Medical Ethics ?

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

Footnotes
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.

References

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

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Afghan Refugees

Coverage of the recent report by the UN High Commissioner for Refugees was commendable in most international media outlets, although some western newspapers did not give Pakistan the prominence it deserves for dealing with a difficult and dangerous problem that was none of its making.

The BBC reported dependably, pointing out that “Afghanistan still accounts for the world’s largest number of refugees, and neighbouring Pakistan is host to more refugees than any other country, with an estimated 1.6 million.”

It is a sad commentary on the collective lunacy of mankind that after thousands of years of social development we find it impossible to live in peace together and that we will never do so. It is shameful that we have created more refugees than ever before and that they exist in squalid misery around the world, but there seems little possibility that the number will decrease to the extent that we can ever heave a sigh of compassionate relief, buoyed by the knowledge that at least some of our fellow-humans have progressed from wretchedness towards what we venture to call normality.

The UN High Commission for Refugees is a saintly organisation run by people whose dedication is admirable, and its latest report – ‘War’s Human Cost: UNHCR Global Trends 2013’ – would, we might think, make even the most callous and iron-hearted extremist give pause for a moment for reflective compassion.

Not a hope. Savages care nothing for human beings, not even the defenceless infants they drive into hopeless misery. The photographs in refugee camps of mothers with their babies are tear-jerking to most people, but the savages are entirely dry-eyed. They care nothing for those on whom they have inflicted endless agony.

The UNHCR states that “by end-2013, 51.2 million individuals were forcibly displaced worldwide as a result of persecution, conflict, generalised violence, or human rights violations. Some 16.7 million were refugees: 11.7 million under UNHCR’s mandate and five million Palestinian refugees registered by UNWRA. The global figure included 33.3 million internally displaced persons (IDPs) and close to 12 million asylum seekers. If these 51.2 million persons were a nation they would make up the 28th largest in the world.”

This is staggering condemnation of the civilisation in which most of us imagine we live. The fact that national governments have permitted such a horrible tragedy to unfold is evidence that we are a morally incompetent species.

I began to become aware of the saintly work of the UNHCR when the first refugees fled into Pakistan from Afghanistan following the Soviet invasion. Indeed I arrived on my first tour of duty in the Subcontinent a few days after Soviet troops arrived in Kabul, and saw the start of the refugee problem, which was heartbreaking.

The Soviets had no idea what they were letting themselves in for in Afghanistan when they invaded in 1979, any more than the Americans had 20-odd years later when they casually assumed that military swagger would result in creation of decent government. The appalling Bush declared in a speech to the UN in 2004

that, “we will finish the historic work of democracy in Afghanistan and Iraq,”

but both the US and the Soviets were defeated by insurrectionists of various persuasions and the only joint achievement they might claim is creation and perpetuation of a vast number of refugees.

When I returned to Pakistan in 1988 it was obvious that the Afghan refugee problem had not gone away. The following year in Quetta I was told by the Afghan mujahideen public relations representative that matters were extremely serious and that international assistance, such as that being undertaken by the mission to which I was accredited, was much appreciated. And this representative, a Mr Karzai (I still have his calling-card, with date inscribed), seemed to be genuine in his concern for his less fortunate country-folk. He may have been a Gucci guerrilla, and he certainly didn’t live in the well-administered but basic camp I visited, but at least he was trying hard for his people.

But in his many years as president Karzai has been unable to encourage many of his fellow-citizens to return to their homeland. As the UNHCR states “one in every five refugees in the world is from Afghanistan” and that last year “renewed conflict and security concerns also displaced 124,000 persons.”

Pakistan has dealt with the Afghan refugee problem on a large scale. While the official figure of resident Afghans with refugee status is 1.6 million, it is obvious that there are very many more Afghans than that living in Pakistan – probably about double the number, some of whom are well-integrated and productive members of whatever local society in which they have settled.

A few, indeed, especially in the transport industry (mostly legal) and drug-trafficking (not at all legal), have become dollar millionaires. But taken as a whole, the Afghan influx has not served Pakistan well. The CIA’s use of Afghan ‘returnees’ from refugee camps to plant drone-alerting tabs on suspects took some time to detect but didn’t create an atmosphere in which Afghan refugees could be regarded with sympathy.

Speaking of his organisation’s report about the appalling plight of refugees, the head of UNHCR, Antonio Guterres, said the obvious, in that “the world is becoming more violent, and more people are being forced to flee.” This honourable man went on to declare that “to see the Security Council paralysed, when all these crises are evolving, is something that doesn’t make sense.”

Exactly. And it doesn’t make sense because the major refugee problems were caused by action or inaction by members of the UN Security Council.

Then Guterres said what most of us think. With conviction that will hardly have endeared him to the centres of power, he declared that “what frustrates me is the suffering of people, to see so many innocent people dying, so many innocent people fleeing, so many innocent people seeing their lives completely broken, and the world being unable to put an end to this nonsense.”

And so far as Afghanistan is concerned, there will be many more innocent people suffering, dying and fleeing as the country collapses into deeper chaos while nobody does anything about it. UNHCR and Pakistan had better be prepared to be even more tolerant, understanding and helpful in the future. And they won’t expect to receive much gratitude from anyone for their efforts.

By: Brian Cloughley

Mr Muhammad Ali Jinnah’s First Address to the New Nation

NOTE: A new country Pakistan was announced at 11:57 on the night between August 14 and 15, 1947 but the Boundary Commission nominated by British government for demarcation between India and Pakistan announced it’s decision on August 17, 1947 (The Radcliffe Award), as such Mr Jinnah did not make a mention to state Jammu and Kashmir in his speech on August 15, 1947.
Radcliffe Award, in total violation of agreed principle, district of Gurdaspur was divided to give passage to India for state Jammu and Kashmir. As a result India, violating the agreement that people of independent states would decide their future, attacked and captured the state of Jammu and Kashmir per force.

Text of the Speech (Delivered on August 15, 1947)
It is with feelings of greatest happiness and emotion that I send you my greetings. August 15 is the birthday of the independent and sovereign State of Pakistan. It marks the fulfilment of the destiny of the Muslim nation which made great sacrifices in the past few years to have its homeland.

At this supreme moment my thoughts are with those valiant fighters in our cause. Pakistan will remain grateful to them and cherish the memory of those who are no more.

The creation of the new State has placed a tremendous responsibility on the citizens of Pakistan. It gives them an opportunity to demonstrate to the world how can a nation, containing many elements, live in peace and amity and work for the betterment of all its citizens, irrespective of caste or creed.

Our object should be peace within and peace without. We want to live peacefully and maintain cordial and friendly relations with our immediate neighbours and with the world at large. We have no aggressive designs against any one. We stand by the United Nations Charter and will gladly make our full contribution to the peace and prosperity of the world.

Muslims of India have shown to the world that they are a united nation, their cause is just and righteous which cannot be denied. Let us, on this day, humbly thank God for His bounty and pray that we might be able to prove that we are worthy of it.

This day marks the end of a poignant phase in our national history and it should also be the beginning of a new and a noble era. Let us impress the minorities by word, deed and thought that as long as they fulfil their duties and obligations as loyal citizens of Pakistan, they have nothing to fear.

To the freedom loving tribes on our borders and the States beyond our borders, we send our greetings and assure that Pakistan will respect their status and will extend to them its most friendly co-operation in preserving peace. We have no ambition beyond the desire to live honourably and let others live honourably.

Today is Jummat-ul-Wida, last Friday of the holy month of Ramazan, a day of rejoicing for all of us wherever we may be in this vast sub-continent and for the matter of that throughout the world. Let the Muslim congregations in their thousands, in all the mosques, bow in all humility before the Almighty and thank Him for His eternal kindness and generosity, seeking His guidance and assistance in the task of making Pakistan into a great State and themselves into its worthy citizens.

Finally, let me tell you, fellow citizens, Pakistan is a land of great potential resources. But to build it up into a country worthy of the Muslim nation, we shall require every ounce of energy that we possess and I am confident that it will come from all whole-heartedly.

Pakistan Zindabad! Happy Independence Day