CENTER FOR PRISONER RIGHTSHEALTHCARE GUIDEFor Detainees & Prisoners in Japan's Penal Institutions

OVERVIEW:

Foreword
The Centre for Prisoners' Rights (CPR) receives many
queries from the inmates of detention centres, prisonsand other penal institutions, as well as from theirfamilies and friends. A large number of these queries
involve serious issues regarding the medical carereceived by the people detained. This booklet wastherefore created to address these issues, and we hopethat it provides a certain amount of help in ensuring thephysical and mental health of inmates as they prepare
for their return to society.

(P2) Features of Medical Care at
Penal Institutions
Medical Expenses
Emphasis on Security(P3) Medical Care Standards at
Penal Institutions(P4) Detention Facility Issues(P5) Medical Care Systems at
Penal Institutions(P6) When Medical Care is
Entrusted to External Institutions(P6) Medical Examinations(P7) Medical Care by Appointed
Doctors(P8) Claim for Review(P9) Suggestions and Opinions ofPenal Institution Visiting
Committees(P10) Informed Consent(P11) Message to Inmates1Features of Medical Care at Penal Institutions
Penal institutions can be largely divided into detention centres housing mainly people
currently undergoing court cases or inmates sentenced to death, and prisons housing
sentenced inmates.
Prisons are further divided into facilities for men and for women, facilities for longterm sentences and short-term sentences, facilities for habitual criminals (repeat
criminals) and non-habitual criminals (first-time criminals), and facilities that differ
depending on the physical and mental condition of the inmates. The lifestyles andmedical care environments are different within each individual facility.

Medical Expenses

Emphasis on Security

All treatment and medical carereceived by inmates of penal
institutions is free of charge as abasic principle. The facilities cover
all costs incurred in doctor
examinations, tests and prescription
issuance, etc., which means thatthese costs are included in the
Ministry of Justice’s budget.

Given the general nature of penal
institutions, they naturally have atendency to place emphasis on
security rather than medical care.

The obligation to and responsibility
for protecting the life and health of
all inmates lies with each penal
institution. Considering that thestate is exercising its right to“deprive citizens of their freedom”, itis natural for the state to be charged
with this responsibility. If
applications for treatment by
designated doctors (details provided
later) at the expense of inmates are
accepted, then the full cost of thismust be incurred by the applicant.

Understandably, they must prevent
prisoners from incidents such as“escaping”, “the outbreaks ofviolence” and “inmate suicide”. The
provision of external medical carerelies on the availability of detention
officials to escort detainees. When
staff are not available to escort
detainees, visits to external medical
facilities might not be possible.

2Medical Care Standards at Penal Institutions
Article 56 of the “Act on Penal Detention Facilities and the Treatment of Inmates andDetainees” set out that “adequate hygienic and medical measures in accordance withpublic standards of hygiene and medical care shall be established.”
A cause for concern here is defining the meaning of “public standards.”
For example, Article 57 states that “Except on Sundays and other days specified by the
Ministry of Justice Order, inmates must be provided with the opportunity to haveadequate outdoor exercise as far as is practical for the purpose of maintaining theirhealth.”Article 24 of the “Regulations for Penal Institutions and Treatment of Inmates”(hereinafter known as the “Treatment Regulations(shoguu kisoku)”)
pertaining to this and issued by the Ministry of Justice states that “inmates must be
provided with the opportunity to exercise for as long a period as is possible amounting
to not less than thirty minutes per day.” Although this regulation states “not less than
thirty minutes,” apparently in nearly all cases, exactly thirty minutes is allowed.

処遇規則

The same Treatment Regulations also state that inmates must be allowed to bathe “atleast twice per week.” This regulation is also covered in further detail in the “Internal
Regulations(nai ki)” issued by each institution, as well as being listed in the“Handbook for Life Inside the Institution(shonai seikatsu no tebiki)”
available in each room.

内規

所内⽣活の⼿引き

If the “Internal Regulations” or actual operational conditions provide fewer number ofbaths or shorter bathing times than those listed in the “Treatment Regulations”, thiswill constitute an issue of illegality.
Q: The exercise times and bathing times at the institution I am committed to include
the time required for traveling to and from the relevant facilities, so the actual timespent there is very short.
A: There is a tendency for the minimal times and minutes stated in “at least XX times”
and “at least XX minutes” being observed during actual operations. Given the style inwhich these details are written, it should be clear that they are calling for the actual
exercise times and bathing times to be interpreted as the minimum length of time
permissible. If shorter times are being normalized, then the suggestions and opinions,etc., submitted to the Penal Institution Visiting Committees (see page 9) should call3
attention to this and appropriate steps demanded.

Detention Facility Issues
The places where people who have beenarrested are first detained are often thedetention facilities in police stations(also known as police cells). Thesefacilities are designed to house suspects
temporarily and consequently do nothave any resident doctors or nurses, andvery little consideration is given to theimpact that detaining suspects over long
periods of time may have on theirhealth.
However, these facilities are also known as “substitute prisons” (or “daiyo kangoku” inJapanese), and they have many inherent issues due to the fact that they continue to be
used for the post-arrest period of confinement and to confine suspects after they havebeen indicted.
For example, there is a tendency for detainees in police stations to be easily provided
with sleeping pills and other medications upon request compared to other penal
institutions (detention centre and prison). One of the reasons for this different approach
might be that detainees in police station are yet to be indicted. However, detainees
might be wrongly provided with an inappropriate amount of medicines, creating
potential for overdoses in some cases from a medical perspective. When these dosages
are reduced or withdrawn after detainees are moved to other institutions, there areoccasionally complaints that “the drugs they used in the police cells can no longer beobtained.”
The health and medication of detainees needs to be carefully monitored and continued
when they are moved from detention facilities to other penal institutions. In otherwords, medication prescribed for neurological disorders has side effects, and care must
be taken when they are used and after they have been withdrawn.

4Medical Care Systems at Penal Institutions
Penal institutions are, in order of substantiality of medical care provided, broadly
categorized into the 3 categories of specialized medical facilities, medical priority
facilities, and general facilities.

Specialized Medical Facilities (4)Medical Priority Facilities (9)East Japan Medical Correction Centre(Akishima City)*Integrated with the Hachioji Medical Prison(for inmates with physical and mental
disorders) and inaugurated in 2018.
Okazaki Medical Prison(for inmates with mental disorders)
Osaka Medical Prison(for inmates with physical and mental
disorders)
Kitakyushu Medical Prison(for inmates with mental disorders)

Sapporo Prison
Miyagi Prison
Fuchu Prison
Tokyo Detention Centre
Nagoya Prison
Osaka Prison
Hiroshima Prison
Takamatsu Prison
Fukuoka Prison

Inmates suffering from illnesses and disorders that are difficult to treat at generalfacilities are moved to medical priority facilities and specialized medical facilities.
General facilities are equipped with medical departments (or medical sections), withthe medical departments operating medical facilities (clinics) required by law andstaffed by one or two doctors, a pharmacist and a nutritionist, etc. They generally do
not employ nurses, although several prison wardens with assistant nurse
qualifications assist the doctors.
Q: I felt unwell and requested a check-up to a staff member, but this was refused because “thedoctors were busy”, and instead I was asked to “state my temperature” and was then told that “I
didn’t need a doctor for such a trivial reason” and that I “should take medicine and see what
happens.” Isn’t such treatment against the law?
A: Article 10 of the “Regulations on the Health, Hygiene and Medical Care of Inmates andDetainees” stipulates the following with regard to who makes the decisions as to whether or not toallow medical examinations by doctors:“Article 10: (1) Wardens of penal institutions shall ensure that nurses or assistant nurses have a fullunderstanding of the reasons for inmates applying for treatment for injuries or underlying illnesses…(omitted)… and shall report said applications to doctors, etc., once the nurse or assistant nurse
concerned have come to a decision on the urgency, etc., of medical examinations. (2) The doctors,
etc., in receipt of the reports stipulated in the previous paragraph shall decide whether or not
medical examinations are required.”5

Was the “staff member” mentioned a prison warden in possession of assistant nurse qualifications?
Even under the assumption that the staff member in question was a qualified assistant nurse, itneeds to be noted that this was a “decision on the urgency of a medical examination” and not adecision on “whether or not medical examinations are required,” and the question as to its “legality”
or “illegality” notwithstanding, that manner of treatment is problematic in the context of theregulations.”
Incidentally, the duties that do not necessarily need to be directly carried out by doctors
themselves as listed in the “Medical Matters in Correction Facilities(Kyousei Iryou)”booklet issued by the Japanese Correctional Association include (1) The creation of documentation,etc., as a doctor assistant; (2) Adjusting the dosages of medication based on instructions provided inadvance by doctors; (3) Giving intravenous injections in accordance with instructions provided bydoctors or dentists; and (4) Making decisions on the order of priority for providing medical care
(page 6 of “Kyousei Iryou” booklet).

矯正医療

When Medical Care is Entrusted to External Institutions
When penal facilities have difficulties securing doctors, there are cases in which
medical care is entrusted to external institutions.
According to the April 2015 edition of the “Kyousei Iryou” booklet, “There are cases inwhich the management, etc., of clinics set up in domestic facilities is entrusted toexternal institutions, and cases in which the medical care offices in facilities have been
set up by private medical care companies” in Tsukigata Prison, Kitsuregawa
Rehabilitation Program Centre, Nagano Prison, Shimane Asahi Rehabilitation Program
Centre, Mine Rehabilitation Program Centre and other such facilities.

Medical Examinations
As stipulated in Article 61 of the “Act on Penal Detention Facilities and Treatment of
Inmates and Detainees”, penal institutions are required to provide medical
examinations when an inmate first enters the facility and thereafter at least once
every year. This Article also states that “Inmates must submit to the medical
examinations prescribed in the preceding paragraph.”
Article 29 of the “Regulations for Penal Institutions and Treatment of Inmates” lists
various health check items that must be included in the medical examinations,although it also stipulates that certain items “may be omitted if the doctor deems them
unnecessary,” and in actual fact nearly all of these items are omitted as being“unnecessary.”

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Medical care by Appointed Doctors
A system for providing “medical care by appointed doctors” is included in “The Act on
Penal Detention Facilities and Treatment of Inmates and Detainees.” This systemallows penal institution wardens to use their discretion in allowing inmates to receive
medical care by external doctors at their own expense if so requested.
This system was highly anticipated and welcomed heartily by inmates and the people
involved who were dissatisfied and distrusted facility doctors, but instead of allowing
inmates to visit external facilities for medical treatment, it simply requires external
doctors to bring the instruments and equipment needed to the facility so that thetreatment can be provided there, which makes it extremely difficult to find doctors
willing to accept these conditions. Even if doctors who agree to these limitations canbe found, there are various other restrictions in effect before they will be permitted toprovide treatment.
A report titled “The Situation Pertaining to the Enforcement of the Act on Penal
Detention Facilities and Treatment of Inmates and Detainees” issued by the Ministryof Justice in May 2011 states that, “A total of 22 instances in which medical care wasprovided by appointed doctors have been recorded since the enactment of the Act(treatment provided: dentistry, dermatology, orthopaedics, cardiology, etc.), and it
cannot be said that this provision is being actively implemented.” The stipulations
were revised following this to omit the condition stating that “inmates must have beentreated by said doctor prior to their confinement,” but despite this, the number ofcases in which appointed doctors were permitted to treat inmates are as shown below.
2012: 10 cases (implants, compartment syndrome, neck and back pain, etc.)
2013: 9 cases (dental treatment, implants, functional recovery rehabilitation, gender
dysphoria)
2014: 7 cases (dental treatment, implants, gender dysphoria, post-accident disorders)
2015: 6 cases (dental treatment, implants, gender dysphoria)

7Claim for Review
With regards to matters such as penal institution wardens “refusing to permit medicalcare by appointed doctors” and “suspending medical care by appointed doctors”, it ispossible to file an appeal under the title of “Claim for Review(Shinsa no
Shinsei)” with the Regional Correction Headquarters.

審査の申請

If objections arise with regard to the manner in which this is arbitrated, it is possible tofile a “Reclaim for Review(Sai Shinsa no Shinsei)” with the Minister ofJustice. When such reclaims are filed, the Ministry of Justice Correction Bureau will
investigate and review the matter. In the event of the case moving toward a situationin which it may be “rejected(ki kyaku)” due to a verdict stating that the measures
implemented by the facility were neither illegal nor inappropriate, the opinions of the“Research Study Committee on Administrative Review of Appeals from Inmates inPenal Institutions” (abbreviated to “Appeals Committee”), consisting of jurists,
lawyers, doctors and other influential people in the private sector, may be heard inadvance.

再審査の申請棄却

The results of these reclaims are posted on the Ministry of Justice website every
month. There are certain restrictions imposed on the Appeals Committee in thatdebate is only carried out under the assumption that the Corrections Bureau’s
decision to reject the case is considered to be appropriate, and there are hardly any
cases in which discussions deliberate on the illegality or inappropriateness of thedecision. However, there are cases in which the opinion of the Ministry of Justicestates that the decision was inappropriate. For example, the following “proposal” wasposted on March 9th, 2017.
“With regards to the reclaim to review a case submitted by an inmate of a penal
institution who has yet to be sentenced, in which the administrative authority concerned did not permit theapplicant to receive medical care from an appointed doctor, it is deemed that the appropriate response is torescind this decision.”

Filing a “Reclaim for Review” should be considered when there is an objection to theverdict of the “Claim for Review”.
Q: A “Claim for Review” does not appear to cover medical issues outside of appointed doctors,
so are there any other procedures available for raising requests or objections to other health or medicalcare issues?

苦情の申出

A: It is possible to file “Complaints(Kujou no Moushide)” regarding all treatment received inpenal institutions. The complaints that can be filed are those against penal institution wardens, thoseagainst inspectors, and those against the Minister of Justice (“inspectors” are workers designated by the
Minister of Justice to carry out on-site inspections at penal institutions at least once per year).

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Writing letters to “Penal Institution Visiting Committees”, explained below, is also effective. In addition,
applying for “human rights assistance(Jinken Kyuusai Moushide)” to the “Human Rights
Protection Committee(Jinken Yougo Iinkai)” run by the Bar Association will initiate an
investigation that includes meetings with lawyers, etc., and in the event of a problem being identified,
the Committee will issue either “Warnings(keikoku)”, “Recommendations(kankoku)” or“Requests(youbou)” to the facility concerned. Although there are differences according to region,
the Human Rights Protection Committee in charge are restricted to a certain extent in their
movements, and the actual investigation requires a lengthy period of time. Even if a “Recommendation”,
etc., is issued, there are, unfortunately, very few cases in which this will result in improvements being
made.

要望

⼈権救済申⽴⼈権擁護委員会
警告

勧告

Although the available procedures might be lamented as useless, the higher the position of the staff inpenal institutions, the more they will need to be conscious of external scrutiny. There are eveninstances where “Complaints” that were filed against penal institution wardens and then left
unattended for long periods of time, suddenly receiving improvements upon submission of “Human
Rights Assistance Applications”. The Human Rights Protection Committee are also, surely delighted
when they receive such reports.

Suggestions and Opinions of Penal Institution Visiting Committees

刑事施設視察委員会

All prison facilities have Penal Institution Visiting Committees(Keiji Shisetsu Shisatsu Iinkai). Lawyers recommended by the Bar Association anddoctors recommended by local medical associations take part in these committees.
Penal Institution Visiting Committees retain the right to point out problems andsubmit proposals and recommendations to request for improvements.

Penal Institution Visiting Committees are not organizations established for the
purpose of providing assistance for human rights infringements against individuals.
The Visiting Committees inspect facilities and then provide their opinions to penal
institution wardens with regards to administrative matters. That being said, issues
pertaining to medical care usually come under the direct jurisdiction of facility
administration. The committee members include doctors to enable them to accurately
understand all issues related to medical care, and the recommendations the committee
submits are highly respected by the penal institutions concerned. These opinions also
carry more weight than those issued by the Bar Association and external NGOs.
In addition, Visiting Committees are allowed to read medical records archived byprisons and are able to question doctors depending on the circumstances. Their ability
to access necessary information in this way is the greatest advantage they have.
The Visiting Committees consider the issues facing facility administration and thenpoint out and demand improvements, and there are cases in which this changed theway in which inmates are treated. There are even cases in which this has resulted in9inmates being moved from general facilities to medical priority facilities and receiving
medical care from external hospitals. The providing of information to the Visiting
Committees can come from inmates, their friends, and their families. This information
is to be addressed to the “Visiting Committee at the XX Prison (“Insert Facility Name”)” (or other facility names, such as Detention Centre or Rehabilitation
Program Centre, etc.). Prison offices are not permitted to open letters addressed to
the Visiting Committee and they are always opened by committee members, so there
is no fear of information being leaked to the prison authorities.

視察委員会御中The Ministry of Justice releases a “List of Measures and Other Reports Based on theOpinions of Penal Institution Visiting Committees” once every year. These also
contain a certain amount of opinions relating to medical care.

Informed Consent [Explanations and Agreements]
Informed consent requires doctors to fully explain the purpose of medical care topatients and obtain their consent, and it is based on a principle of granting maximum
respect to the right to choose and the free will of patients.
However, the medical care provided in prison facilities, where receiving medical carefrom doctors itself is a complex procedure, means that in reality, it is difficult for
prisoners or detainees to receive satisfactory explanations on their own illnesses andmedical care. It is even difficult to obtain copies of one’s own medical records, so it is
impossible to have family members, etc., obtain the opinions of external doctors
separately.
Requests for the release of information are handled in accordance with stipulations
laid down in the inherent Personal Information Protection System, which states that“requests for the release of information include the risk of a person’s past criminal
records being divulged, which puts said person at a disadvantage upon their return tosociety and during rehabilitation,” and court verdicts have precedent for suchinformation being exempt from public release, as in “The information belonging
to Penal Detention Institutions may reveal details of detention methods if released,regardless of whether or not said information contains independent details, and thiscomes under the jurisdiction of it being personal information that must be protectedunder the application of Article 45 Paragraph 1 of the Act on the Protection of
Personal Information Held by Administrative Organs” (Tokyo High Court judgment
issued on July 9th, 2008).
The “Instructions on the Handling of Inmate Medical Records and the Provision of
Medical Care Information” calls for medical workers in penal institutions to pursue
Informed Consent.

10Message to Inmates
From the Center of Prisoner Rights
There is no doubt that many different issues pertaining to
medical care in penal institutions exist.
It is also true that seeking litigation (in courts of law) to address the medical care issues in penal
institutions is not recommended. There is no guarantee that suing the state will result inappropriate medical care being provided, and because litigation requires extremely long periodsof time, it may result in irredeemable situations prior to a verdict being reached in the case ofpeople suffering from serious illnesses. It is necessary to place the emphasis on recovery while
using all available means to access appropriate medical treatment.
If disorders are overlooked in penal institutions or if grave situations caused by errors in medicalcare arise, one way is to file a case requesting compensation from the state. The first step for thisis to contact the Japan Legal Support Centre Houterasu (see below). They can provide advice on
your chances of winning the case and on the costs that will be incurred.

Japan Legal Support Center Houterasu
0570-078377

0570-078374(Multilingual Information Service)
Hours: Mon-Fri (0900-1700)(Japanese Service)
Hours: Mon-Fri (0900-2100)
Sat (0900-1700)

https://www.houterasu.or.jp/en/index.html*The original Japanese version of this guide was published in January 2018 with the assistance of the “Pfizer
Program: Assistance for Citizen Activities and Citizen Research into Mental and Physical Health Care”.

Disclaimer: This English-language version is produced by the Center for
Prisoner Rights in collaboration with the British Embassy Tokyo.
Center for Prisoners’ Rights Japan
Address: Lions Mansion #703,
2-3-16, Shinjuku, Shinjuku-ku, Tokyo, Japan, 160-0022
E-mail: info@prisonersrights.org
Phone-FAX: +81(0)3-5379-5055
Published May 202111