Doctors Without Ethics

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The memory of detainee No. 173379 still haunts Andrew Duffy. The 24-year-old prisoner showed up in March 2006 at Abu Ghraib, where Duffy was stationed as a medic. His job was to treat new arrivals in an overcrowded, sweltering tent. Then 19, Duffy handled everything from common diseases like tuberculosis to festering gunshot wounds.

But the new prisoner stood out. He was belligerent, yelling gibberish, and staggering like a drunk. Having witnessed this kind of behavior before with detainees in diabetic shock, Duffy checked the man’s blood-sugar level and found it was extraordinarily high. The prisoner explained that Iraqi soldiers had held him for five days without his insulin. Duffy called the compound’s hospital to request an immediate transfer. It was denied. Duffy’s medical supervisor ordered him to just give the guy water.

He was used to this. The prison’s medical officers routinely rejected medics’ requests to hospitalize sick and wounded detainees; the general sentiment, Duffy says, was “screw these guys.” Once, he tried to revive an elderly prisoner whose heart had stopped by using CPR and mouth-to-mouth. “Why did you make out with that hajji?” the hospital staffers taunted. “Why didn’t you just let him die?”

Beyond patching up detainees, Duffy and his comrades with the 134th Medical Company of the Iowa National Guard were ordered to soften them up for interrogation. Duffy and an MP once restrained and hog-tied a resisting detainee–cuffing his wrists to his crossed ankles behind his back–so that Duffy could check his vital signs. Guards later boasted that they’d left the man that way for 12 hours.

Throughout Duffy’s year at Abu Ghraib–long after the infamous photos were published and the Pentagon vowed that detainees were no longer abused–men were still being strapped into restraint chairs and left in the sun for hours or locked in cells too small to lie down in. The medics regularly found prisoners dehydrated, wrists bloody from overtight handcuffs, ankles swollen from forced standing, joints dislocated from stress positions. They knew to keep their written evaluations vague, never mentioning cause of injury as a standard medical report would. When they shuttled broken detainees to and from the prison’s interrogation rooms, the orders were explicit: Transport only. No medical care. No paper trail. Flouting the Geneva Conventions, Duffy’s platoon sergeant even ordered the medics to strip their uniforms and ambulances of the Red Cross emblems that denoted them noncombatants. Should anyone from the Red Cross show up to see the prison, the soldiers were told, send them away and tell them nothing.

For more than five decades, starting with the prosecution of Nazi doctors during the Nuremberg trials, the Pentagon ordered its physicians to abide by international norms. The World Medical Association (WMA), which counts the American Medical Association (AMA) as a member, had issued clear directives: Doctors could not assist in torture or cruelty of any kind, and were duty bound to report abuses they witnessed. The United Nations later clarified that the rules apply to all medical personnel, from surgeon to nurse to psychologist to lowly medic. Even now, the Army’s Military Medical Ethics textbook echoes the Geneva Conventions, noting that a doctor-warrior’s priority is always “physician first.”

But even as the nation debates disbarment for the Bush administration lawyers who green-lighted torture, the medical profession has dealt reluctantly, if at all, with its own involvement. “The indifference is shocking,” says retired Army Brigadier General Stephen N. Xenakis, a rare outspoken critic among military doctors. “Some civilian doctors are appalled, but many say, ‘It doesn’t affect my life; I’m not involved.’ “

Doctors were complicit in the torture strategy from the start. In December 2002 Defense Secretary Donald Rumsfeld issued a directive allowing interrogators to withhold medical care in nonemergency situations–men with injuries including gunshot wounds were denied treatment as a way to make them talk. The directive was soon revoked, but the practice continued.

Four months later, Rumsfeld ordered that doctors had to certify prisoners “medically and operationally” suitable for torture and be present for the sessions. At Abu Ghraib, interrogations had to be preapproved by a physician and a psychiatrist. “They have the final say as to what is implemented,” Colonel Thomas M. Pappas told military investigators.

The CIA received similar advice in 2002 and 2005 from the Justice Department, whose torture memos recommended that physicians and psychologists be present for the interrogation of “high value al-Qaida detainees.” These doctors, the lawyers argued, would see to it that interrogators didn’t torture detainees by intentionally inflicting “serious or permanent harm.”

But it was in June 2005 that the Pentagon delivered its biggest ethical bombshell, a memo that allowed doctors to participate in torture and share medical records with interrogators so long as the detainee in question wasn’t officially their patient. The directive’s author, physician and top Pentagon health official William Winkenwerder Jr., received an award from the AMA that year for outstanding contributions “to the betterment of the public health.”

Field medics like Duffy, who were still being trained to do no harm according to the military’s old ethical standards, faced a rude awakening. “You have all these codes you follow as a health care worker, but then it’s, ‘Now we’re in Iraq, forget those,’ ” Duffy says.

Plenty of doctors in uniform felt similarly but, like Duffy, did as they were told. A 2007 Red Cross report indicates that CIA medical personnel presided over hundreds of waterboardings. Gitmo military doctors twice sent alleged 9/11 planner Mohammed al-Qahtani to the hospital after his heart rate fell to dangerously low levels, only to send him back to the torture chamber when he improved.

Aware of the breaches, Xenakis says, a few military physicians called for ethical reviews. But the Pentagon overruled them, and the protests ceased. “There was a blackout,” he explains. Fearing for their careers, “military doctors wouldn’t speak, even informally.” Before long, says M. Gregg Bloche, a Georgetown University law professor who interviewed military physicians on condition of anonymity, the Defense Department was screening doctors and deploying only those on board with the program.

During the 1980s, as a symbolic show of support for doctors working under oppressive regimes, the AMA adopted WMA guidelines that forbade their participation in torture. But even when it became clear that U.S. doctors were violating these rules, the association, which represents a quarter of a million doctors and medical students, took no steps toward censuring its wayward members. Instead, in 2004, it released a statement pointing to its existing guidelines. The AMA’s refusal to take a stronger stand, says Penn State bioethics professor Jonathan H. Marks, has been “a source of shame” for the profession.

What stood out for Steven H. Miles, a bioethicist at the University of Minnesota Medical School, was the association’s resounding silence in February 2006, after the U.N. Commission on Human Rights condemned American doctors for having “systematically” participated in detainee abuse. It should have been “a call to arms,” Miles says. “But the AMA said nothing.”

It wasn’t until November 2006 that the association issued a statement clarifying that doctors cannot participate in interrogations of any kind. Xenakis, who helped shape the new policy, says most of the AMA’s military delegates resisted the move, arguing that “the mission of getting information was greater than the medical ethics they acknowledged we were overriding.” (The four military delegates contacted for this story declined to comment.)

On at least four occasions, doctors have petitioned the AMA’s leaders to endorse an independent investigation of their colleagues’ role in the abuses–only to be voted down. “They said, ‘Look, we trust our military and we aren’t going to step on their toes,’ ” explains Matthew Wynia, director of the association’s Institute for Ethics.

None of the AMA’s top officials would be interviewed for this story. When spokeswoman Kate Cox was pressed on why they were so reluctant to act, even after the complicity of doctors became apparent, she insisted that the association has no specific knowledge of doctors being involved in abuse or torture and that it is not equipped to conduct the sort of investigation needed to “credibly confirm” such allegations. Besides, Cox said, the AMA has fulfilled its duty simply by setting ethical standards.

But the AMA’s critics worry that its half measures have already–perhaps irreparably–damaged the moral standing of American doctors. “It has had a corrosive effect,” says Xenakis. Adds Miles, “We’re now in an extremely poor position to protest abuse in other countries. It will silence us as a medical community.”

Mental health practitionerswere, if anything, even more deeply involved in the abuses. In November 2002 Gitmo commander Major General Geoffrey Miller put together a behavioral science consultation team, a group of psychiatrists and psychologists tasked with preparing prisoner profiles and advising interrogators on the use of environmental manipulation, sleep deprivation, exploitation of individual fears, and other coercive methods.

Among the practitioners was Guantánamo psychologist Major John Leso, who helped plan and implement the 50-day interrogation of Mohammed al-Qahtani. Detailed logs of the torture sessions indicate that the prisoner was sexually humiliated, isolated and deprived of sleep for extended periods, subjected to extreme cold, shackled in stress positions, tormented by military dogs, and leashed and made to perform like a dog.

Leso, who was in the interrogation room for part of Qahtani’s ordeal, advised–among other things–that the detainee could be disoriented by spinning him on a swivel chair. Along with the prison’s medical doctors, he regularly evaluated Qahtani for his ability to tolerate further abuse. During one session, the medical staff injected the prisoner with three and a half IV bags of saline; Qahtani’s questioner then wouldn’t let him urinate until he provided satisfactory answers. Despite evidence of Leso’s actions, the American Psychological Association (APA) has failed to act on an ethics complaint by a fellow APA member.

Psychologists are deeply divided on the subject of torture. In 2005 an association task force (6 of its 10 members had military ties) voted to condemn torture but still allow psychologists in the interrogation room, where, its members argued, they might discourage abuse and even save detainees’ lives. Incensed, thousands of psychologists petitioned for a full member vote in 2008, and in a roughly 60-40 tally, the association decided that psychologists have no place in the interrogation room. It was the right choice, says Robert Jay Lifton, a psychiatrist who has written about the role of Nazi doctors during the Holocaust. Putting health professionals into an abusive setting, he argues, “can confer an aura of legitimacy and can even create an illusion of therapy and healing.”

In May 2006 the American Psychiatric Association, which represents some 38,000 psychiatrists, reiterated its past position that its members should not directly assist in interrogations. But Steven Sharfstein, then the association’s president, also noted that psychiatrists “wouldn’t get in trouble” if they heeded military orders over the association’s advice–which, he added, should not be considered “an ethical rule.”

It’s not that themedical community lacks the tools to police itself. State licensing boards are legally obligated to investigate violations, and they have the power to suspend licenses–yet no state medical board has ever disciplined a doctor for assisting in military torture.

One California complaint illustrates the boards’ reluctance to confront the military. Filed by attorney Scott Sullivan on behalf of four former detainees, the 2005 complaint targeted Captain John S. Edmondson, then Guantánamo’s lead physician. The men claimed that their medical records were shared with interrogators, who then withheld treatment for heart problems, worms, constipation, and injuries inflicted by the camp’s “internal reaction forces”–five-man teams dispatched to beat recalcitrant prisoners. When these attackers showed up, the detainees claimed, medical personnel would instruct them on details: “Hit him around the eye; don’t poke him in the eye.”

But the complaint never got a hearing: The medical board demurred to the Pentagon’s jurisdiction. Citing insufficient subpoena power and resources, the board turned the matter over to military investigators, who found no evidence of wrongdoing. “The board didn’t care how they got out of it,” says Sullivan. “They just didn’t want to be in the middle of a hot-button political issue.”

Absent action from the profession, some states have turned to political pressure. California’s Senate passed a symbolic joint resolution last year urging the state’s licensing boards to warn doctors that they could be prosecuted for participating in torture. (The American Psychiatric Association petitioned unsuccessfully to have psychiatrists exempted.) A bill under consideration in New York would bar any health care worker from participating in torture or “improper treatment,” as defined by international standards. But reform advocates say legislation is no substitute for sanctions by doctors themselves. “The practice of medicine,” says George Annas, a professor of law and public health at Boston University, “is something the profession defines and the profession has to guard.”

Back at Abu Ghraib, Andrew Duffy was in no position to disobey a direct order, so he did as he was told and gave water to his diabetic prisoner. By the next morning, detainee No. 173379 was even weaker and more confused. Duffy and his partner again called for a hospital transfer–their third try–and again the supervisor denied the request. This time, she told them to administer saline through a 14-gauge needle.

That’s a huge needle–more than two millimeters in diameter. A civilian doctor would only use it for extreme trauma situations, with an unconscious patient or with a local anesthetic to numb the pain. At Abu Ghraib, the large needles were used as punishment, or to discourage detainees from asking for care.

A day later, the Army’s criminal investigation unit summoned Duffy and his partner for questioning. No. 173379 was dead. Interpreting his symptoms as insubordination, MPs had pepper-sprayed the man and stuck him in a tiny cell in the scorching heat. Duffy says he filled out a five-page sworn statement, but his captain gave a conflicting account, and the case was dropped. Later, when it became clear that the dead man had been an associate of Abu Musab al-Zarqawi, the bloodthirsty commander of al-Qaida in Iraq, soldiers came up to congratulate the medics.

Duffy did what he felt he could. Beyond his statement (which the investigators now claim they have no record of), he complained to his superiors about the shoddy medical supplies and the stripping of Red Cross emblems. More recently, he filed complaints about his platoon sergeant and captain with the Army Inspector General’s office, but nothing has come of it. In any case, much of the paper trail that might have implicated them is probably lost. When the military abandoned Abu Ghraib in September 2006, Duffy and his comrades were given one last order: Burn all of the compound’s medical records.

Excerpted from Mother Jones (July-Aug. 2009), a bimonthly that combines serious reporting chops with progressive ideals in covering news, politics, and

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