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 Organisations

who assisted with information: Attorney Ibrahim Mahajne, Attorney
Dori Spivak, Attorney Alegra Paceco,
Dr Andrew Coyle, the International
Centre for Prison Studies.

This report is sponsored by the European Commission

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

European Commission, Swiss Agency for Development and

Cooperation, Diakonia, SIVMO, Global Ministries of the Uniting
Churches in the Netherlands, New Israel Fund, Conanima Foundation,
Rich Foundation, Jerusalem Foundation, Richard and Rhoda Goldman
Foundation, Ford foundation, Christian Aid, Medico Intenational
Switzerland, Medico International Germany, EPER, Vicop Stingtung,
EED, The Beracha Foundation, Joyce Mertz-Gilmore Foundation,
Kahanoff Foundation, Oxfam

Production & Design: dafdefet@bezeqint.net

2
 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

3
 Introduction

Over the years that PHR-Israel has been involved in the issue of
the medical rights of prisoners and detainees (1988-2003), a recurring
phenomenon we have encountered is the use of restraints and handcuffs
during medical treatment. Although the majority of cases reaching
PHR-Israel are of Palestinian prisoners and detainees held for ‘security’
offences, this phenomenon is not unique to any specific group and can
take place with all categories of people in custody: detainees held by the
police prior to conviction; criminal prisoners held by the prison service;
‘security’ prisoners held by the prison service; Palestinian prisoners and
detainees held by the military.1

Most of the complaints received by PHR-Israel relate to cases where

prisoners were restrained while receiving medical treatment in civilian
hospitals. Testimony has been received relating to most of the major
hospitals in Israel. The general impression is that prisoners who come to
hospital are handcuffed to their beds – in many cases their legs are also
restrained. Again, in some case, prisoners are left shackled even while
undergoing actual medical treatment. In one case, a female prisoner was
forced to give birth while handcuffed. Even children are not immune to
this phenomenon, and in several cases children have been restrained in
their beds during hospitalisation. Prisoners with severe medical problems,
including prisoners who were not fully conscious, received treatment
while restrained. PHR-Israel is aware of at least one case in which a person
remained shackled while undergoing resuscitation, and died while still
shackled to his bed.

1
Throughout this report, the term ‘prisoners’ is used to refer to all people in custody,
including all those mentioned in the above paragraph. Additionally, although the
language sometimes refers to one gender, apart from the times when specific
individuals are mentioned, any use of the terms physician / nurse/ prisoner, applies
to males and females.

4
 This phenomenon is particularly grave for several reasons:

– Restraints abuse the dignity of the person receiving medical

treatment and lead to a sense of humiliation.
– Restraints may impair the quality of medical treatment.
– Restraints cause unnecessary pain, dangerous immobility, and may
delay or impair the healing process.
– Restrained prisoners do not receive medical treatment equal to that
enjoyed by other patients.
– Restrained prisoners lose confidence in their physician.
– Treating prisoners in unnecessary restraints is a violation of medical
ethics.

This report examines the issue of restraining prisoners undergoing

medical treatment from several angles: Cases illustrating the situation
regarding shackling since PHR-Israel’s establishment; the issues and
ramifications raised by this phenomenon, both in terms of human rights
and medical ethics, as well as from the governmental point of view, and
the PHR-Israel point of view.

Security procedures relating to the hospitalisation of prisoners and

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

5
 Cases
Ahmed and Muhammad Hamis Ismail Al Hanajra, Soroka
Hospital, Beer-Sheva. Ahmed and Muhamed, 13 and 16 years old, were
apprehended and wounded by the Israeli military on Saturday night,
January 11th, 2003. According to the army they were attempting to
infiltrate one of the settlements in the Gaza strip. They were transported to
Soroka Hospital in Beer-Sheva. 13 year-old Ahmed was lightly wounded,
and his brother who was moderately wounded needed surgery. The
brothers were handcuffed to their beds from the moment they arrived
at the hospital. A short while after their arrest there was an appeal for
help from PHR-Israel, who immediately intervened and contacted the
hospital and military. Apart from the shackling, there were complaints
that the children were denied the right to speak to their parents, and were
not being interrogated by special youth interrogators. The physicians at
Soroka stated that the soldiers guarding the children refused to remove
the handcuffs, saying their orders were to keep them in restraints. One of
the soldiers told a physician that he (the physician) “should be thankful
they are only handcuffed by the hands”. During the five days of constant
negotiations, the children remained restrained to their beds. The security
forces claimed there was a danger of escape through a window, despite
the fact that these were injured children under constant guard. After a few
days, a military judge determined that Ahmed could not escape in his
condition, therefore his restraints should be removed. In addition, the
military spokesperson declared that the restraints were against orders.2
Following PHR-Israel’s communications with the authorities, and the
request that they be transferred to a room with barred windows, they were
moved and Ahmed’s restraints were removed. Muhammad was transferred
from the hospital to a detention facility.

Riham As’ad Muhammad Sheikh Mussa, Meir Hospital, Kfar

Saba. On February 23rd, 2003, 15 year-old Riham As’ad Muhammad
Sheikh Mussa was hospitalised in the Meir Hospital in Kfar-Saba. She had
been shot during an incident in which it was alleged that she attempted to
attack a soldier. The girl underwent surgery of the stomach and intestines,

2
In a letter sent to PHR-Israel on January 27th 2003.

6
two bullets were left in her body – in the stomach and leg - and she was
left with a permanent stoma and a bag affixed to her abdomen wall to
drain her intestines. Despite her condition, she lay handcuffed to her bed.
PHR-Israel turned to hospital administration and to the Israel Medical
Association (IMA) requesting they act to have the restraints removed.
After being contacted by PHR-Israel and the IMA, the hospital tried to
bring up the issue with the military, but the Chief Officer for Prisons
in the Military Police did not bother to return any calls from the IMA.3
Throughout the entire period of her hospitalisation, over three weeks, the
child remained in restraints.

Rami Mahamid, HaEmek Hospital, Afula. In September 2002,

young Rami Mahamid, an Israeli citizen, was injured in a bomb attack in
the north of the country and transported to HaEmek Medical Centre. For
four whole days, during which according to media reports he was seriously
injured and not fully conscious, he lay in bed with restraints on his arms
and legs, and under guard. Once his condition enabled interrogation, it was
determined that not only had he nothing to do with the attack, but he even
tried to prevent it. Following this discovery, his restraints were removed.
PHR-Israel inquired with the hospital director why had an injured and
barely conscious youth been held in shackles when he was clearly no
risk. After a short exchange of letters, the director issued instructions to
the various hospital departments, stating that restraining prisoners during
medical treatment contravenes basic medical ethics, that judgement must
be used in each case, and that obviously there is no reason to restrain
seriously ill and wounded patients.

Talal Ida, Hadassah Hospital, Jerusalem. In March 2002, after

collapsing during questioning at an army checkpoint, Talal Ida, an
ambulance driver by profession, was transported to Hadassah Hospital.
During his hospitalisation and treatment, Mr. Ida was handcuffed to his
bed. This was in spite of the fact that he was suffering from exhaustion and
weakness, and was constantly under guard. Throughout the hospitalisation,
his attorney was trying to find out who was responsible for detaining
him, and why he was in restraints. After much questioning and appeals
to various bodies raising doubts about the legitimacy of the arrest, the
handcuffs and the guards were removed. Mr. Ida was released home when
his treatment was completed.
3
See annex.

7
 Shaul Nachmias, Wolfson Hospital, Holon. On May 2nd 2001,
Shaul Nachmias was transferred from the Prison Service Medical Centre
to Asaf Harofeh Hospital in Ramleh. Two days later he was transferred
to Wolfson Hospital. Mr. Nachmias suffered from hepatitis, and was in
a poor state. Despite his condition, his arms and legs were chained to
the bed. After approximately two weeks he was returned to the prison
service. Then following a fall he was back in Wolfson Hospital on May
20th and diagnosed with internal bleeding from the upper gastric tracts,
a deteriorating situation. During this second hospitalisation he was again
chained to his bed. In spite of requests by medical staff, the wardens
refused to remove the handcuffs, apart from the changing of his diapers.
His grave situation and pleas by his family did nothing to have the
restraints removed. Still chained to the bed, his condition deteriorating,
the medical staff attempted resuscitation to no avail. Shaul Nachmias died
chained to a bed.

Mu’ataz Jaradat and Ghaleb Elfaruch, Hadassah Hospital,

Jerusalem. In October 1996, the two youths – 14 and 17 year-olds, were
handcuffed to their beds in Hadassah Hospital, while they were seriously
injured. The boys were not allowed to talk to each other and were under
constant guard. Mu’ataz: “I had pains, and whenever I wanted to move a
little in the bed, the soldiers shouted at me. I was even afraid to cough. All
around there were patients watching TV and laughing. We weren’t even
allowed to move. It was terribly sad.”

Intisar Muhammad Alkak, Meir Hospital, Kfar Saba. On December

rd
3 1990, PHR-Israel turned to Dr Miriam Tsangen, then Chairperson of
the IMA, concerning the restraining of a prisoner while giving birth. On
the same day, Dr Tsangen contacted the director of the Sharon Prison and
the physicians at Meir Hospital, writing: “performing a birth under these
conditions is a violation of physicians’ rules of medical ethics, which are
universal.”4 The prisoner’s restraints were removed, and her mother was
allowed to sit by her side in the hospital.

4
See annex.

8
 Niaz Fareh Muhammad Mazara, Soroka Hospital, Beer-Sheva.
On May 14th 1990, Niaz was hospitalised for a gall-bladder operation.
Throughout his stay at the hospital, he was chained to his bed. He was
handcuffed the minute he came out of surgery, despite still being under
anaesthetic. PHR-Israel’s appeal to the commander of Ketsiot detention
facility (the body responsible for the prisoner) was left unanswered.

Anonymous. The following two cases are based on the testimonies of

physicians, members of PHR-Israel, who wished to avoid publication of
identifying details. The first case is of a prisoner, a Palestinian citizen of
Israel, who arrived at the hospital with chest pains. The man had diabetes
and a heart condition, and an amputated leg (with a prosthesis). During
the hospitalisation, he was diagnosed with renal insufficiency and serious
anaemia; he needed a catheter and hemodialysis. He had one guard in the
room, and two guards to accompany him for tests. In the first three days, he
had a urine catheter. At the start of the hospitalisation, both his hands were
chained to the bed, and later he was chained by one hand and one leg to
the bed. Despite instructions to walk him once every hour to prevent blood
clots, the guards did not always do this. When the physician questioned the
head of the department in the hospital, he was told to contact the IMA, who
responded by sending him their position paper on restraining prisoners (see
below), but did not further intervene. The physician received a reply from
the police that there was no other choice. The amputee with diabetes and a
heart condition remained in restraints throughout his hospitalisation.

The second case took place in March 2003. A resident of Kalkilya (in
the Occupied Territories) was hospitalised at Beilinson Hospital in Petach
Tikva with gunshot wounds in his legs and back. He underwent surgery on
both legs. Despite his condition, which included having a leg in a cast and
being under constant guard, he was handcuffed to the bed.

Asaf-Harofe Hospital, Ramleh. This hospital, situated close to the

headquarters and a number of Israel Prison Service facilities, often has
prisoners brought in for medical treatment. After receiving information
about frequent restraining of patients, a staff member of PHR-Israel
decided to independently assess the situation. His testimony, based on
a visit of the emergency room and the internal medicine ward, on June
2nd 2003, painted a worrying picture. At the time, all three prisoners

9
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.

10
 International Law and Medical
Ethics
When it comes to the rights of prisoners and detainees undergoing
medical treatment, there are obligatory laws, norms and rules accepted
by the international community. The State of Israel and all authorities
operating in its name, whether health authorities or security bodies, are
obliged to respect international human rights laws. In addition, the medical
community, as other professional bodies, has its own specific rules and
ethical principles that provide guidance for particular situations, including
the treatment of prisoners. PHR-Israel, as a human rights NGO dedicated
to the protection of the right to health, human dignity, and body and mind
integrity, regards the above rules as the foundation for its position on the
treatment of prisoners.

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

5
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 University
Press, Oxford, 1999). p. 46-74, 277-279.

11
 The protection of human dignity is also a part of Israeli domestic law,
particularly in Basic Law: Human Dignity and Liberty.7 The Supreme
Court Justices have ruled more than once that the right to dignity remains
with the person even if their freedom has been taken away. A well known
quote of the court says that “the walls of the prison do not separate the
prisoner from human dignity (…) freedom has been denied from the
prisoner, humanity is not taken away”8

The international source providing some of the most detailed rules

for the treatment of prisoners is the Standard Minimum Rules for the
Treatment of Prisoners, adopted by the United Nations.9 Although this
document is not a legally binding treaty, it nevertheless contains detailed
norms and standards, which can be used by the international community
to interpret the rules against cruel, inhuman or degrading treatment or
punishment, and the obligation of humane treatment and respect for human
dignity. Furthermore, some of the rules, amongst them the prohibitions on
degrading punishment and the use of shackling as punishment, could be
considered to reflect binding legal obligations.10

Article 33 of the Standard Minimum Rules states that:

“Instruments of restraint, such as handcuffs, chains, irons and 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 that

they shall be removed when the prisoner appears before a judicial
or administrative authority;11

7
Passed on March 17, 1992
8
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 Treatment
of Offenders, U.N. Doc. A/CONF/611, annex I, E.S.C. res. 663C, 24 U.N. ESCOR
Supp. (No. 1) at 11, U.N. Doc. E/3048 (1957), amended E.S.C.
10
Rodley, p.280-281
11
Emphasis by PHR-Israel

12
 (b) On medical grounds by direction of the medical officer;
(c) By order of the director, if other methods of control fail, in order to
prevent a prisoner from injuring himself or others or from damaging
property; in such instances the director shall at once consult the
medical officer and report to the higher administrative authority.”

From the wording of sub-paragraph (a), the expression “during a

transfer” can be understood as meaning the period of time in which the
prisoner is in movement between locations, and not the later time when
they are being held at their destination, be it a hospital or other place. A
similar interpretation can be inferred from the Israel Police orders (below),
which include separate chapters for ‘securing prisoners during transfer’
and ‘securing prisoners in a medical institution’.

The way the shackling is used can make matters even worse. The
European Committee for the Prevention of Torture has stated, “if recourse
is had to a civil hospital, the question of security arrangements will arise.
In this respect, the CPT wishes to stress that prisoners sent to hospital to
receive treatment should not be physically attached to their hospital beds
or other items of furniture for custodial reasons”.12 Restraining a person to
an inanimate object is generally perceived as an impermissible act also in
the rules and procedures of the Israeli security institutions.13

Medical Ethics
A fundamental rule of medical ethics is the Physician’s primary loyalty
and obligation to the patient. This obligation can be found in a number of
the key declarations of the World Medical Association (WMA), such as
the 1948 Declaration of Geneva.14 Paragraph 10 of the Declaration on the
Rights of the Patient states that “the patient’s dignity and right to privacy
shall be respected at all times in medical care and teaching, as shall his/her
culture and values.”15 Furthermore, according to the opening paragraph
12
3rd General Report on the CPT’s activities covering the period 1 January to 31
December 1992 CPT/Inf (93) 12 [EN] - Publication Date: 4 June 1993. par. 36.
13
see below
14
Declaration of Geneva. Adopted by the 2nd General Assembly of the World
Medical Association, Geneva, Switzerland, September 1948
15
World Medical Association Declaration on the Rights of the Patient. Adopted by
the 34th World Medical Assembly Lisbon, Portugal, September/October 1981and
amended by the 47th General Assembly Bali, Indonesia, September 1995

13
of this declaration “whenever legislation, government action or any other
administration or institution denies patients these rights, physicians should
pursue appropriate means to assure or to restore them.”16 These are not
the only declarations and documents relating explicitly to the 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 doctor’s fundamental role is to alleviate the distress of his
or her fellow men, and no motive whether personal, collective or political
shall prevail against this higher purpose.”

The UN General Assembly, with the assistance of the World Health

Organisation (WHO) drafted and adopted the Principles of Medical Ethics
relevant to the Role of Health Personnel, particularly Physicians, in the
Protection of Prisoners and Detainees against Torture and Other Cruel,
Inhuman or Degrading Treatment or Punishment18. The fifth article of
these principles states that “It is a contravention of medical ethics for
health personnel, particularly physicians, to participate in any procedure
for restraining a prisoner or detainee unless such a procedure is determined
in accordance with purely medical criteria as being necessary for the
protection of the physical or mental health or the safety of the prisoner or
detainee himself, of his fellow prisoners or detainees, or of his guardians,
and presents no hazard to his physical or mental health.” Although the
express prohibition here is on participation, and it is not detailed what this
could mean – the physician actually restraining the patient, being part of
the decision to restrain, or being an acquiescent witness – it is nevertheless
important to note that the possible justifications for shackling that are
mentioned here, include the protection from self-harm or risk to others,
and not shackling to prevent escape.

It should be stressed that the above principles are directed at all health
personnel and not just physicians. All hospital medical staff, especially

16
Emphasis by PHR-Israel
17
World Medical Association Declaration Guidelines for Medical Doctors
Concerning Torture and Other Cruel, Inhuman or Degrading Treatment or
Punishment in Relation to Detention and Imprisonment. Adopted by the 29th
World Medical Assembly Tokyo, Japan, October 1975
18
Adopted by General Assembly resolution 37/194of 18 December 1982.

14
nurses, can find themselves treating a prisoner and faced with a situation
whereby the security agents wish to have the prisoner shackled. The
International Council of Nurses has also produced a declaration on the
treatment of prisoners and detainees.19 Here too, the fundamental obligation
of the nurse is to restore the health and alleviate the suffering of the patient,
including prisoners, and to protect them from abuse and ill treatment.

19
Nurses Role in the Care of Prisoners and Detainees, Adopted by the International
Council of Nurses, Geneva, 1998

15
 The Procedures of the Israeli
Security Institutions

The different security Institutions have orders and procedures for

determining the necessity and the use of shackling and means of restraint
for prisoners and detainees. In general, the need for shackling will be one
of two- restraining the prisoner, or prevention of escape. Shackling as a
means of restraint is usually considered when it is essential for preventing
the prisoner from hurting himself, others or property, and may take place
inside the prison facility. Shackling for escape prevention is usually
considered when the prisoner is not between the facility’s walls, especially
when transporting prisoners to another facility or to other locations, such
as courtrooms. The following are the orders and procedures of the security
bodies regarding the shackling of prisoners:

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

20
The Hebrew term used by the police relates to both prisoners and detainees.

16
regard to their health condition. In sub-paragraph 7, it is written that except
for extreme and urgent cases of life protection, it is prohibited to restrain a
detainee to any inanimate objects.

Israel Prison Service

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

Israeli Military
Regulation no. 9810 of Chief Military Police Orders ‘Shackling
in handcuffs’ details the Israeli Military’s instructions in that matter.
The opening paragraph states that, “A detainee will not be shackled
in handcuffs, unless the person who gives the order considers that the
shackling is necessary to prevent physical harm to the detainee, or to
other persons or to property, or for the prevention of escape”. Paragraph
5 indicates that “Means of shackling, for restraining and securing, will
be: hand shackling, leg shackling or hands and legs shackling”, paragraph
9 contains a prohibition to shackling a prisoner to inanimate objects such
as a bed, and paragraph 25 instructs that “It is forbidden to improvise
additional shackling means, beyond those allowed in this order”. It is

17
therefore clear that restraining a detainee to his bed is a forbidden act.
The use of leg shackles, according to paragraph 19, will only be with the
approval of an officer holding the rank of lieutenant colonel. Paragraph
12, dealing with the shackling of a prisoner who needs medical treatment,
states that “during the medical treatment if there is a physician’s instruction
to undo the shackles, there must be an arrangement for perimeter security,
in order to prevent any possibility of escape. In addition there is a need to
instruct the escorting force that in any case the detainee will be escorted
and guarded”.

In a letter from the IDF spokesperson’s office to PHR-Israel concerning

the shackling of the young brothers (aforementioned) from January
27 2003, there is an admission that the shackling to the bed during the
hospitalisation was against orders, but it was also said that “there is
a procedure which states that every security detainee who is outside
the detention facility must be shackled by his limbs”21. If there is such a
procedure, it stands in contradiction to the Military Orders - as pointed out
earlier, the opening paragraph of the orders explicitly indicates in which
cases restraining must be used ;automatically shackling even when there
is no real threat of physical harm or of escape, is not consistent with this
order.

In the Israeli Military Orders, as with other security bodies, there are
detailed instructions regarding the duration of holding a detainee restrained
inside the prison facility - shackling for more than 72 hours requires the
authorisation of the facility commander, and the approval of the army’s
Chief Military Police Officer and Chief Medical Officer. Moreover, with
the exception of special circumstances, shackles must be released for 15
minutes every 3 hours and during meal hours, toilet time, and at night
(paragraphs 4,10). The Israel Prison Services also imposes restrictions
on the continuous use of shackling as a means of restraint, and requires
written approval of a physician for using means of restraint for more
than 24 hours, and that it be reported to the prison block security officer
(paragraphs e, f). These orders support the view that keeping a person
shackled for a long period is undesirable and should not be applied lightly
and without a critical evaluation of necessity. However, when it comes
to holding an ill or a wounded prisoner in a hospital, it appears that the

21
See appendix.

18
restrictions and supervision decrease considerably, and the prisoner can
find himself restrained for many days, even when he doesn’t pose a threat
to himself or to the people who surround him. In addition, from the cases
that have been reported to PHR-Israel, some of which were detailed above,
it is obvious that even the minimal orders concerning the shackling of
hospitalised prisoners were clearly violated, when prisoners in a medical
condition which did not render them a threat were automatically restrained
during hospitalisation.

19
 The Position of the Israel Medical
Association

The IMA, in addition to being a representative labour organisation,

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

22
The IMA position on the subject: shackling of prisoners and detainees in hospitals,
August 6 , 1997.

20
Criticism of the IMA position
There are two major flaws in the IMA position. The first is the issue
of the final say in the decision to shackle. On the one hand, paragraph 2
explicitly states that the decision is made by the security personnel; on the
other hand paragraph 4 indicates that in the end the issue is subjected to a
medical decision. From the first reading it is possible to think that indeed
the physician is given the responsibility and the discretion regarding the
patient. But, in the continuation of paragraph 4, it says that the physician
needs to decide if the shackling harms the patient and that his position
must be accepted in case of danger to the patient. If so, the impression
that arises is that the decision to shackle stays in the hands of the security
body, unless there is a real threat to the health of the patient. According to
this, if a prisoner is hospitalised with a serious illness and is lying weak
in his bed, perhaps not even fully conscious, so long as his restraints do
not directly endanger the state of his health, it is enough for the physician
to update the security agent about the physical condition of the prisoner.
The security agent may decide not to remove the shackles, and this ends
the ethical responsibility of the physician. Indeed, the conclusion of IMA’s
position makes an additional remark that a physician may decide not to
act against the ethical dictates of conscience. This enables the physician
to escape an unpleasant situation without being reprimanded, and does
not deal with the lack of taking responsibility for a patient’s treatment,
as is reflected in the IMA position. This position is feeble, and treats the
physician unjustly by placing upon him the responsibility for his ethical
behaviour without informing him of his ethical duties. Further more, the
IMA position enables the physician who isn’t aware of the medical ethics
rules, or whose views dictate him to see each prisoner as a dangerous man
and dehumanise him, to act contrary to the ethical rules.

The second shortcoming in the IMA position is that despite the

statement that shackling must be considered only in the absence of a
suitable alternative and not instead of a shortage of manpower, the opening
principle explicitly indicates that the danger of escape can be a reason for
shackling. These points are incompatible. Even in the absence of a suitable
structure such as a room with no windows, or with barred windows, a
prisoner lying on his bed with a soldier or a policeman on guard beside
him, cannot jump out the window unless his guards are not performing
their duty. In that case, the escape risk justification is groundless, and can
be solved by placing necessary guards. Shackling to prevent an escape will

21
almost always be an alternative to manpower and suitable security staffing,
and therefore contrary to IMA’s stand. If so, it is not clear why IMA’s
position enables shackling an ill or wounded person in order to prevent his
escape. An alternative approach that IMA could have taken is the position
published by the British Medical Association.23 The Israeli position was
published about a year after the British position and had a fair amount of
similarity to it, but they are not totally identical. The British position clearly
states that, ”In cases where there is a high risk of escape or where there is a
threat of violence, the safeguards should nevertheless respect the prisoner’s
right to privacy to the maximum extent possible. For example, where there
is a risk of escape, but no likelihood of violence, it should be possible for a
prison officer to be stationed outside the consulting or treatment room with
another in the grounds immediately outside. These precautions will allow
the patient some degree of privacy, dignity and confidentiality whilst also
ensuring that security is maintained. Occasionally where there is a serious
threat of violence, or where the prisoner is considered to be dangerous, it
will be necessary to use restraints and it may also be necessary to have a
prison officer inside the consulting room”.

This position, as opposed to IMA’s position, does not justify shackling

as a means of preventing escape when the prisoner is not a threat to himself
or others.

The IMA implements its policy to a great extent in accordance with the
chairperson serving at the time. Over the years, PHR-Israel has noticed the
crucial influence of the IMA chairperson in shaping the attitude and policy
of the organisation in questions of ethics. Dr. Miriam Tsangen, who served
one term as IMA chairperson, expressed a great deal of sensitivity and
understanding towards human rights and medical ethics. The chairperson’s
attitude influences, among other things, the issue of shackling – Dr.
Ruchama Marton and Dr. Ahmad Massarwah of the PHR-Israel board,
met with Dr. Miriam Tsangen, during her time as IMA chairperson, with
regard to the issue of shackling hospitalised prisoners. It was agreed at
the meeting that this is a particularly grave practice, which contravenes
the rules of medical ethics. Her direct and fast intervention in the case of

23
Guidance for Doctors Providing Medical Care & Treatment to Those Detained in
Prison, British Medical Association, March 1996.

22
Intisar Muhammad Elkak (see above), testifies to the importance of the
chairperson’s position.

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

23
 The Position of the Ministry of
Health
The ministry of health’s position on the issue of safeguarding prisoners
and detainees in hospitals can be found in the medical administration
circular no. 39/9924, which was distributed to the directors of general
and psychiatric hospitals, and to the managers of emergency rooms and
health fund medical departments. Paragraph 3 clearly determines that “the
authority for shackling a patient who is in custody is of the law enforcement
body which is in possession of the patient and is guarding him”. Paragraph
4 indicates, “in any situation in which the shackling of a detainee might, in
the opinion of the attending physician, obstruct the medical treatment or is
unnecessary in his opinion, the physician should demand that the security
body release the patient from the shackling and take alternative measures
of security according to need”. The next paragraph states that in case of
difference of opinion it will be referred to the “decision-making forum”
for a binding and final resolution. Further details about the forum and
generally on the ministry of health position can be found in the ‘procedure
for shackling prisoners and detainees’, which was published by the head
of the security department in the ministry25. This procedure determines in
paragraph 4.1 that one of the considerations to be taken into account is the
“prevention of the prisoner or detainee’s escape, by shackling him or by
any other means.” Paragraph 4.2.4 says that “at the time of admission of
the detainee to the emergency ward or hospitalisation, the guards from the
body that brought him to the hospital will check the possibility that he be
released from the handcuffs, and receive treatment as any other patient”.
Although it is clearly stated in the next paragraph “that shackling a prisoner
during medical treatment is not a routine and automatic act”, it also says
that “where the release of a prisoner from shackling is not necessary for
medical treatment and when according to the estimate of the security agent
in charge, that relies as much as possible on substantial information or
founded intelligence information, the shackling is necessary, it will be
possible to keep the prisoner shackled during his stay in the hospital and
in the absence of alternatives, also during the treatment itself”. Further

24
August 1999.
25
Procedure no. 1019, April 25th, 1999.

24
along it is stated that disputes will be settled by the “decision-making
forum”, which includes the director of the hospital or his deputy and
a representative of the law enforcement authority. When disagreements
arise, the representative of the hospital is supposed to make contact with
the representative of the security authority (there is a specific list of senior
positions holders from all sides) to try and settle the disagreement, while
“the final decision regarding the necessity of the shackling for security
reasons will be of the enforcement law authority in the forum, and the final
decision in this matter of the necessity of the shackling for medical reasons
will be of the medical authority in the forum”.

Criticism of the Ministry of Health position

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

26
Emphasis by PHR-Israel.

25
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.

26
 The Hospitals and the Physicians

The responses of hospitals to enquiries by PHR-Israel, testify to the

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

27
 In his reply to PHR-Israel regarding the case of Muataz Jaradat and
Ghaleb Elfaruch (see above), the chairperson of Hadassah, Professor
Shmuel Pinchas, wrote that “the management of the Hadassah Medical
Organisation instructed the employees a number of years ago, to prevent
the restraining of all patients whoever they may be (prisoners, detainees,
criminal and security detainees)”27.

In the case of Riham Sheikh Mussa aged 15 who was shackled over 20
days in the Meir hospital, the management of the hospital didn’t reply to
PHR-Israel, but their position on the matter was presented in a letter sent
to the IMA. In his letter to the Ethics Board, the director Dr. Davidson says
that the hospital questioned the military about the shackling, and received
the reply that the girl continues to be a security threat. As far as is known
to PHR-Israel, the hospital’s questioning of the military took place only
after the complaints by PHR-Israel and the IMA. Moreover, Dr. Davidson
wrote, “we act in accordance with the Ministry of Health procedures. These
procedures determine that it is permissible for the security’s forces to
demand that a wounded person remain shackled – as long as the attending
physicians do not claim that the shackling itself hinders the medical
treatment. This question was asked by us- and when it was made clear that
shackling itself caused medical harm - we followed all the instructions”.
This answer displays a limited understanding of the Ministry of Health
instructions – these oblige the physician to demand the removal of the
restraints when they are not necessary in his opinion, and not only when
there is direct harm to the medical treatment – and permits the shackling
of people who do not form a real threat, so long as the shackling itself has
no direct harmful impact on the treatment. This position also completely
ignores the physician’s duty to the patient, and presents him as insensitive
to the dignity of the ill or wounded person lying shackled in a bed.

Not only hospital managements, but also individual physicians who

have awareness of the human rights and dignity of the patient, have the
ability to influence the situation. For example: Professor Michael Elkan,
a member of PHR-Israel, from the Soroka Hospital in the Negev, refused
a number of years ago to treat an ill person in shackles, and brought about
the removal of the shackles from the patient. Another physician, from the
same hospital (who requested not to be mentioned by name), informed

27
See appendix.

28
PHR-Israel about a similar case, and helped to remove the shackles from
the patient.

An opposite example: Professor Avi Rifkind from the Hadassah Ein

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

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

29
 The Position of Physicians for
Human Rights - Israel

The situation described is one in which prisoners and detainees are

shackled almost by default, and when it comes to Palestinians being held
by the army, the automatic shackling is an admitted policy. Unfortunately,
the impression that arises is that in most cases not enough is being done
by the medical profession to try and have the shackles removed, whether
the compliance is due to approval or to a feeling of inability to change the
situation. The incidents described don’t leave room for doubt that in Israeli
hospitals, restrained patients lie in their beds without any justification
– including seriously ill people and badly wounded patients – people
whose medical condition hardly enables them to stand by themselves
on their two feet, never mind threaten their surroundings. Particularly
worrying is the easiness in which injured hospitalised children, in spite
of their condition and the fact that they have been put under guard, still
find themselves shackled to their beds. It seems that the procedures of
the security bodies, which are not detailed enough regarding the use of
shackling on hospitalised prisoners and detainees, and the allowance of the
escape prevention as justification, leads the guards to look for an ‘easy life’
by safeguarding most of the people in their charge. The positions of the
IMA and the Ministry of Health have some points to their credit, but leave
too many openings for unnecessary and unjustified restraining, especially
with regards to the issue of escape prevention. These positions, apart from
being weakly worded, were unknown to a large number of physicians with
whom PHR-Israel has been in contact, and have little chance of being
influential. The lack of acquaintance of the issue among physicians is also
a result of not taking the necessary steps when confronted by present and
past information concerning cases of unnecessary shackling.

As mentioned earlier, the widespread use of shackling of prisoners

and detainees contains serious problems. The harm to the patient’s
health is not only a result of impeding medical procedures (as appeared
in the testimonies from the case of Shaul Nachmias), but also of causing
suffering to the patient by the very fact of being in shackles. The shackling
can cause physical pain (in an interview to a newspaper, Rami Mahamid

30
described his feelings when he opened his eyes in hospital for the first time
after being wounded – “and my hand was tied, and the leg was tied. And it
was painful”). The suffering is also mental. The feeling of a man restrained
and shackled with little control of his bodily movements, being dependant
on the mercy of others for everything, even for using the toilet, and all this
while a guard is sitting opposite him watching his helplessness, is a most
distressing feeling that leads to humiliation, suffering and mental despair.
The damage intensifies as time passes, and a person is held continuously
restrained for many days and even weeks. Shackling a person who poses
no real or immediate threat to himself or others, is not justified, and could
also be claimed to be in violation of the prohibition on degrading treatment
and a failure to protect the inherent dignity of the human person.

The severity of the past offence of which the person was suspected or
convicted, is not the main criteria for determining the need to restrain,
but rather the danger that may be caused by him at present. As has been
pointed out, shackling as punishment is absolutely forbidden whether by
international rules and whether by the rules of the Israeli security bodies.
Even when a dangerous prisoner is involved, and there is a well founded
risk that he may be a danger to himself or others, there are still limitations
to the use of shackling - despite the fact that shackling to a bed is forbidden
also by security authorities in Israel (except for extreme and urgent cases),
such shackling takes place frequently in hospitals. The insult to the dignity
and rights of the patient is several times more severe when he is tied to
an inanimate object, and this form of shackling of hospitalised prisoners
and detainees has received criticism from the European Committee for
the Prevention of Torture. The security bodies and the government offices
that supervise them bear the responsibility for improper treatment of
hospitalised prisoners and detainees.

A physician who treats a restrained person loses a great deal of his status
as the guardian of the patient’s best interests, and is unlikely to hold the
patient’s trust. In the eyes of the latter, the physician and the hospital with
him could be perceived as part of the security system responsible for him
being in shackles, whether through direct responsibility or by not taking
a stand against it. The physician’s role goes beyond that of a machine
performing technical medical procedures and immediately withdrawing
from the room. He is meant to be concerned with both the physical and
mental health of the patient, and do the best he can to ease the suffering

31
of the person under his responsibility. Accepting the shackling of a patient
lying in a hospital bed, when there is clearly no justification, is a betrayal
of the physician’s commitment to the patient. This acquiescence could be
regarded as taking a part, even if passive, in a situation that causes the
patient suffering and abuses his dignity, or in other words – in a violation
of his rights as a patient and a human being.

The sanctity of security in Israeli society is a well-known and familiar

phenomenon, as is the violation of human rights in its name. It is
worthwhile to remember that a physician is not a security agent, no matter
what his feelings or personal views are (or his role in the reserve army).
When in the hospital his duty is to guard the health and dignity of his
patients and not the state security, are others who have that role. As long
as he isn’t convinced that there is a real and immediate danger that the
patient might harm himself or others, there are no alternate considerations
that allow the physician to accept the shackling of a person whose health
is his responsibility.

The security pretext should not blind the physician and cause him not
to see or understand that a wounded child who is barely conscious, or
an ill person struggling for life, don’t form an immediate danger to their
surroundings. The use of the term ‘security’ cannot justify their being
shackled to the bed, all the more so in light of the fact that most of the time
they are held under constant guard.

The ministry of health is expected to supervise the activities in hospitals

and medical institutions under its responsibility. The Ministry’s rules on
safeguarding are insufficient and are not carried out even at this minimal
level. The fact is that medical personnel that are in frequent contact with
prisoners and detainees are not familiar with the procedures, and the fact
that people are restrained almost automatically in hospitals in Israel with
little questioning and no repercussions, reveals that the Ministry of Health
is not performing its supervision role adequately, and is giving a hand to
the abuse of patients’ rights. Furthermore, the existing situation confirms
that the IMA is not fulfilling is required role in imparting and safeguarding
the values of medical ethics.

32
 In conclusion, the wholesale shackling of prisoners and detainees
in hospitals in Israel is clearly a worrying phenomenon, which violates
the dignity and rights of the patient, as well as the status of the medical
profession, and contravenes principles of human rights and medical ethics.
The use of restraints in hospitals should be limited to exceptional cases,
where it is obvious that there is a real and immediate danger of the patient
injuring him or others, and that placing a guard is not sufficient. Even in
such cases, the shackling to a bed or other inanimate objects is prohibited,
and the combination of shackling hands and/or legs together with a guard
would be more than enough. These cases of justifiable shackling will be
exceptional and only in cases of risk of immediate violence and with no
other alternative. Medical personnel must use careful judgement. Even
when it is argued that a patient is dangerous, it must be recalled that the
yardstick is a current danger, not past actions. If the patient’s medical
condition is inconsistent with the claim that they present an immediate
threat, medical personnel should not agree to the shackling.

Using restraints as a means for preventing an escape from hospital is

unacceptable. Hospitals, which regularly treat prisoners and detainees,
should have rooms or areas assigned for this population, that don’t have
windows, or have barred windows, that can prevent the opportunity for
any escape. Even in the absence of a special room, there is no justification
for restraining a hospitalised person in order to prevent escape. The
presence of one or more guards, who accompany the patient, as is usually
the practice in hospitals, is sufficient to thwart most attempts. Shackling
may be justified only in extreme and exceptional cases when there is
an immediate danger of violence and no alternative can be found. The
claim that a sick or wounded person, especially a child, could overcome
policemen or soldiers and run away from his sickbed is fundamentally
flawed. The escape argument cannot justify severe and ongoing abuse of
the patient, and it is necessary and possible to find another solution.

33
Recommendations
The cases presented above, show that shackling is often used with
no justification. To prevent the continuation of the abuse of prisoners
and detainees arriving for medical treatment in hospitals, PHR-Israel
recommends the following:

• The security bodies must amend and improve their procedures, making
it clear that shackling a hospitalised prisoner should be an exceptional
act justified only to avert a real and immediate danger of the patient
injuring himself or others.

• In cases of unjustified shackling, the security bodies or supervisory

government bodies must take action against those responsible. The
state has an obligation to take steps when rights have been violated,
thereby also helping to prevent future abuses.

• The Ministry of Health and the Israel Medical Association must

declare that the shackling of patients is unacceptable, apart from the
exceptional cases of real and immediate threat. Prevention of escape is
not a legitimate justification.

• These positions must reach the wide audience of physicians and medical
staff, and not remain ineffectually locked away in a filing cabinet.

• Medical facilities likely to treat prisoners and detainees must set aside
a room or area to ease security considerations. If this is not possible
within the current structures, an appropriate budget must be provided.

• The guidelines of the Ministry of Health and the Israel Medical

Association make it clear that it is the physicians’ duty not to agree to the
shackling of their patients, and provide the physicians with backing and
unequivocal support. Physicians and particularly hospital managements
who accept unjustified shackling and do not act to prevent the abuse
of their patients, should know that they are likely to face disciplinary
proceedings at the hands of the Ministry and the IMA.

34
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 to

Bed during Hospitalization

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

Sincerely,

Major Enrietta Levy

Head of Assistance Desk

35
Israel Medical Association
Ethics Committee

March 2, 2003

To:
Brig.-Gen. Bar-El
Chief Police Officer
IDF

Dear Sir,
Re: Lt.-Col. Shlomo Gispan
Head, Imprisonment Division

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

36
Lt.-Col. Shlomo Gispan, Head of the Imprisonment Division in the Military
Police Officer Command, is an ex officio member of this forum.
On Thursday, February 27, 2003, I contacted his office by telephone in order
to understand his position on the matter of this girl.
Between 09:30 and 10:00 am, I called 5 (!) times, but Lt.-Col. Gispan did not
deign to answer me even once. I presented myself by my full name and my
position as chairperson of the Israel Medical Association’s Ethics Committee.
I explained exactly why I was contacting him, but regrettably all this was in
vain.
The answers I received from a male and female clerk in the office were as
follows: “He is on the telephone now and will get back to you;” “He is on a
lunch break, but he will call you when he gets back;” “He is in a meeting and
very busy;” “He is aware of the problem and is dealing with it.”
It is imperative to point out that even though I left my telephone number at
work with the office, as well as my mobile phone number. Lt.-Col. Gispan did
not take the trouble to respond at all to my repeated calls.
Lt.-Col. Gispan may be right that it was essential to chain the girl. It is not
this aspect of his behavior that is outrageous. It is unthinkable that an officer
staffing such as sensitive position in public terms could ignore my calls in
such a discourteous manner. What is the point of his being a member of the
“Decisions Forum,” where he must provide answers and explanations on a
real-time basis, if he lacks the understanding and sense of responsibility that
are required of someone in such a sensitive position?
We are facing a difficult battle in international public opinion regarding our
character as an enlightened society and our status among the nations. I hardly
need tell you that the difficult war we have faced over the past two years has
devastated this status.
I myself am engaged in the defense of the good name of the State of Israel
among international organizations of physicians. This is a very difficult task
at present. In such forums, I will be unable to explain harsh and insensitive
behavior such as that of Lt.-Col. Gispan.
I will be grateful for your reply to this letter.
Sincerely,

Prof. Avinoam Reches

Chairperson, Ethics Committee

CC:
Minister of Defense
Chief of Staff
Dr. Blachar, Chairperson, IMA
PHR-Israel

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Israel Medical Association Central Committee
39 Shaul Hamelech Blvd, Tel Aviv 64928
December 3, 1990
0945
To:
Commander of Sharon Prison
Israel Prison Service
POB 81
Ramle
Dear sir,

The Association of Israeli-Palestinian Physicians for Human Rights has

brought to my attention photocopies of affidavits given by the prisoner Intisar
Muhammad Alqaq. Photocopies of the two affidavits are attached for your
review.
I would ask you to examine the fact and respond substantively to each of the
claims in the affidavits.
If the young woman’s hands were indeed handcuffed while she gave birth, we
see this in a severe manner. Moreover, a physician performing a delivery in
such conditions would have been acting contrary to the ethical rules of 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 Rights – POB 10265,
Jerusalem 61101

38
Hadassah Medical Organisation
Central Administration

Kiryat Hadassah
P.O.B. 12000
Jerusalem 91120, Israel
Telephone: 02-777111
Cables Hadassah
Fax: 02-434434

The Legal Department

Tel: 02-6776081, Fax: 02-420219

October 22nd, 1996

To:
Dr. Ruhama Marton
Chairperson, PHR-Israel
POB 592
Tel Aviv 61004

Dear Dr. Marton,

Prof. Shmuel Pinchas, director-general of the Hadassah Medical Organization,

has asked me to reply to your letter, ref. 371-96-988, dated October 10, 1996
regarding two young Palestinians who were shackled to their beds by their
guards while undergoing hospitalization and treatment at Hadassah Ein
Kerem Hospital.

Several years ago, the Hadassah Medical Organization instructed its

employees to refrain from shackling any patients (prisoners and detainees,
whether criminal or security) to their beds.

By pure coincidence, this subject came up for discussion on October 10, 1996
at the meeting of the active executive of the Hadassah Medical Organization,
and the director-general of Hadassah repeated the previous instruction and
asked that a written reminder in the above-mentioned spirit be sent to all the
employees.

39
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

40