Time for doctors to stand up our professional ethics
“Where were the doctors?” asked physician and bioethicist Steven Miles after the Abu Ghraib photographs became public.
1۔ A recent task force report from the Institute of Medicine as a Profession (IMAP)/Open Society Foundations provides a disturbing answer.
2. The report discloses that, among other unethical roles, doctors in Abu Ghraib, Guantanamo, and CIA secret prisons were monitoring oxygen saturations during waterboarding, watching for edema in detainees forced to stand in stress positions, and helping increase psychological distress by sharing prisoners’ individual health information with interrogators. Despite criticism, the Department of Defense and the CIA have left in place many protocols that allow, even encourage, this degradation of professional ethics. Given the evidence of the involvement of health professionals in “enhanced” interrogations, we believe that health professionals, international medical societies, and licensing boards should actively oppose this involvement in the abuse of prisoners.
In 2009, President Obama used his executive authority to end the CIA’s detention and interrogation program. But, owing to classification, we still do not fully know the current standards for the involvement of medical personnel in interrogations, and evidence suggests that abusive interrogations continue today.3 In addition, the US government has thwarted efforts to make those involved—including healthcare professionals—accountable, by obstructing the release of information and refusing to prosecute potential crimes. This hazy legacy of confronting abuse dilutes the moral authority of the United States to judge the human rights abuses of other countries.
The United Nations Convention Against Torture defines torture as “any act by which severe pain or suffering, whether physical or mental, is intentionally inflicted on a person . . . at the instigation of . . . a public official.”4 The infamous Bush era “torture memos” medicalized the term “severe suffering,” redefining it as “equivalent in intensity to the pain accompanying serious physical injury, such as organ failure, or impairment of bodily function, or even death.”5 They also mandated that medical professionals be present during interrogations as “safety officers,” flagging suffering as severe enough to merit intervention. These professionals provided protection: if the doctors said no lasting harm would occur, there would be no legal culpability, no matter what harm did occur.
These abusive roles represent a dramatic departure from conventional medical ethics, which are anchored in the “do no harm” principle. Many professional societies, including the American Medical Association and the BMA, have issued strong statements condemning any involvement of physicians in interrogations. In pointed contrast, the American Psychological Association allows involvement of members in interrogations as long as cruel treatment is avoided. The IMAP report calls on professional organizations—specifically the American Psychological Association—to strengthen their ethical stances regarding provider involvement in interrogations.
However, organizational policies alone do not provide an adequate framework to protect prisoners or military doctors. The report therefore calls on professional associations to strengthen ethical guidance, to investigate abuses and speak out publicly against them, and to aggressively discipline members found to have participated. Medical societies and licensing boards need to move beyond statements condemning torture to proactively educating members and the public, while ensuring compliance with our ethical standards.
The report recommends several steps to change policies allowing healthcare professionals to fulfill intelligence roles that conflict with their professional ethical mandates, many of which are relevant to international medical associations. Specifically, it calls for policies that allow these professionals to serve in roles, such as interrogation support, that are inconsistent with furthering people’s welfare, to be rescinded. The report also calls for military approval of abusive measures such as sleep deprivation, prolonged isolation, and exploitation of fears, which are still allowed for certain interrogations, to be recalled.
Importantly, the IMAP report also supports legislation to discourage unethical conduct by health professionals toward prisoners. Several US states have pending legislation directing professional licensing boards to investigate and discipline those guilty of such practices.6 This legislation would protect prisoners from the involvement of medical professionals in interrogations and provide clinicians with credible justification to decline such involvement. Crucially, it would codify in law that interactions between healthcare professionals and prisoners should prioritize the prisoners’ health and welfare. In advocating for these legislative approaches, legislators often ask us why they should take on this issue when the health professions are not demanding it. It is therefore vital for healthcare providers and professional groups opposed to the involvement of their members in interrogations to openly support legislation codifying humane policies into law, in the US and abroad.
By adhering to internationally recognized standards and ethical guidelines, healthcare professions can secure our respected position and help safeguard the human rights of all. The IMAP task force report calls on us to reclaim our profession’s unflinching ethical rejection of the involvement of physicians and psychologists in abusive interrogations.
We know where the doctors were then. Where are they now?
NotesCite this as:BMJ 2014;348:g2947
Competing interests: We have read and understood BMJ policy on declaration of interests and declare the following interests: SS has provided unpaid advocacy as past president and steering committee member, Psychologists for Social Responsibility; was a unpaid cofounder, Coalition for an Ethical Psychology; and has provided unpaid consultancy for Physicians for Human Rights. All three organisations actively oppose health providers’ involvement in torture, prisoner abuse, and interrogations. SK is a volunteer medical asylum trainer for Physicians for Human Rights and a volunteer supporting legislative advocacy through the Massachusetts Coalition Against Torture, which promotes Massachusetts’ legislation to prevent the involvement of healthcare providers in torture.
Provenance and peer review: Not commissioned; externally peer reviewed.
Miles S. Introduction. In: Oath betrayed. 1st ed. Random House, 2006:ix-xxvii.
Institute on Medicine as a Profession. Ethics abandoned: medical professionalism and detainee abuse in the war on terror. 2013.www.imapny.org/File%20Library/Documents/IMAP-EthicsTextFinal2.pdf.
Kaye J. Contrary to Obama’s promises, the US military still permits torture. Guardian2014.www.theguardian.com/commentisfree/2014/jan/25/obama-administration-military-torture-army-field-manual.
United Nations General Assembly. Convention against torture and other cruel, inhuman or degrading treatment or punishment. 1984.www.un.org/documents/ga/res/39/a39r046.htm.
US Department of Justice. Memorandum for Alberto Gonzalez counsel to the president. Re: standards for code of conduct for interrogation under 18 USC 2340-2340A. 2013. http://www.justice.gov/olc/docs/memo-gonzales-aug2002.pdf.
The 188th General Court of the Commonwealth of Massachusetts. Bill H.2017. An act prohibiting the participation of healthcare professionals in the torture and abuse of prisoners. https://malegislature.gov/Bills/188/H