Appropriate Medical Monitoring

I see that today's ( 8th June 2010) New York Times has an editorial on the involvement of medical personnel in torture. Physicians for Human Rights has issued a report concerning the alleged involvement of doctors and other medical professionals in harsh interrogation by the US military and other government agencies. Back in 2004, I wrote a piece for US Medicine on just this subject. Sadly, when the magazine changed hands they ditched the website on which the original article was published. I thought for posterity's sake I would republish the piece here. I like to think that the medical profession has learned its lesson from the debacle of Guantanamo and 'extraordinary rendition' but sometimes I worry.


Appropriate Medical Monitoring (published July 2004)

‘If nothing can protect the nation against itself, neither its traditions nor its loyalties nor its laws…then its behaviour is no more than a matter of opportunity and occasion. Anybody, at any time, may equally find himself victim or executioner’ – Jean-Paul Sartre

The Prisoner
He lay very still with his eyes closed, feigning unconsciousness. He was a big man and had put up a fight. He had a large gash over his left eye and his knuckles were bloodied and torn. The head X-rays were negative and the ‘doc’ completed his exam. He told the medic to clean him up and up and stitch the eyebrow.

They were alone in the cubicle, the medic, the prisoner and the sergeant who brought him in. “He is one bad b…..d,” the sergeant told the medic, “killed six of my soldiers this month.” He pushed the pistol further into the prisoner’s neck. “ On three I knock you over and he gets it. We say he tried to escape. OK?” The medic froze. The sergeant’s eyes were scary. The cubicle door opened, “Need any help stitching him up?” said the nurse. “Yes please,” replied the medic and the moment was past. Not Baghdad 2004 but Belfast 1970. The medic was me and, to this day, I do not know what I would have done had the nurse not opened the door.

Worried
In thirty years of service as military ‘medic’ this was not my last ethical crisis or moment of self-doubt. Safe in retirement I can say more often than not a combination of good luck and leaders wiser than me, saved the day. I am therefore well aware of the minefield I am about to negotiate, but I am worried for my friends in the US military medical services.

It begins with the Congressional hearings on the debacle at Abu Ghraib. I, like most of the world, sat transfixed throughout, angry as the catalogue of events unfolded but aware war is terrible and once good people are often brutalized into committing unspeakable acts. The more I heard the more concerned I became. Whether, as seems increasingly unlikely, this was an isolated incident perpetrated by a group of ill-trained and poorly led junior ranks, or the tip of a sinister iceberg of systemic abuse of prisoners, the damage to the reputation of the US military is huge.

But as I listened to the unrelenting and incisive questioning of lawmakers, I felt better. Whatever wrong had been committed, this was American democracy in action. The truth would come out. Justice would be done. I was reminded of Churchill’s observation, “America always does the right thing, but only after it has explored every alternative.”

Coercive Interrogation
The debate spread wider than Iraq, to Afghanistan and Guantanamo. Details emerged about interrogation described as “coercive interrogation practices”. It seems for some time the Pentagon has authorized the use of a number of techniques, including sleep deprivation, sensory deprivation and forced prolonged positioning as part of interrogation. Lawmakers were assured that these coercive techniques were only used under very limited circumstances. “Every case required the approval of senior Pentagon officials -- and in some cases, of the Defense Secretary. Once approved, the harsher treatment must be accompanied by appropriate medical monitoring”. A red flag went up. I wondered who was doing this ‘medical monitoring’ and what was involved.

Over the past weeks I have scoured every available source from the New York Times to the Army Times. Meanwhile increasingly graphic detail has appeared in the media and it is clear there is more to this than the macabre theatre at Abu Ghraib. A catalogue of events, accusations and allegations would be a pointless exercise. Moreover, many investigations are in train and I am in no position to know all the facts. I can however, offer a couple of comments on the most contentious issues. First, did those at Abu Ghraib act without authority? Answers might lie with the senior officer at Guantanamo who in his inspection report of Abu Ghraib stated, “Detention operations must act as an enabler for interrogation.”

Torture?
Second, do “coercive interrogation practices” amount to torture or cruel and inhumane treatment? It seems to depend upon where you ask the question. The Pentagon is emphatic it does not [use torture]. When questioned as to whether the techniques listed as authorized for ‘coercive interrogation’ (apparently there are 24 interrogation techniques approved by the Secretary of Defense in a classified directive in April 2003) a Pentagon spokesperson offered, “… The techniques on the list are consistent with international law and contain appropriate safeguards such as legal and medical monitoring. "

This position appears at odds with the US State Department. Its annual Country Reports on Human Rights Practices routinely acknowledges the following practices as torture and/or ill treatment:
· sleep deprivation
· forced/prolonged positioning
· forced nakedness and sexual threats and humiliations
· blindfolding or hooding
· isolation, loud music, witnessing or hearing torture
· mock executions, threats to family and insults

This debate is far from over. The Wall Street Journal and the Washington Post have begun a public dissection of a number of Department of Justice, Pentagon and Whitehouse memos from 2002 and 2003, dealing with the legal definitions of torture and the limitations of the Geneva Conventions as applied to US Forces. I smell Pulitzer. The recent decision by the senior military commander in Iraq to ban all forms of harsh treatment of prisoners, suggests there are also serious concerns in the Pentagon regarding both the interpretation and practice of the laws of war in recent years. But I digress; my concern here is not with specific ill-treatment but with aspects of medical involvement.

Medics and Interrogation
I have found no evidence that any individual US military healthcare professional has been directly involved in the torture or ill treatment of prisoners – in Abu Ghraib or elsewhere. However, it is clear that healthcare professionals have been complicit to varying degrees in what I will refer to as ‘coercive interrogation practices’ – the clue is in that odious term ‘appropriate medical monitoring’. There are further indications in the Congressional evidence referring to procedures for interrogation, “The guidelines were the product of three months of discussion between military lawyers, medical personnel and psychologists, and followed several incidents of abuse of prisoners at Guantanamo”.
In a May 13,2004 article in Stars and Stripes, Major General Geoffrey Miller [Commanding General at Guantanamo] implied direct medical involvement at least in Guantanamo interrogations, in his quote “keeping prisoners hungry must be supervised by medical personnel. Also, wounded or medically burdened detainees must be medically cleared prior to interrogation.”

Culpability
Is the involvement of healthcare professionals in the interrogation of prisoners, whether - defined as ‘coercive’, ill treatment or torture – always wrong? Unequivocally, yes. I would go further; healthcare professionals even where they don’t directly participate but advise and train others, facilitate ill treatment or torture and are as culpable as the perpetrator.

I make such sweeping statements with the confidence that history and international law are on my side. The first support I offer is that of the World Medical Association (WMA) (a global institution formed under the aegis of the USA after World War II to address the issues raised by the medical atrocities committed by Nazi doctors). In 1975 the WMA issued the Declaration of Tokyo, which laid down basic precepts for the medical profession and human rights:
The doctor shall not countenance, condone or participate in the practice of torture or other forms of cruel, inhuman or degrading procedures, whatever the offence of which the victim of such procedures is suspected, accused or guilty, and whatever the victim’s beliefs or motives and in all situations, including armed conflict and civil strife
The doctor shall not provide premises instruments substances or knowledge to facilitate the practice of torture or other forms of cruel, inhuman or degrading treatment or to diminish the ability of the victim to resist such treatment
The doctor shall not be present during any procedure during which torture or other forms of cruel, inhuman or degrading treatment are used or threatened
The doctor’s fundamental role is to alleviate the distress of his or her fellow man, and no motive, whether personal, collective or political shall prevail against this higher purpose

Contravening Medical Ethics
The second justification for my argument comes from the UN, which has specifically addressed the ethical obligations of doctors and other health professionals in its clumsily titled document, The Principles of Medical Ethics Relevant to the Role of Health Personnel, Particularly Physicians, in the Protection of Prisoners and Detainees Against
Torture and Other Cruel, Inhuman, or Degrading Treatment or Punishment (1982).
The document states unequivocally ‘It is a gross contravention of medical ethics, as well as an offence under applicable instruments… to engage, actively or passively, in acts which constitute participation in, complicity in incitement to or attempts to commit torture or other cruel, inhuman or degrading treatment and punishment.’
It also states:
Health professionals may not participate, actively or passively, in torture or condone it in any way.
"Participation" in torture includes evaluating an individual’s capacity to withstand ill treatment; being present at, supervising or inflicting maltreatment; resuscitating individuals for the purposes of further maltreatment or providing medical treatment immediately before, during or after torture on the instructions of those likely to be responsible for it; providing professional knowledge or individuals’ personal health information to torturers; intentionally neglecting evidence and falsifying reports, such as autopsy reports and death certificates.

Medically Approved
What might make a healthcare professional get involved in ill treatment or torture of prisoners? Some may attempt to justify their complicity by contending they are obliged to obey orders. Others may claim their presence was necessary to protect the patient in situations where interrogation might go too far. Both are morally bankrupt arguments. Healthcare professionals must recognise that in using medical skills and knowledge to further the aims of the interrogators by making their job easier or reducing risk, they are complicit in any actions deemed to be inhumane. This is all the more insidious when it appears to stem from a concern for the welfare of the detainee. The repulsive expression “appropriate medical monitoring” illustrates the point. It suggests that techniques used will be subjected to medical professional scrutiny and approval. Thereby making them safer and humane?

Poor Training
Experience leads me to believe deliberate involvement of medical professionals in ill treatment of prisoners is rare. Most healthcare professionals err as a result of poor training. Many have scant awareness of prisoner’s rights or their own responsibilities to prisoners. Many too are ill-equipped to deal with moral dilemmas and ethical risks they face. They may have to decide for example whether loyalty to colleagues is more important than the interests of a detainee alleged to be a dangerous terrorist. If, as seems probable, US military healthcare professionals have been involved in “coercive interrogation practices” in Iraq, Guantanamo or elsewhere, I want to believe it was out of poor training and ignorance.

Urgent Action
All the signs are that in the near future the US government and armed forces will be severely censured by the international community, not only for events in Abu Ghraib but also for its general treatment of prisoners, particularly the use of harsh interrogation techniques. There is little doubt that ‘medical monitoring’ of such treatment will be condemned. There is an urgent need for action. First, medical participation in any form of interrogation must stop immediately. Second, the Pentagon should issue an unequivocal ban [on medical involvement] and clear directions for the future. Third, a thorough investigation should take place, of all military medical involvement, active or passive, in alleged prisoner abuse and in ‘coercive interrogation’. Finally, there should be a detailed review of current training of military healthcare professionals in the Geneva Conventions and Human Rights law. An improved training curriculum must be quickly implemented. Absent such urgent action, I am convinced there is grave risk to the ethical reputation of the US medical services. We [in military healthcare] have been teaching and practicing the Geneva Conventions unambiguously for over 50 years, they are our laws. Once you tell people its OK to break the law, there is no telling where they might stop


As a postscript, the reader might wish to know the prisoner I treated was released from detention a few days later, ‘for lack of evidence’. He continued to kill British soldiers for another ten years. The last I heard he was running a used car business and doing nicely.