Examining for evidence of torture

How do doctors assess clinical evidence in claims of human rights abuses?

There may be as many styles of medical practice as there are practitioners. So there can be no one right way to do conduct an examination. However, most doctors who write MLRs compliant with the Istanbul Protocol seek to gather and analyse essentially the same kinds of information by whatever clinical style they have developed and found effective. What follows is an indicative description of one methodology.

Before the visit of the subject to the consulting room the documents cited are read and notes made of potentially relevant issues in order to identify possible medical questions which would assist in critically evaluating statements alleging torture or ill-treatment and in order to determine their current clinical state.

On meeting the subject the adequacy of communications (directly or via the interpreter) is established and that the purposes of the examination and the way in which it will be conducted are understood.  In other words, informed consent is obtained.

As is normal in any medical interview, enquiries commence by means of open-ended, non-directive questions to establish details of current medical problems, if any. Each of these are then explored, seeking to understand whether and how answers to specific related questions provide a coherent and consistent indication suggesting particular conclusions. This is a well established routine clinical practice in reaching a diagnosis, i.e. the identification of the nature of an illness or other problem by collation of the symptoms. Such questions can include, for example, the onset, nature and duration of symptoms, precipitating and relieving factors, and other features relating to them. As the subject receives the question (directly or via the interpreter) and responds, they are scrutinised to determine whether the enquiry has produced a change in presentation (for example facial expression, posture, speed or hesitancy of speech), or general demeanour, behaviour, mood and affect.  These factors also form a critical aspect of a mini-mental state examination (MMSE) and include the following: description of the subject’s appearance (level of cleanliness, clothing, hygiene, and any noticeable physical abnormalities); behaviour (agitated, restless, teary, or acting in an odd manner); mood (happy, hopeful, sad, depressed); affect (anxious, expressionless, angry, or overly aroused); speech (normal, talkative, fast, slow).

Enquiries are then made of the subject’s previous medical history including domestic, occupational, childhood, sporting, military or automotive injuries, past illnesses and medical or surgical treatment, with particular emphasis on those which may have left physical signs such as scars, whether the subject attributes them to mundane or malign causes.

Information about any current general practitioner with whom the subject may be currently registered and recent medication, investigations or referrals to secondary care are all requested at this stage.

Having established the above to the best extent possible enquiries are made concerning the allegation of torture, again using open question. These typically include the locus and circumstances of any arrest, restraint and blindfolding, transportation, events on arrival at a police station, prison or detention centre. The subject is asked to describe what was then done to them, with what implement they were harmed, what position they were in at the time, the temporal pattern of any resulting pain and the longer term results of any such injuries. Where the subject claims to have experienced several distinct forms of mistreatment, each category is explored separately. Specific enquiries are made of medical care received, and if so, when, where, and what the subject remembers of it, and for any injuries, illnesses or operations unrelated to the events at issue.

At this point a physical examination on a standard couch is carried out, having first ensured that consent for such an examination persists.  Privacy and confidentiality are particularly important at this stage. The subject is asked to remove all clothing except underwear and (if they wish) to cover themselves with a sheet.

An examination of the entire body is then carried out, usually starting with the feet and working upwards.  This is irrespective of whether the subject has described injuries in one or more area and not others.  It is important that the examiner satisfies him or herself of the presence or absence of lesions. The categories of the Istanbul Protocol are then applied to individual features of the history and examination (considering likely inconsistencies and consistencies) and to the totality of the medical evidence available in order to arrive at an opinion.