“The involvement of doctors in direct or indirect abuse of prisoners is not just a stain on medical ethics. By abandoning our principles, we add fuel to the fires of distrust and despair, and increase the risk to us all, as the recent outrages in London demonstrate.” Michael Wilks The Lancet 2005; 366:429-431 6th August 2005-08-03
This article quoted above covers the role of doctors in torture and the abuse of prisoners' human rights which has been known about and documented for many years. “ It is therefore disturbing that the cultural and social factors that have seduced individual health professionals and their institutions into participating in abuse have persisted, and have therefore remained unchallenged” , says the author.
He argues that Governments and representative medical bodies have been “ adjusting and blurring their ethical guidance, tilting themselves towards endorsement of gross ethical malpractice”.
Problems were highlighted in 2004 with allegation of sordid mistreatment of prisoners by military staff ( and further horrifying details are still being censored) at Abu Ghraib, and in the detention centre at Guantanamo Bay.
The role of doctors was reported in the press (Slevin P,Stephens J. Detainees' medical files shared. Washington Post June 20 2004 / Lewis N. Interrogators cite doctors' aid at Guantanamo. New York Times June 24 2004) and was further reported in the New England Journal of Medecine Lifton R. Doctors and torture. N Engl J Med 2004; 351: 415-416. /. Bloche M, Marks J. When doctors go to war. N Engl J ed 2005; 352: 3-6. ) Steven Miles researched the prison’s medical treatment, he found that medical records and death certificates were falsified, clinicians had given interrogators their subjects’ medical histories, medical assistance was denied, and medical professionals had consistently failed to report injuries and deaths caused by torture. In some instances, health workers directly aided torture. Miles related one incident in which a doctor called to suture a beaten prisoner gave the suture materials to the man’s attacker, a guard, and allowed him to treat the wound unsupervised.
These reports, confirmed by a US Gubment report And were confirmed and also by a leaked report from the International Committee of the Red Cross, proved medical staff were negligent in failing to report evidence of torture, failing intervene to stop it being repeated, and made available to interrogators information from confidential medical files, thereby allowing interrogators to exploit weaknesses. There is speculation, but no evidence, that death certificates of those who died under torture have been falsified. The former doctor to the President’s father recently and publicly reflected the medical profesions repugnanace to these events (Lee BJ. The stain of torture. Washington Post July 1 2005).
History shows that professional silence will ensure the persistence of such practices. If effective steps are to be made to stop this corruption of ethics, we must accept this corruption is a disease, with a documented aetiology, and has so far defied treatment.
Citing the Nazi practices raises hackles and the hair on your neck, but the involvement of German doctors in the 1930s and 1940s remains an indelible stain on medical ethics; massive and active “euthanasia” and experiments involving Jews, gypsies, and the mentally ill were undertaken without apparent question, concern or guilt.
Lifton in writing “The Nazi doctors: the psychology of medical killing” Papermac 1986 explained how this happened.
1. Uncritical acceptance of a state ideology that created scapegoats for the ills of society.
2. “Doubling” - an ability to exist in two separate but functional halves.
3. Fear or reprisals
4. Poor understanding of basic medical ethical principles.
Examples can be cited subsequently in South Africa, Chile, Turkey, and the former USSR where the negligence became embedded and accepted.
The author argues the same factors are at work in Guantanamo and Abu Ghraib, and no doubt elsewhere in the worldwide secret maze of US prisons and their surrogate jailers and torturers.
In February, 2002, George W Bush, infamously said that Al Qaeda terrorists were no longer covered by the Geneva Convention. In August, a legal memo from the US Justice Department for Alberto Gonzalez, then Counsel to the President, now Attorney General, attempted to redefine torture, stating that “for an act to constitute torture … it must inflict pain that is difficult to endure”. The memo continued: “Physical pain amounting to torture must be equivalent in intensity to the pain accompanying serious physical injury, such as organ failure, impairment of bodily function, or even death.”
US medical bodies publicly remained silent whatever reservations may have been felt or made in private. This failure to oppose and criticise, put prisoners, already incarcerated without trial or access to legal representation, at the mercy of unprincipled doctors.
This inertia is bad enough, but more worrying trends are evident — Gubments and professional bodies rewriting existing ethical guidance in the service of abuse. US Secretary of Defense for Health, William Winkenwerder, accepts that some medical personnel working at Guantanamo are not providing direct care for patients, but are using their skills “to assist the interrogators”, in the role of “behavioural scientists”. These personnel are not answerable to the Department of Defense, but to military intelligence, and work within Behavioural Science Consultation Teams, commonly known as “Biscuits”.
Silence was not total , at Harvard Medical School Ethical Division on March 1st 2005 Leonard Rubenstein, (Executive director of Physicians for Human Rights) Steven Miles, and Robert Jay Lifton discussed how these professionals made the choices they did, and how to help future medical personnel choose differently.
They asked the audience to envision the nurse and her colleagues, medical professionals who falsified medical records, tampered with corpses, and collaborated with violent and humiliating interrogations. “Imagine what it’s like to be a medical professional at Abu Ghraib or Guantanamo Bay.”
Medical workers were caught between their duties to their patients and their duties to the military.Steven Miles of the University of Minnesots gathered evidence from U.S. congressional hearings, sworn statements of prisoners and soldiers, medical journal accounts and news reports to build a picture of physician complicity, and in isolated cases active participation by medical personnel in abuse at the Baghdad prison, as well as in Afghanistan and at the Guantanamo Bay detention center in Cuba.
In one example, cited in a sworn statement from an Abu Ghraib prisoner, another prisoner collapsed and was apparently unconscious after a beating. Medical staff revived the prisoner and left, allowing the abuse to continue, Miles reported.(Also covered in Aug 2004 Lancet Report)
“The doctors at Abu Ghraib were part of a military structure that orchestrated torture until it became normal,” said Lifton, HMS lecturer in psychiatry at Cambridge Hospital and distinguished professor emeritus of psychiatry and psychology at the City University of New York.
Lifton pointed to the unique respect accorded to medical professionals, and said that their presence can “medicalize a criminal event.” Rubenstein agreed, saying that “health personnel should never be instruments by which the state commits human rights violations.”
The Pentagon has subtly changed the wording says Wilkes of a 1982 UN resolution so that Bush's memorandum has placed these suspects outside a protective legal framework, and the Pentagon's guidance allows professional expertise to be used in interrogation techniques.
US medical professional medical bodies have tended to blur ethical boundaries the American Psychiatric Association's Statement on Psychiatric Practices at Guantanamo Bay is weak. The American Psychological Association's “Presidential Task Force Report ”,rehearses conventional ethical principles about care of individual patients, then loops the loop on sanctioning input from psychologists and advice on techniques to be used in interrogation. In effect, it becomes acceptable for a health professional to dispense with any ethical responsibilities if “their training and expertise is used outside a strictly therapeutic context “. Grossly unethical maybe but this professional body has no problems.
What can be done? Wilkes wants an end to the assault, led by the USA and UK Governments on international bodies, such as the United Nations.
The forthcoming World Medical Association meeting in October should put the subject on the agenda. Second, the lack of ethical knowledge identified by Lifton in pre-war Germany should be rapidly corrected by a renewed effort to map out the ethical boundaries appropriate for doctors acting in areas of dual responsibility,at undergraduate and postgraduate level.
He doesn’t say it, but a bit of personal responsibility and moral concern by the doctors involved would be a good starting point.
Robert Jay Lifton (left) and Leonard Rubenstein discuss ways to avoid dual loyalty conflicts in military prisons. (Photo by Liza Green, HMS Media Services)