Medicine in Handcuffs

Restraining of Prisoners and Detainees Undergoing Medical Treatment and Hospitalisation
June 2003

Writing: Research and testimonies:

Noam Lubell, Dr. Ruchama Marton Michal Bar-Or, Shabtai Gold, Anat Litvina, Noam Lubell, Hadas Ziv Yardena Tzintzolker, Shaul Vardi Johanne Malka-Shalom Michal Bar-Or (illustration photo)

Translation: English Editing: Cover photo:

Individuals and Organisations who assisted with information: Attorney Ibrahim Mahajne, Attorney Dori Spivak, Attorney Alegra Paceco, Dr Andrew Coyle, the International Centre for Prison Studies.
This report is sponsored by the European Commission

The work of Physicians for Human Rights - Israel is made possible through the support of the following foundations:

European Commission, Swiss Agency for Development and Cooperation, Diakonia, SIVMO, Global Ministries of the Uniting Churches in the Netherlands, New Israel Fund, Conanima Foundation, Rich Foundation, Jerusalem Foundation, Richard and Rhoda Goldman Foundation, Ford foundation, Christian Aid, Medico Intenational Switzerland, Medico International Germany, EPER, Vicop Stingtung, EED, The Beracha Foundation, Joyce Mertz-Gilmore Foundation, Kahanoff Foundation, Oxfam
Production & Design: dafdefet@bezeqint.net
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Contents
Introduction.........................................................................4 Cases.....................................................................................6 International Law and Medical Ethics ...........................11
International Law ................................................................................ 11 Medical Ethics ....................................................................................13

The Procedures of the Israeli Security Institutions .......16
Police...................................................................................................16 Israel Prison Service ...........................................................................17 Israeli Military ....................................................................................17

The Position of the Israel Medical Association...............20
Criticism of the IMA position ............................................................21

The Position of the Ministry of Health............................24
Criticism of the Ministry of Health position ......................................25

The Hospitals and the Physicians ....................................27 The Position of Physicians for Human Rights - Israel...30
Recommendations...............................................................................34

Appendixes ........................................................................35 IDF Spokesperson letter ...................................................35 IMA Ethics Committee letter...........................................36 IMA Central Committee letter ........................................38 Hadassah Medical Organisation letter............................39
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Introduction
Over the years that PHR-Israel has been involved in the issue of the medical rights of prisoners and detainees (1988-2003), a recurring phenomenon we have encountered is the use of restraints and handcuffs during medical treatment. Although the majority of cases reaching PHR-Israel are of Palestinian prisoners and detainees held for ‘security’ offences, this phenomenon is not unique to any specific group and can take place with all categories of people in custody: detainees held by the police prior to conviction; criminal prisoners held by the prison service; ‘security’ prisoners held by the prison service; Palestinian prisoners and detainees held by the military.1 Most of the complaints received by PHR-Israel relate to cases where prisoners were restrained while receiving medical treatment in civilian hospitals. Testimony has been received relating to most of the major hospitals in Israel. The general impression is that prisoners who come to hospital are handcuffed to their beds – in many cases their legs are also restrained. Again, in some case, prisoners are left shackled even while undergoing actual medical treatment. In one case, a female prisoner was forced to give birth while handcuffed. Even children are not immune to this phenomenon, and in several cases children have been restrained in their beds during hospitalisation. Prisoners with severe medical problems, including prisoners who were not fully conscious, received treatment while restrained. PHR-Israel is aware of at least one case in which a person remained shackled while undergoing resuscitation, and died while still shackled to his bed.

1

Throughout this report, the term ‘prisoners’ is used to refer to all people in custody, including all those mentioned in the above paragraph. Additionally, although the language sometimes refers to one gender, apart from the times when specific individuals are mentioned, any use of the terms physician / nurse/ prisoner, applies to males and females.

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This phenomenon is particularly grave for several reasons: – Restraints abuse the dignity of the person receiving medical treatment and lead to a sense of humiliation. – Restraints may impair the quality of medical treatment. – Restraints cause unnecessary pain, dangerous immobility, and may delay or impair the healing process. – Restrained prisoners do not receive medical treatment equal to that enjoyed by other patients. – Restrained prisoners lose confidence in their physician. – Treating prisoners in unnecessary restraints is a violation of medical ethics. This report examines the issue of restraining prisoners undergoing medical treatment from several angles: Cases illustrating the situation regarding shackling since PHR-Israel’s establishment; the issues and ramifications raised by this phenomenon, both in terms of human rights and medical ethics, as well as from the governmental point of view, and the PHR-Israel point of view.

Security procedures relating to the hospitalisation of prisoners and detainees are not sufficiently detailed. This enables the guards to opt for the “easy way out”, which is to restrain the majority of prisoners and detainees under their charge. The position adopted by the Israel Medical Association and the Ministry of Health leave many loopholes for unnecessary and unjustified cases of shackling. Apart from being weak, these positions are unknown to many physicians with whom PHR-Israel comes into contact, accordingly there is little chance they can have any impact. The lack of awareness among physicians is also due to the fact that ineffectual steps if any, are taken when information is received regarding past and present cases of unnecessary shackling.

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Cases
Ahmed and Muhammad Hamis Ismail Al Hanajra, Soroka Hospital, Beer-Sheva. Ahmed and Muhamed, 13 and 16 years old, were apprehended and wounded by the Israeli military on Saturday night, January 11th, 2003. According to the army they were attempting to infiltrate one of the settlements in the Gaza strip. They were transported to Soroka Hospital in Beer-Sheva. 13 year-old Ahmed was lightly wounded, and his brother who was moderately wounded needed surgery. The brothers were handcuffed to their beds from the moment they arrived at the hospital. A short while after their arrest there was an appeal for help from PHR-Israel, who immediately intervened and contacted the hospital and military. Apart from the shackling, there were complaints that the children were denied the right to speak to their parents, and were not being interrogated by special youth interrogators. The physicians at Soroka stated that the soldiers guarding the children refused to remove the handcuffs, saying their orders were to keep them in restraints. One of the soldiers told a physician that he (the physician) “should be thankful they are only handcuffed by the hands”. During the five days of constant negotiations, the children remained restrained to their beds. The security forces claimed there was a danger of escape through a window, despite the fact that these were injured children under constant guard. After a few days, a military judge determined that Ahmed could not escape in his condition, therefore his restraints should be removed. In addition, the military spokesperson declared that the restraints were against orders.2 Following PHR-Israel’s communications with the authorities, and the request that they be transferred to a room with barred windows, they were moved and Ahmed’s restraints were removed. Muhammad was transferred from the hospital to a detention facility. Riham As’ad Muhammad Sheikh Mussa, Meir Hospital, Kfar Saba. On February 23rd, 2003, 15 year-old Riham As’ad Muhammad Sheikh Mussa was hospitalised in the Meir Hospital in Kfar-Saba. She had been shot during an incident in which it was alleged that she attempted to attack a soldier. The girl underwent surgery of the stomach and intestines,
2

In a letter sent to PHR-Israel on January 27th 2003.

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two bullets were left in her body – in the stomach and leg - and she was left with a permanent stoma and a bag affixed to her abdomen wall to drain her intestines. Despite her condition, she lay handcuffed to her bed. PHR-Israel turned to hospital administration and to the Israel Medical Association (IMA) requesting they act to have the restraints removed. After being contacted by PHR-Israel and the IMA, the hospital tried to bring up the issue with the military, but the Chief Officer for Prisons in the Military Police did not bother to return any calls from the IMA.3 Throughout the entire period of her hospitalisation, over three weeks, the child remained in restraints. Rami Mahamid, HaEmek Hospital, Afula. In September 2002, young Rami Mahamid, an Israeli citizen, was injured in a bomb attack in the north of the country and transported to HaEmek Medical Centre. For four whole days, during which according to media reports he was seriously injured and not fully conscious, he lay in bed with restraints on his arms and legs, and under guard. Once his condition enabled interrogation, it was determined that not only had he nothing to do with the attack, but he even tried to prevent it. Following this discovery, his restraints were removed. PHR-Israel inquired with the hospital director why had an injured and barely conscious youth been held in shackles when he was clearly no risk. After a short exchange of letters, the director issued instructions to the various hospital departments, stating that restraining prisoners during medical treatment contravenes basic medical ethics, that judgement must be used in each case, and that obviously there is no reason to restrain seriously ill and wounded patients. Talal Ida, Hadassah Hospital, Jerusalem. In March 2002, after collapsing during questioning at an army checkpoint, Talal Ida, an ambulance driver by profession, was transported to Hadassah Hospital. During his hospitalisation and treatment, Mr. Ida was handcuffed to his bed. This was in spite of the fact that he was suffering from exhaustion and weakness, and was constantly under guard. Throughout the hospitalisation, his attorney was trying to find out who was responsible for detaining him, and why he was in restraints. After much questioning and appeals to various bodies raising doubts about the legitimacy of the arrest, the handcuffs and the guards were removed. Mr. Ida was released home when his treatment was completed.
3

See annex.
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Shaul Nachmias, Wolfson Hospital, Holon. On May 2nd 2001, Shaul Nachmias was transferred from the Prison Service Medical Centre to Asaf Harofeh Hospital in Ramleh. Two days later he was transferred to Wolfson Hospital. Mr. Nachmias suffered from hepatitis, and was in a poor state. Despite his condition, his arms and legs were chained to the bed. After approximately two weeks he was returned to the prison service. Then following a fall he was back in Wolfson Hospital on May 20th and diagnosed with internal bleeding from the upper gastric tracts, a deteriorating situation. During this second hospitalisation he was again chained to his bed. In spite of requests by medical staff, the wardens refused to remove the handcuffs, apart from the changing of his diapers. His grave situation and pleas by his family did nothing to have the restraints removed. Still chained to the bed, his condition deteriorating, the medical staff attempted resuscitation to no avail. Shaul Nachmias died chained to a bed. Mu’ataz Jaradat and Ghaleb Elfaruch, Hadassah Hospital, Jerusalem. In October 1996, the two youths – 14 and 17 year-olds, were handcuffed to their beds in Hadassah Hospital, while they were seriously injured. The boys were not allowed to talk to each other and were under constant guard. Mu’ataz: “I had pains, and whenever I wanted to move a little in the bed, the soldiers shouted at me. I was even afraid to cough. All around there were patients watching TV and laughing. We weren’t even allowed to move. It was terribly sad.” Intisar Muhammad Alkak, Meir Hospital, Kfar Saba. On December 3 1990, PHR-Israel turned to Dr Miriam Tsangen, then Chairperson of the IMA, concerning the restraining of a prisoner while giving birth. On the same day, Dr Tsangen contacted the director of the Sharon Prison and the physicians at Meir Hospital, writing: “performing a birth under these conditions is a violation of physicians’ rules of medical ethics, which are universal.”4 The prisoner’s restraints were removed, and her mother was allowed to sit by her side in the hospital.
rd

4

See annex.

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Niaz Fareh Muhammad Mazara, Soroka Hospital, Beer-Sheva. On May 14th 1990, Niaz was hospitalised for a gall-bladder operation. Throughout his stay at the hospital, he was chained to his bed. He was handcuffed the minute he came out of surgery, despite still being under anaesthetic. PHR-Israel’s appeal to the commander of Ketsiot detention facility (the body responsible for the prisoner) was left unanswered. Anonymous. The following two cases are based on the testimonies of physicians, members of PHR-Israel, who wished to avoid publication of identifying details. The first case is of a prisoner, a Palestinian citizen of Israel, who arrived at the hospital with chest pains. The man had diabetes and a heart condition, and an amputated leg (with a prosthesis). During the hospitalisation, he was diagnosed with renal insufficiency and serious anaemia; he needed a catheter and hemodialysis. He had one guard in the room, and two guards to accompany him for tests. In the first three days, he had a urine catheter. At the start of the hospitalisation, both his hands were chained to the bed, and later he was chained by one hand and one leg to the bed. Despite instructions to walk him once every hour to prevent blood clots, the guards did not always do this. When the physician questioned the head of the department in the hospital, he was told to contact the IMA, who responded by sending him their position paper on restraining prisoners (see below), but did not further intervene. The physician received a reply from the police that there was no other choice. The amputee with diabetes and a heart condition remained in restraints throughout his hospitalisation. The second case took place in March 2003. A resident of Kalkilya (in the Occupied Territories) was hospitalised at Beilinson Hospital in Petach Tikva with gunshot wounds in his legs and back. He underwent surgery on both legs. Despite his condition, which included having a leg in a cast and being under constant guard, he was handcuffed to the bed. Asaf-Harofe Hospital, Ramleh. This hospital, situated close to the headquarters and a number of Israel Prison Service facilities, often has prisoners brought in for medical treatment. After receiving information about frequent restraining of patients, a staff member of PHR-Israel decided to independently assess the situation. His testimony, based on a visit of the emergency room and the internal medicine ward, on June 2nd 2003, painted a worrying picture. At the time, all three prisoners
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hospitalised in those wards were in restraints; two were handcuffed by the legs, one was chained to the bed by the hands and legs, and all three were under constant guard. From this visit and additional information, it would seem that there is a policy of automatically restraining prisoners arriving for treatment at this hospital.

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International Law and Medical Ethics
When it comes to the rights of prisoners and detainees undergoing medical treatment, there are obligatory laws, norms and rules accepted by the international community. The State of Israel and all authorities operating in its name, whether health authorities or security bodies, are obliged to respect international human rights laws. In addition, the medical community, as other professional bodies, has its own specific rules and ethical principles that provide guidance for particular situations, including the treatment of prisoners. PHR-Israel, as a human rights NGO dedicated to the protection of the right to health, human dignity, and body and mind integrity, regards the above rules as the foundation for its position on the treatment of prisoners.

International Law
Rules concerning the treatment of prisoners and safeguarding their rights are an integral part of international human rights law. The primary human rights convention contains a number of clauses to protect those who have their freedom denied by the state authorities. The International Covenant on Civil and Political Rights,5 which Israel has ratified and is obligated to comply with, states in article 7 that “No one shall be subjected to torture or to cruel, inhuman or degrading treatment or punishment”. Article 10, paragraph 1, stipulates that “All persons deprived of their liberty shall be treated with humanity and with respect for the inherent dignity of the human person”. Other treaties that include certain similar clauses are the UN Convention Against Torture, and the European, African and American regional human rights instruments. The Geneva Conventions and their Additional Protocols, also include prohibitions of torture or cruel, inhuman or degrading treatment or punishment, and require humane treatment of prisoners, even if they belong to enemy forces. The above obligations are unequivocal and could mostly be considered part of general international law, binding regardless of whether a state is party to a specific treaty.6
5

6

International Covenant on Civil and Political Rights, G.A. res. 2200A (XXI), U.N. Doc. A/6316 (1966), entry into force Mar. 23, 1976 N.Rodley, The Treatment of Prisoners Under International Law (Oxford University Press, Oxford, 1999). p. 46-74, 277-279.
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The protection of human dignity is also a part of Israeli domestic law, particularly in Basic Law: Human Dignity and Liberty.7 The Supreme Court Justices have ruled more than once that the right to dignity remains with the person even if their freedom has been taken away. A well known quote of the court says that “the walls of the prison do not separate the prisoner from human dignity (…) freedom has been denied from the prisoner, humanity is not taken away”8 The international source providing some of the most detailed rules for the treatment of prisoners is the Standard Minimum Rules for the Treatment of Prisoners, adopted by the United Nations.9 Although this document is not a legally binding treaty, it nevertheless contains detailed norms and standards, which can be used by the international community to interpret the rules against cruel, inhuman or degrading treatment or punishment, and the obligation of humane treatment and respect for human dignity. Furthermore, some of the rules, amongst them the prohibitions on degrading punishment and the use of shackling as punishment, could be considered to reflect binding legal obligations.10 Article 33 of the Standard Minimum Rules states that: “Instruments of restraint, such as handcuffs, chains, irons and straitjackets, shall never be applied as a punishment. Furthermore, chains or irons shall not be used as restraints. Other instruments of restraint shall not be used except in the following circumstances:

(a) As a precaution against escape during a transfer, provided that they shall be removed when the prisoner appears before a judicial or administrative authority;11

7 8

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10 11

Passed on March 17, 1992 HCJ 79/385 Katalan v Israel Prison Service, PD 34 (3) 298. See also, amongst others, HCJ 540/84 PD 40 (1) 567, 573; HCJ 337/84 PD 38 (2) 826, 832. Standard Minimum Rules for the Treatment of Prisoners, adopted Aug. 30, 1955 by the First United Nations Congress on the Prevention of Crime and the Treatment of Offenders, U.N. Doc. A/CONF/611, annex I, E.S.C. res. 663C, 24 U.N. ESCOR Supp. (No. 1) at 11, U.N. Doc. E/3048 (1957), amended E.S.C. Rodley, p.280-281 Emphasis by PHR-Israel

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(b) On medical grounds by direction of the medical officer; (c) By order of the director, if other methods of control fail, in order to prevent a prisoner from injuring himself or others or from damaging property; in such instances the director shall at once consult the medical officer and report to the higher administrative authority.”
From the wording of sub-paragraph (a), the expression “during a transfer” can be understood as meaning the period of time in which the prisoner is in movement between locations, and not the later time when they are being held at their destination, be it a hospital or other place. A similar interpretation can be inferred from the Israel Police orders (below), which include separate chapters for ‘securing prisoners during transfer’ and ‘securing prisoners in a medical institution’. The way the shackling is used can make matters even worse. The European Committee for the Prevention of Torture has stated, “if recourse is had to a civil hospital, the question of security arrangements will arise. In this respect, the CPT wishes to stress that prisoners sent to hospital to receive treatment should not be physically attached to their hospital beds or other items of furniture for custodial reasons”.12 Restraining a person to an inanimate object is generally perceived as an impermissible act also in the rules and procedures of the Israeli security institutions.13

Medical Ethics
A fundamental rule of medical ethics is the Physician’s primary loyalty and obligation to the patient. This obligation can be found in a number of the key declarations of the World Medical Association (WMA), such as the 1948 Declaration of Geneva.14 Paragraph 10 of the Declaration on the Rights of the Patient states that “the patient’s dignity and right to privacy shall be respected at all times in medical care and teaching, as shall his/her culture and values.”15 Furthermore, according to the opening paragraph
12

13 14

15

3rd General Report on the CPT’s activities covering the period 1 January to 31 December 1992 CPT/Inf (93) 12 [EN] - Publication Date: 4 June 1993. par. 36. see below Declaration of Geneva. Adopted by the 2nd General Assembly of the World Medical Association, Geneva, Switzerland, September 1948 World Medical Association Declaration on the Rights of the Patient. Adopted by the 34th World Medical Assembly Lisbon, Portugal, September/October 1981and amended by the 47th General Assembly Bali, Indonesia, September 1995
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of this declaration “whenever legislation, government action or any other administration or institution denies patients these rights, physicians should pursue appropriate means to assure or to restore them.”16 These are not the only declarations and documents relating explicitly to the physicianpatient relationship. The 1975 Tokyo Declaration, Guidelines for Medical Doctors Concerning Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment in Relation to Detention and Imprisonment,17 gives a clear indication on whose side the physician is supposed to stand, and that “…the doctor’s fundamental role is to alleviate the distress of his or her fellow men, and no motive whether personal, collective or political shall prevail against this higher purpose.” The UN General Assembly, with the assistance of the World Health Organisation (WHO) drafted and adopted the Principles of Medical Ethics relevant to the Role of Health Personnel, particularly Physicians, in the Protection of Prisoners and Detainees against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment18. The fifth article of these principles states that “It is a contravention of medical ethics for health personnel, particularly physicians, to participate in any procedure for restraining a prisoner or detainee unless such a procedure is determined in accordance with purely medical criteria as being necessary for the protection of the physical or mental health or the safety of the prisoner or detainee himself, of his fellow prisoners or detainees, or of his guardians, and presents no hazard to his physical or mental health.” Although the express prohibition here is on participation, and it is not detailed what this could mean – the physician actually restraining the patient, being part of the decision to restrain, or being an acquiescent witness – it is nevertheless important to note that the possible justifications for shackling that are mentioned here, include the protection from self-harm or risk to others, and not shackling to prevent escape. It should be stressed that the above principles are directed at all health personnel and not just physicians. All hospital medical staff, especially
16 17

18

Emphasis by PHR-Israel World Medical Association Declaration Guidelines for Medical Doctors Concerning Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment in Relation to Detention and Imprisonment. Adopted by the 29th World Medical Assembly Tokyo, Japan, October 1975 Adopted by General Assembly resolution 37/194of 18 December 1982.

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nurses, can find themselves treating a prisoner and faced with a situation whereby the security agents wish to have the prisoner shackled. The International Council of Nurses has also produced a declaration on the treatment of prisoners and detainees.19 Here too, the fundamental obligation of the nurse is to restore the health and alleviate the suffering of the patient, including prisoners, and to protect them from abuse and ill treatment.

19

Nurses Role in the Care of Prisoners and Detainees, Adopted by the International Council of Nurses, Geneva, 1998
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The Procedures of the Israeli Security Institutions
The different security Institutions have orders and procedures for determining the necessity and the use of shackling and means of restraint for prisoners and detainees. In general, the need for shackling will be one of two- restraining the prisoner, or prevention of escape. Shackling as a means of restraint is usually considered when it is essential for preventing the prisoner from hurting himself, others or property, and may take place inside the prison facility. Shackling for escape prevention is usually considered when the prisoner is not between the facility’s walls, especially when transporting prisoners to another facility or to other locations, such as courtrooms. The following are the orders and procedures of the security bodies regarding the shackling of prisoners:

Police
The Israel Police orders dealing with this topic, can be found under regulation 12.03.03 ‘transfer and security of prisoners, outside the detention facility’20. Paragraph 6, “Securing prisoners in a medical institution” does not include a specific reference to shackling, and indicates that “Every detainee that stays in a medical institution, will be under guard, and will be secured according to the security regulations in these orders, that are suited to him”. This is in contradiction to the paragraph that deals with securing a detainee in court, where it is specifically mentioned that, “As a general rule, the detainee must not be restrained while in court”. The most precise orders for using restraints can be found in the previous paragraph of the orders, paragraph 3.c, which discusses shackling of detainees during transfer. In sub-paragraphs 2,3 it has been clearly stated that a detainee who is ill would not be restrained, except in cases where he tried to commit suicide or hurt others who were in the same accompanying group. But, sub-paragraphs 5,6 state that regarding certain detainees, such as those who tried to escape in the past or detainees known as violent, there is a need to handcuff them, and in some cases restrain their legs, without any
20

The Hebrew term used by the police relates to both prisoners and detainees.

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regard to their health condition. In sub-paragraph 7, it is written that except for extreme and urgent cases of life protection, it is prohibited to restrain a detainee to any inanimate objects.

Israel Prison Service
IPS order 04.15.00 ‘Means of restraint- shackling of legs and hands’ indicate in the first paragraph that there are situations in which it is necessary to prevent a prisoner from hurting himself, others, or property. The permissible means of restraint in these cases are handcuffs, leg shackles or both. Paragraph e’ defines the rules for using means of restraint, and according to it, shackling hands and legs would be permitted “only in exceptional cases in which a real and immediate danger exists where the prisoner can hurt himself seriously and when there is no other way to protect him from himself”. Moreover, “shackling a prisoner to an object is forbidden, shackling a prisoner to a bed will be permitted only after the officer authorised to order the shackling receives prior approval of a physician”. Paragraph 5.a determines that “Shackling a prisoner for transfer inside the prison or outside of it, will not be considered as using means of restraint”. This is in accordance with regulation 23 of the 1978 Prison Regulations– “The person in charge of transferring prisoners is entitled to shackle the hands and legs of a criminal prisoner if he finds need to do so, and is entitled to join in shackles one criminal prisoner to another or to his escort, it is also permitted to shackle a civil prisoner who tried to escape”.

Israeli Military
Regulation no. 9810 of Chief Military Police Orders ‘Shackling in handcuffs’ details the Israeli Military’s instructions in that matter. The opening paragraph states that, “A detainee will not be shackled in handcuffs, unless the person who gives the order considers that the shackling is necessary to prevent physical harm to the detainee, or to other persons or to property, or for the prevention of escape”. Paragraph 5 indicates that “Means of shackling, for restraining and securing, will be: hand shackling, leg shackling or hands and legs shackling”, paragraph 9 contains a prohibition to shackling a prisoner to inanimate objects such as a bed, and paragraph 25 instructs that “It is forbidden to improvise additional shackling means, beyond those allowed in this order”. It is
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therefore clear that restraining a detainee to his bed is a forbidden act. The use of leg shackles, according to paragraph 19, will only be with the approval of an officer holding the rank of lieutenant colonel. Paragraph 12, dealing with the shackling of a prisoner who needs medical treatment, states that “during the medical treatment if there is a physician’s instruction to undo the shackles, there must be an arrangement for perimeter security, in order to prevent any possibility of escape. In addition there is a need to instruct the escorting force that in any case the detainee will be escorted and guarded”. In a letter from the IDF spokesperson’s office to PHR-Israel concerning the shackling of the young brothers (aforementioned) from January 27 2003, there is an admission that the shackling to the bed during the hospitalisation was against orders, but it was also said that “there is a procedure which states that every security detainee who is outside the detention facility must be shackled by his limbs”21. If there is such a procedure, it stands in contradiction to the Military Orders - as pointed out earlier, the opening paragraph of the orders explicitly indicates in which cases restraining must be used ;automatically shackling even when there is no real threat of physical harm or of escape, is not consistent with this order. In the Israeli Military Orders, as with other security bodies, there are detailed instructions regarding the duration of holding a detainee restrained inside the prison facility - shackling for more than 72 hours requires the authorisation of the facility commander, and the approval of the army’s Chief Military Police Officer and Chief Medical Officer. Moreover, with the exception of special circumstances, shackles must be released for 15 minutes every 3 hours and during meal hours, toilet time, and at night (paragraphs 4,10). The Israel Prison Services also imposes restrictions on the continuous use of shackling as a means of restraint, and requires written approval of a physician for using means of restraint for more than 24 hours, and that it be reported to the prison block security officer (paragraphs e, f). These orders support the view that keeping a person shackled for a long period is undesirable and should not be applied lightly and without a critical evaluation of necessity. However, when it comes to holding an ill or a wounded prisoner in a hospital, it appears that the
21

See appendix.

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restrictions and supervision decrease considerably, and the prisoner can find himself restrained for many days, even when he doesn’t pose a threat to himself or to the people who surround him. In addition, from the cases that have been reported to PHR-Israel, some of which were detailed above, it is obvious that even the minimal orders concerning the shackling of hospitalised prisoners were clearly violated, when prisoners in a medical condition which did not render them a threat were automatically restrained during hospitalisation.

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The Position of the Israel Medical Association
The IMA, in addition to being a representative labour organisation, is the standard bearer for proper professional and ethical standards of medical care in Israel. The IMA has an ethics board which deals with topics and situations in which the physicians might need instruction, forms a binding ethical code, and deals with ethical complaints. Accordingly, the IMA published its proclaimed position regarding the subject of shackling prisoners and detainees in hospitals22. The first paragraph determines that “the rule - patients will not be shackled” and “the point of origin is, that prisoners and detainees will be taken care of without shackling, and without the presence of a security factor, unless there is a real chance of escape or if the person or the medical staff may be exposed to danger”. The decision on the need for shackling, according to paragraph 2, is “the decision of the security units, and needs to be determined by the security factors (Military, Police and the Israel Prison Services)”. A person at senior level should make the decision, or at least give subsequent approval as soon as possible. In addition, this paragraph indicates that, “before taking a decision on the need to shackle, the security agent in charge will get an up-to-date report about the physical condition of the patient, to enable him to estimate the need for shackling. For example, if the injury is more serious, the chances for escape are lower”. The third paragraph determines that shackling can be used only in the absence of a suitable alternative, and not instead of manpower, and that “hospitals which routinely take care of prisoners or detainees, must be encouraged to make changes for alternative security arrangements by providing a suitable budget. For example, a treatment room with no windows, or window that can’t be opened”. According to paragraph 4, “eventually, the decision to shackle a prisoner or a detainee is subjected to a medical decision. The part of the police or the army is to determine the need and the extent of shackling. As a rule, the physician has to decide if the shackling can harm the patient or will prevent the physician from giving the right treatment. In case of danger to the patient, the physician’s position must be accepted”.

22

The IMA position on the subject: shackling of prisoners and detainees in hospitals, August 6 , 1997.

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Criticism of the IMA position
There are two major flaws in the IMA position. The first is the issue of the final say in the decision to shackle. On the one hand, paragraph 2 explicitly states that the decision is made by the security personnel; on the other hand paragraph 4 indicates that in the end the issue is subjected to a medical decision. From the first reading it is possible to think that indeed the physician is given the responsibility and the discretion regarding the patient. But, in the continuation of paragraph 4, it says that the physician needs to decide if the shackling harms the patient and that his position must be accepted in case of danger to the patient. If so, the impression that arises is that the decision to shackle stays in the hands of the security body, unless there is a real threat to the health of the patient. According to this, if a prisoner is hospitalised with a serious illness and is lying weak in his bed, perhaps not even fully conscious, so long as his restraints do not directly endanger the state of his health, it is enough for the physician to update the security agent about the physical condition of the prisoner. The security agent may decide not to remove the shackles, and this ends the ethical responsibility of the physician. Indeed, the conclusion of IMA’s position makes an additional remark that a physician may decide not to act against the ethical dictates of conscience. This enables the physician to escape an unpleasant situation without being reprimanded, and does not deal with the lack of taking responsibility for a patient’s treatment, as is reflected in the IMA position. This position is feeble, and treats the physician unjustly by placing upon him the responsibility for his ethical behaviour without informing him of his ethical duties. Further more, the IMA position enables the physician who isn’t aware of the medical ethics rules, or whose views dictate him to see each prisoner as a dangerous man and dehumanise him, to act contrary to the ethical rules. The second shortcoming in the IMA position is that despite the statement that shackling must be considered only in the absence of a suitable alternative and not instead of a shortage of manpower, the opening principle explicitly indicates that the danger of escape can be a reason for shackling. These points are incompatible. Even in the absence of a suitable structure such as a room with no windows, or with barred windows, a prisoner lying on his bed with a soldier or a policeman on guard beside him, cannot jump out the window unless his guards are not performing their duty. In that case, the escape risk justification is groundless, and can be solved by placing necessary guards. Shackling to prevent an escape will
21

almost always be an alternative to manpower and suitable security staffing, and therefore contrary to IMA’s stand. If so, it is not clear why IMA’s position enables shackling an ill or wounded person in order to prevent his escape. An alternative approach that IMA could have taken is the position published by the British Medical Association.23 The Israeli position was published about a year after the British position and had a fair amount of similarity to it, but they are not totally identical. The British position clearly states that, ”In cases where there is a high risk of escape or where there is a threat of violence, the safeguards should nevertheless respect the prisoner’s right to privacy to the maximum extent possible. For example, where there is a risk of escape, but no likelihood of violence, it should be possible for a prison officer to be stationed outside the consulting or treatment room with another in the grounds immediately outside. These precautions will allow the patient some degree of privacy, dignity and confidentiality whilst also ensuring that security is maintained. Occasionally where there is a serious threat of violence, or where the prisoner is considered to be dangerous, it will be necessary to use restraints and it may also be necessary to have a prison officer inside the consulting room”. This position, as opposed to IMA’s position, does not justify shackling as a means of preventing escape when the prisoner is not a threat to himself or others. The IMA implements its policy to a great extent in accordance with the chairperson serving at the time. Over the years, PHR-Israel has noticed the crucial influence of the IMA chairperson in shaping the attitude and policy of the organisation in questions of ethics. Dr. Miriam Tsangen, who served one term as IMA chairperson, expressed a great deal of sensitivity and understanding towards human rights and medical ethics. The chairperson’s attitude influences, among other things, the issue of shackling – Dr. Ruchama Marton and Dr. Ahmad Massarwah of the PHR-Israel board, met with Dr. Miriam Tsangen, during her time as IMA chairperson, with regard to the issue of shackling hospitalised prisoners. It was agreed at the meeting that this is a particularly grave practice, which contravenes the rules of medical ethics. Her direct and fast intervention in the case of

23

Guidance for Doctors Providing Medical Care & Treatment to Those Detained in Prison, British Medical Association, March 1996.

22

Intisar Muhammad Elkak (see above), testifies to the importance of the chairperson’s position. The IMA is meant to promote the values and rules of medical ethics among the physicians, and provide the right tools and solid backup to all physicians, so that they will refuse to treat a restrained prisoner, unless he is a threat to himself or others. To the credit of IMA’s position, it gives recognition to most of the problems and obstacles that surface when dealing with safeguarding, but ultimately the above failings and the fact that even these minimal guidelines have been ignored in most of the hospitals without any criticism from the IMA, make their position paper ineffective.

23

The Position of the Ministry of Health
The ministry of health’s position on the issue of safeguarding prisoners and detainees in hospitals can be found in the medical administration circular no. 39/9924, which was distributed to the directors of general and psychiatric hospitals, and to the managers of emergency rooms and health fund medical departments. Paragraph 3 clearly determines that “the authority for shackling a patient who is in custody is of the law enforcement body which is in possession of the patient and is guarding him”. Paragraph 4 indicates, “in any situation in which the shackling of a detainee might, in the opinion of the attending physician, obstruct the medical treatment or is unnecessary in his opinion, the physician should demand that the security body release the patient from the shackling and take alternative measures of security according to need”. The next paragraph states that in case of difference of opinion it will be referred to the “decision-making forum” for a binding and final resolution. Further details about the forum and generally on the ministry of health position can be found in the ‘procedure for shackling prisoners and detainees’, which was published by the head of the security department in the ministry25. This procedure determines in paragraph 4.1 that one of the considerations to be taken into account is the “prevention of the prisoner or detainee’s escape, by shackling him or by any other means.” Paragraph 4.2.4 says that “at the time of admission of the detainee to the emergency ward or hospitalisation, the guards from the body that brought him to the hospital will check the possibility that he be released from the handcuffs, and receive treatment as any other patient”. Although it is clearly stated in the next paragraph “that shackling a prisoner during medical treatment is not a routine and automatic act”, it also says that “where the release of a prisoner from shackling is not necessary for medical treatment and when according to the estimate of the security agent in charge, that relies as much as possible on substantial information or founded intelligence information, the shackling is necessary, it will be possible to keep the prisoner shackled during his stay in the hospital and in the absence of alternatives, also during the treatment itself”. Further
24 25

August 1999. Procedure no. 1019, April 25th, 1999.

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along it is stated that disputes will be settled by the “decision-making forum”, which includes the director of the hospital or his deputy and a representative of the law enforcement authority. When disagreements arise, the representative of the hospital is supposed to make contact with the representative of the security authority (there is a specific list of senior positions holders from all sides) to try and settle the disagreement, while “the final decision regarding the necessity of the shackling for security reasons will be of the enforcement law authority in the forum, and the final decision in this matter of the necessity of the shackling for medical reasons will be of the medical authority in the forum”.

Criticism of the Ministry of Health position
Similarly to the IMA position, the ministry of health procedures include the prevention of escape as a legitimate consideration when deciding whether to restrain a patient, despite the often-existing alternatives to handle this risk. Paragraph 4 in the medical administration circular mentions situations in which the shackling isn’t necessary in the opinion of the physician, but it does not provide the physician any tools to assist his decision, and it does not explicitly indicate what the legitimate purposes of shackling are (such as imminent and real danger to self or others). The procedural document of the head of the security department does contain more details, but the impression created by paragraph 4.2.5 of the procedure, and paragraph 4 of the circular, is that the chief problem to be dealt with, is the potential harm to the quality of the medical treatment, and that as long as the treatment itself is not directly impaired, the patient can remain restrained. This is even clearer in cases where the patient lays in his bed while not actually receiving treatment at that moment. As will be seen later, this is indeed the interpretation given by some of the hospitals. According to this, there is nothing to prevent prisoners and detainees that are not a threat to themselves or others, from being systematically safeguarded with no regard to their human dignity or to the physician’s responsibility to alleviate their distress, apart from exceptional circumstances when the shackling must be removed for a medical procedure. It’s hard to believe that this was the intention of the Ministry of Health, but this is exactly the result we found. One must note to the credit of the Ministry’s circular, that in incidents in which the shackling is unnecessary, the physician is to demand the release of the patient from shackling26. This version, as
26

Emphasis by PHR-Israel.
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opposed to the passive language of the IMA position (which allows the physician to avoid acting against his conscience, but forgets his duty to the patient), obliges the physician to take action and determines that he has responsibility to take steps towards removal of the shackling. The “decision-making forum” for resolving differences of opinion between the security bodies and the medical bodies, could provide a solution for part of the obstacles, but does not solve the main problems – as long as the physicians are led to believe that shackling is easily justified in many cases, such as for escape prevention, then these cases will never reach the forum. Secondly, when escape prevention is considered a legitimate justification as long as there is no direct harm to the medical treatment, all the security authority need say is that preventing escape is an essential security consideration, and have the final word in the decision to shackle. Moreover, in the case of Riham Sheikh Mussa (see above), who was hospitalised at the Meir Hospital, the chairperson of the IMA Ethics Board, Professor Avinoam Reches, appealed to the Prison officer of the Military Police, who is a member of the forum, but the Military representative did not bother to reply. A forum cannot reach decisions if its members do not cooperate.

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The Hospitals and the Physicians
The responses of hospitals to enquiries by PHR-Israel, testify to the questionable treatment of prisoners, and the failure to internalise and implement even the minimal and unsatisfactory guidelines of the Health Ministry and IMA. In January 2002, attorney Allegra Paceco turned to the management of “Ha’emek” hospital, regarding two administrative detainees who were treated while metal restraints were fixed to their hands and legs. One of them even remained shackled, according to his testimony, while undergoing head surgery. In the director of the hospital’s response, Dr. Halpern, he says that these were “detainees in excellent physical condition who received routine medical treatment, and stayed in the hospital for a short while (about two hours each)” and that “therefore the medical team didn’t think that there was a reason to release them from the safeguards or turn to the military authorities for this matter (which would have certainly made them stay in the hospital for an additional number of hours)”. According to this response, patients can be restrained without any claim of being a risk, and in contradiction to the instructions of the health ministry, which determine that the physician must demand the removal of the restraints if there is no justification for them. An additional case from “Ha’emek” hospital, of the boy Rami Mahamid (see above), dealt with a wounded patient who stayed in the hospital for a long period , in a physical condition which was far from being excellent (the opposite of the described situation of the detainees in the former case). This time the first response of the hospital director mentioned the dedicated treatment given to all patients without distinctions of religion or race, but with no specific reference to the shackling of the boy. In the reply to the second letter by PHR-Israel, there was a copy of new instructions to the heads of departments in the hospital, stating that when a shackled prisoner or detainee is in the department, “consideration must be given to whether in his physical condition the detainee can form a threat to the surroundings”, and “it is clear that there is no need or reason to shackle a seriously ill and/ or wounded detainee”. PHR-Israel organisation welcomes the progress, and hopes that the instructions will lead to a decrease in the safeguarding of patients in this hospital.

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In his reply to PHR-Israel regarding the case of Muataz Jaradat and Ghaleb Elfaruch (see above), the chairperson of Hadassah, Professor Shmuel Pinchas, wrote that “the management of the Hadassah Medical Organisation instructed the employees a number of years ago, to prevent the restraining of all patients whoever they may be (prisoners, detainees, criminal and security detainees)”27. In the case of Riham Sheikh Mussa aged 15 who was shackled over 20 days in the Meir hospital, the management of the hospital didn’t reply to PHR-Israel, but their position on the matter was presented in a letter sent to the IMA. In his letter to the Ethics Board, the director Dr. Davidson says that the hospital questioned the military about the shackling, and received the reply that the girl continues to be a security threat. As far as is known to PHR-Israel, the hospital’s questioning of the military took place only after the complaints by PHR-Israel and the IMA. Moreover, Dr. Davidson wrote, “we act in accordance with the Ministry of Health procedures. These procedures determine that it is permissible for the security’s forces to demand that a wounded person remain shackled – as long as the attending physicians do not claim that the shackling itself hinders the medical treatment. This question was asked by us- and when it was made clear that shackling itself caused medical harm - we followed all the instructions”. This answer displays a limited understanding of the Ministry of Health instructions – these oblige the physician to demand the removal of the restraints when they are not necessary in his opinion, and not only when there is direct harm to the medical treatment – and permits the shackling of people who do not form a real threat, so long as the shackling itself has no direct harmful impact on the treatment. This position also completely ignores the physician’s duty to the patient, and presents him as insensitive to the dignity of the ill or wounded person lying shackled in a bed. Not only hospital managements, but also individual physicians who have awareness of the human rights and dignity of the patient, have the ability to influence the situation. For example: Professor Michael Elkan, a member of PHR-Israel, from the Soroka Hospital in the Negev, refused a number of years ago to treat an ill person in shackles, and brought about the removal of the shackles from the patient. Another physician, from the same hospital (who requested not to be mentioned by name), informed
27

See appendix.

28

PHR-Israel about a similar case, and helped to remove the shackles from the patient. An opposite example: Professor Avi Rifkind from the Hadassah Ein Kerem Hospital in Jerusalem was cited in the case of the shackled boy Muataz Garadat (see above)28:”The shackles didn’t bother me during the treatment, though I wasn’t happy about them. The soldier said to me – does it bother you? As soon as it does, we’ll remove it. What could I do?”.29 The answer is clear – had Professor Rifkind been properly aware of the ethical rules (and this is the IMA’s responsibility) he would have instructed to remove the shackles from the injured, hurt and frightened boy.

28 29

In a report by Gideon Levi, Ha’aretz newspaper, 18.10.96 . Emphasis by PHR-Israel.
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The Position of Physicians for Human Rights - Israel
The situation described is one in which prisoners and detainees are shackled almost by default, and when it comes to Palestinians being held by the army, the automatic shackling is an admitted policy. Unfortunately, the impression that arises is that in most cases not enough is being done by the medical profession to try and have the shackles removed, whether the compliance is due to approval or to a feeling of inability to change the situation. The incidents described don’t leave room for doubt that in Israeli hospitals, restrained patients lie in their beds without any justification – including seriously ill people and badly wounded patients – people whose medical condition hardly enables them to stand by themselves on their two feet, never mind threaten their surroundings. Particularly worrying is the easiness in which injured hospitalised children, in spite of their condition and the fact that they have been put under guard, still find themselves shackled to their beds. It seems that the procedures of the security bodies, which are not detailed enough regarding the use of shackling on hospitalised prisoners and detainees, and the allowance of the escape prevention as justification, leads the guards to look for an ‘easy life’ by safeguarding most of the people in their charge. The positions of the IMA and the Ministry of Health have some points to their credit, but leave too many openings for unnecessary and unjustified restraining, especially with regards to the issue of escape prevention. These positions, apart from being weakly worded, were unknown to a large number of physicians with whom PHR-Israel has been in contact, and have little chance of being influential. The lack of acquaintance of the issue among physicians is also a result of not taking the necessary steps when confronted by present and past information concerning cases of unnecessary shackling. As mentioned earlier, the widespread use of shackling of prisoners and detainees contains serious problems. The harm to the patient’s health is not only a result of impeding medical procedures (as appeared in the testimonies from the case of Shaul Nachmias), but also of causing suffering to the patient by the very fact of being in shackles. The shackling can cause physical pain (in an interview to a newspaper, Rami Mahamid
30

described his feelings when he opened his eyes in hospital for the first time after being wounded – “and my hand was tied, and the leg was tied. And it was painful”). The suffering is also mental. The feeling of a man restrained and shackled with little control of his bodily movements, being dependant on the mercy of others for everything, even for using the toilet, and all this while a guard is sitting opposite him watching his helplessness, is a most distressing feeling that leads to humiliation, suffering and mental despair. The damage intensifies as time passes, and a person is held continuously restrained for many days and even weeks. Shackling a person who poses no real or immediate threat to himself or others, is not justified, and could also be claimed to be in violation of the prohibition on degrading treatment and a failure to protect the inherent dignity of the human person. The severity of the past offence of which the person was suspected or convicted, is not the main criteria for determining the need to restrain, but rather the danger that may be caused by him at present. As has been pointed out, shackling as punishment is absolutely forbidden whether by international rules and whether by the rules of the Israeli security bodies. Even when a dangerous prisoner is involved, and there is a well founded risk that he may be a danger to himself or others, there are still limitations to the use of shackling - despite the fact that shackling to a bed is forbidden also by security authorities in Israel (except for extreme and urgent cases), such shackling takes place frequently in hospitals. The insult to the dignity and rights of the patient is several times more severe when he is tied to an inanimate object, and this form of shackling of hospitalised prisoners and detainees has received criticism from the European Committee for the Prevention of Torture. The security bodies and the government offices that supervise them bear the responsibility for improper treatment of hospitalised prisoners and detainees. A physician who treats a restrained person loses a great deal of his status as the guardian of the patient’s best interests, and is unlikely to hold the patient’s trust. In the eyes of the latter, the physician and the hospital with him could be perceived as part of the security system responsible for him being in shackles, whether through direct responsibility or by not taking a stand against it. The physician’s role goes beyond that of a machine performing technical medical procedures and immediately withdrawing from the room. He is meant to be concerned with both the physical and mental health of the patient, and do the best he can to ease the suffering
31

of the person under his responsibility. Accepting the shackling of a patient lying in a hospital bed, when there is clearly no justification, is a betrayal of the physician’s commitment to the patient. This acquiescence could be regarded as taking a part, even if passive, in a situation that causes the patient suffering and abuses his dignity, or in other words – in a violation of his rights as a patient and a human being. The sanctity of security in Israeli society is a well-known and familiar phenomenon, as is the violation of human rights in its name. It is worthwhile to remember that a physician is not a security agent, no matter what his feelings or personal views are (or his role in the reserve army). When in the hospital his duty is to guard the health and dignity of his patients and not the state security, are others who have that role. As long as he isn’t convinced that there is a real and immediate danger that the patient might harm himself or others, there are no alternate considerations that allow the physician to accept the shackling of a person whose health is his responsibility. The security pretext should not blind the physician and cause him not to see or understand that a wounded child who is barely conscious, or an ill person struggling for life, don’t form an immediate danger to their surroundings. The use of the term ‘security’ cannot justify their being shackled to the bed, all the more so in light of the fact that most of the time they are held under constant guard. The ministry of health is expected to supervise the activities in hospitals and medical institutions under its responsibility. The Ministry’s rules on safeguarding are insufficient and are not carried out even at this minimal level. The fact is that medical personnel that are in frequent contact with prisoners and detainees are not familiar with the procedures, and the fact that people are restrained almost automatically in hospitals in Israel with little questioning and no repercussions, reveals that the Ministry of Health is not performing its supervision role adequately, and is giving a hand to the abuse of patients’ rights. Furthermore, the existing situation confirms that the IMA is not fulfilling is required role in imparting and safeguarding the values of medical ethics.

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In conclusion, the wholesale shackling of prisoners and detainees in hospitals in Israel is clearly a worrying phenomenon, which violates the dignity and rights of the patient, as well as the status of the medical profession, and contravenes principles of human rights and medical ethics. The use of restraints in hospitals should be limited to exceptional cases, where it is obvious that there is a real and immediate danger of the patient injuring him or others, and that placing a guard is not sufficient. Even in such cases, the shackling to a bed or other inanimate objects is prohibited, and the combination of shackling hands and/or legs together with a guard would be more than enough. These cases of justifiable shackling will be exceptional and only in cases of risk of immediate violence and with no other alternative. Medical personnel must use careful judgement. Even when it is argued that a patient is dangerous, it must be recalled that the yardstick is a current danger, not past actions. If the patient’s medical condition is inconsistent with the claim that they present an immediate threat, medical personnel should not agree to the shackling. Using restraints as a means for preventing an escape from hospital is unacceptable. Hospitals, which regularly treat prisoners and detainees, should have rooms or areas assigned for this population, that don’t have windows, or have barred windows, that can prevent the opportunity for any escape. Even in the absence of a special room, there is no justification for restraining a hospitalised person in order to prevent escape. The presence of one or more guards, who accompany the patient, as is usually the practice in hospitals, is sufficient to thwart most attempts. Shackling may be justified only in extreme and exceptional cases when there is an immediate danger of violence and no alternative can be found. The claim that a sick or wounded person, especially a child, could overcome policemen or soldiers and run away from his sickbed is fundamentally flawed. The escape argument cannot justify severe and ongoing abuse of the patient, and it is necessary and possible to find another solution.

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Recommendations
The cases presented above, show that shackling is often used with no justification. To prevent the continuation of the abuse of prisoners and detainees arriving for medical treatment in hospitals, PHR-Israel recommends the following:

• The security bodies must amend and improve their procedures, making it clear that shackling a hospitalised prisoner should be an exceptional act justified only to avert a real and immediate danger of the patient injuring himself or others. • In cases of unjustified shackling, the security bodies or supervisory government bodies must take action against those responsible. The state has an obligation to take steps when rights have been violated, thereby also helping to prevent future abuses. • The Ministry of Health and the Israel Medical Association must declare that the shackling of patients is unacceptable, apart from the exceptional cases of real and immediate threat. Prevention of escape is not a legitimate justification. • These positions must reach the wide audience of physicians and medical staff, and not remain ineffectually locked away in a filing cabinet. • Medical facilities likely to treat prisoners and detainees must set aside a room or area to ease security considerations. If this is not possible within the current structures, an appropriate budget must be provided. • The guidelines of the Ministry of Health and the Israel Medical Association make it clear that it is the physicians’ duty not to agree to the shackling of their patients, and provide the physicians with backing and unequivocal support. Physicians and particularly hospital managements who accept unjustified shackling and do not act to prevent the abuse of their patients, should know that they are likely to face disciplinary proceedings at the hands of the Ministry and the IMA.
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Israeli Defense Forces Spokesperson Public Relations Desk

Tel: 03-6080340/1 Fax: 03-6080343

January 27th, 2003

To: Ms. Michal Bar-Or Physicians for Human Rights

Re: Ahmed and Mohammad Hamis Ismail Al Hanajra – Shackleing to Bed during Hospitalization

Dear Madam, Our office received a letter from Ms. Hadas Ziv on the above-mentioned matter. The following is our response: A procedure exists in accordance with which any security prisoner outside the detention facility is to be restrained by his limbs. Due to the type of injuries sustained by the detainees (injuries to the limbs), and in an effort to alleviate their situation, the detainees were shackled to their beds. After undertaking an examination, it emerged that shackling to a bed is contrary to the regulations. Accordingly, new security arrangements have been established in accordance with the recommendations and in coordination with the medical staff at the hospital. Sincerely,

Major Enrietta Levy Head of Assistance Desk

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Israel Medical Association Ethics Committee March 2, 2003 To: Brig.-Gen. Bar-El Chief Police Officer IDF Dear Sir, Re: Lt.-Col. Shlomo Gispan Head, Imprisonment Division

The Palestinian youth Riham As’ad Muhammad Sheikh Mussa, age 15, was injured after she was shot at by IDF soldiers. The circumstances and date of her injury are not known to me; as far as I know, she was shot while attempting to assault a soldier. As a result of the shooting, she sustained grave injuries to the stomach. She was hospitalized at Meir Hospital, where it was necessary to perform urgent stomach surgery in which part of the intestine was removed. After she awoke from anesthesia, she was shackled to her bed with handcuffs. On February 25, 2003, PHR-Israel contacted the Ethics Committee of the Israel Medical Association by fax and telephone, asking that action be taken to release the girl from the handcuffs. On Wednesday, February 26, 2003, I spoke several times to the hospital management in order to understand the girl’s medical situation and the necessity for her to be chained. Dr. Wishlitzky, deputy director of the hospital, was extremely courteous and prompt in his responses. He also explained that the obligation to shackle the girl was imposed on the physicians by the army authorities, and that they insisted that the girl was dangerous and must continue to be shacled. The position of the Israel Medical Association regarding the shacking of prisoners and detainees in hospitals is clear and well-known. The guiding rule is that patients are not to be shackled unless there is a tangible danger that they will escape or the patient poses a threat to the medical staff. The instructions of the Head of the Medical Administration in the Ministry of Health are also formulated in this spirit. In order to resolve problems of this type when disagreements emerge, a “Decisions Forum” was established. Its function, as I understand it, is to provide appropriate responses in cases such as this one.
36

Lt.-Col. Shlomo Gispan, Head of the Imprisonment Division in the Military Police Officer Command, is an ex officio member of this forum. On Thursday, February 27, 2003, I contacted his office by telephone in order to understand his position on the matter of this girl. Between 09:30 and 10:00 am, I called 5 (!) times, but Lt.-Col. Gispan did not deign to answer me even once. I presented myself by my full name and my position as chairperson of the Israel Medical Association’s Ethics Committee. I explained exactly why I was contacting him, but regrettably all this was in vain. The answers I received from a male and female clerk in the office were as follows: “He is on the telephone now and will get back to you;” “He is on a lunch break, but he will call you when he gets back;” “He is in a meeting and very busy;” “He is aware of the problem and is dealing with it.” It is imperative to point out that even though I left my telephone number at work with the office, as well as my mobile phone number. Lt.-Col. Gispan did not take the trouble to respond at all to my repeated calls. Lt.-Col. Gispan may be right that it was essential to chain the girl. It is not this aspect of his behavior that is outrageous. It is unthinkable that an officer staffing such as sensitive position in public terms could ignore my calls in such a discourteous manner. What is the point of his being a member of the “Decisions Forum,” where he must provide answers and explanations on a real-time basis, if he lacks the understanding and sense of responsibility that are required of someone in such a sensitive position? We are facing a difficult battle in international public opinion regarding our character as an enlightened society and our status among the nations. I hardly need tell you that the difficult war we have faced over the past two years has devastated this status. I myself am engaged in the defense of the good name of the State of Israel among international organizations of physicians. This is a very difficult task at present. In such forums, I will be unable to explain harsh and insensitive behavior such as that of Lt.-Col. Gispan. I will be grateful for your reply to this letter. Sincerely, Prof. Avinoam Reches Chairperson, Ethics Committee CC: Minister of Defense Chief of Staff Dr. Blachar, Chairperson, IMA PHR-Israel
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Israel Medical Association Central Committee 39 Shaul Hamelech Blvd, Tel Aviv 64928 December 3, 1990 0945 To: Commander of Sharon Prison Israel Prison Service POB 81 Ramle Dear sir, The Association of Israeli-Palestinian Physicians for Human Rights has brought to my attention photocopies of affidavits given by the prisoner Intisar Muhammad Alqaq. Photocopies of the two affidavits are attached for your review. I would ask you to examine the fact and respond substantively to each of the claims in the affidavits. If the young woman’s hands were indeed handcuffed while she gave birth, we see this in a severe manner. Moreover, a physician performing a delivery in such conditions would have been acting contrary to the ethical rules of physicians, which are universal. I would ask to receive explanations as soon as possible. sincerely, Dr. M. Zangen Chairperson BCC Association of Israeli-Palestinian Physicians for Human Rights – POB 10265, Jerusalem 61101

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Hadassah Medical Organisation Central Administration Kiryat Hadassah P.O.B. 12000 Jerusalem 91120, Israel Telephone: 02-777111 Cables Hadassah Fax: 02-434434 The Legal Department Tel: 02-6776081, Fax: 02-420219 October 22nd, 1996 To: Dr. Ruhama Marton Chairperson, PHR-Israel POB 592 Tel Aviv 61004 Dear Dr. Marton, Prof. Shmuel Pinchas, director-general of the Hadassah Medical Organization, has asked me to reply to your letter, ref. 371-96-988, dated October 10, 1996 regarding two young Palestinians who were shackled to their beds by their guards while undergoing hospitalization and treatment at Hadassah Ein Kerem Hospital. Several years ago, the Hadassah Medical Organization instructed its employees to refrain from shackling any patients (prisoners and detainees, whether criminal or security) to their beds. By pure coincidence, this subject came up for discussion on October 10, 1996 at the meeting of the active executive of the Hadassah Medical Organization, and the director-general of Hadassah repeated the previous instruction and asked that a written reminder in the above-mentioned spirit be sent to all the employees.
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This instruction is naturally subject to the legal authority of those responsible for guarding such patients, if any. The director-general of Hadassah has also contacted the relevant authorities on this matter. Sincerely, Dan Sheffi, Advocate Legal Adviser CC: Minister of Health Mr. Zahi Hanegbi Dr. Yoram Blachar, Chairperson, IMA Prof. Eran Dolav, Chairperson, IMA Ethics Committee Prof. S. Pinchas, Director-General, Hadassah

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