Ethics 2: 2016

Accreditation: MDB006-MD271-0066-1-2016 (6 ethics CEU’s in level 2i)
This tutorial is worth 6 CEU’s. The 2016 ethics tutorials will cost R300 in total for both ethics tutorials. Complete the questionnaire at the end of the tutorial and get 70% or more. We immediately receive confirmation. Once the payment has been received we will email the certificates (see the Get CEU’S page for banking details). Certificates will only be issued on weekdays and may take up to 24 hours

Medical Ethics at Guantanamo Bay and Abu Ghraib: The Problem of Dual Loyalty

Peter A. Clark

Although knowledge of torture and physical and psychological abuse was widespread at both the Guantanamo Bay detention facility and Abu Ghraib prison in Iraq, and known to medical personnel, there was no official report before the January 2004 Army investigatinon of military health personnel reporting abuse, degradation, or signs of torture. Mounting information from many sources, including Pentagon documents, the International Committee of the Red Cross (ICRC), Amnesty International, Human Rights Watch, etc., indicate that medical personnel failed to maintain medical records, conduct routine medical examinations, provide proper care of disabled and injured detainees, accurately report illnesses and injuries, and falsified medical records and death certificates. Medical personnel and medical information was also used to design and implement psychologically and physically coercive interrogations. The United States military medical system failed to protect detainee’s human rights, violated the basic principles of medical ethics and ignored the basic tenets of medical professionalism. The fundamental question raised by many Americans is how could military medical personnel have been directly involved or complicit with these human rights violations? One reason, according to Amnesty International’s Report, Combating Torture: A Manual For Action, is that since the September 11 attacks, terrorism has been linked inextricably to the public mind (in the west) to people from middle-eastern and Muslim backgrounds, generating the type of extreme prejudice that, in a poorly monitored detention environment such as Abu Ghraib, offers moral license for torturers. The result is that human rights are allowed to be overlooked and even violated in order to gain information to win the war against terrorism. In other words, the end – to win the war on terrorism – justifies any means, including techniques used to gain invaluable information. As a result, military medical personnel are placed in a position of a “dual loyalty” conflict. They have to balance the medical needs of their patients, who happen to be detainees, with their military duty to their employer. Unfortunately, this “dual loyalty” situation is not a concept that is new to military medical personnel. An extreme case in recent history occurred in Nazi death camps, where doctors supervised killings and selected which people went into the camps and which were killed. Physicians who interviewed Nazi doctors said most were normal people who went home on weekends to be fathers and husbands. They weren’t killers before serving in the death camps and didn’t continue killing afterward. Those who interviewed U. S. soldiers about atrocities in Vietnam, said there’s an internalization of the ethos of the organization that then prompts actions the person wouldn’t ordinarily perform.

In a country that deplores human rights violations around the world and even sanctions such countries for them, the United States cannot justify these actions by stating that just a small number of medical personnel succumbed to certain situations. To regain its credibility as a champion of human rights, the United States must initiate a thorough investigation of these situations in order to find the root of these systemic violations. Fundamental questions need to be answered. Is there something systemically wrong with our medical education system that allowed well-trained medical personnel to become actively involved in these abuses, or worse, to remain silent? Can new checks and balances and early warning systems be initiated that would bring needed reforms in the military medical system? Is there a need for guidelines to be established that assist medical military personnel in dealing with the issue of “dual loyalty?”

The purpose of this article is three-fold: first, to examine the “dual loyalty” conflict of the medical personell at both the Guantanamo Bay detention facility and Abu Ghraib prison; second, to give an ethical analysis of the role and behavior of medical personnel in military prisons and detention centers and the military health system in general; third, to give concrete recommendations in hope that this situation will not occur in the future.

Dual Loyalty Conflict
The “dual loyalty” conflict is a complex issue that continues to plague the medical profession. It is unavoidable and often commonplace. “It occurs when a managed care plan or hospital exerts financial control over physicians’ choices, when public health regulations require that a physician break patient confidentiality and report someone with a communicable disease, or when a psychiatrist is bound to report that his/her patient may be dangerous to a vulnerable third party.” Military medical personnel, especially in a time of war, are faced with the most ethically difficult dual loyalty of doing what is in the best interest of their patient and doing what is in the best interest of their government and fellow soldiers. This conflict has existed for as long as we have fought wars. It is the most difficult because it is the state or the military exerting the pressure on the medical professional. Recently, the military medical personnel in Afghanistan and Iraq have been confronted by the issues of “dual loyalty” and moral complicity by being accused of violating human rights, medical ethics, and the basic tenets of the medical profession. Military medical personnel were aware of situations of abuse and torture by interrogators, military police, soldiers and intelligence personnel. Confirmed and reliably reported abuses of detainees in Iraq and Afghanistan include beatings, burns, shocks, bodily suspensions, asphyxia, threats against detainees and their relatives, sexual humiliation, isolation, prolonged hooding and shackling, and exposure to heat, cold and loud noise. Other abuses include deprivation of sleep, food, clothing, and material for personal hygiene, and denigration of Islam and forced violation of its rights. Detainees were forced to work in areas that were determined not to be safe and were seriously injured. Abuses of women detainees are less well documented but include credible allegations of sexual humiliation and rape.

At Guantanamo Bay, interrogators with the assistance of military medical personnel have been accused of using aggressive counter-resistance measures in systematic fashion to pressure detainees to cooperate. These measures include: “sleep deprivation, prolonged isolation, painful body positions, feigned suffocation, and beatings. Other stress-inducing tactics have allegedly included sexual provocation and displays of contempt for Islamic symbols.” Evidence suggests that health information on the detainees was made available to behavioral science consultants and others who were responsible for carrying out interrogation strategies. According to M. Bloche and J. Marks, who investigated these abuses and documented them in an article for the New England Journal of Medicine, “since late 2002, psychiatrists and psychologists were part of a strategy that employs extreme stress, combined with behavior-shaping rewards, to extract actionable intelligence from resistant captives.” The ICRC and other human rights organizations argue that these tactics constitute cruel and inhumane treatment and even torture, which violate various international declarations and conventions.

The United States has signed and enacted numerous international declarations and conventions that prohibit torture and abuse of human rights. The U. N. Universal Declaration of Human Rights clearly stipu- lates “No one shall be subjected to torture or cruel, inhumane or degrading treatment or punishment.” The Geneva Convention states:
Persons taking no active part in the hostilities, including members of armed forces who have laid down their arms and those placed hors de combat by sickness, wounds, detention, or any other cause,shall in all circumstances be treated humanely, without any adverse distinction…The following acts are and shall remain prohibited at any time and in any place whatsoever with respect to the above mentioned persons: violence to life and persons, in particular murder of all kinds, mutilation, cruel treatment and torture; …Outrages upon personal dignity, in particular, humiliating and degrading treatment…No physical or mental torture, nor any other form of coercion, may be inflicted on prisoners of war to secure from them information of any kind whatever. Prisoners of war who refuse to an- swer may not be threatened, insulted, or exposed to any unpleasant or disadvantageous treatment of any kind. Other instruments such as the U. N. Body of Principles for the Protection of All Persons Under Any Form of Detention or Imprisonment, U.N. Standard Minimum Rules for the Treatment of Prisoners, the Convention Against Torture and Other Cruel, Inhumane, or Degrading Treatment or Punishment, and U. S. military internment and interrogation policies, collectively contain mandatory and voluntary standards barring U. S. armed forces from practicing torture or degrading treatments of all persons.

Even though the United States is a signatory government to these international conventions, the Bush Administration claims they have found various “loop- holes” that have allowed for a broad interpretation of the laws. These loopholes have also contributed to the “dual loyalty” conflict among the military medical personnel. For example, al-Qaeda and Taliban detainees have been called “unlawful combatants,” a term coined by the Bush Administration, which has been used to by-pass the Geneva Conventions and detain more than 600 suspected terrorists incommunicado at Guantanamo Bay. In a January 2002 memorandum from the Department of Justice to the Department of Defense, it was decided that since al-Qaeda was not a national signatory to international conventions and treaties, these obligations did not apply. It was also decided that the convention did not apply to Taliban detainees because al-Qaeda’s influence over Afghanistan’s government meant that it could not be a party to treaties. As a result, the President signed an executive order in February 2002 stating that even though the Geneva Conventions did not apply to al-Qaeda and Taliban detainees, the U.S. would continue to be a strong supporter of the Geneva Convention and its principles and that “the United States Armed Forces shall continue to treat detainees humanely and, to the extent appropriate and consistent with military necessity in a manner consistent with the principles of Geneva.” The importance of the phrasing is that it subordinates U.S. compliance to the Geneva Convention to undefined “military necessity.” In addition, an August 2002 Justice Department memorandum to the President and a March 2003 Defense Department Working Group distinguished cruel, inhumane, or degrading treatment, which could be permitted in U.S. military detention centers, from torture, which was ordinarily banned except when the President set aside the U.S. commitment to the Geneva Convention in exercising his discretionary war-making powers. Late in 2002, the Secretary of Defense approved “Counter Resistance Techniques” including nudity, isolation, and exploiting fear of dogs for interrogating al-Qaeda suspects at Guantanamo Bay. These supposed “loopholes” in the international conventions not only allowed these abuses to occur but officially authorized them, depending on how one interpreted the U. S. government policies. The problem is that these incidents are not “loopholes.” A legal loop- hole is an actual gap in the law that is legally exploited. What the Bush Administration did was misinterpret and misrepresent clear legal precedents, rather than finding gaps that could be exploited. An example would be how the Bush Administration defines torture in particularly narrow terms. Torture was defined as “where the pain is physical it must be of an intensity akin to that which accompanies serious physical injury such as death or organ failure.”

After the abuses were confirmed, the U. S. military placed some of the blame on the fact that even though the military personnel received thirty-six minutes of basic training on human rights, the detention facility military personnel did not receive additional human rights training. Civilian interrogators received no training on human rights. And some “military medical personnel in charge of detainees in Iraq and Afghanistan denied being trained in Army human rights policies.” Basic training in human rights is necessary but it would not have resolved the inconsistency for military medical personnel on how to interpret correctly these international conventions.

Inadequate training in human rights is part of the problem, but alone it cannot justify the actions or inactions of the military medical personnel. Both civilian and military medical personnel are trained in the basic medical-ethical principles that serve as the foundation of being a medical professional. Besides the medical protections guaranteed by the Geneva Convention, the Hippocratic Oath clearly states: I will prescribe regimen for the good of my patients according to my ability and my judgment and never do harm to anyone. To please no one will I prescribe a deadly drug, nor give advice which may cause his death…All that may come to my knowledge in the existence of my profession or outside of my profession or in daily commerce with men, which ought not to be spread abroad, I will keep secret and never reveal.

Medical personnel have the ethical and professional responsibility to do what is in the best interest of their patient. This means they must treat all injuries and diseases, they must never do anything that would cause direct harm to a patient, and they must keep all priviledged medical information confidential as a basic tenet of the physician-patient relationship. The World Medical Association’s (WMA) “Declaration of Tokyo” in 1975 states: “The physician shall not countenance, condone or participate in the practice of torture or other cruel, inhuman or degrading procedures, whatever the offense of which the victim of such procedure is suspected, accused or guilty, and whatever the victim’s belief or motives, and in all situations, including armed conflict and civil strife.” The position of the WMA is quite clear that condoning or participating in the practice of torture is prohibited. The American Medical Association also has a definitive position on torture that was issued in December 1999:
Torture refers to the deliberate, systematic, or wanton administration of cruel, inhumane, and degrading treatments or punishments during imprisonment or detainment. Physicians must oppose and must not participate in torture for any reasons. Participation in torture includes, but is not limited to, providing or withholding any services, substances, or knowledge to facilitate the practice of torture. Physicians must not be present when torture is used or threatened. Physicians may treat prisoners or detainees if doing so is in their best interest, but physicians should not treat individuals to verify their health so that torture can begin or continue. Physicians who treat torture victims should not be persecuted. Physicians should help provide support for victims of torture and, whenever possible, strive to change situations in which torture is practiced or the potential for torture is great.

Military medical professionals include pathologists, primary care physicians, psychiatrists/psychologists, nurses, battlefield clinicians and advisors to interrogators. All these medical professionals are covered by the same international conventions and codes of ethics. According to WHA and the AMA standards, military medical personnel violated both codes of ethics and the Geneva Conventions in numerous ways. First, The U. S. Army investigators concluded that the medical system at Abu Ghraib for detainees was inadequately staffed and equipped. The ICRC found that the medical system failed to maintain internment cards with medical information necessary to protect the detainee’s health, as required by the Geneva Convention. Few units in Iraq and Afghanistan complied with the Geneva obligation to provide monthly health inspections. Second, the medical system failed to assure that prisoners could request proper medical care. An example was given of a hand injury caused by torture that was left untreated. Third, the medical system failed to establish procedures, as called for by Article 30 of the Geneva Convention, to ensure proper treatment to prisoners with disabilities. One example cited was where a prisoner’s crutch due to a broken leg was taken away from him and his leg was beaten as he was ordered to renounce Islam. Fourth, the medical system failed to accurately report witnessed or suspected abuse. It was documented that a medic inserted an intravenous catheter into a corpse of a detainee who died under torture in order to create evidence that he was alive at the hospital. Fifth, death certificates of detainees in Afghanistan and Iraq were falsified or their release or completion was delayed for months. 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. Sixth, medical records of detainees were shared with interrogators thus violating physician-patient confidentiality. Finally, the medical system collaborated with designing and implementing psychologically and physically coercive interrogations. At Abu Ghraib, a physician and a psychiatrist helped design, approve, and monitor interrogations. At Guantanamo Bay interrogators were given access to medical records and “psychiatrists and psychologists were part of the strategy that employed extreme stress, combined with behavior-shaping rewards, to extract actionable intelligence from resistant captives.” This is in direct violation of the American Psychological Association’s Ethical Standards that prohibits engagement in any form of torture or cruel, inhumane or degrading treatment; it requires psychologists/psychiatrists to report such treatment; and prohibits the support of an interrogation by using an individual’s medical record to the detriment of the individual’s safety and well-being.

The “dual loyalty” conflict has led to abuses, but it would be a disservice not to commend the military medical personnel in Afghanistan and Iraq for their medical and humanitarian service. The military medical staffs in Afghanistan, Iraq and Guantanamo Bay have provided very fine medical care not only to American military personnel but to the Iraqi and Afghan people and to the detainees. They have saved many lives at a great risk to their own lives. It is also clear that not all military medical personnel were directly involved in the abuses or collaborated with the harsh interrogations at Guantanamo or Abu Ghraib. However, it appears that the majority knew of these abuses and human rights violations and remained silent. Steven Miles cites a clear example of this: “The entire detention centre medical command should have acted on widespread and prolonged failure to meet minimum standards for medical internment cards, tuberculosis screening, monthly health checks, etc.”,Complicity deals with both the intention of the agent and his or her role in cases of individual and collective harm. Issues of timing, proximity, certitude, knowledge and intent have some bearing on the presence or absence, and possibly on the degree, of moral complicity. The point is that if the medical personnel knew of these abuses, at their own facilities, and were aware it was abuse and did nothing, then they are complicit by their silence. However, moral complicity is different than “dual loyalty.” Being placed in the situation as primary care physicians to these detainees at a time of war, when the world is living in fear of yet another suicide bomb attack, places these military medical professionals in a delicate balancing act between loyalty to their patients and loyalty to their country. This is not to say that these two loyalties are mutually exclusive or have not been kept in balance in the past. One must also acknowledge that the problem of “dual loyalty” could be experienced by a highly ethical agent. A compelling hypothetical argument could be made in which a small deviation from medical confidentiality could make possible an important military maneuver that meant saving many innocent civilian lives. These more complicated situations are not the situations being addressed. The “dual loyalty” being discussed here is a conflict between the best interest of their patients and those of the military organization and fellow soldiers they serve with on a daily basis. The issue is that because of a lack of checks and balances, or the initiation of an early warning system, the relationship between these two loyalties became unbalanced.

Military medical personnel treating prisoners or detainees in a time of war have always and will always face this “dual loyalty” conflict. The Geneva Convention addresses this military and ethical dilemma when it stipulates: “Although [medical personnel] shall be subject to the internal discipline of the camp…such personnel may not be compelled to carry out any work order other than that concerned with their medical …duties.” This standard of behavior for military medical personnel was clearly violated and as a result detainees were injured and even killed, human rights were violated, and the role of a physician as one who acts in the best interest of his/her patient was irreparably damaged.

Ethical Analysis
All military medical personnel receive basic training on human rights, and those in charge of detainees or prisoners should be even more familiar with the Geneva Convention or Army Regulations regarding abuses. Understanding the importance of human rights and how they can be abused should make these medical professionals more aware of the problem of the “dual loyalty” conflict. As a result, when situations arise regarding a conflict in “dual loyalty” these medical professionals should be trained to recognize these situations and respond appropriately. However, at times there is a fineu line that separates these loyalties. Leonard Rubenstein, executive director of Physicians for Human Rights, explains how this can occur. A doctor approached by a commanding officer for advice on a sleep deprivation program inflicted on a prisoner can reasonably argue that he wants to be sure the program doesn’t do lasting harm. Similarly, a medic can advise an interrogator on a patient’s physical limitations to avoid serious injury during interrogation. In these situations it may seem reasonable for a doctor to offer advice, but that advice ultimately makes the doctor complicit in torture. In each case, that information can provide interrogators an idea of a subject’s weaknesses and allow them to exploit those weaknesses.

These examples show how the conduct of the military medical personnel at Guantanamo and Abu Ghraib raise new questions about the boundaries of medical ethics as they relate to the war against terrorism. Some Pentagon officials have argued that medical personnel advising interrogators were not bound by ethic strictures because they were not treating patients but rather were acting as behavioral scientists. Others argue that the clinical information given to the military and the Central Intelligence Officers was not confidential and thus not protected under the physician-patient rela- tionship. This was confirmed on August 6, 2002 when the U. S. Southern Command instructed health care providers that communications from “enemy persons under U.S. control at Guantanamo are not confidential and thus not protected under the physician-patient relationship. This was confirmed on August 6, 2002 when the U. S. Southern Command instructed health care providers that communications from “enemy persons under U.S. control at Guantanamo are not confidentialtial and are not subject to the assertion of privileges by detainees.” This statement also instructs medical personnel “to convey any information concerning…the accomplishment of a military or national security mission…obtained from detainees in the course of treatment to non-medical or other United States personnel who have apparent need to know the information. Such information shall be communicated to other United States personnel with the apparent need to know, whether the exchange of information with the non-medical person is initiated by the provider or by the non-medical person.” The only limitation is that they cannot act as interrogators. The line between civic duty/duty to employer and undermining patient trust, by putting patients at greater risk of serious abuse, appears to have been compromised despite the ethical obligation to act in the best interest of the patient and protect patient confidentiality. Ethically, it appears that some medical professionals were directly involved in abuse and torture and others were complicit in the abuse and accessories in gathering information. This author will argue that under the ethical principles of respect for persons, beneficence, nonmaleficences and justice, the participation of military medical personnel in the abuses at Guantanamo and Abu Ghraib was unethical and that an independent board of inquiry should be called to examine the full nature of these abuses.

“Respect for persons” refers to the right of a person to exercise self-determination and to be treated with dignity and respect. The principle of respect for persons divides into two separate moral requirements: the requirement to acknowledge autonomy and the requirement to protect those with diminished autonomy. Numerous abuses of detainees have been documented at both Abu Ghraib and Guantanamo, such as beatings, burns, shocks, bodily suspensions, sexual humilation, exposure to cold, etc. “Pentagon officials offer many reasons for these abuses including poor training, understaffing, overcrowding of detainees and military personnel, anti-Islamic prejudice, racism, pressure to procure intelligence, a few criminally-inclined guards, the stress of war and uncertain lengths of deploy- ment.” These abuses should be abhorrent to anyone. But for military medical personnel, who have been trained in human rights and ethical principles, these abuses should have been reported and stopped. To witness or to have known about any of these abuses and not to have reported them or tried to stop them is a direct violation of the principle of respect for persons. Every ethical document
from the Hippocratic Oath and the Geneva Conventions to the U. N. Universal Declaration of Human Rights clearly state that, “no human person should be subjected to torture or to cruel, inhumane or degrading treatment or punishment.” In addition, prisoners or detainees are truly vulnerable persons with diminished autonomy and deserve added protection. To highlight this point, as of June 2005, the International Committee of the Red Cross reported that there were 107 detainees under the age of eighteen identified during visits to six prisons controlled by coalition forces. Some detainees were as young as eight years of age. They report that juvenile detainees in Abu Ghraib and Bagram Air Base have been subjected to the same mistreatment as adults. The International Red Cross, Amnesty International, and the Pentagon itself have gathered substantial testimony of torture of children, bolstered by accounts from soldiers who witnessed or participated in the abuse. A Pentagon investigation by Major General George Fay reported in January 2004 that “a leashed but unmuzzled military guard dog was allowed into a cell holding two children. The intention was for the dog to ‘go nuts on the kids,’ barking and scaring them. The children were screaming and the smaller one tried to hide behind the larger, as a soldier allowed the dog to get within one foot of them.” Amnesty International reported that a fourteen-year old boy held in Abu Ghraib was allowed to be bitten by a guard dog on the leg. Also, children in Abu Ghraib were denied the right to see their parents or a lawyer. The military medical personnel allegedly were aware of these actions and must have treated some of these children for injuries including dog bites, etc. Not to report such action as torture or cruel, inhumane and degrading treatment or punishment defies comprehension militarily, legally, ethically, and from a humanitarian perspective.

Second, critics of those in the military medical profession who were complicit in the abuses at Guantanamo and Abu Ghraib or directly involved in the interrogations argue that the physician-patient relationship is the primary focus of ethics in medicine. Trust is the bridge to the physician-patient relationship, and the burden is on the physician not only to expect the patient’s trust but also to build a solid foundation upon which the patient can place his or her trust. If this relationship becomes fractured, a loss of confidence will result, and the effect on the patient could be devastating. For prisoners and detainees to see their primary care physicians also in the role of assisting those who tortured and abused them, or to see them remain silent in the face of such human rights violations, undermines the credibility of the medical profession and is irreconcilable with the physician’s role as healer. There also seems to be a conflict of interest present between preserving the primary fiduciary relationship between physician and patient and the responsibility of an employee to an employer. One example of this is in the area of confidentiality regarding detainee’s medical records. According to the Church Report that was issued in Spring 2005, “while access to medical information was carefully controlled at Guantanamo Bay, we found in Afghanistan and Iraq that interrogators had easy access to such information.” According to Bloche and Marks this would make one believe that medical confidentiality was shielded at Guantanamo Bay. However, in the U. S. Southern Command policy statement, in effect since August 6, 2002, the official policy not only requires caregivers to provide clinical information to military and Central Intelligence Agency interrogation teams on request; it calls on them to volunteer information they believe might be of value. According to the ICRC, behavioral science consultation teams at Guantanamo met regularly with the medical staff to discuss the medical condition of prisoners. The report states that such “apparent integration of access to medical care with the system of coercion means that detainees may discover that their interrogators have intimate knowledge of their medical histories, knowledge entrusted to medical professionals that is then used to design an ‘interrogation plan’ which potentially involves torture.” Medical privacy is not an ethical absolute. “Caregivers in civilian and military settings have an obligation to report information to third parties when doing so can avert threats to health or safety of individual person, but confidentiality is the starting point.” However, despite these few exceptions, there are ethical standards that hold medical privacy as sacrosanct. There is a definite conflict between the military medical personnel’s duty to his/her patient and the medical professional’s duty to his/her employer.
Participation in the blatant breaches of confidentiality of patients not only violates the fiduciary relationship between physician and patient but shows a clear conflict between a physician who serves the interests of the state and not those of his/her patient. This violation of confidentiality may also prevent some detainees from seeking needed medical care because of the fear that the information may be used against them in inter- rogation. A basic tenet of the principle of respect for persons is that one must never use another person as a means to an end. The detainees were used as means to an end in an attempt to gain results that would help win the war against terrorism. Human rights and the basic dignity and respect that every person deserves became the casualty.
“Beneficence” is the obligation to prevent and remove harms and to promote the good of the person by minimizing the risks incurred to the patient and maximizing the benefits to them and others. Beneficence includes nonmaleficence, which prohibits the infliction of harm, injury, or death upon others.

The ICRC, Amnesty International and even the Pentagon investigations show that the abuses of detainees in Afghanistan, Iraq and Guantanamo violated the principle of beneficence.
The medical system failed to maintain internment cards with medical information to protect the detainee’s health as required under the Geneva Convention. The medical system failed to assure detainees could request proper medical care also required under the Geneva Convention. The medical system failed to establish procedures, as called for by Article 30 of the Geneva Convention, to ensure proper treatment of detainees with disabilities. The medical system collaborated with designing and implementing psychologically and physically coercive interrogations. Finally, the medical system failed to accurately report illnesses and injuries.

Various examples of these violations have been stated above. Whether the military medical personnel directly or indirectly participated in these abuses or knew of them and remained silent, all those involved failed to prevent and remove harms and to promote the good of their patients.

Those who support the military medical personnel’s participation in assisting of interrogators argue that it is in the prisoner’s best interest that medical personnel be involved. “Once caregivers share information with interrogators, why should they refrain from giving advice about how best to use the data? Won’t such advice better protect detainees, while furthering the intelligence-gathering mission? And if so, why not oversee isolation and sleep deprivation or monitor beatings to make sure nothing terrible happens?” This logic is skewed. By violating the trust of their patients, the military medical personnel put their patients at greater risk and in some situations may have caused their death. Some argue that having a medical professional present at interrogations may invite interrogators to be more aggressive, because they imagine that the medical professionals will set needed limitations. This did not happen. These medical professionals had direct knowledge that detainees had been abused, because they treated their burns, broken bones and other assorted injuries and then allowed these detainees to be placed back into harm’s way. These actions fail the basic tenet of the principle of beneficence. The ethical duty of every medical professional is to maximize comfort and minimize pain and suffering. Not only did these medical professionals violate this ethical maxim; they also violated the basic Hippocratic dictum, “first, do no harm.” Participation by military medical personnel in the abuses and torture subverts the profession for the nonbeneficent goals of the state. Medicine is at heart a profession of care, compassion, and healing. Medical professionals are given the responsibility to treat and heal, not to facilitate interrogations. Participation in the criminal abuse and torture of detainees is “a practice reminiscent of the crimes carried out by the likes of the Nazis’ Josef Mengele, the infamous doctor at the Auschwitz death camp.” Assisting in these actions at the command of the state not only fails the test of beneficence but also fails the test of nonmaleficence.

Finally, the principle of “justice” recognizes that each person should be treated fairly and equitably, and be given his or her due. The principle of justice can be applied to the circumstances of “dual loyalty” when military medical professionals must choose between responsibility for their patients in need of care and the demands placed upon them by the United States military. The most common rationale for medical professionals’ willingness to participate in or overlook the various incidents of abuse and torture was their sense of military duty. When military medical professionals were called upon to help interrogators to refine interrogations of detainees by providing advice on increasing stress levels or exploiting fears, or when they treated detainees who had undergone cruel and inhumane abuses, they believed they were acting in the best interests of the detainees, the nation and humanity. The argument is that the medical professionals have a moral duty to ensure that the interrogations are carried out in the most fair, humane and painless way possible. They argue that the information they provided ensured that the techniques used, like sleep deprivation, did not have any lasting harm on the detainees and the advice on a detainee’s physical limitations avoided serious injury to the detainee during the interrogation. In addition, they believed that the information gathered from the detainees would help save the lives of their fellow citizens and hopefully, help to end the war on terror. Further, these medical professionals believed they had a duty as citizens and as members of the military to participate because the techniques used were authorized and sanctioned as legitimate by the military and the state, and were therefore just. Opponents of the military medical professionals’ participation argue that the abuse, torture, and methods of interrogation violated the basic tenets of human rights law and the ethical standards of the medical profession. It may be true that medical professional’s participation could add some degree of humanness to the methods of interrogation, but this does not outweigh the greater harm of causing injury and even death to the detainees. This is not treating someone fairly and equitably. Finally, state or military approval or authorization of an act does not constitute a requirement on the part of any citizen to take action. To argue that medical professionals in the military have a duty as members of the military and citizens to participate in abuse and torture is an exaggerated sense of military and civic duty, the type that has been attributed to physicians in Nazi Germany who performed medicalized killings. Every medical professional has the right, with a well-formed conscience, to refuse any order that he/she believes is unjustified and personally unethical. The failure of medical professionals to recognize that military and civic duty can never trump medical ethical principles is clearly an injustice. It is an injustice not only to those who were abused but to humanity as a whole. If the principle of justice mandates that each person should be treated fairly and equitably, then the participation of military medical professionals in torture and cruel, inhumane or degrading treatment or punishment of detainees clearly violates the principle of justice.

Conclusion
The abuses that occurred at Abu Ghraib and Guantanamo happened because explicit ethical and legal boundaries were either not established or, if present, were not enforced for the military medical personnel. Loopholes were created that allowed the military to circumvent international conventions and even the basic principles of medical ethics. Watchdog agencies like the International Committee of the Red Cross, Human Rights Watch, and Amnesty International did call attention to these abuses, but often times these organizations are severely under-funded, which can limit their capacity for surveillance and investigation of allegations of human rights violations. To verify that this type of abuse does not occur in the future, the following recommendations are proposed:
1. The President of the United States should appoint an independent board to perform a comprehensive investigation to fully assess the performance of military medical personnel with regard to human rights abuses. This board should include U. S. military medical service representatives, human rights groups, legal and medical academics, ethicists, and health professional associations. Various Army investigations have examined a small set of human rights abuses, but what is needed is an independent comprehensive investigation that can examine the systemic cause of these abuses.
2. The military must implement a comprehensive training program for all health care professionals in international humanitarian law and for developing the skills necessary for recognizing situations of dual loyalty in which human rights are at stake. There are models available for training those who work in prisons. On a more fundamental level, training in human rights abuses should be part of every medical school curriculum. It is important that all medical professionals understand not only the roots of abuse but how to address situations when confronted with examples of abuse.
3. The military should create and implement a Military Ethics Committee that can be used to assist military medical professionals in understanding the problem of “dual loyalty” and where necessary serve as a conduit for medical professionals to not only recognize these situations and respond appropriately but also serve as an avenue for reporting potential abuses. This Committee must be independent, completely confidential, and accessible to all military medical professionals without fear of reprisals.
4. The American Psychological Association (APA) formulated a Task Force to examine their longstanding ethics policy in the light of the roles that psychologists were asked to perform with regard to a wide variety of national security concerns, including involvement in military investigations. The Task Force stipulated twelve statements that applied the APA Ethics Code to the national security-related activity of psychologists. Medical and Nursing societies should initiate similar task forces to articulate guidelines for their members.
5. The various medical associations must not only condemn in writing medical professionals who are complicit in abuse and torture, they must also place various sanctions on those who violate these rules. Until these medical associations back-up their rhetoric with concrete actions, those who fall under their jurisdiction will not take these policies seriously. For example, “a resolution has passed the House of Delegates of the AMA asking for an investigation into the abuses, but the ‘resolved’ section of the resolution does not mention physicians specifically, let alone condemn the specific instances of physician involvement in abuse. There was concern that an AMA resolution might offend the Bush Administration that had supported the AMA on liability reform.” Politics should never be allowed to circumvent issues as basic as human rights.

The abuses at Abu Ghraib and Guantanamo were medically, legally and ethically unjustified. They violated every major international human rights convention and the four basic principles of medical ethics. However, these incidents, while deplorable, can “serve as an eleventh hour wake-up call for the western world to rediscover and live by the values enshrined in its international treaties and democratic constitutions.” The United States government and American medical professionals lost a great deal of international credibility in its fight to uphold human rights worldwide as a result of these abuses. Only through immediate needed reforms will this credibility ever be restored. Failure to restore this credibility has the potential to allow the basic human rights of the most vulnerable in the world to be violated in an ever greater way.

Postscript
On November 5, 2005 the American Medical Association’s House of Delegates passed a resolution stating: That our American Medical Association ask the Council on Ethical and Judicial Affairs, with input from all appropriate AMA stakeholders, “to delineate clearly for physicians the boundaries of ethical practice with respect to par- ticipation in the interrogation of prisoners and detainees,” available at .

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References
1. Editor, “Medical Personnel at Abu Ghraib Ignored Medical Ethics and Human Rights,” News-Medical.Net (August 20, 2004): 1-5. See also U.S. Army Inspector General, Detainee Operations Inves- tigation, July 21, 2004. at
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