The recent confirmation hearings for attorney general nominee Alberto R. Gonzales and the trials of the soldiers accused of misconduct at Abu Ghraib have once again brought to the fore questions about the use of torture in our war on terrorism. But one aspect that is never mentioned -- one I believe is essential to consider -- are the actions or, more to the point, the apparent inaction of medical personnel at both Guantanamo Bay and Abu Ghraib.
Detention facilities like these typically have fully staffed clinics with primary care physicians, nurses and a host of other support personnel to treat American soldiers as well as detainees. Their common duty -- from corpsmen with basic medical skills training to physicians with leadership positions -- is to provide care according to high standards of medical practice to all who need it and, of course, to report any signs of physical or psychological abuse.
As a physician holding the title of brigadier general by the time I retired in 1998, I directed major medical support efforts during the 1991 Gulf War and have seen the Army leadership up close. So, as the scandals at Abu Ghraib in Iraq and Guantanamo in Cuba unfolded, I wondered why we had heard so little from the medics. When faced with the twin pressures of performing their military duty and providing treatment, did the staffs at these facilities turn a blind eye to the physical and mental torture inflicted on the prisoners, or perhaps even collude with interrogators? There are few other explanations for why they didn't report suspicious findings from the examinations of the detainees. Unless, of course, those reports were suppressed.
I've also wondered whether the senior medical leadership of the Army, Navy and Air Force knew of the abuses -- and whether their reports could have been concealed.
My growing concern has been reinforced by an appalling case of glib reasoning, in which the office of the deputy assistant secretary of defense for health affairs, as reported in a recent issue of the New England Journal of Medicine, has taken the position that the medical personnel at these facilities had not breached the Hippocratic oath because there was not a recognized doctor-patient relationship. The NEJM reported that the deputy assistant secretary endorsed the view that some of the medics supporting interrogators in Iraq and Guantanamo were operating outside the bounds of the doctor-patient relationship and were thus not required to abide by accepted ethical guidelines.
What precisely does this mean? That the prisoners were not being billed by the medical personnel? That there were no neat files, none of those signed privacy forms known as HIPAAs? Don't worry, the Defense Department seems to be saying, being a military physician doesn't mean that you need to stick to the time-honored maxim of "First, do no harm"?
Indeed, the same article noted that the office contended that the legitimate objective of fighting terrorism trumps the ethical responsibility of the healing practitioner. In other words, "the ends justify the means": A few brutalized prisoners is a small price to pay for protecting the citizens of the United States.
According to this line of reasoning, military medical personnel should put a higher priority on fighting the war against terrorism than on abiding by the recognized ethical and moral principles of their profession. Moreover, no worries about potential malpractice suits need cloud their day; they can feel protected and relieved of the duty to exercise personal and individual responsibility.
That's not how I was trained. I attended both college and medical school on Army scholarships during the turbulent years of Vietnam and the My Lai massacre, with cynicism over the practices in our military echoing in my ears. Fifteen years later, in 1989 and 1990, I attended the Army War College as a medical corps colonel. At all these institutions, clear parameters for conduct were laid out. The war colleges teach senior officers -- future generals and admirals -- that commanders are responsible for the ethical and moral climate of their units. They are also responsible for what the men and women who serve under them do and don't do.
There is no escaping the fact that responsibility for the conduct of the medics at Guantanamo Bay and Abu Ghraib rests with the senior leadership of the medical departments. This leadership faced tough questions from the outset of operations in both Afghanistan and Iraq about how medics were supposed to treat detainees; the burden of leadership is to ensure that high moral and ethical practices are maintained in even the most demanding situations.
But there is not much evidence to show that the Defense Department wrote out guidelines for adherence to the high standards. In fact, there is only evidence to the contrary: There are few, if any, reports from medics about detainee abuse and there is no sign of inquiries or reviews of the policies and conduct of the medical teams at those facilities. But documents of testimony taken during investigation into the abuses at Abu Ghraib recently released under the Freedom of Information Act and posted on the Web sites of the American Civil Liberties Union and Center for Public Integrity suggest that medical personnel were aware of abuses, may have witnessed some and may even have advised interrogators on the individual medical conditions of the prisoners and their vulnerabilities to specific stresses that could induce them to disclose valuable intelligence -- actions that may have bordered on torture.
With disturbing echoes of unsavory regimes in history, medics abdicated their responsibilities toward the detainees, their patients, instead of making interrogations more humane, more in keeping with international standards of decency.
Unlike soldiers, doctors have a duty to patients as well as country. That is what separates U.S. military physicians from the German doctors who aided the Nazis in concentration camps or, in perhaps a closer parallel, the South African prison doctors who examined anti-apartheid leader Steve Biko (a fellow physician no less), filed incomplete reports, deferred to police interrogators and failed to stop the brutal treatment that ended in Biko's death.
But there is an even bigger failure to be reckoned with. These are times when the country deserves great leadership, and that kind of leadership anticipates the toughest problems. Military leaders should first have asked the hard questions about the ethical parameters guiding the conduct of medics and focused on the policies that governed that conduct: What is the historical precedent; what are the best ideas about the role of medics in this war; and what are the long-term consequences of their actions? For these leaders to speak up as the scandals were investigated would have taken great courage -- generals and admirals would have been forced to retire.
But heroism is not just the stuff of the battlefield. Patients trust doctors, nurses and medics because they expect them to do what is right -- to put the needs of others over their own. Nations expect their generals to be bold and to take risks -- and to show moral courage.
Something doesn't smell right here, and it just may be an abscess of ethical lapses. While there can be long and learned legal discussions about the role of torture during wartime, the medical aspect of these discussions should be very brief: No doctor -- and no military medical leader -- should participate in torture in any way. Either by advising interrogators of prisoners' vulnerabilities or by simply doing nothing, they did participate. And that says more about the problems of military leadership than any memo on legal protections.
Author's e-mail: firstname.lastname@example.org
Stephen N. Xenakis, a retired brigadier general with the U.S. Army, now works as a child and adolescent psychiatrist at the Psychiatric Institute of Washington.