Ethics AbAndonEd: Medical Professionalism and Detainee Abuse in the “War on Terror” A task force report funded by IMAP/OSF November 2013 Copyright © 2013 Institute on Medicine as a Profession Table of Contents All rights reserved. this book or any portion thereof may not be reproduced or used in any manner whatsoever without the express written permission of the AboUt iMAP And osF v publisher except for the use of brief quotations in a book review. AcknoWlEdgMEnts vii Printed in the United states of America First Printing, 2013 ExEcUtivE sUMMArY xi institUtE on MEdicinE As A ProFEssion Findings And rEcoMMEndAtions xxxi columbia University, college of Physicians and surgeons 630 West 168th street P&s box 11, new York, nY 10032 introdUction 1 www.imapny.org chAPtEr 1: The role of health professionals in abuse of 11 prisoners in U.S. custody chAPtEr 2: Organizational structures and policies that 55 directed the role of health professionals in detainee abuse chAPtEr 3: Hunger strikes and force-feeding 83 chAPtEr 4: Education and training of military physicians on 121 treatment of prisoners chAPtEr 5: Health professional accountability for acts of 135 torture through state licensing and discipline tAsk ForcE MEMbEr biogrAPhiEs 157 APPEndicEs 1. Istanbul Protocol Guidelines for Medical Evaluations of 169 Torture and Cruel, Inhuman or Degrading Treatment, Annex 4 2. World Medical Association Declaration of Malta on Hunger Strikes 175 3. Ethics Statements and Opinions of Professional Associations on 181 Interrogation and Torture 4. Professional Misconduct Complaints Filed 201 notEs 215 About IMAP and OSF Funding for this report was provided by: thE institUtE on MEdicinE As A ProFEssion (iMAP) aims to make medical professionalism a field and a force. it promotes this mission through research and policy initiatives. Four key values underlie medical professionalism: physicians and the health care system must be committed to (1) altruism and promotion of patients’ best interests, (2) effective physician self-regulation, (3) maintenance of technical competence, and (4) physician civic engagement to promote patient and societal well-being. thE oPEn sociEtY FoUndAtions work to build vibrant and tolerant soci- eties whose governments are accountable to their citizens. Working with local communities in more than 100 countries, the open society Foundations sup- port justice and human rights, freedom of expression, and access to public health and education. Acknowledgments tAsk ForcE MEMbErs: scott A. Allen, Md, FAcP steven reisner, Phd University of California, Riverside Coalition for an Ethical Psychology george J. Annas, Jd, MPh hernán reyes, Md, FMh ob/gyn Boston University International Committee of the Red Cross karen brudney, Md david J. rothman, Phd Columbia University Columbia University richard n. gottfried, Jd leonard s. rubenstein, Jd New York State Assembly Johns Hopkins University vincent iacopino, Md, Phd steven s. sharfstein, Md, MPA Physicians for Human Rights Sheppard Pratt Health Systems Allen s. keller, Md Albert J. shimkus, Jr. New York University U.S. Naval War College robert s. lawrence, Md Eric stover Johns Hopkins University University of California, Berkeley steven h. Miles, Md gerald E. thomson, Md University of Minnesota Columbia University Aryeh neier Frederick E. turton, Md, MbA, MAcP Open Society Foundations Emory University deborah Alejandra Popowski, Jd brig. gen. (ret.) stephen n. xenakis, Md Harvard University United States Army viii | Ethics AbAndonEd Acknowledgments | ix leonard rubenstein and gerald thomson provided overall leadership in the Funding for the project was provided by iMAP and the open society Foundations. organization of the task Force and the research, writing, and review of this report. the overview of clinically and ethically appropriate responses to hunger strikes The principal authors and reviewers of chapters and other sections are as follows. contained in chapter 3 was published in expanded form in hernán reyes, scott Institutional affiliations listed for identification purposes only. A. Allen, and george J. Annas, “Physicians and hunger strikes in Prison: confrontation, Manipulation, Medicalization and Medical Ethics,” World introdUction: david rothman, Aryeh neier Medical Journal 59, no. 1 (February 2013) and no. 2 (April 2013). it is used here review by steven Miles, leonard rubenstein, gerald thomson with permission. chAPtEr 1: leonard rubenstein review by vincent iacopino, steven Miles, steven reisner, Albert shimkus, Eric stover, gerald thomson, stephen xenakis chAPtEr 2: leonard rubenstein review by vincent iacopino, steven Miles, steven reisner, Albert shimkus, Eric stover, gerald thomson, stephen xenakis chAPtEr 3: hernán reyes, scott Allen, leonard rubenstein, george Annas review by steven Miles, gerald thomson chAPtEr 4: karen brudney, Frederica stahl (not a task Force member), with assistance from david rothman review by leonard rubenstein, steven Miles chAPtEr 5: deborah Popowski, kate nicholson, with contributors shuenn (Patrick) ho, Pooja nair (nicholson, ho, and nair are not task Force members) review by richard gottfried, leonard rubenstein Eric stover read the entire report for consistency, accuracy, and style. Albert Pierce, Phd, University Professor of Ethics and national security, national defense University, participated in task Force discussions as an observer. Jonathan Marks, director, bioethics Program, Pennsylvania state University, reviewed and provided extensive comments on draft chapters of the report. sondra crosby, Md, Associate Professor of Medicine, boston University, reviewed chapter 3. in addition, the task Force thanks the following individuals for research assistance: Frederica stahl, Whitney Adair, katherine Footer, shuenn (Patrick) ho, sarah humphries, and Pooja nair. Jonathan cobb read and contributed helpful comments on the entire manuscript. laura sider Jost edited the manuscript. other individuals who made substantial contributions to this report wish to remain anonymous. Executive Summary thE 9/11 tErrorist AttAcks on the United states resulted in U.s. govern- ment-approved harsh treatment and torture of detainees suspected of having information about terrorism.1 Military and intelligence-agency physicians and other health professionals, particularly psychologists, became involved in the design and administration of that harsh treatment and torture—in clear conflict with established international and national professional principles and laws.2 in 2010, the institute on Medicine as a Profession (iMAP) and the open society Foundations convened the task Force on Preserving Medical Profes- sionalism in national security detention centers (task Force) to examine what is known about the involvement of health professionals in infliction of torture or cruel, inhuman, or degrading treatment of detainees in U.s. custody and how such deviation from professional standards and ethically proper conduct occurred, including actions that were taken by the U.s. department of defense (dod) and the ciA to direct this conduct. the task Force met regularly between december 2009 and January 2012. its members authored and reviewed chapters and policy proposals for the group to consider. this report contains the task Force’s analyses, findings, and recom- mendations. the report is based on information from unclassified, publicly avail- able information. Where gaps in knowledge exist, we note that information is missing and discuss its importance and its potential impact on the issue assessed, as well as the value of further investigation. in a few instances, a member of the task Force had personal knowledge of facts discussed, but consistent with an approach that relied on the public record, the report is not based on information obtained by any of its members in another capacity. Additionally, because of the professional roles they play, some members of the task Force may have a person- al stake in the report’s findings and conclusions; in such instances, we disclose that fact in the discussion. the task Force sought consensus on findings and xii | Ethics AbAndonEd Executive Summary | xiii recommendations. Members agreed to approve the final product, however, even violations against detainees progressed differently in the military and when they did not agree with every statement and recommendation. the ciA, both facilitated that involvement in similar ways, including A note on the terminology used in this report: When a document refers to a undermining health professionals’ allegiances to established principles specific category of medical personnel (e.g., physician or psychologist), this of professional ethics and conduct through reinterpretation of those report refers to that individual using the same term. in many of the documents, principles. however, no specific occupation is identified. in such cases, we use more gener- 3. the secrecy surrounding detention policies that prevailed until 2004– al terminology, either “health professional,” where the context is clear that it 2005, when leaked documents began to reveal those policies. secrecy refers to someone holding a professional license, or “medical personnel,” which allowed the unlawful and unethical interrogation and mistreatment of includes all occupations in the health field, including physicians, psychologists, detainees to proceed unfettered by established ethical principles and registered nurses, nurse practitioners, physician assistants, corpsmen (U.s. standards of conduct as well as societal, professional,