Medical Oaths Betrayed

By Steven H. Miles
Sunday, July 9, 2006; B01

In November 2003, an Iraqi guard smuggled a pistol into the U.S. military prison at Abu Ghraib and gave it to a prisoner, Ameen Saeed al-Sheik. Tipped off, military police quickly began a cell-to-cell search. When they reached his cell, Sheik went for the hidden pistol; gunfire was exchanged and a sergeant was hit. According to sworn testimony, the soldiers wrestled the prisoner to the floor and sent him to the hospital with a dislocated shoulder and shotgun wounds to his legs.

When Sheik returned to prison, he was beaten with a baton and his arms were handcuffed over his head, putting stress on his injured shoulder and leg. On a cold night, a medic, Sgt. Theresa Adams, saw Sheik naked and bleeding from a catheter that should have been connected to a bag to prevent infection. According to a sworn statement, the physician on call (who held the rank of colonel) agreed that the hospital had erred in leaving the catheter open but refused to remove it or to transfer Sheik to a hospital. When Adams asked him whether he had ever heard of the Geneva Conventions, the physician answered, "Fine, Sergeant, you do what you have to do; I am going back to bed."

In May 2004, photographs of prisoners being abused at Abu Ghraib shocked the world. When I saw the pictures, a simple question came to mind: Where were the prison doctors, nurses and medics while this abuse was happening?

Based on my review of tens of thousands of pages of declassified government documents, congressional testimony, press accounts and reports by human rights organizations, the answer is clear: Many armed forces physicians, nurses and medics have been passive and active partners in the systematic neglect and abuse of prisoners. At facilities in Iraq, Afghanistan and Guantanamo Bay, Cuba, the United States often failed to provide prisoners with minimally adequate medical and health systems. Some physicians and psychologists provided information that was used to determine the harshness of physically and psychologically abusive interrogations, which were then monitored by health professionals. Some doctors responsible for the medical records of detainees omitted evidence of abuse from their official reports. Medical personnel who knew of this system of neglect, abuse and torture remained silent.

Certainly, the vast majority of military clinicians are responsible and competent. But even silence or indifference concerning prisoners' injuries was common enough to enable prison abuse to continue in Iraq, Afghanistan and at Guantanamo Bay. My new book on this subject cites incidents involving 120 to 150 clinicians at these locations -- most remaining quiet in the face of abuse, at least 10 delaying or suppressing death certificates in cases of abuse, and at least 30 involved in designing or monitoring harsh interrogations.

These were not isolated acts of medical complicity; rather, they formed a pattern of abuse authorized (or ignored) by senior U.S. officials.

In November 2002, Defense Secretary Donald H. Rumsfeld appointed a working group to develop an interrogation policy for the prison at Guantanamo Bay. Upon receiving the working group's reports, Rumsfeld approved techniques such as isolation, interrogation for 20 hours, deprivation of light and sound and the use of loud sounds, as well as "manipulation of the detainees' emotions and weaknesses."

But his April 2003 directive also proposed three roles for medical professionals in interrogations. First, "the use of isolation as an interrogation technique requires detailed implementation instructions, including . . . medical and psychological review." Second, application of such interrogation methods was contingent on the detainee being "medically and operationally evaluated as suitable." Third, the interrogations required "the presence or availability of qualified medical personnel."

Rumsfeld's vision was fleshed out in Army prisons in Iraq, Afghanistan and at Guantanamo Bay, with health professionals cooperating in all phases of coercive interrogation. Some provided information from medical records and clinical interviews for use in designing interrogation plans. Others recommended ways to break down prisoners, using insights from cross-cultural psychology to degrade and demoralize them.

'The Man Was Old'

Although few records describing interrogations have been declassified, investigative files confirm that clinicians were present during some harsh inquiries. Guantanamo Bay interrogators and officers reported that doctors observed such questioning from behind a mirror or were in the room while it was occurring. And in Samarra, various soldiers offered sworn testimony about a particular interrogation:

[Linguist -- name redacted]: I witnessed concern on the part of the primary interrogator toward preventing the detainee from going into a medical crisis as a result of the questioning. He stopped the questioning several times so that a medical professional could examine him and determine if he was still doing fine. All indications were that, aside from the stress of being captured and questioned, he was suffering no health crisis.

Q: During any interrogations did Staff Sergeant [name redacted] ever have to stop it because of medical problems?

A: I don't think so. The only one was [same inmate as above] but Staff Sergeant never stopped it. He only voiced concern that we ease up on the detainee so he could remain calm and keep his blood pressure down. . . .

[Interrogator -- name redacted]: [Name redacted] and I were the agents while [name redacted] sat in as the medic on standby. . . . Every time, maybe two or three times, the [detainee] showed any sign of difficulty, [co-interrogator] would take a break to allow [medic] to attend to him. . . . We took several breaks that night. The man was old and in the middle of the interrogation, we gathered up his pills (or medication) and gave it to him .

One log that detailed the medical monitoring of interrogations was leaked from Guantanamo Bay, excerpted in Time magazine and later authenticated by the Pentagon. According to the log, in 2002 psychologist John Leso monitored the interrogation of Mohamed al-Qahtani, making suggestions on how to increase the stress on the prisoner. The 50-day chronology details the techniques employed: isolation, sleep deprivation, masking, head shaving, shackling, threatening with a dog and so on. The log shows regular monitoring by medics, who, at one point, administered nearly three bags of medical saline intravenously while the prisoner was tied to a chair. When Qahtani asked to urinate, he was told to do so in his pants. He was treated twice for a slow heart rate caused by hypothermia that was intentionally induced by air conditioning.

Medical examinations of prisoners -- both before and after interrogations -- were often skipped. In 2005, the Army's surgeon general found that 15 to 50 percent of prisoners in Iraq, Afghanistan and at Guantanamo Bay were examined before being questioned, and less than 15 percent were examined for injuries afterward. Even when such exams took place, however, they were not necessarily for the prisoners' benefit. According to the 2004 report by Army Maj. Gen. Antonio M. Taguba on abuse at Abu Ghraib, medical personnel vetted prisoners for interrogations that were designed in accordance with the medical findings to include stress positions, sleep deprivation, isolation and dietary manipulation.

This process required the use of Behavioral Science Consultation Teams (BSCTs or "biscuits"), which helped design interrogation plans to exploit prisoners' psychological and physical vulnerabilities. The BSCTs used clinical information to clear prisoners for harsh interrogation plans; they also used medical information to develop a plan to break a prisoner's resistance to questioning. Clinicians at Guantanamo Bay met with BSCT personnel to offer insight on prisoners' weaknesses, according to the report by Maj. Gen Geoffrey D. Miller, who took command of the Abu Ghraib prison after the abuse scandal broke out.

At times, behavioral clinicians reportedly micromanaged some interrogations; one Guantanamo Bay psychiatrist even suggested rationing toilet paper to seven sheets per day and limiting water for bathing. Similarly, a military intelligence specialist in Iraq applied her background in psychology to design approaches to "interrogate those who could not be broken." She approved coercive interrogation plans involving sleep deprivation but vainly protested the use of dogs or nudity. She eventually asked to be relieved of interrogation duties.

'The Dude Eventually Died'

In December 2002, Rumsfeld empowered Guantanamo Bay interrogators to deny a prisoner's "medical visits of a non-emergent nature." Although he later revoked the order on advice of legal counsel, the practice of punitive denial of treatment apparently continued throughout the prison system.

In Iraq, Army investigators reviewed a video showing a prisoner with bound wrists lying on the ground near a checkpoint. Entry and exit gunshot wounds are visible. While the soldiers discuss whether to summon medical care, one soldier tells the moaning prisoner to "shut up" and kicks him in the face or upper chest, according to the report of an Army criminal investigation. A soldier who was present during the videotaping later joked that they "weren't in any hurry to call the medics," adding that he "thought the dude eventually died."

A recently filed lawsuit and an FBI memo describe four prisoners, three at Guantanamo Bay and one apparently in Afghanistan, who were denied a prosthetic limb, antibiotics for wounds (two cases), and treatment for constipation until they cooperated with interrogators. An FBI memo tells of a prisoner, arrested in Afghanistan, who was denied treatment for a gunshot wound and was tortured for at least three days before being taken to a hospital.

At Guantanamo Bay, a psychology technician complained to an officer who refused to allow a prisoner to receive a medical evaluation for back pain. According to "Inside the Wire," a 2005 book co-written by former Army linguist Erik Saar, the officer answered, "I run this cellblock the way I see fit. If I think a detainee is complaining about back pain just to get to walk across the camp to the medical clinic one sunny afternoon, then I'm not going to put it in my log. Now leave my block and next time stay in your lane."

Another Guantanamo Bay interrogator, who had read a prisoner's medical files, asked for medical treatment for the prisoner's eyes, according to a June 2005 report by Jane Mayer in the New Yorker. His commander replied, "He should have gotten the medical help before he went on jihad."

'Blood on the Wall'

Investigations of prison abuse describe clinicians who could not "see" abuse. A Navy medic, Petty Officer Carlton Blay, testified in a prison-abuse trial that he watched a guard slap and punch prisoners at Camp Whitehorse in Iraq. Blay said that the beatings were meant to get the prisoners "to know that these people were now in charge." He testified that he did not report the beatings because he thought they were reasonable.

The records also show instances of clinicians who did not confront abusive acts. In late 2003, Sgt. Neil Wallin, a medic, was called to a cell after Abu Ghraib guards slammed a prisoner into a wall, lacerating his chin. He saw the prisoner with a sandbag over his head and blood running down his clothes from a 2 1/2 -inch cut. According to a sworn statement, he saw "blood on the wall near a metal weld, which I believed to be the place where the detainee received his injury." He sutured the wound with 13 stitches but did not report it because he said he did "not know how he was injured or if it was done by himself or another."

Physicians are responsible for collecting medical evidence from patients who report being assaulted. Bruises disappear, fractures heal and witnesses move on, so a physician's job includes describing and, if possible, photographing injuries. One Abu Ghraib record recounts a prisoner's story of beatings, stress positions, being forced underwater until he vomited and being sodomized with an "industrial penis."

But such records were the exception. Red Cross medical monitors described a number of prisoners with injuries from beatings or burns that had not been recorded in clinical notes. In 2003, U.S. soldiers arrested Sadiq Zoman and imprisoned him at their base in Tikrit. A month later, soldiers dropped him off at a hospital, according to a New York Times account. His family found him there four months later, unconscious, with three skull fractures, a broken thumb and burns on the soles of his feet. The Army had given the hospital a medical record saying that Zoman had suffered a heart attack and heatstroke.

'The Authority of God'

A medic who beat prisoners during his service in Iraq described his experience to a reporter like this: "You get a burning in your stomach, a rush, a feeling of hot lead running through your veins and you get a sense of power. . . . Imagine wearing point-blank body armor, an M-16 and all the power in the world and the authority of God."

In his 1973 study of Vietnam veterans, psychiatrist Robert Jay Lifton wrote that "atrocity-producing situations" arise at the confluence of extreme stress, a dehumanized enemy and the assurance from authorities that ordinary limits on conduct do not apply. However, a torturing society also needs the passive assent or active complicity of its medical profession. In the 20th century, such circumstances came together on several occasions. How does U.S. medical culpability in the war on terrorism compare to the role physicians played in the horrific abuse in Nazi Germany and the Soviet Union, or to medical complicity in the "dirty wars" of Argentina and Chile?

Nazi and Soviet physicians were architects of torture. Nazi doctors put their profession at the service of the party. They built a pseudoscientific foundation for anti-Semitism, called race hygiene. Physicians and politicians then used that "science" to build and operate the machinery for fascist eugenics, first killing the chronically ill and then, in the Holocaust, committing genocide. Soviet physicians constructed a diagnosis of "sluggish schizophrenia" and put it at the service of the state for incarcerating political dissidents. By contrast, the torture physicians of Argentina and Chile simply went to work in the prisons. They did what was asked of them and did not report what they saw.

The complicity and silence of U.S. clinicians and military medical commanders are more like the behavior of physicians in this second category. There were enough clinicians who were willing to be culpably ignorant, silent or actively complicit to staff the prisons and to allow the abuse to continue without medical challenge. Many civilian and military health professionals knew nothing of the abuse and bear no responsibility. But some senior military medical commanders, and the leadership of civilian medical associations, should have known or should have taken steps to know.

Clinicians are frontline monitors for human rights abuse in prisons. We are in prisons in which the Red Cross never goes and we are there when it is not. We can discern physical and psychic injuries even if they are not disclosed. Torturers need medical accomplices to keep prisoners alive as trauma is inflicted, to predict how severely detainees can be twisted. Such complicity shows a prisoner that he or she is utterly beyond help; complicit clinicians thus inflict the torment of despair.

It will require tenacious professionalism for medicine to remove the stain of its complicity with torture. We might start by recalling the story of the birth of Western medicine in ancient Greece. In grief over his beloved's death, Apollo, the god of healing and reason, dedicated their son, Asclepius, to healing. Asclepius ("Unceasingly gentle") married Epione ("Soothing"), and Hippocrates descended from that lineage. Greek medicine of 2,500 years ago had two foundations: medicine as a natural science and medical practice as a moral enterprise. The Hippocratic Oath speaks of those values in its vow to society, to patients and even to the prisoners at Abu Ghraib: "I will use regimens for the beneit of the ill in accordance with my ability and my judgment, but from what is to their harm or injustice I will keep them."

Steven H. Miles is a professor of medicine at

the University of Minnesota Medical School

and a member of its Center for Bioethics. He

is author of "Oath Betrayed: Torture, Medical Complicity, and the War on Terror" (Random House), from which this article is adapted.

© 2007 The Washington Post Company