1070
while, one of them said to the other, ’It’s about time we stimulated his brain. We’d better suspend him’. They said something like ’we’ll squeeze you so we can see what’s inside’. They applied the electric tool repeatedly to sensitive parts of the body in circles and strokes. They began on my shoulders and chest, and then applied it to my nipples, scrotum, and penis, even on the urethral orifice... From Friday night until Saturday afternoon I was suspended from my wrists but with my feet still touching the ground. Once, they took me down from this position and asked me whether I was prepared to talk. When I refused, they put me back in the same position. I was exhausted. On the Saturday they said, ’Are you going to talk or not?’. When I asked what I was supposed to be talking about, they responded with a battery of blows all over my body. I was still blindfolded. They stripped me down to my underpants and applied the electric tool above my nipples. My body jerked in an involuntary spasm. They slapped my face and I reeled backwards. As I lay on my back I could feel four pieces of iron over my chest and other pieces of iron keeping my legs apart. This was to restrict my body’s movements while they applied the electricity". Dr Mandour was released on Feb 23. Formal complaints were lodged on his behalf by the Egyptian Organisation for Human Rights, and Amnesty International raised his case with the Egyptian Government in February. In May, 1991, this organisation was informed by the Egyptian Embassy in London that "The investigation conducted by the competent authorities in Egypt proved that allegations [that Dr Mandour was] subjected to torture or other forms of ill-treatment were unfounded". In June Dr Mandour was unaware of any official investigation into his complaints of torture.
Political detainees who are charged and who claim to have been subjected to torture may be examined by forensic doctors at the request of the niyaba (state procuracy) or the trial court. Administrative detainees, held without charge or trial, usually have no opportunity to submit a complaint about their treatment to the competent authorities. Medical examinations have often taken place long after the alleged torture occurred, which clearly detracts from their usefulness. In addition, methods of torture used may, as in the case of electric shocks, leave few or no physical traces. However, in some cases, forensic doctors are able to conclude that physical marks on the bodies of political detainees are consistent with the methods of torture they describe and with the date(s) on which the torture is alleged to have taken place. Amnesty International has obtained many reports substantiating alleged torture during the past 10 years. The most recent relate to examinations carried out by forensic doctors in late 1990, on victims who claimed that they were tortured in October, November, and December, 1990. In February, 1991, in response to representations by Amnesty International, the Egyptian Government responded that allegations were "a fabrication devoid of truth" and that defendants had given false information about torture to the media and human-rights organisations to tarnish the image of the security forces, cast doubt on the correctness of legal procedures in Egypt, and gain sympathy. Amnesty International has also received responses to specific cases of torture it raised with the Egyptian authorities. They included those of Dr Fahmy al-Shinawi, Dr Mohammad Mandour, Dr ’Emad ’Atrees, and Dr Mohammad ’Abd al-Latif Tala’at. The Government said in all cases that investigations had been carried out and found that torture had not occurred. Amnesty International has not been given any details about the Government’s investigations and has requested that this information be made publicly available. It considers this point all the more important since alleged victims and their
have told the organisation that they have neither been interviewed nor informed of any investigation having been initiated. Since then, Amnesty International has obtained medical reports written by doctors in the Forensic Department of the Ministry of Justice relating to examinations carried out on some of the 25 defendants involved. They spoke of detainees in a state of prostration and extreme exhaustion, marks consistent with electric shocks, and scars that could have resulted from suspension or contact with solid objects.
lawyers
Amnesty International British Section, Medical Group, 99-119 Rosebery Avenue,
Duncan Forrest
London EC1R 4RE 1.
Amnesty
International.
Egypt: ten years of torture. Ref no MDE12/18/91.
Medicine and the Law Child abuse
guidelines
There have been several consequences to the Cleveland child-abuse cases and the public outcry that followed. The Butler-Sloss inquiry’s report (1987) emphasised the need for coordination between the different agencies (eg, social workers, police, and doctors) that deal with suspected child abuse, for evidence to be gathered by techniques that do not require children to be repeatedly examined, physically and verbally, and for a full picture to be available before applications are made to remove children from their homes. That report was largely responsible for the Children Act 1989 that came into force on Oct 14,1991, and brings with it a plethora of new rules, regulations, and guidance. Some civil actions brought by Cleveland parents were settled out of court earlier this month. Incidents in which children thought to be the subject of child sexual abuse are snatched from their homes still give cause for concern-while at the other end of the scale, social workers and doctors are liable to be blamed if they have failed to act speedily to remove from their parents’ custody children who are then battered to death. Last year social workers near Manchester thought they had discovered a network practising ritualistic child abuse. Thirteen children, all members of an extended family, were made wards of court and removed from their parents’ care or subjected to very close day-to-day supervision. The local authority applied to the High Court for care orders. Following an 11-week hearing in chambers in Manchester, Mr Justic Hollings delivered a judgment in open court on Dec 17, 1990, laying down clear guidelines for those involved in investigating allegations of child sexual and ritual abuse. The judge criticised the authority’s behaviour and refused five out of twelve applications for the children to be retained in care and removed from their parents. He said the Cleveland guidelines had been breached in many instances. This judgment has only just appeared in full, in the current Weekly Law Report. Sexual abuse of two girls (C aged 8 years and D aged 6 years) was suspected after certain observations made in hospital. The children were taken into emergency care and wardship summons were issued. Medical examination confirmed sexual abuse. Pursuant to a court order, social workers from the National Society for the
Prevention of Cruelty to Children and, to begin with, a policewoman conducted investigative interviews. This led to concerns for three more children (E, F, and G). After further checks, an ex parte applicatiorl (in which the other party does not have an opportunity to attend the hearing) for interim care and control in wardship was granted. The children were removed from their home and their parents were arrested. Subsequently, charges
1071
of sexual assault were dropped but medical examination showed clear signs of sexual abuse, and the children had remained in foster homes ever since. It was at this stage that the local authority became concerned that they had uncovered a ring of child abuse in ritual, even satanic, settings. E and F (G was too young) were subjected to investigative interviews. The judge said that, as with C and D, "these interviews were numerous and prolonged". Notes were also taken of what the children had said to their foster parents, and it was concluded that seven more children were involved, and they were removed from their homes early on the morning of Feb 26, 1990, by police and social workers. Medical examinations indicated that the two eldest girls (ages ranged from 13 to 10) had been sexually interfered with. The oldest girl said that this had been by an uncle; she had complained to her parents and they had taken appropriate action a long time previously. There was a similar explanation for the other girl, and her parents had also responded appropriately. The children were placed in foster homes, mostly in pairs. Mr Justice Hollings said that the gist of what the children had been saying was that sadistic abuse had been committed on them and other children at gatherings in buildings "confusingly described and never safely identified". The abuse had been by adults, some of them parents. There had been "a great deal of fantasy and misleading replies to leading questions or otherwise in response to improper techniques". Breaches of the Cleveland guidelines included the use of untrained interviewers; absence of an open mind (the interviewers were apparently obsessed with the belief they were investigating satanic ritual abuse and many of their questions were loaded); the use of leading questions; the number of interviews (well above the suggested two, though the judge accepted that in a serious and difficult case such as this more interviews might be justifiable); and the conducting of interviews at the pace, not of the child, but of the adult. Furthermore, there had been grossly inadequate recording of videotapes and audiotapes; the interviewers frequently lacked background information so that they were unable to understand all of what the children were saying; too many interviewers were used and they had told one child what another had said; and the possibility that children had been describing information from books, magazines, videos, and television was not properly evaluated. And, "above all", the judge said, there was "pressure and anxiety to obtain results".
Providing guidance for future cases, the judge said that, where possible, application should not be made to take children into care ex parte and for the initial purpose of a medical examination unless there is immediate apprehension of emergency or there are reasonable grounds for believing that parents would refuse to cooperate. Save in emergencies, case conferences should be held before a child is sought to be removed. Early morning removal of children by police should be reserved for instances in which there are clear grounds for believing that substantial harm would otherwise be caused to the children or when vital evidence is obtainable only by such means. In complex cases likely to be contested, an overview of disclosure techniques is desirable. The Official Solicitor should be asked to help or, if the Official Solicitor is not appointed, the local authority should consider appointing their own expert. When separate teams are working on "disclosure work" in the same case, social services should appoint a coordinator. The judge had been very concerned to fmd that affidavits filed on behalf of the local authority had been drafted so as to present most attractively and strongly the case advancednamely, removal of the children from their homes"without paying proper regard to the information and materials" on which they were based. The result had been an exaggerated or one-sided case presented to the court certainly at the interim stages, and which was shown to be misleading.
Conference Curriculum innovation: from rhetoric to action On the need to change undergraduate medical education, the King’s Fund certainly has the bit between its teeth-and it is running well. There was a conference earlier this year (see Lancet 1991; 337: 1087-88) and a full account of the recent inquiry amongst British medical schools has now been published, with numerous recommendations.’1 Fortuitously, a consultation document paper for the General Medical Council’s education committee reached every dean’s desk this summer. It is no secret that next year’s pronouncement from the GMC will advocate, even perhaps demand, substantial reforms; in essence these will include a reduction of factual load, a core curriculum plus options, and more student-centred learning based on problemsolving in small groups. Two weeks ago, the King’s Fund Centre took matters a step further with a conference designed to discover practical steps that forward-thinkers in medical schools might take to persuade their colleagues towards innovation. Since few are lucky enough to start new schools, the conference casestudies were of traditional schools. A central task for the delegates was to advise a fictitious dean (lately returned from a stimulating visit to Harvard) on how to approach sceptical colleagues. Some fine thespian skills emerged, along with common-sense strategies for dealing with the inevitable traditionalist ("Professor Higgins in basic science") doggedly determined to pursue his established 40 hours of biochemistry lectures. Unfairly, such fictitious characters always come from departments of surgery and basic science. Prof Gordon Moore from Harvard described how the
change to a problem-based curriculum was managed by running both the conventional and innovative courses in parallel for a while. Tensions and competition inevitably followed, but led eventually to a total switch by the now converted faculty. Other North American schools have effected the change without even a trial period, but it requires a very forceful dean (as at Hawaii). A common ploy few electives of innovative character. Such clearly much easier if, as in American experiences have a high staff to student ratio. And there was schools, you the fact that innovative problem-based curricula no escaping more are expensive in both staff and resources, if done properly (a figure of 125%, relative to a conventional is
to start
with
a
are
curriculum, was cited). The conference papers included several accounts of innovation in British schools, some successful and some less so. Often simple things seem to work best, such as the learning of surface anatomy and clinical technique by students working in pairs during their first year. Vertical integration, so desirable in theory, is often beset by practical problems, and students have a habit of voting with their feet. Amidst the enthusiasm and fun of this conference, there was a recognition that the introduction of innovation to the medical curriculum is a hard task, not necessarily of instant appeal to students, and needing immense cooperation and commitment from a substantial proportion of the faculty staff. R.
Godfrey
Diana Brahams 1. In re A and others (minors) (child abuse: guidelines).
[1991] 1 WLR 1026.
1. Towle A. Critical thinking: the future of undergraduate medical education. London: King’s Fund Centre, 1991.
while, one of them said to the other, ’It’s about time we stimulated his brain. We’d better suspend him’. They said something like ’we’ll squeeze you so we can see what’s inside’. They applied the electric tool repeatedly to sensitive parts of the body in circles and strokes. They began on my shoulders and chest, and then applied it to my nipples, scrotum, and penis, even on the urethral orifice... From Friday night until Saturday afternoon I was suspended from my wrists but with my feet still touching the ground. Once, they took me down from this position and asked me whether I was prepared to talk. When I refused, they put me back in the same position. I was exhausted. On the Saturday they said, ’Are you going to talk or not?’. When I asked what I was supposed to be talking about, they responded with a battery of blows all over my body. I was still blindfolded. They stripped me down to my underpants and applied the electric tool above my nipples. My body jerked in an involuntary spasm. They slapped my face and I reeled backwards. As I lay on my back I could feel four pieces of iron over my chest and other pieces of iron keeping my legs apart. This was to restrict my body’s movements while they applied the electricity". Dr Mandour was released on Feb 23. Formal complaints were lodged on his behalf by the Egyptian Organisation for Human Rights, and Amnesty International raised his case with the Egyptian Government in February. In May, 1991, this organisation was informed by the Egyptian Embassy in London that "The investigation conducted by the competent authorities in Egypt proved that allegations [that Dr Mandour was] subjected to torture or other forms of ill-treatment were unfounded". In June Dr Mandour was unaware of any official investigation into his complaints of torture.
Political detainees who are charged and who claim to have been subjected to torture may be examined by forensic doctors at the request of the niyaba (state procuracy) or the trial court. Administrative detainees, held without charge or trial, usually have no opportunity to submit a complaint about their treatment to the competent authorities. Medical examinations have often taken place long after the alleged torture occurred, which clearly detracts from their usefulness. In addition, methods of torture used may, as in the case of electric shocks, leave few or no physical traces. However, in some cases, forensic doctors are able to conclude that physical marks on the bodies of political detainees are consistent with the methods of torture they describe and with the date(s) on which the torture is alleged to have taken place. Amnesty International has obtained many reports substantiating alleged torture during the past 10 years. The most recent relate to examinations carried out by forensic doctors in late 1990, on victims who claimed that they were tortured in October, November, and December, 1990. In February, 1991, in response to representations by Amnesty International, the Egyptian Government responded that allegations were "a fabrication devoid of truth" and that defendants had given false information about torture to the media and human-rights organisations to tarnish the image of the security forces, cast doubt on the correctness of legal procedures in Egypt, and gain sympathy. Amnesty International has also received responses to specific cases of torture it raised with the Egyptian authorities. They included those of Dr Fahmy al-Shinawi, Dr Mohammad Mandour, Dr ’Emad ’Atrees, and Dr Mohammad ’Abd al-Latif Tala’at. The Government said in all cases that investigations had been carried out and found that torture had not occurred. Amnesty International has not been given any details about the Government’s investigations and has requested that this information be made publicly available. It considers this point all the more important since alleged victims and their
have told the organisation that they have neither been interviewed nor informed of any investigation having been initiated. Since then, Amnesty International has obtained medical reports written by doctors in the Forensic Department of the Ministry of Justice relating to examinations carried out on some of the 25 defendants involved. They spoke of detainees in a state of prostration and extreme exhaustion, marks consistent with electric shocks, and scars that could have resulted from suspension or contact with solid objects.
lawyers
Amnesty International British Section, Medical Group, 99-119 Rosebery Avenue,
Duncan Forrest
London EC1R 4RE 1.
Amnesty
International.
Egypt: ten years of torture. Ref no MDE12/18/91.
Medicine and the Law Child abuse
guidelines
There have been several consequences to the Cleveland child-abuse cases and the public outcry that followed. The Butler-Sloss inquiry’s report (1987) emphasised the need for coordination between the different agencies (eg, social workers, police, and doctors) that deal with suspected child abuse, for evidence to be gathered by techniques that do not require children to be repeatedly examined, physically and verbally, and for a full picture to be available before applications are made to remove children from their homes. That report was largely responsible for the Children Act 1989 that came into force on Oct 14,1991, and brings with it a plethora of new rules, regulations, and guidance. Some civil actions brought by Cleveland parents were settled out of court earlier this month. Incidents in which children thought to be the subject of child sexual abuse are snatched from their homes still give cause for concern-while at the other end of the scale, social workers and doctors are liable to be blamed if they have failed to act speedily to remove from their parents’ custody children who are then battered to death. Last year social workers near Manchester thought they had discovered a network practising ritualistic child abuse. Thirteen children, all members of an extended family, were made wards of court and removed from their parents’ care or subjected to very close day-to-day supervision. The local authority applied to the High Court for care orders. Following an 11-week hearing in chambers in Manchester, Mr Justic Hollings delivered a judgment in open court on Dec 17, 1990, laying down clear guidelines for those involved in investigating allegations of child sexual and ritual abuse. The judge criticised the authority’s behaviour and refused five out of twelve applications for the children to be retained in care and removed from their parents. He said the Cleveland guidelines had been breached in many instances. This judgment has only just appeared in full, in the current Weekly Law Report. Sexual abuse of two girls (C aged 8 years and D aged 6 years) was suspected after certain observations made in hospital. The children were taken into emergency care and wardship summons were issued. Medical examination confirmed sexual abuse. Pursuant to a court order, social workers from the National Society for the
Prevention of Cruelty to Children and, to begin with, a policewoman conducted investigative interviews. This led to concerns for three more children (E, F, and G). After further checks, an ex parte applicatiorl (in which the other party does not have an opportunity to attend the hearing) for interim care and control in wardship was granted. The children were removed from their home and their parents were arrested. Subsequently, charges
1071
of sexual assault were dropped but medical examination showed clear signs of sexual abuse, and the children had remained in foster homes ever since. It was at this stage that the local authority became concerned that they had uncovered a ring of child abuse in ritual, even satanic, settings. E and F (G was too young) were subjected to investigative interviews. The judge said that, as with C and D, "these interviews were numerous and prolonged". Notes were also taken of what the children had said to their foster parents, and it was concluded that seven more children were involved, and they were removed from their homes early on the morning of Feb 26, 1990, by police and social workers. Medical examinations indicated that the two eldest girls (ages ranged from 13 to 10) had been sexually interfered with. The oldest girl said that this had been by an uncle; she had complained to her parents and they had taken appropriate action a long time previously. There was a similar explanation for the other girl, and her parents had also responded appropriately. The children were placed in foster homes, mostly in pairs. Mr Justice Hollings said that the gist of what the children had been saying was that sadistic abuse had been committed on them and other children at gatherings in buildings "confusingly described and never safely identified". The abuse had been by adults, some of them parents. There had been "a great deal of fantasy and misleading replies to leading questions or otherwise in response to improper techniques". Breaches of the Cleveland guidelines included the use of untrained interviewers; absence of an open mind (the interviewers were apparently obsessed with the belief they were investigating satanic ritual abuse and many of their questions were loaded); the use of leading questions; the number of interviews (well above the suggested two, though the judge accepted that in a serious and difficult case such as this more interviews might be justifiable); and the conducting of interviews at the pace, not of the child, but of the adult. Furthermore, there had been grossly inadequate recording of videotapes and audiotapes; the interviewers frequently lacked background information so that they were unable to understand all of what the children were saying; too many interviewers were used and they had told one child what another had said; and the possibility that children had been describing information from books, magazines, videos, and television was not properly evaluated. And, "above all", the judge said, there was "pressure and anxiety to obtain results".
Providing guidance for future cases, the judge said that, where possible, application should not be made to take children into care ex parte and for the initial purpose of a medical examination unless there is immediate apprehension of emergency or there are reasonable grounds for believing that parents would refuse to cooperate. Save in emergencies, case conferences should be held before a child is sought to be removed. Early morning removal of children by police should be reserved for instances in which there are clear grounds for believing that substantial harm would otherwise be caused to the children or when vital evidence is obtainable only by such means. In complex cases likely to be contested, an overview of disclosure techniques is desirable. The Official Solicitor should be asked to help or, if the Official Solicitor is not appointed, the local authority should consider appointing their own expert. When separate teams are working on "disclosure work" in the same case, social services should appoint a coordinator. The judge had been very concerned to fmd that affidavits filed on behalf of the local authority had been drafted so as to present most attractively and strongly the case advancednamely, removal of the children from their homes"without paying proper regard to the information and materials" on which they were based. The result had been an exaggerated or one-sided case presented to the court certainly at the interim stages, and which was shown to be misleading.
Conference Curriculum innovation: from rhetoric to action On the need to change undergraduate medical education, the King’s Fund certainly has the bit between its teeth-and it is running well. There was a conference earlier this year (see Lancet 1991; 337: 1087-88) and a full account of the recent inquiry amongst British medical schools has now been published, with numerous recommendations.’1 Fortuitously, a consultation document paper for the General Medical Council’s education committee reached every dean’s desk this summer. It is no secret that next year’s pronouncement from the GMC will advocate, even perhaps demand, substantial reforms; in essence these will include a reduction of factual load, a core curriculum plus options, and more student-centred learning based on problemsolving in small groups. Two weeks ago, the King’s Fund Centre took matters a step further with a conference designed to discover practical steps that forward-thinkers in medical schools might take to persuade their colleagues towards innovation. Since few are lucky enough to start new schools, the conference casestudies were of traditional schools. A central task for the delegates was to advise a fictitious dean (lately returned from a stimulating visit to Harvard) on how to approach sceptical colleagues. Some fine thespian skills emerged, along with common-sense strategies for dealing with the inevitable traditionalist ("Professor Higgins in basic science") doggedly determined to pursue his established 40 hours of biochemistry lectures. Unfairly, such fictitious characters always come from departments of surgery and basic science. Prof Gordon Moore from Harvard described how the
change to a problem-based curriculum was managed by running both the conventional and innovative courses in parallel for a while. Tensions and competition inevitably followed, but led eventually to a total switch by the now converted faculty. Other North American schools have effected the change without even a trial period, but it requires a very forceful dean (as at Hawaii). A common ploy few electives of innovative character. Such clearly much easier if, as in American experiences have a high staff to student ratio. And there was schools, you the fact that innovative problem-based curricula no escaping more are expensive in both staff and resources, if done properly (a figure of 125%, relative to a conventional is
to start
with
a
are
curriculum, was cited). The conference papers included several accounts of innovation in British schools, some successful and some less so. Often simple things seem to work best, such as the learning of surface anatomy and clinical technique by students working in pairs during their first year. Vertical integration, so desirable in theory, is often beset by practical problems, and students have a habit of voting with their feet. Amidst the enthusiasm and fun of this conference, there was a recognition that the introduction of innovation to the medical curriculum is a hard task, not necessarily of instant appeal to students, and needing immense cooperation and commitment from a substantial proportion of the faculty staff. R.
Godfrey
Diana Brahams 1. In re A and others (minors) (child abuse: guidelines).
[1991] 1 WLR 1026.
1. Towle A. Critical thinking: the future of undergraduate medical education. London: King’s Fund Centre, 1991.
