Holding Doctors Responsible at Guantánamo

This is a piece that takes up the issues of military doctor’s responsibilities in interrogation, written for the Kennedy Institute of Ethics Journal and published by Johns Hopkins. Parts of the essay appeared earlier in the LA Times op-ed.

Bioethics Inside the Beltway
Holding Doctors Responsible at Guantánamo

I recently visited the Guantánamo Bay Detention Center with a small group
of civilian psychiatrists, psychologists, top military doctors, and Department of
Defense health affairs officials to discuss detainee medical and mental health care.
The unspoken reason for the invitation to go on this unusual day trip was the
bruising criticism the Bush administration has received for its use of psychiatrists
and psychologists in the interrogation of suspected terrorist detainees.

We disembarked from our Navy jet to find an island lush and green from recent
storms. A small boat took us from the airfield to the naval hospital. From the boat
there was no sign of Camp Delta, where the detainees are actually held. Nor was
there a sign of prisons or barbed wire or the detention facility’s 505 inmates.
Our host was the commanding officer of Gitmo, Major General Jay W. Hood
(an artillery officer by training), who had replaced Major General Geoffrey Miller,
implicated in the “migration” of torture methods from Gitmo to Abu Ghraib.
Dressed in fatigues, General Hood briefed us using PowerPoint. His intelligence
director told us that interrogators have not used harsh “fear up” tactics—the
ones designed to terrify—since 2003.

We went by bus from the naval hospital to the 30-bed detainee hospital for
quick briefings from a psychiatrist and a physician. Still, we were not permitted
to see any detainees or hunger strikers, despite our requests. During our six hours
on the ground, we had only a fleeting glimpse of a few detainees outside their
cellblocks behind barbed wire and screened fences.

Indeed, when I got home and saw the play “Guantánamo: Honor Bound to
Defend Freedom,” by Victoria Brittain and Gillian Slovo, I had the disquieting
feeling that I had absorbed more about detainee life at the theater than I had from
actually being at Gitmo. This only amplified my anxiety that what I had heard
and seen during my VIP visit sidestepped the central moral issue of whether abuse
is still occurring at Gitmo and whether health professionals are, or have been, a
party to coercive interrogation.

The question that the Pentagon leadership has been focusing on, and which
was a key subject of discussion during our day at Gitmo, is whether there is an
ethical difference between using psychologists or psychiatrists on interrogation
teams—what the Pentagon calls, “behavioral consultation teams,” or BSCTs,
pronounced “biscuit.” Some in the Pentagon would like to have doctors and
psychiatrists, who are bound by the Hippocratic teaching to “do no harm,” be the
clinicians treating detainees. Psychologists, who are not as bound by Hippocratic
dicta, would consult with and advise interrogators. But this is a red herring. It is
hair-splitting that detracts from the real issue of whether health professionals of
any stripe can ethically be involved in interrogations that may involve coercive
techniques or torture. The answer is clearly no. They should not be involved,
directly or indirectly, in situations that may lead to the breach of confidential
medical records; to torture or to cruel, inhumane, and degrading treatment; or to
exploitation of fears or phobias. Mental health professionals simply should not
be collaborating with interrogators in inflicting psychological torture.

Hood said that “rapport building” was the preferred and an effective interrogation
technique, but that is no guarantee that rougher tactics will not be
used. The fact is that there is enormous pressure on the people at Guantánamo
Bay to get good intelligence for the war on terror, and it is as easy for behavioral
scientists as it is for interrogators to compromise their moral standards. Cunning
and deception to extract information may be acceptable in some cases. But many
people have been outraged to learn from media reports that methods developed
by military psychologists to train our own troops to resist torture—the so-called
“survival, evasion, resistance, and escape” methods taught at Ft. Bragg—have
been “reverse engineered” at Guantánamo Bay to create coercive, psychologically
manipulative interrogation techniques for use against detainees.

Plato warned long ago that a doctor’s skill, abstracted from good character
and wisdom, is a neutral ability: It can be used to heal or to harm. So, too, the
science of psychological trauma can be the science of torture. How it is used is a
matter of the virtue of the doctor. Doctors should serve at Gitmo to treat patients
for medical and mental health conditions, but the American Psychiatric Association
and the American Psychological Association must insist that their members
shun practices that compromise professional conduct. Like the good soldier who
should resist orders that may be lawful but immoral, the good military doctor
must do the same.

This warning is especially critical in the face of recent news reports about the
current treatment of hunger strikers. During our trip to Gitmo, we were assured
that hunger strikers were being treated humanely. The commanding doctor, Captain
John Edmonson, showed our group, which included U.S. Surgeon General
Richard Carmona and Army Surgeon General Kevin Kiley, the tube used for feeding—
a thin nasogastric tube, a 10-French Dobhoff—and explained that anesthesia
routinely was administered before insertion. We were told that there was overall
“complicity,” in the sense that most strikers did not forcibly resist insertion of
the tubes or remove them once they were in place. Of course, acquiescence in the
face of harsh treatment or torture is hardly consent, and given the pain of pulling
out a nose tube, failure to do so likewise is no sign that consent was given.

However, the procedure has changed of late. In some recent cases, victims have
been strapped into a chair during and immediately after force-feeding, in order
to prevent purging. In addition, there have been reports that the detainees have
been force-fed not only nutrients, but also diuretics and laxatives. The result is
that, while in the chair, victims are forced to urinate and defecate on themselves.
This is far from humane medical treatment.

Moreover, the practice raises many questions that Americans should be asking:
Are military doctors complicit or responsible? Did they advocate for or consent
to the use of the chair and the administration of diuretics and laxatives? Was this
practice approved by those at the head of the chain of command, namely, the Army
Surgeon General and Assistant Secretary of Defense for Health Affairs, who are
ultimately “charged with assuring quality medical care for all beneficiaries of the
Department of Defense, including detainees and prisoners of war”? Has Congress
properly investigated the matter and held those reponsible accountable?
It may come as no surprise to some that being forced to urinate and defecate
on oneself has a long history at Gitmo. At a recent conference featuring interviews
with four released Gitmo detainees, there was repeated mention of the tactic
(Voices of Guantánamo, George Washington Law School, 20 March 2006). I
heard first hand of their ordeal of being “processed” for 8–10 hours by U.S.
troops at Bagram air field base. Skimpily dressed in freezing cold weather, the
detainees were made to walk in circles with bare feet on sand mixed with shards
of glass. Denied the use of toilets, they were forced to urinate and defecate on
themselves. They then were shackled in stress positions for the 10-hour flight to
Guantánamo Bay; they were hooded, with their eyes taped, and, again, denied
the use of toilets.

It is important to be clear about the nature of this form of degradation. However
one defines either torture or cruel, inhumane, and degrading treatment, one
common element is that victims often are made to feel complicit in their own
abuse. The sense of self-betrayal, of shame, of self-contempt that so many torture
victims feel reflects a feeling of compromised agency, of turning against oneself
through the very exercise of one’s own will.

Urinating or defecating on oneself, because one is denied more decent forms of relief, is a way of experiencing oneself as an agent without agency—one let’s oneself “do it;” the case is different from that of a toddler who has not yet mastered bladder or sphincter control or an infirm person who has lost full control. Rather, this is actively “doing it,” and yet still, it is being made to “do it” on oneself. It is experiencing oneself as helpless in one’s agency. The victim is prevented from exercising control of body functions that are basic loci of self-control, and this is humiliating. Moreover, it makes a mockery of one of the few modes of selfassertion and protest left to a victim—namely, hunger striking.

It may well be true that many hunger strikers are not in the position to think
carefully and reflectively through the consequences of their actions. They are
without family contact and consultation from spiritual counselors. Some have
spent months in isolation. Others have endured repeated physical and psychological
abuse. They are not in conditions that promote autonomy. In such circumstances,
force-feeding may be a humane option, although a far more humane
approach would be to ameliorate the background conditions that deprive them
of more meaningful autonomy. But the use of the chair and force-fed diuretics
and laxatives are in no sense humane, however effective they are in deterring
strikers. Doctors, military and civilian alike, should protest their use. Moreover,
military doctors must be, first and foremost, doctors, committed to the humane
treatment of those in their care. They must not break from that role even if it
means disobeying orders from their superiors.

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