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How It Is: Psychiatrists, Physicians, and Torture

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Our current troubles with torture by agencies of our government, and the shock of many that medical doctors stood by or even assisted in such torture, will be with us for a while. There is never too much of knowledge, and usually too little of knowledge of the past, and our present time is apparently an illustration of our public failings.

To be clear about my own views, the publicized recent physical and psychological stresses used in the interrogation of prisoners in American hands, from the perspective of medicine, neuroscience, and psychiatry, were indeed torture. Various legal minds apparently twisted the meanings of words and phrases into knots in their attempts to provide cover for the use of terror in interrogations, but my guess is they and everyone around them knew the truth. And now various media hacks sound the same corrupted chant, more out of foolishness than any reasoned argument. It's an ugly dance, a jig that reminds one of a crazy gavotte in Bedlam.

Maybe the saddest cut of all is that we've been here before. Too many people are bemused by the illusion that physicians are incapable of standing by or assisting in the mechanics of torture. Maybe most are, but to say that all are is a public lie -- and how many psychiatrists and internist physicians do you need to help turn the rack or rip at the mind with terror? Not many. For the few hundred prisoners at a place like Guantanamo, a handful of assisting psychiatrists and internists would be sufficient, both psychiatrists and internists already on the agency payroll and committed to agency operations.

Physicians of various kinds have always been involved in government interrogations. and it's a bit silly to pretend otherwise.

In the Inquisition, physicians were present when joints were torn apart at the rack or when a head-crusher device was applied to the skull during interrogations.

The Nazis had their physicians present in every death camp and in every Gestapo headquarters.

The British had their physicians present when they put their questions to members of the IRA.

The French had their physicians assisting in interrogations during the Algerian War.

The list is long, and now history will add Americans of the early 21st century as a people who tortured prisoners. History has put blood on our hands.

I suspect psychiatrists were involved in recommending both the use of waterboarding and the recently revealed "caterpillar" treatment. As I noted in one of my previous columns, waterboarding was already known in American insane asylums in the middle of the 19th century (called the "spread-eagle cure") as a method of terrorizing inmates in order to "cure" them. Also known was the Utica Crib, an adult-size restraining device like a closed slatted coffin into which patients could be confined for terrorizing "therapy." My guess is some psychiatrist with a knowledge of history got the bright idea of using an insect as an adjunct to the Utica Crib.

We have a serious moral problem on our hands, because all of these agency physicians and intelligence officers work for the public, to protect the public, and it's the public that tells them what they can and cannot do in a prison camp.

I believe we must excuse completely any ordinary CIA officers involved in methods of interrogation approved by their superiors. Such officers are not qualified to make psychiatric judgments about what is or is not "torture" They have committed to protect the American people and to follow orders in doing so. They're blameless, and my view is that it would be a travesty of reason to condemn any of them.

As for the internists, even if they were only passive bystanders ready to save a prisoner's life if necessary, they did have a moral dilemma, and maybe some of them did choose to resign rather than continue to participate. The others, unless they're psychopaths, will not forget their experience. But an internist is no specialist of the mind and brain, and I don't think they deserve full condemnation.

As for the psychiatrists, they are a different kettle of fish completely. Any trained psychiatrist is aware that terror is as much torture as physical harm, and any psychiatrist who knows the history of his discipline also knows that terror has been used against the insane as a cock-and-bull "cure" since at least the Middle Ages. I suspect the design of torture techniques used at Guantanamo (techniques known or still unknown to us) came from psychiatrists, and if that's true, it's the psychiatrists who should bear the full brunt of public condemnation. They really knew what they were doing; we cannot say as much for anyone else at the CIA.

This American torture mess will not go away so fast, and it's been slithering around us for some time. Four years ago, the New England Journal of Medicine (2005, 353:6) published a brief note about our interrogation methods, but hardly anyone paid any attention. The authors of the note (M.G. Bloche and J.H. Marks) made the following points:

1) Mounting evidence from many sources, including Pentagon documents, indicates that military interrogators at Guantanamo Bay have used aggressive counter-resistance measures in systematic fashion to pressure detainees to cooperate. These measures have reportedly included sleep deprivation, prolonged isolation, painful body positions, feigned suffocation, and beatings. Other stress-inducing tactics have allegedly included sexual provocation and displays of contempt for Islamic symbols. The International Committee of the Red Cross (ICRC) and others charge that such tactics constitute cruel and inhuman treatment, even torture.

2) To what extent did interrogators draw on detainees' health information in designing and pursuing such approaches? The Pentagon has persistently denied this practice. After the ICRC charged last year that interrogators tapped clinical data to craft interrogation strategies, Defense Department officials issued a statement denying "the allegation that detainee medical files were used to harm detainees." This spring, an inquiry led by Vice Admiral Albert T. Church, the inspector general of the U.S. Navy, concluded: "While access to medical information was carefully controlled at GTMO [Guantanamo Bay], we found in Afghanistan and Iraq that interrogators sometimes had easy access to such information." The implication is that interrogators had no such access at Guantanamo and that medical confidentiality was shielded, albeit with exceptions. Other Pentagon officials have reinforced this message. In a memo made public last month, announcing "Principles . . . for the Protection and Treatment of Detainees," William Winkenwerder, the Assistant Secretary of Defense for Health Affairs, said that limits on detainees' medical privacy are "analogous to legal standards applicable to U.S. citizens."

3) However, the inquiry of the authors has determined that this claim is sharply at odds with orders given to military medical personnel -- and with actual practice at Guantanamo. Health information has been routinely available to behavioral science consultants and others who are responsible for crafting and carrying out interrogation strategies. Through early 2003 (and possibly later), interrogators themselves had access to medical records. And since late 2002, psychiatrists and psychologists have been part of a strategy that employs extreme stress, combined with behavior-shaping rewards, to extract actionable intelligence from resistant captives.

4) A previously unreported U.S. Southern Command (SouthCom) policy statement, in effect since August 6, 2002, instructs health care providers that communications from "enemy persons under U.S. control" at Guantanamo "are not confidential and are not subject to the assertion of privileges" by detainees. The statement, from SouthCom's chief of staff, also instructs medical personnel to "convey any information concerning . . . the accomplishment of a military or national security mission . . . obtained from detainees in the course of treatment to non-medical military or other United States personnel who have an apparent need to know the information. Such information," it adds, "shall be communicated to other United States personnel with an apparent need to know, whether the exchange of information with the non-medical person is initiated by the provider or by the non-medical person." The only limit this policy imposes on caregivers' role in intelligence gathering is that they cannot act as interrogators.

So went the published note in 2005.

Ultimately, the blame for any wrongdoing by our military or CIA personnel falls on all of us. We find too many reasons not to insist on decency in the people we entrust to act in our name. We are self-righteous but morally lazy -- an endemic state of hypocrisy. If national security means we must turn into lizards promoting extreme pain and suffering, maybe we need to say the hell with national security. We're a free people and it's our choice. Maybe the time has come to look in the mirror and choose what we want to be.