusion of physicians In torture led to investigations by the association's De- partment of Ethics of physicians accused of participating or colluding in the torture of detainees. The first of these investigations was be- gun four years ago. Today, the cases of 15 physicians accused of participating in abuses of political detainees have been investigated; almost all have been expelled from our association. The importance of the work to expose participation of physicians in torture is not a matter of the number of cases that can be verified. The importance is the establishment of proof that physicians, in direct contradiction of the most fundamental precept of medical ethics, participate in such monstrous activity. To accuse a physician of being a torturer or of colluding in torture is such a serious claim that our work must be carried out with the utmost discretion and prudence. To create even one small doubt

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about the integrity of a physician is a very serious matter that could make life very difficult for the physician and for his or her family. For this reason, our private investigations are long, painstaking, and often tedious. We also require maximum discretion from those who may learn about our investigations. When charges are finally made, they must be beyond challenge. According to the statements provided by torture victims, torture usually happens when the pris- oners are blindfolded, making identification of the torturer practically impossible. In addition, medical certification procedures used by the prisons allow acts of torture and secret detention to appear legal. According to Chilean law, every person who is detained in prison or a public place of detention is to be examined by a physician upon entering and leaving. By studying the legal dossiers of the courts, we have learned that there are physicians in secret detention centers who certify that the person has not been physically mistreated or is in good physical condition. This is done without performing the exam or by performing a very superficial one. These health certificates serve other purposes as well. More significantly, they can reveal the degree of torture a prisoner can withstand, so that the torturer will know how much and what kind of torture can be inflicted. These health certificates are usually signed illegibly, making it impossible to identify the physician who attended to the prisoner. Because this procedure has been accepted by the courts without any apparent objection, the governing board of the Medical Association of Chile met with the chief justice of the supreme court to discuss its concern regarding this practice. The human rights activities of the Medical Association of Chile include support for physicians who are victims of repression; presen- tation of a declaration to the World Medical Association in Venice, together with the Argentine Medical Confederation, supporting re- spect for human rights of physicians and condemning the partici- pation of physicians in torture; dissemination of information about torture through the association's information channels and, when it is possible, through the press; and promotion of ethics, awareness, and behavior. In summary, the work of the Medical Association of Chile has been to gather information on and promote awareness of the in- volvement of physicians in torture; to disseminate information about the ethical stance of the association against torture in the hope of preventing other physicians from becoming involved; to incorporate

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into our ethical code an article taken from the 1975 Declaration of Tokyo condemning torture; to support physicians in other in- stitutions working in defense of human rights; and to promote the discussion of ethical topics at conferences and in publications. Recently, the Medical Association of Chile asked the Chilean government to establish an ethical code for law enforcement officers. For the future, we see it necessary to abolish the participation of physicians in torture. We have said that our position is not to classify torturers as psychotics, but to see torturers as the result of a sick society. It is heartening to see the rebirth of ethical values and the search for what is the historical, honorable, and dignified tradition of our country. The Medical Association of Chill ~ believes it must continue the activities it has started and provide ~ Oral and material support to institutions fighting to abolish torture. We believe that the only true solution for our country is to return to democracy. Thank you very much. COMMENTS Helen Rodney Members and guests of the academy, ~ join Dr. Debreu and other members of the National Academy of Sciences in expressing admiration and respect for Dr. Gonzalez, whose activities, together with those of his colleagues in Chile, assure the world that protection of human rights still constitutes a Chilean ideal. The comments that ~ am going to make today were prepared by me in association with Dr. Elena Nightingale, a member of the Insti- tute of Medicine and a scholar in the subject of medical participation in uses of torture. Torture is defined by the World Medical Association as a deliber- ate, systematic infliction of physical or mental suffering on a person in order to induce a confession or to obtain information or for any other reason. It is not necessary to point out to this audience that torture is a violation of the ethical and religious codes of civilized nations. Yet, despite the recognition that this is an unacceptable relic of a primitive past, there are more than 60 countries in which torture is sanctioned or tolerated by the governments, themselves. To extract confessions or to obtain information about enemies of the state are reasons often given for using torture. Usually, indeed often, the motives are far more sinister: to intimidate the prisoners,

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27 to destroy their sense of persona] integrity, and to control political dissent. Many groups have investigated and spoken out against the prac- tice of torture. Amnesty International has issued numerous reports on torture. Our Department of State has a section on torture and cruel treatment or punishment in its annual Country Report to the U.S. Congress. The American Association for the Advancement of Science, under the editorship of Mr. Eric Stover and Dr. Nightingale, issued a report on torture, The Breaking of Bodies and Minds, and the United Nations has established a voluntary fund for victims of torture. In addition, in 1984 the General Assembly of the United Na- tions adopted one of the most detailed and important documents about torture: "The Convention Against Torture and Other Cruel Inhuman, or Degrading Treatment or Punishment." This document obliges states to make torture a punishable of- fense and to provide for the extradition of torturers and compensation for their victims. This convention was adopted by the United Na- tions by consensus; such consensus adoption by the United Nations indicates a long-standing acceptance in many cultures. Why should scientists and physicians, in particular, be concerned about torture? Because they are people who are committed to ap- plying science for the betterment of mankind and, in medicine, for healing and relieving pain and suffering. The fact that men, women, and even children are being neglected and tortured by their fellow man is, as Dr. Gonzalez has said, an outrage. Why are scientists and health professionals so often victims of torture? There are several reasons. One is because they are generally respected members of their communities; attacks on them make obvious the vulnerability of other individuals in the group. If a dissident who is a respected scientist or teacher can be tortured, his colleagues and students can also take heed and they, to say nothing of the departmental clerk, will be less inclined to become dissidents. Health workers, by the nature of their profession, are more likely to be seized for offenses against the state in countries in which violence and civil strife are common. Those offenses may include treating victuns of torture, documenting or reporting the incidence of alleged torture, and showing the authorities and private organiza- tions, such as human rights groups, the evidence concerning torture. Dr. Gonzalez has pointed out the participation of some physi- cians in torture. This is, of course, an aspect of participation that

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28 has had a long history and can only be condemned. The control of torture and providing advice about what will constitute unaccept- able physical evidence of torture are among the offenses that have been recorded. Falsification of records and devising grmly methods of torture have also been documented. The reasons why health professionals become torturers are, of course, very complicated. A physician's failure to report knowledge of torture or refusal to falsify a death certificate can be based on fear for personal safety and safety of his or her family members. Loss of his or her place of work may be a concern. There Is one older case from Paraguay in which the son of a physician who ran a free health clinic was cruelly tortured and murdered. We can only join Dr. Gonzalez in our appreciation of the many ways in which the medical profession participates in the condem- nation of torture. We must also recognize that physicians are the victims of torture and may lose their civil rights. We are concerned with the refugees who have been tortured and who have now found a home in this country. There are centers here and in Canada and Denmark for the treatment of victims of torture, who have been found to have increased incidence of deafness, nervous problems, psychiatric problems, and psychological problems. The Institute of Medicine recently decided to establish another human rights program in order to facilitate the expansion of human rights activities here on Constitution Avenue. The Institute of Medicine will have a somewhat broader mission, including efforts to bring about basic institutional changes for the protection of individuals from torture and mistreatment. The work of the Cornrnittee on Human Rights is unlike most of our professional activities. It is often difficult to tell when we have been effective or when a particular result has been a consequence of our efforts. If, however, our voices are heard and just one colleague benefits from our expression of concern, then our work has been a success. COMMENTS Albert Soluit I join others in expressing my respect and gratitude to Dr. Juan Luis Gonzalez, president of the Medical Association of Chile, for his stirring condemnation of torture and his efforts to safeguard those who have been or could be victims of torture by or with the assistance

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of physicians and the allied professions. At the same time, we are relieved and encouraged by the recent release and emigration of Dr. Anatoly Koryagin from the Soviet Union to Switzerland. As a psychiatrist, psychoanalyst, and pediatrician and as a U.S. citizen with concern for the rights and needs of children and their parents, ~ am sharply aware of the dangers that follow when our knowledge and our professional authority is misused and abused; that is, subverted to political and ideological processes. In this symposium, the damage caused by such misuse and abuse has been addressed by asking, What are the issues when science and human rights are in conflict? What largely determines the quality of life in any given commu- nity are the prevalent value preferences that become the bases for, or the guiding standards of, acceptable and unacceptable human behav- ior in that community. For example, the Ten Commandments are a set of rules derived from the value preferences of the Judeo-Christian culture from ancient times until now. Of course, the interpretation and modification or rejection of such value preferences represents the process of review and revision and is usually an expression of chang- ing conditions and changing value preferences of a particular culture and especially of the hierarchy of those values that are standards of behavior for a given community in a specific era of our history. Opti- mistically, we hope that change will indicate our capacity to advance civilization. In terms of misuse and abuse of psychiatric knowledge and au- thority, there are a number of crucial value preferences in protecting human rights and assuring psychiatric competency. First, the best interest of the patient is a value preference that requires that the clin- ician do no harm. If there is a conflict between the patient's needs and those of the clinician, the patient's needs shall be paramount. Second, the patient must have the assurance of confidentiality, and if confidentiality cannot be assured, the patient must be warned that confidentiality cannot be provided or guaranteed. Fair warning must be given if confidentiality cannot be assumed. Third, the diagnostic and therapeutic procedures used must be the least intrusive and risky in the context of effective diagnostic and therapeutic procedure alternatives that are available. Fourth, if an experimental treatment or procedure is offered, it should be preceded by providing adequate knowledge and under- standing to enable the patient to make an informed choice and to

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an give informed consent. Further, the risks inherent in such experi- mental treatment or procedures should be overbalanced by what can be gained for the patient by such procedures or treatment. Finally, coercive procedures for diagnosis or treatment are ac- ceptable only if the information and evidence justifying this consid- eration are approved by a peer group of competent clinicians who agree that such coercive procedures will prevent or minimize the threat to life by the patient's deranged behavior. The lives and safety of others and that of the patient must be protected by such coercive procedures. They should not produce a greater risk than those conditions and behaviors that evoked the recommendation of coercive diagnostic, therapeutic, and custodial care and procedures. There should be the guarantee that each child, ordinarily those under the age of 18, will be helped to have the permanent care and guidance of at least one adult who wants that child and can provide him or her with a continuity of affectionate care and safety; that the parent and child will have community support; and that children's needs and rights will be paramount if the family is unable to function adequately, resulting in a conflict between adults' needs and rights and those of the children involved. Although the aforementioned principles should be useful in a wide variety of cultural, political, and ideological settings by those who share these value preferences, they should also be viewed as part of an ongoing process. This process enables us to review and improve our scientific knowledge and its application and to avoid those blind spots associated with smugness. Such clarity is essential, especially when we are witnessing flagrant violations of these principles of clinical practice by governments and groups with whom we are in serious ideological, political, econorrflc, military, and scientific conflict and competition. This is an especially crucial perspective when it becomes state policy to view disagreement with that government as evidence of mental illness. In three recent reports, we can read how unending vigilance is crucial if clinical scientists are to work together in a manner in which we can learn from each other's errors and deficiencies and remain, above all, ethically involved. Elyn R. Saks reviews the use of mechanical restraints in U.S. psychiatric hospitals. Mechanical restraints " . . . in this Note refers

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~1 to the more severe restraining devices such as 'four' and 'six' point re- stra~nts, body sacks and camisoles."8 Saks concludes, after a careful analysis of advantages and disadvantages of restraint and other coer- cive measures, that the abuse of mechanical restraints and seclusion led to 30 deaths between 1979 and 1982 in the State of New York. She further concluded that the law should use a principle of liability that would be designed to deter doctors from using restraints out of the fear that malpractice suits will be brought. According to Saks, this principle of liability, recognizing the limits of a doctor's ability to predict violence, should ease pressure on doctors a. . . besieged by conflicting demands both to protect patients and not to restrain them by making a clear value choice. For example, greater numbers of patients should not be restrained in order to protect against the rare occurrence of self-inflicted injury." The enlightened principle of liability, she continues, should . . . reduce both the use of restraints and the supervention of patients' choices. The fear that, if effective, the rule would cause a dramatic rise in self-injuries is unfounded, as may be seen from the situation in England. English doctors have not significantly resorted to seclusion or medication to compensate for not using mechanical restraints. Such an enlightened rule is needed to reduce the use of mechanical restraints which cause a. . . grave injury to individual liberty and dignity. 9 Time does not permit me to go on, but ~ think when we talk about fighting for the freedom of such a person as Dr. Anatoly Koryagin, for example, who was punitively incarcerated because he criticized what he viewed as egregiously punitive and coercive uses of psychiatric diagnosis and hospitalization, we could temper and better harness our righteous indignation by an awareness of how we are confronted In various countries by the risk of "there, but for the grace of God, go I." For example, in the March 21, 1987 issue of L,ancet there are two significant reports. The first, "Japan's Search for International Evelyn R. Saks, "The Use of Mechanical Restraints in Psychiatric Hospi- tals,n 17`c Yale Law Journal, Vol. 95, No. 8, pp. 1836-1856, July 1986. 9 Ibid.

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Guidelines on Rights of Mental Patients,~ concludes with the fol- lowing: "In view of . . . the absence of a clear set of international standards for the protection of the mentally ill, it would be useful to define a set of basic principles. These were formulated by a pane! of The International Forum on Mental Health Law Reform, organized jointly by the Japanese Society for Psychiatry and Neurology and the International Academy of Psychiatry and the Law and held in Kyoto in January 1987. The Kyoto Principles, unanimously accepted by the panel, state that: 1. Mentally ill persons should receive humane, dignified and professional treatment. 2. Mentally ill persons should not be discriminated against by reason of their mental illness. 3. Voluntary admission should be encouraged whenever hospital treatment is necessary. 4. There should be an impartial and informal hearing before an independent tribunal to decide, within a reasonable admission, whether an involuntary patient needs continued hospital care. 5. Hospital patients should enjoy as free an environment an possible, and should be able to communicate with other persons. Similar concerns and considerations are described in the same issue of Lancetii in the next article with brief reports on the man- agement of mental illness in Japan, United States, India, and Egypt, which concludes that "every government needs to formulate a strat- egy for looking after those usually seen as the least acceptable mem- bers of our society. Because mental illness is still viewed with more superstitious attitudes than physical illness and because ideological convictions may confuse ideological dissent with mental illness (and indeed of- ten have), it is crucial that our efforts to define mental health and mental illness be free of ideological jargon and distortions and free of self-serving ideological and political ambitions. Mental illness and treatment should not, wittingly or unwittingly, be exploited for and corrupted by political and ideological aims. Conversely, by maximizing voluntary mental health services, that is, by minimizing the use of coercion in providing mental health 10T. W. Harding, "Japan Search for International Guidelines on Rights of Mental Patients, Lanect, March 21, 1987, pp. 676-677. ii"The Management of Mental Illness: Forgotten Millions," Lancet, March. 21, 1987, pp. 678-679.

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33 services, we will be able to avoid or minimize those tendencies that put psychiatric diagnosis and treatment in the service of ideological and political goals. Clearly, Dr. Anatoly Koryagin has been committed to the sep- aration of clinical science and ideological processes. We applaud, admire, and seek to emulate his courage and steadfast search for truth. COMMENTS M. Aliked Eaynes Professor Debreu, colleagues, and friends. To discuss ethics and ethical principles is an important intellectual exercise, but to see ethics personified in the form of Dr. Gonzalez and the other special guests whom we have here today is a very sobering experience. Health professionals are, by the very nature of their profession, likely to have a broader role in the arena of human rights than most other professionals. Recognition of this broader role has been a matter of careful consideration by the Institute of Medicine. Physicians may be victimized without any regard to the practice of their profession. They are incidentally caught in the practice of torture and repression, and they deserve the consideration and concern of all persons who are unjustly treated. In the second case, physicians may be victimized because they are performing their professional duties in accordance with a well-defined code of ethics under which we operate. This code is very clear with respect to what physicians should do. But some physicians have been victimized because they acted in accordance with these principles. They deserve our very special consideration. In the third case, physicians may actuary be in collusion with those who violate human rights. When, for example, as we have just heard, psychiatrists who have a special power to commit persons to mental hospitals allow their professional skills to be used for the purposes of illegally committing dissidents, this is an outrageous abuse of psychiatry and deserves our condemnation. The fourth category includes the nonparticipant observers. have chosen to define the nonparticipant observers as those health persons who, in the course of their duties, see the results of torture but refuse to keep silent. The case of Wendy Orr is a fine example. This young, white South African physician was assigned to treat

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34 detainees and prisoners. She saw the physical results of persons who were punished, whipped, kicked, and teargassed, and her medical superiors refused to investigate the prisoners' complaints. She saw a lawyer who gave her two choices. She could, like the rest of her fellow physicians, ignore what she had seen or she could go to court and seek an injunction and possibly lose her job. She chose to be a nonparticipant observer and went to court and won a temporary restraining order against assaults by the police. Such persons deserve our commendation. Finally, there are those ~ call the participant observers. You might wonder why I call them participants, because all they do is observe. In fact, they participate by their silence. Jacobo Timerman, the distinguished Argentine newspaper editor, said the holocaust will be understood not so much through the number of its victims as through the silence in which it existed. The Institute of Medicine has decided not to be counted among those who participate by their silence and is exploring a variety of ways in which it can join other scientists in the defense of human rights. QUESTIONS AND ANSWERS Gerard Debreu The speakers will welcome questions. Douglas Sanmelson, American Statistical Association, Committee on Scientific Freedom and Human Rights As you know, in many cases, such as detainment of a scientist, it is possible for scientific societies in the West to argue forcefully in that scientist's behalf with the government responsible for the action. To raise similar arguments for the end of torture or for chang- ing the medical ethics practiced within a government is much more difficult. Do any of you have any thoughts, any insights, about what means Western scientific societies may use to persuade governments to restrict the use of torture?

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35 Juan [uis Gonzalez ~ think my government is absolutely resistant to any kind of pressure that can be made by scientific associations. For the Chilean government, the only pressure that can be made is political pressure. So, that Is the way to do things. Helen Rodney ~ would like to ask Dr. Gonzalez if other groups are protesting the abuse of human rights by the current government there outside of the medical group that has done such an admirable job In Chile. Juan [nis Gonzalez Not only the Chilean medical association has been protesting against abuses and defending human rights. Also the Catholic church and other churches have been working very hard on that, along with other professional associations, such as the lawyers, the engineers, and many others. Helen Penney Is there any second political party that is being allowed to emerge at all? Juan [uis Gonzalez In my country, political parties are forbidden. Joe} Lebowitz, Rutgers University ~ was just going to ask members, especially those from the In- stitute of Medicine, to what extent medical ethics, particularly con- cerning torture, Is now being taught in all medical schools. How much can such education be extended in the hope that it will have some effect, in general? Albert Soinit ~ think that the concept of informed consent is one that fails to be implemented perfectly. It is an effort on the part of orga- nizations conducting experunental treatments or treatments of any

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36 kind to make sure that obtaining consent ~ legitimately delegated to an appropriate person and is provided for painful or experimental treatments. ~ believe we have entered into an era when we can begin to approx~nate a healthy answer to that question. Virginia M. Bouncier, Washington Office on Latin America ~ would like to ask Dr. Gonzalez if he could comment on the recent ruling by the Chilean government regarding the use of secret detention centers, what he thinks that will mean for the pattern of torture in Chile, and if the Chilean medical association has taken a stand on that. Juan [ule Gonzalez You will have to excuse me, but ~ do not understand what you say, Ginny. Virginia M. Bouvier There was a recent ruling by the Chilean government banning the use of secret detention centers, ~ understand. ~ wonder if you had heard that and what you think that will mean for Chile. Juan Luis Gonzalez Yes, ~ have heard of that, and ~ think they are only words and nothing more. Participant ~ would like to direct my comment to Dr. Haynes. My hope is that the Institute of Medicine will make its activities public, so that a broader range of people than those in this room and those who read occasional documents about the abuse of medicine in torture will become aware of this situation. ~ think that it is necessary, in the end, that a political process brings this practice of torture to an end in any country around the world, but if this remains private information of Chilean or American medical associations or other associations, then ~ think it will fall far short. ~ hope that that can be done.

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37 M. Aided Haynes ~ am reasonably certain that this will be done. As ~ said earlier, what the institute has been trying to clarify is exactly what its role can be. The problems are so enormous worldwide and they appear, in some cases, to be increasing. The institute is reluctant to take on more than it can handle competently, but ~ can assure you that there is a very serious attempt on the part of the institute to do all it can and that it wiB take appropriate steps to encourage others who come within its domain to do their part.

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