ADF Health April 2005 - Volume 6 Number 1Personal viewAppropriate medical monitoring?
The prisoner lay very still with his eyes closed, feigning unconsciousness. He had a large gash over his left eye and his knuckles were torn and bloodied - the result of a previous attempt to resist arrest. The prisoner's x-rays had excluded a skull fracture and the medic was assigned to suture the laceration. As the medic sutured, the sergeant explained that the prisoner had killed six of his colleagues in the past 4 weeks. Pushing the pistol further into the prisoner's neck, the sergeant spoke softly with a strange expression on his face: "On the count of three, I will knock you over and then he gets it. We'll say he tried to escape. OK?" The medic froze. At that moment, the cell door swung open and a nurse entered: "Need any help with the suturing?" The medic jumped at the offer and the tense situation evaporated. This was not Baghdad in 2004 - it was Belfast in 1970. One of the authors (R L) was that medic and still has no idea what he would have done, but for the unknowing intervention of that nurse. For that author, 30 years of service as a military medic brought other moments of ethical dilemmas and selfdoubt. Mostly, he was saved either by wiser superiors or by just good luck. Therefore, it was with considerable interest that he watched the 2004 Congressional hearings on Abu Ghraib prison torture unfold. War is dehumanising, and otherwise good people are capable of brutality and committing unspeakable acts. Certainly, great damage has been done to the reputation of the United States military. The legal process of unrelenting and incisive questioning has demonstrated that the US retains a robust process:
As the subsequent fallout spread to involve Afghanistan and Guantanamo Bay, details emerged of more widespread "coercive interrogation practices". 2 The Pentagon had apparently authorised a limited number of these techniques, including sleep deprivation, sensory deprivation and enforced prolonged positioning, as part of interrogation. In some cases, this required the consent of the Defense Secretary, and in every case the permission of a senior Pentagon official was to be obtained. "Once approved, the harsher treatment must be accompanied by appropriate medical monitoring." Alarmed at the implications of this expression, we were keen to determine who and what was involved in appropriate medical monitoring. In particular, two questions were important:
Did the military police act alone?During the trial of US Army Specialist (MP) Charles Graner, 372nd Military Police Company, who was sentenced to 10 years imprisonment for beating and sexually abusing prisoners at Abu Ghraib prison, claims were made that he repeatedly complained to his superiors but was instructed to continue the rough treatment. 3 In October 2003, Major General Donald Ryder (Provost Marshal of the US Army) was commissioned by General Ricardo Sanchez (the senior commander in Iraq) to review the prison system in Iraq and recommend ways of improving it.
Ryder’s report in November 2003 concluded that there were potential human rights, training and manpower issues that needed immediate attention. 3 Ryder stated that there was evidence, dating back to the Afghanistan war, that US military police had worked with intelligence operatives to “set favorable conditions for subsequent interviews” - a means of breaking the will of prisoners to resist interrogation. However, Ryder claimed that there were “no military police units purposefully applying inappropriate confinement practices”. In late February 2004, Major General Antonio M Taguba was appointed to do a second investigation. He was the deputy commanding general for support of the Coalition Forces Land Component Command in Kuwait. Taguba produced a report on the Army’s prison system in which he detailed “sadistic, blatant and wanton criminal abuses” at Abu Ghraib by members of the 372nd Military Police Company and by members of the US intelligence community between October and December 2003. Six US Army members have been charged, including Graner. General Taguba stated:
Taguba recommended that the commander of one of the military intelligence brigades and the former director of the Joint Interrogation and Debriefing Centre be reprimanded and the latter relieved of his duty. Taguba also recommended sanctions against two employees of Consolidated Analysis Centers Incorporated (CACI) - a civilian private intelligence contractor with about 9500 employees worldwide and an annual revenue of $1.15 billion in 2004 - for “. . . allowing or ordering military policemen . . . to facilitate interrogations by ‘setting conditions’ which were not . . . in accordance with Army regulations”. In January 2004, the commander of the 800th Military Police Brigade was formally admonished and suspended. 4 The involvement of medical personnel in the Abu Ghraib torture was alleged by Professor Steven Miles, a bioethicist from the University of Minnesota, in an article published in the Lancet. 6 He described:
Part of the source for this material included the US congressional hearings, statements from detainees and soldiers, medical journal accounts, and media reports. Did the treatment to prisoners constitute torture?According to the 1984 Convention against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment, 7 an agreement ratified by 136 nations, including the US, the term torture:
For the purposes of the definition, the act of torture must be “inflicted by, at the instigation of or with the consent or acquiescence of a public official or other person acting in an official capacity”. 7 In the case of Abu Ghraib, the Pentagon’s version and that of General Taguba is that the mistreatment fell short of torture. 3 The Red Cross had less doubt in its report to coalition authorities in February 2004, 8,9 and the US Department of State acknowledges that the following practices constitute torture or ill treatment: 10,11
The recent decision by the senior military commander in Iraq to ban all forms of harsh treatment of prisoners suggests that the Pentagon shares serious concerns regarding the interpretation of the Geneva Conventions by US military personnel. Medical involvement in tortureAlthough there have been no charges or convictions against US military medical personnel (as at 16 January 2005), it is clear that health care professionals (either military or civilian contractors) have been complicit in “coercive interrogation practices”, as evidenced by the official US statement on appropriate medical monitoring in relation to the techniques of interrogation approved by the Pentagon for use at Guantanamo Bay in April 2003. 2 These guidelines:
The Interrogation Rules of Engagement at Abu Ghraib prison (Box) stated in part that “wounded or medically burdened detainees must be medically cleared prior to interrogation” and “dietary manip (monitored by med)”. 12 Doctors have had a long association with torture, usually but not exclusively in the assessment of physical suitability for interrogation and in the treatment of prisoners after torture. 13,14 Is such involvement by health care professionals in the interrogation of prisoners always wrong? Is it at least permissible to advise or train others in “safe” interrogation techniques? Two authorities have asserted that any such involvement is unethical. The World Medical Association (WMA) was set up after World War II, following the medical atrocities committed by Nazi doctors. In its Declaration of Tokyo in 1975, the following basic precepts were established:
The WMA asserted that the fundamental role of a doctor is to alleviate the suffering of his fellow man, and no motive, whether personal, collective or political, should prevail against that higher purpose. More recently, the WMA has established an online self-administered course for doctors on medical management of prisoners. 15 The United Nations has stated that:
Participation is defined as including evaluating an individual’s capacity to withstand ill treatment, being present at acts of torture, resuscitating individuals for the purpose of further maltreatment, or providing medical treatment immediately before, during or after torture on the instructions of those likely to be responsible for that torture. It further prohibits the release of personal medical information about prisoners to their torturers and the deliberate falsification of autopsy reports and death certificates of tortured prisoners. The motivation of health care professionals to become involved in torture may include obedience to superiors or protection of prisoners from extreme torture. Neither justifies complicity, as evidenced by the WMA and UN statements. The expression “appropriate medical monitoring” implies that medical scrutiny and approval can result in a safer or humane form of torture. To describe any torture as humane is clearly contradictory. In our experience, deliberate involvement by medical staff in ill treatment of prisoners is rare and born from poor education: a poor awareness of the rights of prisoners or their own responsibilities. The ethical dilemma of (say) complicity with comrades versus championing the rights of an alleged dangerous terrorist is not an easy one. There is no doubt that any “medical monitoring” of US military torture will be rightly condemned. Such involvement should cease immediately and the Pentagon should repudiate any such medical involvement. A detailed investigation of medical involvement in “coercive interrogation” and other abuses of US military prisoners is warranted. We suggest that the training of military health care professionals on the Geneva Conventions should be improved. We who have practised and taught these Conventions unambiguously over many years should reclaim them emphatically as the quintessence of military medical practice. References
(Received 20 Jul 2004, accepted 18 Jan 2005)
Colonel (Retd) Robert Leitch retired from the British Army in 1996, after 30 years service, to work for the US Department of Defense, where he wrote several papers on combat medicine. He is now employed by the African Medical and Research Foundation in Nairobi, Kenya, where he is involved with refugees and is piloting a telemedicine program. Commander Mike O’Connor is immediate past Vice President of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists and chairs the Chapter of Military Obstetrics and Gynaecology. He has been a consultant obstetrician and gynaecologist to the RAN since 1982. He has appointments at St George public and private hospitals in Sydney and is chairman of the Division of Obstetrics and Gynaecology at St George Private Hospital. He has served on HMAS Stalwart, HMAS Tobruk and HMAS Manoora, the last being as support for pregnant refugees during the Tampa crisis in 2001. He has also served in Bougainville and East Timor. African Medical and Research Foundation, Nairobi, Kenya.Robert Leitch, RN, MBE. Department of Obstetrics and Gynaecology, St George Hospital, Kogarah, NSW.Mike O’Connor, MB BS(Hons), MD, DCH, DDU, FRCOG, FRANZCOG, JP, RANR, Consultant obstetrician and gynaecologist. Correspondence: Commander Mike O’Connor, Department of Obstetrics and Gynaecology, St George Hospital, PO Box 185, Kogarah, NSW 2217.
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