Report on the Organisation of health care services in prisons in European member states
1. THE GENERAL SITUATION 
1.1 Responsibility in health care
In most European countries the provision of health care in prisons is under the responsibility of the Ministry of Justice and the medical services are organised by the prison administration. The Ministry of Health is responsible for providing health care in only a few countries (e.g. Norway). In some countries, measures have been taken to involve the Ministry of Health (France).
In all countries health care is financed by the State. In the United Kingdom regional administrations are responsible for the budget and take part in the services organisation. In Italy it is, strictly speaking, the Ministry of Justice which bears the costs of the health care in prisons.
Prisoners may be admitted to hospital either in prison or outside prison in the vast majority of countries. In Cyprus, Lithuania, Luxembourg, Norway, Sweden and Turkey, hospital treatment is available only outside prison.
1.2 Current prison conditions
Current prison conditions in Europe are characterised, with few exceptions, by old buildings from the last century or the beginning of this century, built according to the expectations, specifications and conditions of the time. Despite reconstruction and renovation, it is very difficult to alter the original conditions.
This situation is aggravated by overcrowding in all member states, as well as by the number of inmates addicted to illicit drugs, with HIV positive infections, with HBV positive infections or carrier status and sexually transmitted infections. In some countries these increases include a rise in the number of inmates with TBC infections. There is also an increase in the number of inmates with psychiatric conditions. Closely connected to the health care are improvements in hygienic conditions. There are far too many institutions where the hygienic conditions are unacceptable. Likewise, the traditional one shower a week, characteristic of a lot of prisons, is equally unacceptable for the maintenance of personal hygiene.
Moreover, many of the prisons are too large. In such establishments it is difficult to establish good personal contacts between inmates and counsellors, plan educational programmes and ensure effective surveillance. In many instances there are large bed capacity prison hospitals, which are costly. It would be more practical to have small regional units in civil hospitals with a smaller central infirmary for treatment of maximum security prisoners.
Large institutions have their own medical and health care staff, while other institutions have part time primary health care staff which may include psychologists, psychiatrists, dentists, gynaecologists. All cases requiring specialist care are referred to local or regional hospitals or health care centres. In those cases where physicians are employed part-time, full-time college-trained health care assistants together with trained nursing staff provide the basic health care needs.
The psychological evaluation of the inmates is an integral part of the provision of health care. This helps to screen them for personality disorders, assess the need for treatment and detect and prevent the development of dependency behaviour. It is therefore necessary to provide psychology groups and have, in parallel to medical care, psychological staff at larger penal institutions.
Working under prison conditions demands special training. The physician works under stress and needs appropriate psychological training. Appropriate training-courses should be organised for those wishing to work under prison conditions either full- or part-time. Physicians and nursing staff must be trained and experienced in recognising the signs of drug use, dependence and addiction, their dangers and methods of detection such as rapid screening from urine samples if necessary.
Further skills must be acquired to detect various infectious diseases and disorders and to educate the inmates about the advantages of voluntary HIV, HBV, sexually transmitted diseases and TBC screening, diagnosis and treatment.
2. MAJOR PROBLEMS IN CARE DELIVERY
2.1. The care of:
- persons with AIDS or STD
- persons with TBC
- drug addicts
- persons with hepatitis
In all countries prison conditions are characterised by a number of drug addicts, AIDS cases, persons infected with sexually transmitted diseases, tuberculosis and hepatitis viralis type B or C. In many of them the numbers are increasing.
Information about diseases is essential to organise an effective prison health care system. Besides, all the above mentioned diseases imply a wide range of problems which are not only of medical but also of psychological and sociological nature.
Generally speaking, all prisoners upon their committal undergo a medical screening aimed at diagnosing any infectious or progressive disease liable to require isolation measures or urgent treatment. Nevertheless, that is not always the case for every disease and in every country.
- AIDS
As far as AIDS is concerned, free and anonymous HIV screening tests are available to all prisoners in nearly all of the countries studied. Greece and Turkey do not make screening systematically available and they do not make a point of informing prisoners about HIV/AIDS problems.
In Lithuania and Hungary serological tests are compulsory. Anonymity is not guaranteed in Lithuania, whereas in Hungary information about seropositive prisoners is only transmitted to the Public Centre for Diseases Control.
In all other countries HIV tests cannot take place without the consent of the person concerned and may be recommended but not imposed on prisoners who display high risk behaviour. Inmates are provided with all relevant information concerning HIV infection risk behaviour and prevention measures. Condoms are made regularly available in Finland, Denmark, Portugal, Belgium, Italy, Switzerland, Norway, Spain and Sweden.
As a general rule, HIV tests results are given to prisoners by the internal medical services. The treatment of HIV positive inmates is carried out by the prison medical staff. In cases where AIDS is developed, patients are admitted into public medical centres or to other kinds of appropriate hospitals outside.
In several countries (France, Spain, Finland, Norway, Ireland, Sweden, Italy, Luxembourg, Hungary) prisoners with HIV/AIDS get psychological support; they are entitled to psychotherapy and other forms of help.
In Ireland there are special wings where HIV/AIDS patients are actually segregated. In Belgium and Poland they may have a single cell but they sometimes prefer to be together with other inmates in the same condition.
In Sweden, United Kingdom, Switzerland and Poland all prison staff have basic information about HIV/AIDS infection, risk behaviour, prevention, testing and treatment. On the other hand in Lithuania, for example, training is limited to some brochures that the Lithuanian AIDS Centre periodically sends to the prisons. In Greek and Turkish prisons the information on the subject is scarce.
- STD
The testing and treatment of sexually transmitted diseases is compulsory for prisoners in France, Lithuania and Poland. Systematic serological screening on committal is often carried out in Bulgaria. In Hungary tests are mandatory when the disease is suspected and in Spain the responsibility of the screening and the treatment lies within the prison's medical service. In Portugal screening of STD is only systematic in respect of syphilis and it is a factor of discrimination because it is restricted to women.
In all the other countries there is no systematic STD screening and the problem is seldom perceived as a particularly dramatic one.
Very little is known of STD treatment procedures.
- TBC
Cases of pulmonary and extra pulmonary tuberculosis are relatively common in Spain and Lithuania but extremely rare in Luxembourg, Norway and Finland.
In Lithuania a fluorography is performed on every prisoner on committal and those with pulmonary active tuberculosis have special imprisonment institutions.
In Spain an X-ray examination of the thorax is given to all prisoners who show early symptoms of the disease. Pulmonary radiographic examination is only carried out for diagnostic purposes under a doctor's prescription.
Other countries which provide systematic X-ray examination for tuberculosis are Poland and Hungary.
In France article L.273 of the Public Health Code provides for systematic screening for pulmonary tuberculosis on committal to prison. Article D.394 of the Penal Code of Procedure specifies that the responsibility for screening lies with the regional councils. Whenever infectious tuberculosis is suspected the patient must be isolated and, if necessary hospitalised. There is very little information regarding TBC in the other countries.
- Drug addiction, alcoholism, hepatitis
Drug addiction, alcoholism and hepatitis are frequent problems in prisons all over Europe, yet only certain countries provide statistics on these matters.
It is known that in Belgium the rate of drug addiction in prisons is 42%, the rate of alcoholism 34%, the rate of regular consumption of psychotropic drug 30%. In the United Kingdom about 20 % of the prison population are drug addicts.
In Spanish prisons drug addiction is one of the priorities of the health programmes. Seriously ill drug addicts and alcoholics are treated in special prison wings or in outside hospitals. Also in Poland there are special wings for prisoners suffering from drug dependence. In Portugal there is an open centre for young drug addicts with a number of psychiatrists, psychologists, general practitioners etc. In Italy and Austria all prisons' health services cooperate with outside national care services in treatment of drug dependence and alcoholism.
It is possible to vaccinate against hepatitis in Swedish prisons. In countries like Finland the question does not arise because hepatitis cases are extremely rare. In Lithuania mass hepatitis B vaccination is deemed desirable but is not carried out because of the country's financial constraints.
- Information, prevention and education for health
Serious efforts are made in all European countries to provide general advice on health.
Particular emphasis is put on the prevention of AIDS and other sexually transmitted diseases. Practically everywhere prisoners are given an information booklet. In some countries like Sweden, Norway, the Netherlands and the United Kingdom the methods of the information programmes and teaching material are particularly sophisticated as they feature written and audiovisual material, individual and group meetings. Also in Luxembourg and Portugal talks are systematically given to persons in detention. In Ireland there is a strip cartoon easily understandable by everybody. In Switzerland and the Netherlands all the material is translated in several languages. Finally, in Greece there is at present no programme to inform prisoners about AIDS and no details are available on the provision of information for inmates in Turkish prisons.
2.2. Mental illness in prison.
In virtually all countries each prison has a number of psychologists who are there to provide treatment for mentally disturbed prisoners and to help them to adapt to prison conditions.
Psychiatric examinations are systematically carried out in Greece and in Italy, where all prisoners are also seen by the suicide prevention team in the course of a compulsory general medical examination which all prisoners undergo on committal to prison.
Everywhere the courts or some other relevant judicial authorities can ask for a psychiatric report to be drawn by a psychiatrist/psychologist before and during the trial. In France such an examination can be carried out at the request of the prisoner or of his family and friends. In Luxembourg it is possible only before and in Lithuania only during the trial. In some countries such as Cyprus or Finland a psychiatric screening can be requested even during the period of imprisonment. Health legislation in Europe contains provisions for the treatment of mentally ill offenders and allows for such treatment to be given inside or outside the prison, usually in a public psychiatric hospital. The decisive factor is not the seriousness of the offence but the mental condition of the offender. The Lithuanian legislation provides for treatment of mentally ill prisoners in hospitals within the prison system. In Spain a new Penal Code is in force. As for the United Kingdom, the CPT has indicated in his report that it had taken note of a circular published by the Home Office in September 1990 drawing the attention of the courts to the possibility of treating mentally ill persons in the care of the community's health and social services instead of in prison. Even though in recent years there has been a substantial increase of transfers to the health care system, a considerable number of mentally ill persons are still in prison. In Bulgaria the jail sentence is suspended for the period during which the prisoner is considered ill by the prison medical service in charge. Once the prisoner is judged to have recovered the period of imprisonment is resumed.
In some countries there are a number of special psychiatric institutions for mentally ill prisoners. In Portugal the prison service has a psychiatric and mental health clinic where mentally ill prisoners are detained; prisoners whose behaviour gives reason to suppose that they are mentally ill can also be kept in two psychiatric annexes for observation if their treatment does not last longer than six months. In France there are two central units where psychopathic prisoners are housed, in Metz-Barres and in Chateau-Thierry. In Austria treatment for prisoners who are not seriously ill is provided in a separate 45-bed unit situated just outside Vienna.. In Italy there are six psychiatric hospitals (HPJ) which are part of the prison system for mentally ill persons not sentenced to imprisonment but placed in custody as a security measure and for treatment.
It is important to highlight the fact that the special psychiatric institutions for prisoners function not just as detention centres but can also be seen as treatment centres. France and Italy are significant examples of the increasingly close co-operation of the detention system with local bodies and, through them, with the health system and in particular the psychiatric care system of the countries. In France some prisons, 18 in all, are served by regional psychological health departments which includes a full hospital team from a specialist hospital. This team works in the prison, making the diagnosis and following up mentally ill prisoners. If, during detention a prisoner shows signs of a mental condition which requires treatment, he is referred to the prison psychiatrist or to the team from the relevant prison psychiatric department. In Italy the prison administration can call on the relevant national services according to the agreements made with them. This is a two-way arrangement, in that personnel from the national health services can visit the prisons and, on the other hand, detainees can "leave" and go to external satellite sections of the HPJ such as the one established in Castiglione delle Stiviere. In Belgium follow-up treatment by a psychiatrist or by a psychologist may also be offered to prisoners released on parole.
2.3. Difficulties involving the presence of persons detained for sexual offenses.
In general, during the past four years there has been a considerable increase in the number of sex crimes. Sex offenders prisoners are not a homogeneous group of persons. They are of various ages and levels of intelligence and come from very different socioeconomic backgrounds.
In some countries like for example Ireland and Spain they are segregated in special confinement sections with a view to guaranteeing their own safety. As a matter of fact, it is often believed that they could otherwise be exposed to aggressive behaviour and even attacks at the hands of the other inmates. In Denmark there is a treatment centre in Herstedvester which has a long tradition of intensive psychotherapy for prisoners guilty of sexual offenses. In recent years, persons convicted of grave sexual offences may be offered medical castration following medical advice.
The most promising therapeutic approach in a prison environment is considered to be the one based on the cognitive behavioural model. This approach is based on the principle that the actions of sex offenders arise from abnormal thinking processes which allow them to act as they do and then justify their behaviour.
The objective of the cognitive behavioural approach is to challenge these abnormal thinking processes and enable the offenders to appreciate the impact of their actions on their victims and to accept responsibility for those actions. The programme also aims at enabling the offenders to recognise the feelings which led to the offensive behaviour. It is usually structured for a group of 8 to 10 participants. The interaction of the group gives a considerable contribution to counteract the attempts of such offenders to deny or justify their crime.
3. SOCIAL ASPECTS
Introduction.
The different services which provide aid and care for the detainees cannot be seen as completely separate from one another. In fact they are in some way and to some extent mutually linked, in so far as they all interact in contributing to the physical, mental and social well-being of the prisoners.
This phenomenon implies, among other things, that the effects of the assistance activities often have a wider scope than it is formally intended. Just to give an example, the prison chaplain can somehow contribute to the improvement of the health state of prisoners. Another implication of this fact is that if one of the services is missing or performing badly, it may affect the other services negatively. Certainly, the social welfare of the prisoners is very important for their health state. Many other aspects of prisoners' life, however, have a vital impact on their general condition and therefore on their health, such as their social contacts and relations, particularly the maintenance of family ties and other intimate ties. Of course the relation between mothers and their little children has its special place.
3.1. Social services available.
It is clear that in many countries social workers operate in prisons, although not much is known exactly of their numbers and of the content and extent of their tasks.
Moreover, prison social services might be arranged by the prison system itself, but they may also be provided by general government welfare services (for instance in Cyprus) or by private associations, perhaps State-sponsored (for instance the probation service in the Netherlands).
Ideally, every social service ought to have sufficient staff to fulfil a certain number of fundamental tasks:
a. to contribute to the prisoners' resignation and adaptation to the prison environment;
b. to assist the prisoners in solving their social problems (as mentioned in the Dutch Prison Act) and in asserting their social rights and social insurance; it may be particularly urgent for very recently arrested persons in pretrial detention;
c. to advise the prisoners on their future perspectives, on schooling and vocational training (as in Switzerland);
d. to provide pre-release assistance, which implies help with the preparation of real reintegration in society (in personal, financial and social respects); work and housing have to be arranged and eventually help of competent social benefit agencies is required (for instance in Germany and the Netherlands).
It is clear that the social workers concerned need not only a general vocational training but also a specific training oriented to the prisoners' assistance (comparable to the specific training needed by prison doctors).
Good social workers should be able to communicate and help directly in the early detection and prevention of psychological stress, infectious diseases and mental disorders.
3.2. Maintaining family ties.
One of the inevitable consequences of imprisonment is the temporary weakening of social contacts. It is true that family ties are not broken off completely, in the sense that in most cases a visit of at least one hour per week is permitted, nevertheless the prisoners' relationships suffer enormously from the confinement. A large number of wives, husbands and children of detainees feel punished themselves to a similar extent as their convicted spouses and fathers. Besides, and worse still, in many cases the marriage is bound to fail or be ruined. Social contacts in general are also suffering as a consequence of the imprisonment. In some countries like Denmark and Switzerland prisoners, are given the opportunity to receive their partners without supervision. Also in Sweden supervision is fairly relaxed.
In order to prevent HIV transmission condoms have to be made accessible not only on the occasion of intimate visits, but also in the event of occasional homosexuality among inmates. This is not possible in some countries because homosexual intercourse is officially forbidden.
Condoms can be offered in places where privacy is guaranteed such as the medical service centre (as in Luxembourg) or in the telephone cells (as in the Netherlands and in Switzerland).
A particularly delicate question is that of female prisoners, who give birth to a baby or have already a baby or little children. Some countries, namely Cyprus and Norway, do not make provision for this issue, but in the vast majority of systems there are special facilities for mothers with children in prison. The age limits up to which children are allowed to stay in prison with the mother vary considerably: in Germany, for example the provision applies to every child under compulsory school age, in other countries the maximum age is lower (for instance in Spain and Switzerland 3 years, in France and the Netherlands, 2-3 years, in Finland 18 months).
The permanence of children in prisons is a very contentious issue. Some people fear its dramatic repercussion on the future life of these children because of the unnatural, coercive conditions of detention. In some systems detainees have access to external facilities such as creches (France), in other systems there are special centres or prison wings with appropriate accommodation. In Spain and in Switzerland, for instance, a creche for babies, a day nursery and a child-minding service are provided. In Portugal children have a special wing of their own too; children who normally live outside the prison are allowed 15 days of their holidays in prison with their mother.
3.3. Influence of schooling, work, sport and leisure activities on the equilibrium of the prisoners
3.3.1. Schooling and work
The average level of education of prisoners throughout Europe is relatively low (many convicts did not even have a primary education). In many cases there is a lack of vocational qualification which often leads to unemployment and generally bad social circumstances (housing, way of life etc.). Their average age ranges between 31 and 33.
It is blatantly obvious that the greatest part of the prison population is placed at a disadvantaged level of development, vocational training and work. For that reason nearly every correctional system is oriented to the most fundamental forms of reintegration in society. In other words all prisoners are offered a primary education. Advanced teaching and vocational training are offered in a great number of systems, although they are not granted in all institutions and they are sometimes available only in the last stage of imprisonment (for example in Denmark).
In some cases vocational training involves paid activities (art and handicraft in Cyprus). The training may vary from technical training (in Sweden: courses in machine tools operation, wood industry engineering, sheet-metal work and welding, electronic work) to artistic training.
The usual daily prison labour is compulsory for all convicts and entitles them to a very moderate salary, only for purchases in the prison shop sufficient for some tobacco, sweets, drinks and so on. In some cases the income can be moderately higher as a result of favourable labour agreements between prisons and outside industries (like in Luxembourg).
Prison rules usually intend to promote some forms of prison labour oriented to develop or improve skills that are useful for the future of prisoners. The attempt to get prisoners involved in activities which are of some interest to them is however not always successful.
Given the high unemployment rate of most European countries it is problematic to find work for all the prisoners and there are even institutions with no possibility whatsoever to work such as for instance the remand house in Antwerp, Belgium, where not surprisingly many prisoners take advantage of the prison doctor's consulting hour in order to leave the cells where they are locked up for 23 hours a day.
Vocational training may be supervised either by the Ministry of Justice (through the use of external courses) or by the Ministry of Education (for instance in Portugal). In some systems all types of study at any educational level (from primary to advanced) entitle studying prisoners to the same wage as working prisoners. In addition to that, labour and study are scheduled at the same time in the day programme.
Vocational training is of course expensive. However, as many training programmes as possible should be made available to prisoners and everybody without primary education is given the opportunity to be educated in prison.
Some pay would be stimulating. As a matter of fact, some responsibility is important for the equilibrium of the prisoner. Rule 37 of the German Prison Act is very much to the point:
1) The main aim of work, work therapeutic occupation, vocational training and further education is to provide the prisoner with skill and knowledge to enable him to earn a living after his release or to preserve and promote the already existing skill and knowledge;
2) The prison authority should allocate to the prisoner some economically productive work, taking into account his abilities, skills and inclinations;
3) Prisoners with an aptitude should be given a chance for vocational training, further vocational training, retraining for a new job, participation in other activities of vocational training or further education;
4) When a prisoner who is fit for work cannot be given any economically productive work or an opportunity to participate in any leisure activities, he should be given some other reasonable form of occupation;
5) If a prisoner is not fit to perform some economically productive work he should be given some occupation of a therapeutic nature.
3.3.2. Sport.
Sports practice in prisons depends mainly on the availability of facilities and instructing personnel. Generally there is always some kind of activity set up for prisoners, particularly group sports (football, volleyball, handball).
In the United Kingdom,in the Netherlands and Switzerland,some institutions have plenty of fitness facilities. In some other countries not every institution is prepared.
When facilities are missing improvisation often plays a crucial role and certain places in the institution concerned are allocated for physical exercise; it is the case with wrestling in Greek prisons.
In all systems a minimum walk in the fresh air is prescribed, for example 1 hour (Sweden, Germany), 2 hours in the morning and 2 hours in the evening (Italy) or simply when the prisoner chooses.
The frequency of sports practice varies extensively across the different countries. It can for example be twice a week (the Netherlands), at least 1 hour a day (in Finland). In Sweden, Portugal and Switzerland, some institutions organise matches between the prisoners and other clubs from outside.
In Belgium sports practice is mandatory unless the prisoner is not able to do so because of illness or age.
3.3.3. Leisure activities.
A very common kind of recreation is television-viewing. In many countries private television in the cell is allowed, in other countries the television is only to be found in common rooms. Games like chess and billiards can be played everywhere. In the institution there is usually a library and at least a domestic radio programme.
Sometimes films are shown and in some countries theatre performances and/or concerts are given within the prison walls (for instance in Sweden, Cyprus, Greece, Switzerland); open prisons organise cultural excursions to museums (for example in Luxembourg). It is normally the prison governor and the staff members who have to take the initiative. In many countries there are associations like the Red Cross which devote themselves to visiting prisoners who are somehow isolated. Private associations may also be active, especially in assisting prisoners of a certain origin (or of a certain native country) in their private needs.
The existence of hobby and handicraft rooms is very important for the relaxation and the development of the prisoners but it goes without saying that they are not guaranteed everywhere.
4. SOME EXAMPLES OF FUNDAMENTAL RIGHTS OF PRISONERS AND RELATED ETHICAL QUESTION.
Introduction.
As a starting point, the legal status of the prisoner has to be as much as possible equalised to the legal status of the free citizen and infringements on his position should be restricted to a minimum and only by statutory law. In case of special restrictions prison authorities should have to justify the inevitability and strict necessity of the measures and furthermore they should abide by legal standards. Especially the citizen's constitutional, fundamental and civil rights have to be fully respected within the prison walls. Judicial control must be exerted.
The European Court of Human Rights and Fundamental Freedoms has rejected the theory that a sentence to imprisonment in itself implies certain aggravations and restrictions such as self-evident elements of punishment (the so-called theory of "inherent limitations").
Since the focus of this report is on the medical care services for prisoners, the issue of the prisoner's legal status can only be touched very briefly. It cannot be forgotten, however, that the respect of human rights and dignity has, more or less directly, a tremendous influence on the health state of the prisoners.
Two elements of the legal position have to be distinguished: the guarantee of substantial rights and the possibility to implement these rights in a legal procedure.
In the light of the specific coercive character of prison conditions a well structured procedure is of the utmost importance.
The absence of legal provisions does not necessarily imply a neglect of the prisoner's rights: reality may be better than the law suggests. The contrary can also be the case: the written rule may look good without having any value in practice. Nevertheless, a number of fundamental rights, also regarding medical care, are easier to implement when they are laid down in statutory law.
The European Prison Rules have undoubted influence and moral value. Furthermore, prisoners have access to the European Commission of Human Rights, the Committee for the Prevention of Torture and the UN Human Rights Committee.
4.1. Right to complain
Two different kinds of complaints have to be distinguished:
A. Complaints on the quality of the medical treatment.
Professional medical treatment can only be judged by doctors in the light of medical disciplinary codes, or by medical inspections. Medical inspections can be routine or ordered by the Ministry of Justice with a view to controlling the medical care.
For complaints to be effective, prisoners should be granted the right to have free and direct access (without censorship) to medical inspections and medical disciplinary tribunals.
B. Complaints on the arrangement and provision of medical care.
In these cases prisoners should have free and direct access to a judicial body, a specific committee for complaints, an ombudsman or any other sort of authority that has the legal competence to deal with such complaints and the power to make binding decisions.
4.2. Medical confidentiality.
The standards of medical confidentiality generally observed in prisons are lower than those in a free society. Where the universal criteria apply, only the prison health staff is allowed to take note of the medical documentation of the prisoners. Others, for example the members of the prison general staff, are only given information for professional purposes and under the condition that they keep the information secret. Consent of the prisoner concerned is necessary but exceptions are envisaged when for example a prisoner suffering from a transmittable disease wants to hide it and his fellow prisoners are exposed to risks.
The circumstances under which disclosure of medical information is authorised and the related procedures have to be governed by law.
4.3. The choice of the doctor.
The general rule is that inmates call on the prison medical staff. In some systems no exceptions to this norm are admitted. In other systems prisoners are allowed to turn to private doctors at their own expenses (Portugal) or if their preference is considered to be medically sound and well founded (Sweden).
Prisoners who are allowed to leave the institution are regarded as a special category. In several systems pretrial prisoners are allowed to consult their own doctor at their own expense (for example in the Netherlands). This is in accordance with rule 98 of the European Prison Rules (consultation or treatment to be given by the doctor or dentist, unless the petition is unreasonable). This provision is based on the principle of the presumption of innocence. Prisoners cannot therefore be subjected to more limitations than is strictly necessary.
Recourse to different doctors can give rise to ambiguous situations: the medicines prescribed may differ from those usually given in the prison and fellow prisoners who are not entitled to have a private doctor might feel discriminated.
4.4. Specific rights of ethnic minorities.
Most prison institutions have a significant number of prisoners belonging to ethnic minorities (exceptional in this respect is the Irish prison system) that differ in religion, culture, language, lifestyle and food.
Ignoring those differences threatens the overall well-being of the prisoner.
In many systems the prison kitchen are equipped to offer special kinds of food that are in accordance with the different cultures represented in the institution.
To ensure real religious tolerance, it is essential for the prison to establish contacts with different religious ministers and with counsellors. The most important holy days of the different religions represented also have to be respected, particularly in relation to obligatory labour and special food.
Language is another potential factor of isolation. A way of breaking down language barriers is to lodge together prisoners with similar linguistic problems of communication. It is also useful to provide interpretation and to call on outside associations with people who can speak the same language.
4.5. Medical experimentation
The vulnerable position of detainees, who are highly dependent, makes it difficult to assess the voluntary nature of their consent. It is therefore too dangerous to carry out any form of medical experimentation on prisoners. This is the view expressed in the General Ethical Codes of the World Medical Association.
4.6. Hunger strikes
Hunger strikes represent some of the biggest dilemmas that prison governors have to deal with from time to time.
Some countries (for instance Finland) follow the WMA Tokyo Declaration: prisoners on hunger strike are informed of the consequences of their actions and their state of health is monitored; hospital treatment is arranged when needed (if the patient consents), advice is given on the importance of fluid intake. No treatment takes place when the prisoner refuses it.
In other countries (Spain and Sweden) involuntary feeding may be given if, in the opinion of the physician, there is immediate danger for the life or the health of the patient.
In some systems (like Italy) involuntary feeding is prohibited, unless the hunger striker is no longer able to be aware of the consequences of his refusal.
Everywhere in Europe it is considered important to inform the hunger strikers on the possible consequences of their choice right from the beginning and in a systematic way.
In 1985, the State Secretary of Justice of the Netherlands gave some guidelines on how to act in cases of hunger strike by inmates. These rules are to be interpreted in the context of the human being's right to self-determination regarding his health. It is crucial that the doctor informs the hunger striker regularly and at every stage about the effects of his actions and that the will of the inmate concerned to continue the strike is clearly recorded. One or more statements made by the striker to both the prison governor and the prison doctor will have to stress that he does not want his strike to be interrupted if he falls in a coma.
The setting up of a permanent team is not seen as the most appropriate way of attending to the needs of the hunger strikers. It is self-evident that external specialists who enjoy the confidence of the prisoner can be extremely helpful, provided that the prisoner approves of their involvement. It cannot be forgotten, however, that the institution's physician remains legally and medically responsible and therefore has always to be consulted as well.
4.7. Alternative sanctions
In some cases criminal law prescribes alternative sanctions of a non-custodial nature and are meant to replace short prison sentences, e.g. community work during a number of hours/days.
Another alternative is an open prison at the last stage of the prison sentence. People in open prisons usually have fewer health problems than those in closed prisons.
The voluntary consent of the people convicted to an alternative sanction is required because forced labour is prohibited under article 4 of the European Convention for the protection of Human Rights and Fundamental Freedoms.
A drawback of alternative sanctions is that judges are inclined to impose them as alternatives to conditional sentences or fines rather than to unconditional sentences. This phenomenon is called "the widening of the net" or the "extending effects of the alternative sanctions" and is particularly visible in countries like the Netherlands.
