Don’t be Complicit in Torture

A few years ago, my best friend was getting married. I knew his fiancé well–they had been dating for 9 or 10 years(!) In all that time, I had never met her father. He and his wife had been divorced, and he worked abroad much of the time. What he actually did wasn’t clear, but it took him to out of the way places in Africa and central Asia.

We were finally introduced at a pre-wedding party. In the course of the usual small talk, he asked what I do for a living. I told him and he said, “Neurologist, huh? We could use a neurologist.”

“Who’s we?” I asked.

“Here.” He handed me a cheap-looking business card with the United Nations logo that showed his title as Chief of Security for Kyrgyzstan. “How’s your Russian?” he asked.

“Not so good. Why would a U.N. security team based in Kyrgyzstan need an American neurologist?”

He just laughed and changed the subject.

I was thinking of that encounter the other day after I read this article about a traffic stop in New Mexico. Warning: It’s a sickening story. In brief, the victim alleges that the police falsely suspected him of harboring illicit drugs in his rectum. They secured a warrant to search his rectum and brought him to the local medical center for the search. The medical staff there refused to perform it, citing their ethical concerns. They then took him to another medical center, where he was subjected to two abdominal x-rays, a digital rectal exam, 3 enemas, and finally a colonoscopy, all without his consent. No drugs were found.

And then the medical center billed him for their “services.”

As I said, it’s a sickening story and there are many issues worthy of discussion. The one I would like to focus on, however, is the complicity of the physicians and other medical staff in this terrible episode. One of the key ethical principles in medicine is respect for persons, also known as autonomy. Respect for persons is why we obtain informed consent before treating patients or performing research on them. Some historical violations of this principle in the research context are well-known, such as the Tuskegee syphilis study in the 1940s and Nazi experimentation on concentration camp prisoners. The Stanford Prison Experiment is a more recent example. Lest you think that those days are over now that we have institutional review boards, there is the contemporary example of so-called HeLa cells, derived without consent from a cancer patient named Henrietta Lacks and used for thousands of experiments. Rebecca Skloot wrote a very interesting book on this.

Regrettably, there’s also a history of physician complicity in torture; here’s a review. In 2004, it came to light that U.S. personnel were torturing prisoners at Abu Ghraib in Bagdhad, Iraq. In 2009, the Justice Department’s Office of Professional Responsibility issued a report regarding the Office of Legal Counsel’s memoranda that essentially authorized the CIA to torture those prisoners. I read the report online in 2010 and found numerous references to the fact that CIA psychologists were central to this program:

 The CIA’s perception that a more aggressive approach to interrogation was needed accelerated the ongoing development by the CIA of a formal set of EITs [enhanced interrogation techniques] by CIA contractor/psychologists, some of whom had been involved in the United States military’s Survival, Evasion, Resistance, and Escape (SERE) training program for military personnel.

The CIA psychologists eventually proposed the following twelve EITs to be used in the interrogation of Abu Zubaydah . . .  [The report then lists torture techniques including “walling”, cramped confinement (with the option of adding an insect to the box), stress positions, sleep deprivation for up to 11 days at a time, waterboarding, and a twelfth technique that is redacted.]

According to the CIA OIG Report, independent contractor psychologists were assigned to lead the interrogation team . . . psychologist/interrogators administered all of the interrogation sessions involving EITs . . .

. . . unlike the method described in the DOJ memorandum, which involved a damp cloth and small applications of water, the CIA interrogators continuously applied large volumes of water to the subject’s mouth and nose. One of the psychologists involved in the interrogation program reportedly told CIA OIG that the technique was different because it was ‘for real’ and was therefore more ‘poignant and convincing’.

The conditions of [Office of Legal Counsel attorney Dan] Levin’s approval [of waterboarding] were: . . . (2) a physician and psychologist would approve the use of the technique before each session, would be present for the session, and would have the authority to stop the session at any time; (3) there would be no material change in the subject’s medical and psychological condition . . .

So when my friend’s father-in-law remarked that his organization had a need for neurologists in Kyrgyzstan, my first thought was not that I was being recruited to help develop stroke systems of care in underserved parts of the world. It was that I was being sized up as a participant in a black operation. And while that particular scenario is quite remote from our everyday experience as neurologists, the New Mexico traffic stop episode shows that physician complicity in human rights violations comes in more mundane forms as well–perpetrated not just in remote corners of the globe, but occasionally in U.S. hospitals. There will, from time to time, arise occasions where some authority asks us to use our medical knowledge and expertise in a way discordant with professional ethics to further some supposedly higher interest such as the war on terror, the war on drugs, etc. The purpose of this post is to put this issue on the radar and point out our ethical obligations of nonmaleficence (not harming people) and respect for persons. Don’t be complicit in torture.

About Justin A. Sattin

I'm a vascular neurologist and residency program director. I created this blog in order to share some thoughts with my resident and other colleagues, and to foster my own learning as well.
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