Reviews Book

Oath Betrayed: Torture, Medical Complicity, and the War on Terror

BMJ 2006; 333 doi: (Published 17 August 2006) Cite this as: BMJ 2006;333:401
  1. Jeanne Lenzer, medical investigative journalist (jeanne.lenzer{at}
  1. Kingston, New York State, USA

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    I had to force myself to open Oath Betrayed. After all, the topic is grim and, I thought to myself, why bother—we know torture happens. We know it's bad. What more is there to say?

    Steven H Miles

    Random House, $23.95, pp 240 ISBN 1 4000 6578 X Also available as an ebook, $17.95

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    A lot, it turns out. A professor of medicine and bioethics at the University of Minnesota, who has worked with torture victims and refugees in Africa, Europe, and Asia, Steven H Miles was moved to write Oath Betrayed after he saw the now infamous pictures of victims at Iraq's Abu Ghraib prison, their bodies beaten, bones broken. He was haunted by a seemingly simple question: why didn't medical personnel blow the whistle long before the scandal became public?

    The answer, it turns out, is far more complex than one might imagine, and in the process of exploring his question, Miles places torture in a historical perspective, dismantles common myths about its practice, and examines US policies that allow and even encourage it.

    Miles relates a conundrum posed by Dostoevsky in The Brothers Karamazov in which Ivan puts the following question to his younger brother, Alyosha, a priest: “Imagine that you are creating a fabric of human destiny with the object of making men happy in the end, giving them peace and rest at last, but that it was essential and inevitable to torture to death only one tiny creature—that baby beating its breast with its fist, for instance—and to found that edifice on its unavenged tears, would you consent to be the architect on those conditions?”

    After reading that passage, I found myself troubled by my reaction to Ivan's question. Surely it's better to sacrifice one person—even a “baby beating its breast”—for a world of eternal peace, isn't it, I thought? Still, I felt uneasy, even morally deficient for considering such a Faustian choice.

    Morality, however, is not the basis on which Miles responds. Instead, he provides a sober and systematic review of the historical and practical aspects of torture and what torture has yielded over the past five centuries and during this most recent “war on terror.”

    Relying on 35 000 pages of official documents, including emails, memos, internal documents, policy directives, and in-person interviews that were released to the American Civil Liberties Union under the Freedom of Information Act, Miles provides disquieting evidence of the harms induced by torture—and of physician complicity with “harsh interrogations”—interrogations that sometimes ended in violent deaths.

    Physician compliance with torture included writing false death certificates

    In his opening chapter, the author addresses the question, “Does torture work?” He cites case studies and extensive reviews by the Central Intelligence Agency (CIA) and Federal Bureau of Investigation (FBI) regarding the efficacy of torture. Their conclusion? Torture yields bad information and should be abandoned. Miles cites the case of Ibn al-Shaykh al-Libi, who was caught by US authorities on 11 November 2001 and sent to Egypt, where he was tortured. Al-Libi provided the now discredited information that Saddam Hussein had weapons of mass destruction and was cooperating with Al Qaeda. The Pentagon cited al-Libi's statements, obtained while being tortured, as a key part of the basis for the US led invasion of Iraq.

    Beyond bad information, Miles argues, torture alienates host populations and allies, it endangers US prisoners of war, increases future acts of terrorism, and it undermines US credibility when it challenges human rights violations elsewhere. Disturbingly, torture may be committed largely against people who are either innocent or ignorant of terrorism. The author cites the US army's own intelligence estimates that up to 85% of 50 000 prisoners (60% at Guantanamo) “were innocent or ignorant pertaining to the insurgency or Al Qaeda.” Not surprisingly, Abu Ghraib became known as “Jihad University” in certain military and intelligence circles; it would appear the prison is better at creating terrorists than finding them.

    Physician compliance with abuse and torture took different forms, according to Miles. These included the use of medical records to aid interrogators in attempts to “break down” prisoners; writing false death certificates; failing to provide medical care (including the failure to diagnose and treat conditions such as tuberculosis and diabetes at prisons in Iraq and Afghanistan); delaying reports of deaths; and giving medical “clearance” to allow harsh interrogation and torture to proceed.

    Examples are short and distressing. One prisoner, beaten and suffocated, was reported by the Pentagon (citing statements by the on-site surgeon) to have died from “natural causes,” even though the prisoner had six broken ribs and died within minutes of being stuffed head first into a sleeping bag and wrapped with 20 feet of electrical wire.

    Are such incidents the acts of an occasional wayward doctor or nurse? Miles reviews policy directives coming from the highest levels of the Bush administration, such as the 2003 directive issued by defence secretary Donald Rumsfeld ordering physician supervision of interrogations. The directive met with enough opposition that the Pentagon issued an extraordinary and little known policy in June 2006, dividing doctors into healer doctors and non-healer (or non-clinical) doctors. Non-clinical doctors, according to the policy, supervise interrogations and may assist in devising plans to break down prisoners using such threats as military working dogs to instil fear, mock executions, sexual humiliation, and threats of death. These and other policies, in Miles' view, made abuse and torture a predictable, if not desired, outcome.

    One can only imagine the reasons why some doctors defy their oaths as healers to participate in such schemes. Perhaps they worry they will lose their jobs if they don't comply. But undoubtedly, at least some hold the belief that one can stop terrorism through the use of torture—a belief Miles shows us is as fantastical as the notion that one could save the world by slaughtering Dostoevsky's infant.


    Items reviewed are rated on a 4 star scale (4=excellent)

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