A/HRC/38/36 international human rights treaties also contain provisions to protect the right to health of specific groups, including persons in situations of deprivation of liberty and confinement. 23. The Standard Minimum Rules for the Treatment of Prisoners (the Nelson Mandela Rules) include provisions on the responsibility of States regarding health care for persons detained in prisons (rules 24–35). For example, States have the obligation to ensure that medical services in prisons guarantee continuity of treatment and care, including for HIV infection, tuberculosis and other infectious diseases, and drug dependence. Also set out in the Rules is the obligation to transfer prisoners requiring specialized treatment to specialized institutions or civil hospitals, and to ensure that clinical decisions are taken solely by responsible health-care professionals and not overruled or ignored by non-medical prison staff. 24. Bearing in mind the goal of the progressive realization of the right to health, measures are needed to ensure its realization in closed settings, including a plan to end forced confinement in hospitals and long-term care institutions. Such a plan must be supported by strategies to strengthen community-based alternatives.16 Informed consent17 25. The right to informed consent is a fundamental element of the right to physical and mental health. Informed consent involves a voluntary and sufficiently informed decision, and serves to promote a person’s autonomy, self-determination, bodily integrity and wellbeing. It encompasses the right to consent to, refuse or choose an alternative medical treatment.18 26. While the right to consent to and refuse treatment involves careful consideration in the context of life-saving procedures, it must otherwise be respected, protected and fulfilled, notably in cases of isolation and confinement, where support and encouragement must be provided so that treatment is completed voluntarily. However, the right to consent to treatment continues to be ambiguously applied among those deprived of liberty, who remain at a high risk of being subjected to coercive, involuntary or mandatory testing and treatment, including compulsory drug testing, research trials and, among hunger strikers, force-feeding; in other cases, organs have been removed from executed prisoners without prior consent. These types of practices are harmful and some have implications on the reporting of symptoms for testing and treatment of stigmatized infections, such as HIV infection and tuberculosis. Equality and non-discrimination 27. Entrenched inequalities and discrimination characterize the experience of deprivation of liberty and confinement, from the discriminatory apprehension of persons to the discriminatory and inequitable arrangement of services once a person is deprived of liberty or confined. 28. Health and prison officials often perpetuate discrimination through the denial of health care, including opioid substitution therapy, clean needles and syringes, antiretroviral therapy, and sexual health supplies or contraceptives. The status of being incarcerated can elicit prejudicial action by prison and health officials. Those seeking health care in prisons, detention centres and settings of confinement, particularly those with serious health issues, are often denied access as a form of informal punishment; access has also been denied where they are wrongly deemed to lack legal capacity on the basis of a perceived or actual impairment or other reasons. Barriers to ensuring non-discriminatory access to health care, including health-care facilities that are independently regulated outside the penal system, must be addressed immediately. The failures of staff training in this regard demonstrate the need for alternative and assertive approaches. 16 17 18 A/HRC/35/21. For more on the issue of informed consent, see A/64/272, paras. 9, 28, 34 and 79–84. Ibid., para. 10. 7