I grew up on a staple of detective novels. Agatha Christie, Ian Fleming, P.D. James, Colin Dexter… there was always the smart forensics team that ultimately cracked the case. The dried blood stain nobody had noticed, the single hair on the comb, the fingerprints on the backdoor doorknob… I wanted to become a forensics expert when I grew up. Either that, or a psychiatrist. There was something fascinating about being able to read people’s minds, and to set them right if they were disturbed. I carried these thoughts with me into medical school.
The psychiatrist option suffered a rude jolt during the three weeks I spent on the psychiatry rotation as a junior clerk. It seemed as though the patients never got well. Most patients we met had been there before, several times. There were three, at most four, drugs that were used to treat all conditions. And then there was the electroconvulsive therapy, which left me persuaded that I did not want to return to that unit if I had the choice. I am glad things have changed tremendously since.
I went into internship with an open mind. Two weeks in, I was told I was on medico-legal duty. The assigned doctor did post-mortems and could be called upon to examine inmates at the municipal prison. These were usually convicts whose sentences included corporal punishment – caning. Thankfully, it has been outlawed as a form of punishment.
Anyway, I was asked to go and examine a couple of inmates who were coming up for the cane. I was required to ascertain that they were fit to withstand the trauma, and afterwards, to confirm that they had survived. As fate would have it, that day’s inmates were small-bodied men in their fifties. When you are in your early twenties, you think anyone on the other side of fifty has one foot in the grave. I examined the men and, based purely on the physical exam, found them to be in good health. I recorded my findings in their files and appended my signature to the report.
Then I went to the office, only a few feet away from where the corporal punishment was to be administered, and waited to re-examine them post-trauma.
Before I had settled in the chair, I heard what sounded like a cross between a muffled gunshot and a loud door bang… punctuated by an “uughhh” from deep in a human being’s throat. This went on for several minutes – or so it seemed. Then a second name was called, and a repeat. With each strike there was a tightening in my chest. Then it was over. The prison staff who had administered the punishment came and invited me to go and ascertain that the men were alive. I cannot recall how I got through that part. I only remember thinking afterwards that if this was the path to becoming a forensic expert then I was going to have to find another way to become famous.
I suppose as long as there have been health workers taking care of prisoners, there has been that conflict – the dual loyalty bind. The medical worker’s professional duty to the patient on one hand, and the requirement by the state for medical workers to provide information, cooperation, or compliance on the other.
Doctors may be expected to disclose information about patients, to permit security officials access to patients or their records, or to downplay conditions whose mention would get in the way of the state’s objectives concerning the patients.
As a young doctor, I was only vaguely aware of this universal dilemma. My medical ethics classes had taken place in lecture rooms far removed from the reality of the harsh prison yard. Apartheid was still the official policy of South Africa. Steve Biko had been dead for ten years, having died in custody, in circumstances that came to light through the t South African Truth and Reconciliation Commission (TRC) hearings.
Generations of doctors have studied Biko’s case in medical ethics, yet the dilemma is as real today as it was then. And in some ways, it has become more entrenched, with the thin line becoming more tenuous by the day.
Often, the state’s requests of health workers looking after prisoners may come across as reasonable. They are often made of doctors who take pride in their profession, and who look at requests for information as purely objective, and delinked from any background “political noise”. Sometimes they do not ask the simple question: What is this information going to be used for? Is this in the best interests of my patient? Is it neutral?
It rarely is.
In apartheid South Africa, medical workers were found to have facilitated the mistreatment of prisoners in various ways. Former detainees reported instances in which medical files were handed to the security police; doctors and nurses failed to properly document injuries; doctors declared detainees medically fit for further interrogation or torture; psychologists breached patient confidentiality for security reasons; doctors examined detainees in the presence of police or prison warders, making confidential disclosure of torture or other complaints virtually impossible.
In all those cases, the results of these actions hurt patients and strengthened the already powerful arm of the state against the vulnerable patient.
Let us look at Steve Biko in particular. He died in police custody in 1977. He had sustained severe head injuries while in detention. Doctors examined him while he was under police control. Despite evidence of serious neurological injury, they accepted the police’s refusal to transfer him to hospital and eventually permitted him to remain in police custody. The TRC found failures, including failure to maintain confidentiality, failure to properly examine him, failure to record injuries accurately, and failure to provide appropriate treatment.
But there is more. The TRC heard evidence that a medical certificate and medical record had been falsified at the request of the security police.
The significance of Biko is that the doctors did not necessarily have to be enthusiastic supporters of torture. The system could work through institutional pressure, subordination to police authority, fear of repercussions, and gradual normalization of abuses.
Apartheid South Africa’s medical ethics problems might sound extreme, but they were neither unique to South Africa nor limited to the few well-known names. They were systemic.
South African district surgeons were employed within a system in which they had responsibilities both to the patient and to the prison/security authorities. The TRC described these as “dual obligations”. Doctors had statutory duties to examine prisoners and ensure appropriate health care – but they were operating within an institution whose primary objective was incarceration and security.
The TRC’s evidence showed that the most common failing was not necessarily actively torturing people, but failing to perform ordinary medical duties because the security system took precedence.
That distinction is important. A doctor could become complicit in abuse simply by examining but not documenting the injury; documenting but not reporting it; reporting but accepting the security officer’s decision; or treating a patient in a way that allowed the security operation to continue.
This is a classic example of how an authoritarian system can compromise medical ethics without requiring every doctor to become an active perpetrator.
History is replete with examples of medical workers failing to protect, defend, and advocate for their patients, primarily because of “security interests”.
In Nazi Germany, doctors and health officials became integrated into the machinery of racial persecution.
In the Soviet Union, psychiatrists – mental health practitioners – were sometimes used as an instrument of political repression. Some psychiatrists cooperated voluntarily; others gave in to coercion.
During Argentina’s military dictatorship of 1976–1983, political prisoners and people suspected of being subversives were tortured and disappeared. Medical personnel worked within detention and military institutions, and there were documented instances of medical professionals participating in or facilitating the treatment of detainees in ways that served the security apparatus rather than the patient’s interests. Here again the fundamental ethical conflict was between the doctor as protector of the patient and the doctor as an agent within a state-controlled detention system.
Research shows that there is a clear pattern of progression, from something that appears benign, to something definitely sinister.
First comes the state’s asking for patient information: “What is his/her problem? What are they complaining of?” Then medical workers are asked to disclose information that should ordinarily be confidential – diagnoses, medication, test results, medical records. It then progresses to doctors being asked or expected to examine patients in the presence of security personnel. If the breach was subtle before, at this point a red flag should shoot up.
But it gets worse. Modification of care: treatment, transfer or investigation is delayed or denied because it would interfere with the state’s objectives. Documentation failure: complaints, symptoms, test results that might be inconvenient to the state’s case are omitted from the records. Finally comes normalization: what initially appears exceptional becomes routine practice.
The lesson these cases contribute to modern medical ethics is that a doctor does not cease to have a duty to the patient because the patient has become a prisoner, political suspect, protester, or even an enemy of the government.
So – how is all this relevant to Uganda today? What has the state done to people in custody, and how have medical workers responded?
We have medical workers employed by the armed forces – military, police, and prisons. They have statutory duties to examine prisoners, and ensure appropriate health care, yet they operate within institutions whose primary objectives (regarding inmates) are incarceration and security.
We have seen repeatedly that when the two obligations collide, security almost always carries the day. Patients such as Eddie Mutwe are brought to court with obvious signs of torture, from institutions where doctors and nurses are on staff.
On 17 June 2026, Erias Lukwago was brought to court via Kira police station, where it was reported that a police doctor examined him. He found him to have a blood pressure reading that, under normal circumstances, would warrant an emergency admission to a health facility. The doctor administered some first aid and allowed security operatives to cart him off to court. (To their credit, when Mulago Hospital doctors finally saw Lukwago, their report was unequivocal – he needed to be in hospital and not in prison. Their recommendations have been summarily ignored by the state.)
Kizza Besigye’s saga between the courts, prison, and health facilities is still unfolding, but it is clear that at almost every stage the state has expected medical workers to put security concerns above medical priorities. Prisons staff have normalized being present during examinations, and demands for patient information are without regard for doctor – patient confidentiality.
These might be considered small steps by some, but they are a slippery slope to disaster – for vulnerable patients in custody, and for health workers who have to live with the knowledge that they could have done better for their patients.
The World Medical Association’s post-war formulation captures the fundamental ethical principle: medical knowledge must not be used contrary to humanity. The ethical problem of “dual loyalty” arises precisely when a physician is simultaneously being asked to serve the patient and the interests of the state.
A government may sometimes legitimately require medical information – for example, in public-health situations or through lawful judicial processes. But that is very different from compelling a doctor to disclose information because it will facilitate the persecution, interrogation, detention or harm of the patient.
