'Just World News' with Helena Cobban

Health professionals and U.S. torture

My friend Maureen's son is a newly graduated medical doctor who paid for his med school through a U.S. Army-run scheme and as a result is soon going to be deployed to Iraq. I can barely imagine how worried she is about the whole situation. Mo, this post is for you (and him).

I guess many JWN readers will have seen reference to this article, in the current issue of the premier British medical journal The Lancet, in which University of Minnesota bioethicist Stephen Miles pulled together the available evidence about the failures of U.S. military medical personnel to abide by their professional duty--and the Geneva Conventions-- in their work in detention situations in Iraq (mainly Abu Ghraib), Guantanamo, and Afghanistan.

As this excellent editorial in the same issue of The Lancet summarizes Dr. Miles's case,

there are now reports of medical personnel in Afghanistan and Iraq allegedly abusing detainees, falsifying and delaying death certificates, and covering up homicides. No unprompted reports of abuses were initiated by medical personnel before the official investigation into practices at Abu Ghraib. At Guantanamo Bay, medical records were routinely shared with interrogators in a clear breach of confidentiality and with the knowledge that such information can be misused despite objections by the medical team of the International Committee of the Red Cross, who in protest suspended their medical visits.

I'm glad that a number of global media organizations, including CNN, ABC News, Al-Jazeera, The Guardian, etc have picked up on Miles's study, even if only very briefly.

I note, too, that (the US branch of) Physicians for Human Rights has also paid some good attention to the Miles study, which meshes in well with their own continuing project to look at "Dual Loyalty and Human Rights in health professional practise" . The PHR folks have been carrying out that project in collaboration with researchers at the University of Cape Town who are only too well aware of how--during the apartheid era in South Africa--health professionals were routinely forced by the grossly abusive state to violate their own professional ethics, especially in situations of conflict against national liberation forces.

Welcome to the dilemmas and "conflicting loyalties" faced by the medical personnel working with the US military in Iraq...

According to Dr. Miles's article, the essential context for the medical-related abuses committed in US detention facilities post-9/11 is that they occurred within the broader frame of the Bush administration's attempts to reduce or deny the applicability of Geneva Convention protections afforded to detainees, and also to minimize the implementation in practice of the US Army's own regulations concerning treatment of detainees:

Although US military personnel receive at least 36 minutes of basic training on human rights, Abu Ghraib military personnel did not receive additional human rights training and did not train civilian interrogators working there. Military medical personnel in charge of detainees in Iraq and Afghanistan denied being trained in Army human rights policies. Local commanding officers were unfamiliar with the Geneva Convention or Army Regulations regarding abuses. Arab language synopses of Geneva protections were not posted in the cellblocks in Iraq and Afghanistan as required by Army regulation.

(Most of the sources Miles uses are the US Army reports that have already been published. I note that the 9,000-word Fay report--also an internal Army report--is due to be released this Wednesday. Further note from HC: 36 minutes seems like tragically little time for this 'training'.)

So these, according to Miles, were the kinds of malpractices that US military medical personnel engaged in:

The International Committee of the Red Cross (ICRC) found that the medical system failed to maintain internment cards with medical information necessary to protect the detainees' health as required by the Geneva Convention; this reportedly was due to a policy of not officially processing (ie, recording their presence in the prison) new detainees. Few units in Iraq and Afghanistan complied with the Geneva obligation to provide monthly health inspections. The medical system also failed to assure that prisoners could request proper medical care as required by the Geneva Convention...

The medical system failed to establish procedures, as called for by Article 30 of the Geneva Convention, to ensure proper treatment of prisoners with disabilities...

The medical system collaborated with designing and implementing psychologically and physically coercive interrogations. Army officials stated that a physician and a psychiatrist helped design, approve, and monitor interrogations at Abu Ghraib. This echoes the Secretary of Defense's 2003 memo ordering interrogators to ensure that detainees are "medically and operationally evaluated as suitable" for interrogation plans. In one example of a compromised medically monitored interrogation, a detainee collapsed and was apparently unconscious after a beating, medical staff revived the detainee and left, and the abuse continued. There are isolated reports that medical personnel directly abused detainees. Two detainees' depositions describe an incident where a doctor allowed a medically untrained guard to suture a prisoner's laceration from being beaten.

The medical system failed to accurately report illnesses and injuries...

Death certificates of detainees in Afghanistan and Iraq were falsified or their release or completion was delayed for months...

Finally, although knowledge of torture and degrading treatment was widespread at Abu Ghraib and known to medical personnel, there is no report before the January 2004 Army investigation of military health personnel reporting abuse, degradation, or signs of torture...

His analysis of the situation is as follows:

Legal arguments as to whether detainees were prisoners of war, soldiers, enemy combatants, terrorists, citizens of a failed state, insurgents, or criminals miss an essential point. The US has signed or enacted numerous instruments including the UN Universal Declaration of Human Rights, the UN Body of Principles for the Protection of All Persons under Any Form of Detention or Imprisonment, UN Standard Minimum Rules for the Treatment of Prisoners, the Convention Against Torture and Other Cruel, Inhuman, or Degrading Treatment or Punishment, and US military internment and inter-rogation policies, collectively containing mandatory and voluntary standards barring US armed forces from practicing torture or degrading treatments of all persons...

The role of military medicine in these abuses merits special attention because of the moral obligations of medical professionals with regard to torture and because of horror at health professionals who are silently or actively complicit with torture. Active medical complicity with torture has occurred throughout the world. Physicians collaborated with torture during Saddam Hussein's regime. Physicians' and nurses' professional organisations have created codes against participation in torture. Physicians in Chile, Egypt, Turkey and other nations have taken great personal risks to expose state-sponsored torture. Health professionals have created organisations including Physicians for Human Rights and Amnesty International's Health Professionals Network. Numerous non-medical groups have asserted that healers must be advocates for persons at risk of torture.

Military personnel treating prisoners of war face a "dual loyalty conflict". The Geneva Convention addresses this ethical dilemma squarely: "Although [medical personnel] shall be subject to the internal discipline of the camp . . . such personnel may not be compelled to carry out any work other than that concerned with their medical . . . duties."

... Which medical professionals were responsible for this misconduct? The US Armed Forces deploy physicians, physicians' assistants, nurses, medics (with several months of training), and various command and administrative staff. International statements assert that every health-care worker has an ethical duty to oppose torture...

In conclusion, Miles calls for a serious investigation into precisely the role that medics and other health professionals played (and, I would add, most likely continue to play) in enabling the tortures and cruel, inhuman, and degrading punishments to continue.

Physicians for Human Rights has also called for an investigation of the health-professional aspects of the incidents. In addition, they are calling for adherence to a set of guidelines that they developed from the "Dual Loyalty" project. See the guidelines at that link there.

Basically, they call on health professionals to uphold the same professional standards of patient-centered care, attention, and confidentiality in work that they do in detention centers that they would uphold in normal care-giving practice. I wish, though, that the guidelines had also included something about health workers' duty to ensure they are fully familiar with the content of all relevant legal codes including the Geneva Conventions, the relevant US Army regs, etc...

This whole situation has many parallels with the practices uncovered during the special "Health Sector" investigation undertaken by South Africa's Truth and Reconciliation Commission. This investigation was looking at the role of health professionals mainly inthe apartheid state's horrendous battles against its "internal" enemies. But the situation--of health professionals enabling or abetting the abuse/torture of detainees to the point of death--was very similar to what has been happening in US detention facilities in the past three years.

In the "Health Sector" chapter of its report, the TRC noted the difficult, "dual-loyalty" role forced onto the district surgeons, who were government employees with special responsibilities for health-care in the prisons:

13-- The evidence available to the Commission suggests that most district surgeons were not directly involved in committing gross violations of human rights during the period under review. Their most common offence was a failure to carry out their duties within internationally accepted guidelines of medical ethics and human rights. All these points are starkly illustrated by the Steve Biko story. The doctors failed to: a, maintain patient-doctor confidentiality norms; b, treat their patient with dignity and respect; c, examine the patient thoroughly; d, record and report injuries accurately; e, diagnose illnesses and prescribe appropriate medication; f, register complaints (particularly pertaining to assault and torture).

14-- On many occasions, district surgeons examined patients with security officers or prison warders in the room, which may have inhibited patients from disclosing abuse or torture by the police. This practice also reinforced the belief of prisoners that district surgeons collaborated with the authorities. District surgeons breached patient-doctor confidentiality by allowing third parties (police or prison authorities) automatic access to patients? files without informing the patients concerned or obtaining their consent. International standards require a doctor to inform the patient before he or she conducts an examination if the information in the medical records will be released. Finally, a number of deponents (generally detainees) told the Commission that they did not receive what they believed to be appropriate care from district surgeons.

15-- These circumstances were aggravated by the fact that most district surgeons were white, while the majority of the detainees were black. Because white and black people had for years been separated by apartheid policies, there was a strained relationship and a lack of mutual trust and understanding between doctor and patient.

16-- Many district surgeons also claimed that they did not know they could override the orders or wishes of prison warders or police on medical matters - for example, by not releasing information or by insisting that warders leave the room during examinations. Finally, where a district surgeon did take a stand to uphold the human rights of his or her patients, he or she received little or no official support from the profession or the Department of Health.

17-- At the height of the state of emergency in the mid-1980s, there was a flood of detainees into the prisons. The increased workload pushed district surgeons into unprofessional medical practices ? such as failing to examine detainees properly, failing to insist on private examinations and failing to investigate complaints by their patients. While a number of independent sources reported evidence of almost routine torture and assault of detainees, district surgeons, with only one exception, failed to report or speak out about these violations.

18-- While it is easy to criticise district surgeons, it must also be appreciated that the conditions under which they had to work made it difficult for them to uphold human rights. They were given no specific training for work in the prisons, no continuing medical education and no independent avenues to report abuses. They were generally isolated from the rest of the profession and sometimes actively ostracised. It is, thus, perhaps not surprising that they adopted the culture of the police and prison officials from whom they received affirmation and support. The Department of Health submission said:

[District Surgeons had] a firm belief that the detainees were the enemy of the State and that it was the right thing to do to assist the police in getting the information out of the detainees, as they were trying to overthrow the government. The country was fundamentally racist and this included many district surgeons. The ideology was such that it was regarded as completely normal not to give black people the same services as whites and to treat black people as second class citizens.

Okay, so with a few quick transpositions, doesn't that situation look eerily the same as today's?

The TRC report also identified the broad support that the health sector's professional bodies had given to the apartheid government and its practices... All of which raises an interesting question for me: Why was Dr. Miles's report published in The Lancet rather than, for example, the Journal of the American Medical Association?

Maybe there's an innocent explanation for this. If so, I'd love to hear it.

In the mean-time--for all the medical/health personnel working with the US forces around the world in situations where there are detainees-- I wish you safety and sanity, and the ability to practice your hard-earned skills.

But most of all, we should remind you of your responsibilities under both the codes of ethics of your own professions, and international law. Please, make sure you educate yourselves about the requirements of international law and the US Army Code that are relevant to your situation.

And please, don't ever let your own situation of, perhaps, some immediate sense of threat, tempt you ever to become someone who holds "the belief that the detainees were the enemy of the [United States] and that it is the right thing to do to assist the security forces in getting the information out of the detainees." Or, to regard it, "as completely normal not to give non-American people the same services as Americans..." Your own profession's code of ethics would never allow this.

And if you should see signs that abuses have been committed, then you in the health professions should be the very first to report it on up the chain of command, and not to let the situation continue. It's shocking that there are no records of any of the involved health professionals having done that in Abu Ghraib.