Australia's punitive policy towards people seeking asylum deliberately causes severe psychological harm and meets recognised definitions of torture. Consequently, there is a tension between doctors' obligation not to be complicit in torture and doctors' obligation to provide best possible care to their patients, including those seeking asylum. In this paper, we explore the nature of complicity and discuss the arguments for and against a proposed call for doctors to boycott working in immigration detention. We conclude that a degree of complicity is unavoidable when working in immigration detention, but that it may be ethically justifiable. We identify ways to minimise the harms associated with complicity and argue that it is ethical to continue working in immigration detention as long as due care and attention is paid to minimising the harms of complicity.

Our patient was a 14-year-old girl who presented with a 3-week history of intermittent fresh bleeding from her conjunctiva, nose, ears and nail beds. The bleeds would occur spontaneously with no obvious triggers, and would last for several minutes. She sought further medical attention because of the increasing frequency and duration of the bleeds, which were consistently worse during the warmer months.With respect to the haemolacria (Fig. 1), she gave no history of conjunctival trauma, and complained of no associated ocular pain or irritation. The bleeds would initially begin as a trickle of blood along the conjunctiva lining her lower eyelid, but could become profuse with clots and spill over her cheeks. It was noted that when she cried physiological tears they appeared normal.She next presented with spontaneous bleeds from the hair follicles in her scalp (Fig. 2). This could occur several times in a day, and was associated with a bilateral temporal pulsating headache. We were able to witness and record multiple spontaneous bleeding episodes during her hospital admissions.She had begun regularly menstruating a year before these episodes began, and other than menorrhagia, her cycles were normal and had no temporal association with her bleeding episodes and her menstrual cycles. We trialled her on the oral contraceptive pill, which did not change either the frequency or intensity of her spontaneous cutaneous bleeds, of which she continued to have up to 20 episodes per day. Similarly she had no symptomatic improvement with either the subdermal progesterone implant or transexamic acid.Opinion was sought from multiple Specialty teams, including haematology, opthalmology, dermatology, gynaecology, ENT and rheumatology, but they were not able to offer an explanation for her bleeding tendency despite multiple investigations (Table 1).We have done multiple literature searches in an attempt to identify other potential interventions to help our patient. Following success in case reports by Wang et al., 1 we trialled her on propranolol; however, this was ineffective for our patient at a maximally tolerated dose. A recent report by Biswas et al.2 found atropine transdermal patches to be effective, but patch application is not practical given the location of our patient's bleeds. Systemic atropine seems inappropriate with respect to the potential side effects.We have continued to monitor her clinical course in the General Paediatric clinic. At the peak of her bleeding episodes, she progressed to have bleeds from her palms, feet and ears, in Key Points1 Unexplained intermittent bleeding in the paediatric setting poses a diagnostic dilemma for clinicians. 2 Haematohidrosis is an unusual presentation without a defined pathogenesis. It is important to consider a range of haematological and other organic diagnoses, in addition to the potential psychological causes and effects of the symptoms. 3 In the face of medically unexplained symptoms, it is important for clinicians to maintain an open mind in working through differential dia...

No abstract