Some deja vu experiences are welcome, some not so. Remember the photos from Abu Ghraib, showing humiliating and pointless abuse of prisoners in the "war on terror"? I was unpleasantly reminded of those when I read a New York Times story this week titled "Medical Ethics Violated at Detention Sites, a New Report Says."
The "blistering" report, from a committee of leading medical experts, found that, "Among the abuses cited in the report are doctors' force-feeding of hunger strikers by pushing feeding tubes into their noses and down their throats. The task force also suggested that medical personnel ignored their duty to report evidence of beatings or torture of detainees, and that the Defense Department "improperly designated licensed health professionals to use their professional skills to interrogate detainees as military combatants, a status incompatible with licensing"; and that "C.I.A. medical personnel were present during waterboarding."
The CIA and Defense Department deny all this, unsurprisingly. They've repeatedly classified all such actions as secret, to avoid too much sunlight. But other reports and even a United States judge have already called what the United States has done to detainees "torture".
This is now a long and ugly story, but the healthcare professional sub-story is a bit less convoluted. One of the authors of the new report, Steven Miles MD, authored an entire book taking the medical and psychological professions -- and our government -- to task for allowing and covering up torture Even worse, as he noted, such "enhanced interrogation" techniques do not even "work," but do increase the risk of backlash. Reviewing Miles' book for the San Francisco Chronicle, I concluded with a question: "Miles likens our nation's use of torture to a scourge that has infected us; he's now diagnosed it. Will denial continue, or will treatment and prevention follow?"
And even before that, appalled by what had come to light, I co-authored a letter to the New England Journal of Medicine noting that all military physicians are licensed by somebody and should be investigated if there were any suspicions of participation in torture, however defined. My co-author included a famed leader in the response to AIDS and a former United States Assistant Secretary of Health.
Our letter, as it appeared in 2005:
Participation of Health Care Personnel in Torture and Interrogation
To the Editor:
The profession of medicine has developed codes of ethical conduct over thousands of years. A central element of such codes is expressed in the imperative to "do no harm." Disclosures with regard to the treatment of detainees by licensed medical personnel in the "war on terror" in Iraq, Afghanistan, and Guantanamo Bay, Cuba, have revealed undeniable breaches of medical ethics among U.S. military health care personnel involved at these -- and perhaps other -- sites. The International Red Cross has charged that some of the physical and emotional tactics used constitute cruel and unusual punishment.
The Geneva Convention provides that medical personnel "shall not be compelled to perform or carry out work contrary to the rules of medical ethics." The Code of Medical Ethics of the American Medical Association (AMA) states that "ethical obligations typically exceed legal duties." The World Medical Association, of which the AMA is a member, prohibits participation even as a monitor in torture or abuse. The Uniform Code of Military Justice proscribes U.S. forces from engaging in cruelty, maltreatment, or oppression of prisoners and even from the threat of such harm. As the Nuremberg trials after World War II taught us, the extreme circumstances of times of war, whether declared or not, do not excuse physicians and other health care professionals from their ethical responsibilities.
Those who have served in the U.S. military know that there is a documented chain of command for every action. Health care personnel serving in the military all work under the authority of licensed military physicians, who are responsible for actions performed under their authority. We therefore call on the AMA and the American Psychological Association to request that relevant authorities act, at a minimum, as follows. First, the military must provide full disclosure of all medical personnel involved, directly or by chain of command, in the treatment of detainees in Iraq, Afghanistan, and Cuba -- and elsewhere if relevant -- since September 11, 2001. Second, the records and conduct of these personnel should be reviewed by the medical licensing boards, other responsible licensing authorities in each state where the military physicians are licensed, or both. Independent expertise in bioethical standards should be sought in conducting these reviews. Third, appropriate disciplinary action should be taken on the basis of the results of the reviews, and these actions should be made publicly available.
Philip R. Lee, M.D.
Marcus Conant, M.D.
University of California, San Francisco, San Francisco, CA
Steve Heilig, M.P.H.
Cambridge Quarterly of Healthcare Ethics, San Francisco, CA
Although the NEJM is probably the most widely-read medical journal in the nation, if not the world, it seems we were ignored. Now we have another call for truth and justice, and another chance to hopefully redeem some of the reputation of our "healing" professions and even our nation. Hopefully denial will not be the response this time.
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