BMJ  2006;332:560-561 (11 March), doi:10.1136/bmj.332.7541.560

Editorial

Guantanamo: a call for action

Doctors and their professional bodies can do more than they think

According to the British prime minister, Tony Blair, the detention facility at Guantanamo Bay, Cuba, is an "anomaly." Set against the Western tradition of ethics and human rights, the facility most certainly is, but it is also a place where detainees have lost all legal protection, torture is rife, and doctors have abandoned their ethical responsibilities.

The psychiatrist Robert Lifton, in studying the history and psychology of the Nazi doctors, showed how easily ethical principles were lost and replaced by acts that classified Jews, Romany gypsies, disabled people, and homosexuals as fit for the gas chamber and the medical laboratory.¹ Such behaviour by doctors has been repeated (in different contexts) in the former Soviet Union, South Africa, and Chile, and now in Guantanamo Bay.

The cultural context in Guantanamo Bay was set by two US presidential decrees. The first was to remove the protection of the Geneva Convention from "combatants" suspected to be members of Al Qaeda and the Taliban.² The second was to upwardly regrade torture, defining it as such only when the physical pain inflicted was "of an intensity that accompanies serious physical injury such as death or organ failure." Mental torture could only be so described if it produced "lasting psychological harm."³

Doctors at Guantanamo Bay have been implicated in failing to report psychological and physical abuse of detainees, being present while torture takes place, and sharing detainees' medical records with interrogators.^{4 5} In addition, psychiatrists and psychologists have trained interrogators in techniques designed to inflict damage to mental health.⁶ The American Psychological Association has gone so far as to offer assistance in refining such methods.⁷ And now the long term hunger strike at Guantanamo Bay has been broken by force feeding, in which physicians are alleged to be willingly complicit.⁸

Towards the end of 2005 Senator John McCain, himself a survivor of torture, piloted legislation through the US Senate requiring detainees, wherever held, to be treated humanely.⁹ This principle is now enshrined in the Detainee Treatment Act 2005, the provisions of which are currently being used as the basis for an action in a US Federal Court by lawyers acting on behalf of four hunger strikers at Guantanamo Bay. The case centres on whether the force feeding of detainees amounts to torture, not only in the context that feeding is in conflict with a consistent and competent refusal, but that the forcible methods used also amount to torture.¹⁰

Last month, four of the United Nations' special rapporteurs, reporting to the UN Commission on Human Rights, declared that interrogations authorised by the US Department of Defense and force feeding "amounted to torture" as defined in article 1 of the Convention against Torture.¹¹ The US government allowed the rapporteurs to visit Guantanamo Bay but refused them any contact with detainees: thus the UN report depended, in the main, on interviews with lawyers and former detainees.

Until recently, international codes of ethics—particularly the World Medical Association's (WMA) codes of Tokyo and Geneva—have been thought sufficient to protect patients and to inhibit doctors from taking part in this kind of abuse. Events at Guantanamo Bay show that this is no longer the case, primarily because of the legal vacuum in which detainees are held there.

In relation to force feeding, the WMA's Declaration of Malta (1991)¹² is wholly inadequate. In 2001, after long hunger strikes in Turkish prisons caused many deaths, the BMA identified discrepancies between the two relevant WMA declarations. Whereas the Tokyo declaration—in line with general ethical rules—advises against involuntary artificial feeding of protesters who have competently refused nutrition (even if this leads to their death),¹³ the Malta declaration allows doctors to decide on the appropriateness of resuscitation and artificial feeding. Support for this discretion is based on the view that it is essential to look beyond what initially seems to be an autonomous decision to go on hunger strike, and to consider the possibility of peer pressure.

In an attempt to resolve these contradictions, in 2001 the BMA offered a revised draft of the Malta declaration, which requires doctors to respect an informed refusal of feeding unless the refusal was coerced. The WMA refused to alter the declaration. In the light of events at Guantanamo Bay, the BMA has submitted a completely new version of the Malta declaration for the WMA meeting in May 2006, in an attempt to make it both relevant and effective. But, even if the WMA adopts this new declaration, this will have limited effect unless national medical associations are willing to make their members accountable when practice departs from principles.

The individual doctor-patient relationship is founded on the principles of autonomy, beneficence, and justice. That these principles apply on a wider national and international scale, and that they are articulated by a caring profession, gives doctors enormous power. That they can successfully challenge authorities demanding their collusion in unethical behaviour is illustrated by the recent successful, possibly permanent, suspension of capital punishment in California after a refusal by doctors to administer lethal injections.¹⁴

Lifton has shown the ease with which doctors can drop their ethical guard, in ways that do not have to be as stark as the horrors of Guantanamo Bay.¹ National and international medical bodies need to understand that not only do they have more power than they generally assume, or choose to use, but that to use that power is a basic ethical duty. This duty is as basic as the application of ethical principles in the daily life of a practising doctor.

British Medical Association, London WC1H 9JP
(mwilks{at}bma.org.uk)

---

Competing interests: None declared.

See also News p 569

References

1. Lifton R. The Nazi doctors: the psychology of medical killing. London: Papermac, 1986.
2. Humane Treatment of al Qaeda and Taliban detainees. Memo from the President. 7 Feb 2002. Washington. www.washingtonpost.com/wp-srv/nation/documents/020702bush.pdf (accessed 6 Mar 2006).
3. Standards of Conduct for Interrogation under Sections 2340-2340A of title 18 of the United States Code. Memorandum for Alberto R Gonzales, Counsel to the President. 1 Aug 2002; US Department of Justice. Washington. www.washingtonpost.com/wp-srv/nation/documents/dojinterrogationmemo20020801.pdf (accessed 6 Mar 2006).
4. Bloche M, Marks J. Doctors and interrogators at Guantanamo Bay. N Engl J Med 2005;353: 6-8.[Free Full Text]
5. Lifton R. Doctors and torture. N Engl J Med 2004;351: 415-6.[Free Full Text]
6. Physicians for Human Rights. Break them down—systematic use of psychological torture by US Forces. Boston, MA: PHR, 2005. www.phrusa.org/research/torture/pdf/psych_torture.pdf (accessed 6 Mar 2006).
7. Report on the American Psychological Association Presidential Task Force on Psychological Ethics and National Security. 2005. www.apa.org/releases/PENSTaskForceReportFinal.pdf (accessed 6 Mar 2006).
8. District Court of British Columbia: case 1:05-cv-00520-RMU; doc.58-3, Declaration of John S Edmondson MD, filed 30 Sep 2005.
9. Analysis: US torture ban law. 2005. http://news.bbc.co.uk/1/hi/world/americas/4533612.stm (accessed 6 Mar 2006).
10. US cites exception in torture ban. Washington Post 2006;Mar 3:section A: 4.
11. United Nations Commission on Human Rights. Situation of detainees at Guantanamo Bay. Geneva: UN Economic and Social Council, 2006. (E/CN.4/2006/120.)
12. World Medical Association. Declaration of Malta. Geneva: WMA, 1991.
13. World Medical Association. Declaration of Tokyo. WMA, 1975. (Revised 2005.) www.wma.net/e/policy/c18.htm (accessed 6 Mar 2006).
14. Doctors halt "painless" execution. http://news.bbc.co.uk/1/hi/world/americas/4734908.stm (accessed 6 Mar 2006).

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