physicians for human rights-israel: medicine in handcuffs, june 2003

8/8/2019 Physicians for Human Rights-Israel: Medicine in Handcuffs, June 2003

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Medicine in Handcuffs

Restraining of Prisoners and Detainees

Undergoing Medical Treatment and

Hospitalisation

June 2003

Writing: Noam Lubell, Dr. Ruchama Marton

Research and testimonies: Michal Bar-Or, Shabtai Gold, Anat

Litvina, Noam Lubell, Hadas Ziv

Translation: Yardena Tzintzolker, Shaul Vardi

English Editing: Johanne Malka-Shalom

Cover photo: Michal Bar-Or (illustration photo)

Individuals and Organisationswho 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


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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 GoldmanFoundation, 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: [email protected]


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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 thepolice 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 whileundergoing 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 thelanguage sometimes refers to one gender, apart from the times when specificindividuals are mentioned, any use of the terms physician / nurse/ prisoner, appliesto 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-Israels 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 tomany 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 arrivedat 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-Israels communications with the authorities, and the

request that they be transferred to a room with barred windows, they were

moved and Ahmeds restraints were removed. Muhammad was transferred

from the hospital to a detention facility.

Riham Asad Muhammad Sheikh Mussa, Meir Hospital, Kfar

Saba. On February 23rd, 2003, 15 year-old Riham Asad 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, aftercollapsing 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 therestraints removed. Still chained to the bed, his condition deteriorating,

the medical staff attempted resuscitation to no avail. Shaul Nachmias died

chained to a bed.

Muataz Jaradat and Ghaleb Elfaruch, Hadassah Hospital,Jerusalem. In October 1996, the two youths14 and 17 year-olds, werehandcuffed 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. Muataz: 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. Allaround there were patients watching TV and laughing. We werent even

allowed to move. It was terribly sad.

Intisar Muhammad Alkak, Meir Hospital, Kfar Saba. On December3rd 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 prisoners restraints were removed, and her mother wasallowed to sit by her side in the hospital.

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-Israels 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 ofphysicians, 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 fromthe 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 theheadquarters 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 LawRules 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 International Covenant on Civil and Political Rights, G.A. res. 2200A (XXI), U.N.Doc. A/6316 (1966), entry into force Mar. 23, 1976

6 N.Rodley, The Treatment of Prisoners Under International Law (Oxford UniversityPress, 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 away8

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 strait- jackets, 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 thatthey shall be removed when the prisoner appears before a judicial

or administrative authority;11

7 Passed on March 17, 19928 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, 832.9 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 Treatmentof Offenders, U.N. Doc. A/CONF/611, annex I, E.S.C. res. 663C, 24 U.N. ESCORSupp. (No. 1) at 11, U.N. Doc. E/3048 (1957), amended E.S.C.

10 Rodley, p.280-28111 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 EthicsA fundamental rule of medical ethics is the Physicians 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 theDeclaration on the

Rights of the Patient states that the patients 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 3rd General Report on the CPTs activities covering the period 1 January to 31December 1992 CPT/Inf (93) 12 [EN] - Publication Date: 4 June 1993. par. 36.

13 see below14 Declaration of Geneva. Adopted by the 2nd General Assembly of the World

Medical Association, Geneva, Switzerland, September 194815 World Medical Association Declaration on the Rights of the Patient. Adopted by

the 34th World Medical Assembly Lisbon, Portugal, September/October 1981andamended 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 shouldpursue appropriate means to assure or to restore them.16These are notthe only declarations and documents relating explicitly to the physician-

patient 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 doctors 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 thePrinciples 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 ordetainee 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 meanthe physician actually restraining the patient, being part of

the decision to restrain, or being an acquiescent witnessit 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 Emphasis by PHR-Israel17 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 29thWorld Medical Assembly Tokyo, Japan, October 1975

18 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 InternationalCouncil of Nurses, Geneva, 1998


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The Procedures of the IsraeliSecurity 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 placeinside the prison facility. Shackling for escape prevention is usually

considered when the prisoner is not between the facilitys 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 detentionfacility20. 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 ServiceIPS 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 permittedonly 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 findsneed 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 MilitaryRegulation no. 9810 of Chief Military Police Orders Shackling

in handcuffs details the Israeli Militarys 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 physicians 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 spokespersons 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 limbs21. 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 armys

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 morethan 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 doesnt 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 MedicalAssociation

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 shacklingprisoners 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 cant

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, thephysician 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 physicians 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 positionThere are two majorflaws 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 tothis, 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 IMAs

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 patients 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 isnt 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


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almost always be an alternative to manpower and suitable security staffing,

and therefore contrary to IMAs stand. If so, it is not clear why IMAs

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 prisoners

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 withanother 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 IMAs 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 chairpersons

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, withregard 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 inPrison, British Medical Association, March 1996.


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Intisar Muhammad Elkak (see above), testifies to the importance of the

chairpersons 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 IMAs 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.


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The Position of the Ministry ofHealth

The ministry of healths 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 enforcementbody 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 detainees 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 agentin 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 August 1999.25 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 positionSimilarly 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 isnt 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 theprocedure, 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 physicians responsibility

to alleviate their distress, apart from exceptional circumstances when the

shackling must be removed for a medical procedure. Its 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 Ministrys circular,

that in incidents in which the shackling is unnecessary, the physician isto 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 Haemek 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 hospitals 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 didnt 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 casefrom Haemek 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 didnt 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 hospitals 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 securitys forces to

demand that a wounded person remain shackledas 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 Healthinstructions 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 treatmentand 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 physicians 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 theability 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.


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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 didnt botherme during thetreatment, though I wasnt happy about them. The soldier said to medoes

it bother you? As soon as it does, well remove it. What could I do?.29 The

answer is clearhad Professor Rifkind been properly aware of the ethical

rules (and this is the IMAs responsibility) he would have instructed to

remove the shackles from the injured, hurt and frightened boy.

28 In a report by Gideon Levi, Haaretz newspaper, 18.10.96 .29 Emphasis by PHR-Israel.


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The Position of Physicians forHuman 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 thesituation. The incidents described dont 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 patients

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


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described his feelings when he opened his eyes in hospital for the first time

after being woundedand 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 patients best interests, and is unlikely to hold thepatients 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 physicians 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


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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 physicians 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 isnt 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, dont 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 Ministrys 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. Evenwhen it is argued that a patient is dangerous, it must be recalled that the

yardstick is a current danger, not past actions. If the patients 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 dont 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 justificationfor 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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RecommendationsThe 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 MedicalAssociation make it clear that it is the physiciansduty 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 Tel: 03-6080340/1

Spokesperson Fax: 03-6080343

Public Relations Desk

January 27th, 2003

To:

Ms. Michal Bar-Or

Physicians for Human Rights

Re: Ahmed and Mohammad Hamis Ismail Al Hanajra Shackleing toBed 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 Asad 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 theIsrael 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 girls 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 guidingrule 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.


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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 orderto 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 notdeign to answer me even once. I presented myself by my full name and myposition as chairperson of the Israel Medical Associations Ethics Committee.I explained exactly why I was contacting him, but regrettably all this was invain.

The answers I received from a male and female clerk in the office were asfollows: He is on the telephone now and will get back to you;He is on alunch 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 atwork with the office, as well as my mobile phone number. Lt.-Col. Gispan didnot 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 notthis aspect of his behavior that is outrageous. It is unthinkable that an officerstaffing such as sensitive position in public terms could ignore my calls insuch a discourteous manner. What is the point of his being a member of theDecisions Forum, where he must provide answers and explanations on areal-time basis, if he lacks the understanding and sense of responsibility thatare required of someone in such a sensitive position?

We are facing a difficult battle in international public opinion regarding ourcharacter as an enlightened society and our status among the nations. I hardlyneed tell you that the difficult war we have faced over the past two years hasdevastated this status.

I myself am engaged in the defense of the good name of the State of Israelamong international organizations of physicians. This is a very difficult taskat present. In such forums, I will be unable to explain harsh and insensitivebehavior such as that of Lt.-Col. Gispan.

I will be grateful for your reply to this letter.

Sincerely,

Prof. Avinoam RechesChairperson, 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 womans 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 physi-

cians, 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 RightsPOB 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 DepartmentTel: 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

physicians for human rights-israel: medicine in handcuffs, june 2003

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