This article examines the relationship of military medical personnel to abuses of detainees at Abu Ghraib and other detention centers in Iraq, Afghanistan, and Guantanamo Bay. It is based on testimony before the US Senate and House, 1,2 US government policy documents,3-7 US armed forces' policies,8-12 US Army investigations of abuses,13-17 trial documents,18-23 human rights groups' investigations,24-26 and news media accounts. These documents suggest that the military medical system and its personnel failed to protect the human rights of detainees, sometimes collaborated with interrogators or abusive guards, and failed to properly report injuries or deaths caused by torture. The emerging evidence of the relationship of military medicine to these abuses deserves a full investigation and has profound implications.
As the Bush administration planned to retaliate against Al Queda for the terrorist attacks on the US, it was reluctant to accept that the Geneva Convention Relative to the Treatment of Prisoners of War would apply to Al Queda detainees at Guantanamo and Afghanistan.24 Policy documents shed light on their reasoning. A January 2002 Department of Justice memorandum to the Department of Defense concluded that international treaties and laws did not apply to Al Queda detainees because it was not a national signatory to those conventions.4 It also concluded that the Convention did not apply to Taliban detainees because of Al Queda influence over the government of Afghanistan and the country was a failed state" that could not function as a party to treaties. In February 2002, the US president signed an executive order stating that although the Geneva Conventions did not apply to Al Queda or Taliban detainees, Our Nation &will continue to be a strong supporter of Geneva and its principles. . . . The United States Armed Forces shall continue to treat detainees humanely and, to the extent appropriate and consistent with military necessity [emphasis added] in a manner consistent with the principles of Geneva.5 This phrasing subordinates US compliance to the Geneva Convention to undefined military necessity."
An August 2002 Justice Department memorandum to the President and a March 2003 Defense Department Working Group distinguished cruel, inhumane, or degrading treatment, which could be permitted in US military detention centers, from torture, which was ordinarily banned except when the President set aside the US commitment to the Convention in exercising his discretionary war-making powers.3,7 Those memoranda semantically analyzed words severe," harm," or profound disruption of the personality" in legal definitions of torture without grounding those terms on any references to research showing the prevalence, severity, or duration of harm from abusing detainees.27-32
In late 2002, the Secretary of Defense approved Counter Resistance Techniques" including nudity, isolation, and exploiting fear of dogs," for interrogating Al Queda suspects at Guantanamo Bay.6 On April 16, 2003, he approved a revised list of techniques, again subordinating the Geneva Convention to military necessity," and adding, Nothing in this memorandum in any way restricts your existing authority to maintain good order and discipline among detainees.6 That directive states that persons devising interrogation plans should give consideration" to the view" by other countries that some of the authorized techniques such as threats, insults, or intimidation violate the Geneva Convention. Interrogation policies for detainees in Iraq and Afghanistan remain unavailable as of this writing.
In announcing its investigation of human rights abuses at Abu Ghraib in January 2004, US Central Command (CENTCOM) stated that the Coalition is committed to treating all persons under its control with dignity, respect and humanity.33 That description of CENTCOM policy, and a similar memorandum by Abu Ghraib's commanding officer,12 do not acknowledge Geneva obligations to detainees but do reject a distinction between torture and inhumane treatment with regard to interrogating Abu Ghraib detainees who were suspected of Al-Qaida ties. The Interrogation Rules of Engagement posted at Abu Ghraib stated, [Interrogation] Approaches must always be humane . . . Detainees will NEVER be touched in a malicious or unwanted manner. & The Geneva Conventions apply.11 However, local commanding officers were unfamiliar with the Geneva Convention or Army Regulations regarding abuses.13-15 Although US military personnel receive at least a 36 minutes of basic training film on respecting human rights, military personnel at Abu Ghraib did not receive additional human rights training and did not give such training to civilian interrogators working there.1,15,17
Military medical personnel in charge of detainees in Iraq and Afghanistan denied being trained in Army human rights policies.17 Arab language synopses of Geneva protections were not posted in the cellblocks in Iraq and Afghanistan as required by Army regulation.2,10,13,17
The public record contains little on US policy for the role of health personnel in interrogating detainees in Iraq, Afghanistan, and Guantanamo Bay. The August 2002 Department of Justice and the March 2003 Defense Department Working Group memoranda do not distinguish between coercive interrogation involving soldiers from those employing medical personnel or expertise. For example, both documents excuse the use of drugs during interrogation.3,7 Neither document mentions medical ethics codes or the history of medical or psychiatric complicity with torture or inhumane treatment.27,28,34,35
The Secretary of Defense authorized two practices at Guantanamo Bay that undermined the medical care for Al Qaida suspects. In November 2002, he directed, that for selected detainees" [of those being interrogated by being kept in isolation], the Officer in Charge of Interrogation will approve all contacts with the detainee, to include medical visits of a non emergent nature.6 This provision empowers an interrogator to deny and thus abridge a detainee's Geneva right to request a medical evaluation. The potential adverse effect of such a policy may be illustrated by the allegation that analgesia was withheld during the interrogation of Abu Zubaida, an Al Qaida operative, who suffered a gunshot wound during his arrest.36 In April 2003, the Secretary directed Guantanamo Bay interrogators to ensure that detainees are medically and operationally evaluated as suitable (considering all techniques to be used in combination).6 That provision, as discussed below, risks engaging medical personnel in setting the harshness of the interrogation. The Interrogation Rules of Engagement posted at Abu Ghraib were imported from the US operation in Afghanistan and echoed the April 2003 memo by the Secretary of Defense. They stated, Wounded or medically burdened detainees must be medically cleared prior to interrogation" and also approved Dietary manipulation (monitored by med)" for interrogation.11 Although Defense Department memoranda define the latter as dietary substitution (e.g., from hot meals to cold field rations) rather than food deprivation or compulsory violation of Islamic dietary rules, there are credible allegations of food deprivation.6,19,25
The list of confirmed or reliably reported abuses of detainees in Iraq and Afghanistan include beatings, burns, shocks, bodily suspensions, asphyxia, threats against detainees and their relatives, sexual humiliation, isolation, prolonged hooding and shackling, and exposure to heat, cold, and loud noise.1,14,19,24-26 They include deprivation of sleep, food, clothing, and materiel for personal hygiene. They include denigration of Islam and forced violation of its rites.19 Detainees were forced to work in areas that were not de-mined and seriously injured.26 [Editor's Note: It should also be noted that among the detainees at both Abu Ghraib and Guantanamo Bay are children as younbg as 11 who are presumably also being subjected to the torture and abuse described above.] Abuses of women detainees are less well documented but include credible allegations of sexual humiliation and rape.13,14,37
US Army' investigators concluded that Abu Ghraib's medical system for detainees was inadequately staffed and equipped.8,11,13,16,17 The ICRC found that the medical system failed to maintain internment cards" with medical information necessary to protect the detainees' health as required by the Geneva Convention; this appears to have been due to a policy decision to not process new detainees.16,26 Few units in Iraq and Afghanistan complied with the Geneva obligation to provide monthly health inspections.17 The medical system also failed to assure that prisoners could request proper medical care as required by Geneva Convention. For example, an Abu Ghraib detainee described how a purulent hand injury caused by torture went untreated and that an Iraqi physician tending to detainees at the behest of the US military treated him in a cellblock hallway after saying that he could not treat the detainee's ear that was bleeding after a beating in a clinic. 20 The medical system failed to establish procedures, as called for by Article 30 of the Geneva Convention, to ensure proper treatment of prisoners with disabilities. For example, an Abu Ghraib detainee's deposition reports the crutch that he used because of a broken leg was taken from him and his leg was beaten as he was ordered to renounce Islam. That detainee told a guard that the prison doctor" had told him to immobilize a badly injured shoulder; the guard then suspended him from the shoulder.21
The medical system collaborated with designing and implementing psychologically and physically coercive interrogations. Army officials stated that a physician and a psychiatrist helped design, approve, and monitor interrogations at Abu Ghraib.15 In one example of the compromised medical supervision of such work, a detainee collapsed and was apparently unconscious after being beaten by a guard, medical staff revived the detainee with an inhaler and left and the abuse continued.22 Guantanamo Bay's Commanding General said that the medical records of detainees were routinely shared with interrogators despite objections by the International Committee of the Red Cross.38 Such records may have contained information about phobias and family names that would have been important to interrogation techniques such as Fear Up Harsh."
There are isolated reports that medical personnel directly abused detainees. Two detainees' depositions describe an incident where a Doctor" came to a cellblock to treat a prisoner who was lacerated during a beating. The medic gave suture materials to the guard to suture the laceration.22,23 Another medic told a reporter that he had hit a detainee out of anger.39
The military medical system in Iraq and Afghanistan failed to accurately report illnesses and injuries.26 Abu Ghraib' authorities did not notify families of deaths, sicknesses, or transfers to other medical facilities as required by Conventions.26,50 Trial testimony tells of a medic placing a fake intravenous catheter into the arm of a detainee who died under torture in order to create evidence that he was alive at the hospital.40 In another case, an Iraqi man, taken into custody by US soldiers was found months later by his family in an Iraqi hospital. He was obtunded or comatose, had three skull fractures, a severe thumb fracture and burns on the bottoms of his feet. A US medical report at the hospital stated that heat stroke had triggered a heart attack that put him in a coma; it did not mention the injuries.41 In another instance, a US soldier at Guantanamo Bay was ordered to simulate a resisting prisoner.42 Guards, unaware of the deception, beat him and caused a traumatic brain injury and seizures that remain refractory to treatment. Military authorities initially maintained that medical personnel had informed them that the soldier's medical discharge was unrelated to the beating. Two weeks later, in response to news media inquiries, an amended medical report was released.
Death certificates of detainees in Afghanistan and Iraq were falsified or their release or completion was delayed for months.24,43 Medical investigators either failed to investigate unexpected deaths of detainees in Iraq and Afghanistan or performed cursory evaluations and physicians routinely attributed detainee deaths on death certificates to heart attacks," heat stroke," or natural causes" without noting the unnatural etiology of the death.44,47 In one example, soldiers tied a beaten detainee to the top of his cell door and gagged him. The death certificate indicated that he died of natural causes . . . during his sleep." After news media coverage, the Pentagon revised the certificate to say that the death was a homicide" caused by blunt force injuries, and asphyxia.24 In November 2003, Iraqi Major General Abed Mowhoush's head was pushed into a sleeping bag while interrogators sat on his chest. He died; CPR by medics was unsuccessful and a surgeon at the scene said he died of natural causes. Six months later, the Pentagon released a death certificate calling the death a homicide by asphyxia.45 Medical authorities allowed misleading information released by military authorities to go unchallenged. For example, for more than a year, military spokespeople said that a 22-year-old Afghan detainee had died of a heart attack" until news media released a military autopsy report indicating that he died of blunt force injuries to lower extremities complicating coronary artery disease.24 In June 2004, the US Secretary of Defense issued a more stringent policy for death investigations.46
Finally, although knowledge of torture and degrading treatment was widespread at Abu Ghraib, and was known to medical personnel,13,39,47 there is no report prior to the January 2004 Taguba investigation of military health personnel reporting abuse, degradation, or signs of torture up or outside the chain of command to stop those practices.
Pentagon officials offer many reasons for the human rights abuses including poor training, understaffing, overcrowding of detainees and military personnel, anti-Islamic prejudice, racism, pressure to procure intelligence, a few criminally-inclined guards, and the stress of war and uncertain lengths of deployment.1,2,13,16,17 Fundamentally however, the stage for these offenses was set by policies that were lax or permissive with regard to human rights abuses and a military command that was inattentive to human rights. [Editor's Note: A simpler explanation is that every documented abuse that has come to light is merely the expected culmination of explicit policy decisions. That no ranking or commanding officer has been disciplined, reprimanded or in anyway held responsible for the abuses indicates they are indeed de facto policy.]
Legal arguments as to whether Iraqi, Afghan, or Guantanamo' detainees were prisoners of war, soldiers, enemy combatants," terrorists, citizens of a failed state, insurgents, or common criminals miss an essential point. The US has signed or enacted numerous instruments including the UNs' Universal Declaration of Human Rights,48 the UN Body of Principles for the Protection of All Persons under Any Form of Detention or Imprisonment, 49 UN Standard Minimum Rules for the Treatment of Prisoners,50 the Convention Against Torture and Other Cruel, Inhuman, or Degrading Treatment or Punishment,51 and US military internment and interrogation policies,8-10 that collectively contain mandatory and voluntary standards barring US armed forces from practicing torture or degrading treatments of all persons. For example, the United Nations' Universal Declaration of Human Rights states, No one shall be subjected to torture or to cruel, inhuman or degrading treatment or punishment." 48 The Geneva Convention states Persons taking no active part in the hostilities, including members of armed forces who have laid down their arms and those placed hors de combat by sickness, wounds, detention, or any other cause, shall in all circumstances be treated humanely, without any adverse distinction . . . The following acts are and shall remain prohibited at any time and in any place whatsoever with respect to the above-mentioned persons: Violence to life and person, in particular murder of all kinds, mutilation, cruel treatment and torture; . . . Outrages upon personal dignity, in particular, humiliating and degrading treatment. . . . No physical or mental torture, nor any other form of coercion, may be inflicted on prisoners of war to secure from them information of any kind whatever. Prisoners of war who refuse to answer may not be threatened, insulted, or exposed to any unpleasant or disadvantageous treatment of any kind.52 Furthermore, the US War Crimes Act says that US forces will comply with the Annex to the Hague Convention Respecting the Laws and Customs of War on Land and the Geneva Convention Relative to the Treatment of Prisoners of War both of which bar torture or inhumane treatment.52-54
Pentagon leaders testified that military officials did not investigate or act on reports by Amnesty International and the International Committee of the Red Cross (ICRC) of abuses at Abu Ghraib and other coalition detention facilities throughout 2002 and 2003.1,24-26 The command at Abu Ghraib and in Iraq was inattentive to human rights organizations' and to soldiers' oral and written reports of abuses.55 After the ICRC criticized the treatment of Abu Ghraib detainees, its access to the facility was curtailed.1
The relationship of military medicine with regard to these abuses merits special attention because of the moral obligations of medical professionals with regard to torture and because of horror at health professionals who are complicit by deed or silence with torture. Active medical complicity with torture has occurred in South America, Europe, Africa, and Asia. Iraqi physicians collaborated with torture under Saddam Hussein's regime.56 In response, physicians' and nurses' professional organizations have created codes forswearing participation in torture.27,28,29,34,57,58 Physicians in Chile, Egypt, Turkey and other nations have taken great personal risk to expose and stop the practice of state-sponsored torture.27,28,59 Health professionals have created organizations including Physicians for Human Rights and Amnesty International's Health Professionals Network. Over the last fifty years, non-medical groups have asserted that healers must be advocates for persons at risk of torture.27,28,34,35,60
Military personnel treating prisoners of war, the enemy, face a particular dual loyalty conflict.61 The Geneva Convention addresses this ethical dilemma squarely: Although [medical personnel] shall be subject to the internal discipline of the camp . . . , such personnel may not be compelled to carry out any work other than that concerned with their medical . . . duties.52 By this standard, the moral advocacy of military medicine for the detainees of the war on terror broke down.
If Abu Ghraib is to leave a legacy of reform, it will be important to clarify how the breakdown occurred. The emerging evidence points to policy and operational failures. High-level Defense Department policies were inattentive to human rights and to the ethical obligations of medical care for detainees.6 One policy empowered interrogators to evaluate and refuse the request of a person under interrogation for medical evaluation. Another directed clinicians to medically clear and monitor interrogations. Although proposed as a Safeguard," that role threatens clinicians' advocacy for detainee's well-being by positioning clinicians to use medical judgments to set the harshness of interrogation.61 It will be important to determine whether and how senior military medical officials reviewed, challenged, or tempered those policies.
At the operational level, medical personnel assumed the role, assigned by policy, of evaluating persons for interrogation and monitoring coercive interrogations and interrogators used medical records to develop interrogation approaches. Medical records and death certificates were falsified to conceal torture, a form of complicity in torture.62,63 Furthermore, the military medical service failed to assure that health care for detainees met minimal staffing, equipment and performance standards that were designed to promote humane care of detainees.13,17,26 Medical personnel who knew about abuses condoned torture by failing to put their status and credibility in service of halting the abuses in violation of their duty to detainees.34,47,61
Which medical professionals were responsible for this misconduct? The US Armed Forces deploy physicians, physicians' assistants, nurses, medics (with several months of training) and various command and administrative staff. International statements assert that every health care worker has an ethical duty to oppose torture. For example, the UN Principles of Medical Ethics Relevant to the Protection of Prisoners Against Torture refers to health personnel," particularly physicians" but it also names physician assistants, paramedics, physical therapists and nurse practitioners.35 Likewise, the Geneva Convention refers to the obligations of medical personnel," defined as including physicians, surgeons, dentists, nurses or medical orderlies.52 Furthermore, the US Armed Forces medical services are under physician commanders and each medic, as with civilian physician's assistants, is personally accountable to a physician. Thus, physicians are responsible for the policies of the medical system; military medical personnel are accountable to ethics of medicine regarding torture.47
Abu Ghraib will leave a substantial legacy. Some detainees died and others will suffer long-term effects. As the prison milieu became brutalized, alcohol abuse and sexual misconduct by soldiers increased. To address this morbidity and misconduct among US soldiers, medical personnel prescribed anti-depressants and supported an Alcoholics Anonymous group instead of challenging torture as a critical piece of psychologically destructive prison milieu.39 The mission in Iraq was damaged. The reputation of military medicine, the US Armed Forces, and the United States was tarnished. Careers ended with criminal or administrative sanctions or courts martial. The eroded status of international law has increased the risk to persons who become detainees of war in a post Abu Ghraib world as it has decreased the credibility of international appeals on their behalf.
It is true, but beside the point, that the US Armed Forces' medical services are overwhelmingly staffed by humane and skilled personnel. The offenses described in this article do not merely fall short of medical ideals; some may constitute grave breaches of international or United States law. Various voices call for courts martial, a special prosecutor, or compensation. Such measures will be inadequate if unaccompanied by even more ardently pursued reform.
Such reform must begin with a comprehensive investigation. At this time, it is not possible to know the absolute or relative prevalence of the various abuses or fully assess the performance of military medical personnel with regard to human rights abuses in Iraq, Afghanistan, and Guantanamo Bay. Army investigations have looked at a limited set of human rights abuses, have not investigated reports from human rights organizations, have not focused on the role of medical personnel, and have not examined detention centers not operated by the Army.13-17 Six more investigations are underway.64 The Army's Miller and Ryder Investigations remain classified.17 Several thousand pages of the Taguba report's appendices are unavailable. There are a number of secret detention centers which remain unmonitored. At some future date, the US military medical services, human rights groups, legal and medical scholars, and health professional associations should jointly and comprehensively review this material in light of US and international law, medical ethics, the military code of justice, military training, the system for handling reports of human rights abuses, and standards for the treatment of detainees. Reforms stemming from such an inquiry could yet create a valuable legacy from the ruins of Abu Ghraib.
[Editor's Note: The role of doctors in the American prison system has all too often been extremely negative. Doctors presided over the massive use of prisoner guinea pigs in medical experiments from which many doctors profited personally and professionally. Many of the doctors employed in American prisons and jails are professionally barred from practicing medicine in any other environment, have histories of sexually assaulting their patients and have also performed the same cover ups of torture and brutality carried out by US prison guards as those described in the article above. In addition, as recently reported in PLN, some doctors also preside over executions. The medical profession as a whole has remained largely silent about these abuses and tacitly condones them by issuing doctors medical licenses that are suspended for practice anywhere but a detention facility, not revoking the medical licenses of health care professionals who condone or facilitate torture or murder, etc. Professionals can and should be held to a higher standard than they currently are. Surely asking them to comply with international law banning murder and torture is not too much to ask for.]
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[This article originally appeared in The Lancet. It is reprinted with permission. The author is a professor of bio ethics at the University of Minnesota.]
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