Do no harm

Since we've been thinking about The Lancet the past couple of days, I was reminded of Steven Miles's essay two years ago, on the legacy for military medicine of abu Ghraib. (Access is free, fairly painless registration required -- I recommend you go for it.) Funny thing about that, this got little or no attention in the U.S., as far as I know. Miles, by the way, has just come out with a book expanding on this work: Oath Betrayed: Torture, Medical Complicity, and the War on Terror (Random House).

In the Lancet piece, he catalogs the horrors of Abu Ghraib and the prison camps in Afghanistan. Okay, we've heard it before. But his focus is on the participation of medical personnel in the torture and degradation of prisoners, including condoning medical neglect, active participation in torture, and issuance of false death certificates to cover up murder by U.S. military and civilian personnel. Here are just a few examples:

he 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 This echoes the Secretary of Defense's 2003 memo ordering interrogators to ensure that detainees are “medically and operationally evaluated as suitable” for interrogation plans.6 In one example of a compromised medically monitored interrogation, a detainee collapsed and was apparently unconscious after a beating, medical staff revived the detainee and left, and the abuse continued.22 There are isolated reports that medical personnel directly abused detainees. Two detainees' depositions describe an incident where a doctor allowed a medically untrained guard to suture a prisoner's lacertation from being beaten.22,23

The medical system failed to accurately report illnesses and injuries.34 Abu Ghraib authorities did not notify families of deaths, sicknesses, or transfers to medical facilities as required by the Convention.34,36 A medic inserted a intravenous catheter into the corpse of a detainee who died under torture in order to create evidence that he was alive at the hospital.37 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 comatose, had three skull fractures, a severe thumb fracture, and burns on the bottoms of his feet. An accompanying US medical report stated that heat stroke had triggered a heart attack that put him in a coma; it did not mention the injuries.38

Death certificates of detainees in Afghanistan and Iraq were falsified or their release or completion was delayed for months.24,39 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 aetiology of the death.40,41 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 Mowhoush's head was pushed into a sleeping bag while interrogators sat on his chest. He died; medics could not resuscitate him, and a surgeon stated that he died of natural causes.42 6 months later, the Pentagon released a death certificate calling the death a homicide by asphyxia.42 Medical authorities allowed misleading information released by military authorities to go unchallenged for many months.24 In 2004, the US Secretary of Defense issued a stringent policy for death investigations.43

Finally, although knowledge of torture and degrading treatment was widespread at Abu Ghraib and known to medical personnel,13,41,44 there is no report before the January 2004 Army investigation of military health personnel reporting abuse, degradation, or signs of torture.

Although there have been calls over the years for prosecution of the physicians and other medical personnel involved in these crimes, there have been none. The names of any physicians and other licensed providers (such as nurses) who may have participated have not been made public, although I read in a review of Miles's book that he does name at least a couple. The relevant state licensing authorities should investigate and, if the allegations are confirmed, revoke the licenses of any guilty personnel; and there should be assurances that they cannot subsequently be licensed in any other state, as too often happens with incompetent or unethical doctors.

Before joining the military, physicians have already taken an oath. Military service does not in any way change the ethical obligations of physicians, nurses, or paramedics. Orders to a military physician to violate ethical requirements are unlawful and must not be obeyed. According to the Geneva convention, as quoted by Miles, "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." If the military can't live with that, however quaint, it can't employ physicians.

Finally, Miles notes that most of the results of Army investigations of these abuses remain classified. The prisoners already know what was done to them. The only people they're keeping this information from are you and me.