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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.
Representative terms from entire chapter:
value preferences
