What is ethical when your patient may be a terrorist?
What is ethical when your patient may be a terrorist?
Medical providers’ role in war an age-old issue
Allegations that prisoners of war were tortured by American military interrogators at Abu Ghraib and Guantanamo, possibly with the complicity or knowledge of physicians working with interrogators, resurrected a question that has come up in every war for centuries: What role, if any, should health care practitioners play in the interrogation and torture of enemies of their government?
"It’s an ancient topic. Read Henry V, and it’s there," says Nancy Berlinger, PhD, MDiv, deputy director and associate for religious studies at The Hastings Center in Garrison, NY. "It’s a topic that’s perennial — the ethics of how we conduct war and how we treat prisoners, and the role of the medical professional in respect to waging war."
Professional associations weigh in
Health care professionals who serve in the military or work under the auspices of the military at bases, hospitals or prisons can be faced with a quandary of dual loyalties. In situations where professional ethics clash with national security obligations, which prevails?
It has been suggested that psychologists working at Guantanamo Bay were not acting as health care professionals but rather as researchers and advisors. The American Psychological Association (APA) was quick to issue an advisory indicating that it recognizes no such distinction when it comes to the humane treatment of prisoners.
Psychologists have ethical responsibility
"[The APA] acknowledged that while psychologists may be asked to advise on how to break’ prisoners, [the APA] does not condone training for torture, and psychologists have an ethical responsibility toward prisoners," says Berlinger.
The American Medical Association (AMA) Code of Ethics specifically opposes physician participation in torture, which it defines as "the deliberate, systematic, or wanton administration of cruel, inhumane, and degrading treatments or punishments during imprisonment or detainment."
The AMA code states: "Physicians must oppose and must not participate in torture for any reason. Participation in torture includes, but is not limited to, providing or withholding any services, substances, or knowledge to facilitate the practice of torture. Physicians must not be present when torture is used or threatened. Physicians may treat prisoners or detainees if doing so is in their best interest, but physicians should not treat individuals to verify their health so that torture can begin or continue. Physicians who treat torture victims should not be persecuted. Physicians should help provide support for victims of torture and, whenever possible, strive to change situations in which torture is practiced or the potential for torture is great."
The APA’s council of representatives recently endorsed a task force report that set forth ethical guidelines for psychologists’ participation in national-security-related investigations and interrogations, on the heels of a report in The Lancet by University of Minnesota physician and researcher Steven Miles, MD, who wrote in 2004 that military physicians had been complicit in abuse and torture in Abu Ghraib, Afghanistan, and Guantanamo.1
Miles reviewed government and military documents that led him to conclude that military physicians violated World Medical Association and Geneva Convention guidelines for humanitarian treatment of prisoners of war by divulging confidential medical information to interrogators, failing to report abuse, advising interrogators on how to effectively perform harsh interrogations, and falsifying or not completing death certificates.
"When you have war, you have a lot of records generated," Berlinger points out. "When you’re looking at [the actions of health care professionals] in context with detainees, what are the documents revealing about how prisoners are treated? How does that compare to codes of ethics of their professions?"
The APA advisory, while strongly opposing psychologists’ participation in harsh treatment of prisoners, does approve psychologists’ involvement as consultants to others performing interrogation and information-gathering activities, saying that psychologists’ scrutiny can help ensure that the interrogation processes are safe and ethical. The APA council strongly restated its position that psychologists "do not engage in, direct, support, facilitate, or offer training in torture or other cruel, inhuman, or degrading treatment and that psychologists have an ethical responsibility to be alert to and report any such acts to the authorities."
Berlinger says the debate on the role of health care professionals in war primarily revolves around two areas of concern: participation in torture and interrogations, and neglect of medical needs.
Professional ethics vs. other obligations
"These are the sorts of things covered under the Geneva Conventions, but the contentious issue, with regard to Afghanistan and Guantanamo, has been the status of the detainees: Are they prisoners of war, covered by the Geneva Conventions? Or are they caught up in the military conflict in other ways?"
In any case, the health care practitioner who is under military or governmental auspices may find himself having to decide whether professional ethics are in conflict with obligations to a military unit or nation.
Harvard Medical School social medicine ethics professor and researcher Mildred Solomon, EdD, writes in Medscape General Medicine that the problem of dual loyalty is one that health care professionals experience in most professional settings at one time or another, such as when a managed care plan or institution controls physician choices, when the law requires that patient confidentiality be breached, or when military obligations require a physician to participate in what his or her professional ethics would deem harsh or inhumane treatment of prisoners.2
Citing work by Physicians for Human Rights, Solomon lists four behaviors that medical professionals can engage in that are violations of the human rights of individuals in their care: compromising medical judgment; imposing medical procedures that only serve state interests; providing lower quality of care than is available; and remaining silent when the opportunity arises to provide information that supports the individual’s care. All four, Solomon writes, are unacceptable violations of human rights.
Ethicist decries consequentialist analysis’
In the American Journal of Bioethics, AMA’s ethics institute director, Matthew K. Wynia, MD, says those who condone physicians’ participation or assistance in harsh treatment and interrogation of prisoners of war are making a public health argument based on a "consequentialist analysis."3
"That is, to protect the well-being of large numbers of innocents, it is acceptable to harm individual terrorist suspects," says Wynia, who concludes in his report that the information yielded by harsh interrogations probably is not worth the negative consequences.
"What impulses are we giving way to when we sanction torture and harsh consequences?" asks Berlinger. "For more than 25 years, U.S. law has allowed torture victims to sue their torturers, because we recognize that it is wrong."
The Sept. 11, 2001, terrorist attacks on the United States continue to influence how we view the morality of assisting in or facilitating torture or harsh treatment of prisoners or detainees who are viewed as having even peripheral connections to terrorist organizations or terrorist-sympathetic regimes.
"When people feel violated, understandably they have rage, vengeance, and a desire for things to go back as they were, and we don’t always articulate this very well," says Berlinger. "We hope we don’t have to grapple with it every day, but when we give in to those things, we can lose control of rational thought pretty quickly.
"People can get used to hurting other people. It’s a very frightening part of our nature."
A health care provider’s own moral code and professional ethics are tested when his or her patient is a suspected terrorist, she cautions.
"What if this patient is presented to you as an enemy, and you have the power [to aid in interrogation of him or her] — what are your checks and balances? How do you make sure this is conducted ethically? Ethics are relations between persons, and once you dehumanize the person you regard as other,’ then you have no checks and balances."
Though Sept. 11 changed our perceptions of our national and personal security, Berlinger says the role of medical providers during times of conflict is age-old.
Torture often proves counterproductive
"It’s a perennial problem, and we have to keep re-learning the things we forget," she says. "How often do we have to learn the same lesson, and why do we keep resisting the lesson?"
Wynia, in researching methods of interrogation used in World War II and in wars since, says it’s common knowledge among seasoned interrogators that "abusing prisoners is not simply illegal and immoral, it is also remarkably ineffective," because it frequently strengthens detainees’ resolve to withhold any information they may have.
Being able to claim the moral high ground as an ethical, humane culture with medical providers whose aim is to do no harm requires that medical providers avoid taking part in torture, Berlinger says.
"What happens to us — how are we violating ourselves — when we are complicit in the torture of another person or withhold medical care from someone for reasons of security? What have we done to our own body politic or our soul?"
References
- Miles S. Abu Ghraib: Its legacy for military medicine. Lancet 2004; 364:725-729.
- Solomon MZ. Healthcare professionals and dual loyalty: Technical proficiency is not enough. MedGenMed Aug. 4, 2005. Available at www.medscape.com/viewarticle/508877.
- Wynia MK. Consequentialism and harsh interrogations. Am J Bioethics 2005; 5:4-6.
Source
- Nancy Berlinger, PhD, MDiv, deputy director and associate for religious studies, The Hastings Center, 21 Malcolm Gordon Road, Garrison, NY 10524. Phone: (845) 424-4040. E-mail: [email protected].
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