Raif Badawi’s 1000 lashes: The medical implications of flogging

Freedom from Torture's head of doctors, Juliet Cohen, describes the medical implications of flogging and discusses the specifics of the case of Saudi blogger Raif Badawi.

Background: Judicial corporal punishment means that a specified physical punishment is carried out as a result of a sentence by a court of law. Once common in many countries around the world, it is now limited to a few. The last flogging in Britain was in 1962. Although prohibited in international law, it is still common in Saudi Arabia and Iran as well as occurring in other countries including United Arab Emirates, Qatar, Singapore and Malaysia.

There is some variation in the way in which the punishment is inflicted, both from country to country and within one country. Victims may be forced to remove clothing, which both increases the humiliation and the pain and physical injury caused. In Malaysia victims are caned on their bare buttocks while restrained in a device designed for the purpose. The back and thighs are specifically avoided. Although only a relatively lower number of lashes are given in most sentences, ranging from 2 to 24, the cane used is long and the arm of the perpetrator takes a long swing, so that the force used is sufficient to break the skin with a single stroke. In contrast, in Saudi Arabia and Iran sentences are for many lashes, usually with a shorter cane or whip, a greater contact area such as the whole of the back and not necessarily with maximum force.

I have examined a number of victims of multiple lashes from Iran where a sentence of 70 or more lashes administered in one session is not unusual for someone accused of drinking alcohol, for example.

There are other clinical consequences beyond the immediate pain and risk of infection. Psychologically, flogging may cause feelings of fear, anxiety, humiliation and shame

The more blows are inflicted on top of one another, the more chance of open wounds being caused. This is important because they are likely to be more painful and at risk of infection, which will cause further pain over a prolonged period as infection delays the wounds' healing.

In Mr. Badawi's case, a newspaper interview with his wife states he has developed diabetes. This condition has some specific effects on the immune system and the body's ability to heal injuries and fight infection. Diabetics are advised to take more care of minor injuries than other people for this reason, and because if infection takes hold it can also significantly impair their blood sugar control causing exacerbation of their diabetes.

A further session of 50 lashes before the first have completely healed would risk reopening wounds, increasing the risk of infection.

There are other clinical consequences beyond the immediate pain and risk of infection. Psychologically, flogging may cause feelings of fear, anxiety, humiliation and shame. Anticipation of the next scheduled flogging is likely to cause heightened emotions especially of fear, anxiety and difficulty sleeping. Individuals may have different levels of reserves to cope with such feelings, and undoubtedly support from others may be extremely important in helping them to cope, but pain and fear together over a prolonged period have a deeply debilitating effect and recovery from such experiences may take considerable time.

Medical role: The routine involvement of doctors in the process is of concern. While it does at least allow for the possibility of the doctor finding a person unfit for the punishment and arranging for treatment of their injuries, any time the doctor gives medical sanction to the punishment going ahead they are in breach of their medical ethical code, to protect their patient and do no harm. For the doctor in such a role, employed by State authorities who are enforcing judicial corporal punishment, their obligations are clearly set out in the UN Manual on the Effective Investigation of Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment 1999- the 'Istanbul Protocol' . The protocol sets out how doctors must refuse to comply with procedures that may cause direct harm, or leave patients vulnerable to harm, they must ensure their contract allows independence of clinical judgements and have a duty to speak out if their patients' health is threatened or they do not have adequate access to treatment needed. In practice, this places doctors who work in such settings in a very difficult situation, as there may be institutional or direct pressure or coercion to comply with the states' wishes and the orders of senior officers. Medical Associations in such countries, and the World Medical Association, have an important role in supporting doctors to keep to their ethical obligations.