Medical professionalism and abuse of detainees in the war on terror
BMJ 2014; 348 doi: https://doi.org/10.1136/bmj.g2947 (Published 29 April 2014) Cite this as: BMJ 2014;348:g2947
All rapid responses
Derek Summerfield
Honorary senior lecturer, Institute of Psychiatry, King’s College, London UK
It is three years since we last reported on the progress of a medical ethical appeal representing 725 doctors (235 from UK) from 43 countries.(1) In May 2009 we asked the World Medical Association (WMA), the official watchdog on medical ethics worldwide, to take action on the voluminous evidence base attesting to systematic collusion with torture by Israeli doctors, protected by the Israeli Medical Association (IMA), over many years. The WMA is mandated to ensure that its members, which include the IMA, adhere to the Declaration of Tokyo: doctors must not participate in torture but are also mandated to report and denounce it wherever encountered.
The WMA will not act against Israel. It refused even to acknowledge our letters and evidence, and WMA President Blachar (also the longstanding IMA President) used London lawyers to threaten me as convenor with a libel suit. The BMA stonewalled our appeals for them to assist at the WMA. Thus in 2010 we escalated our appeal to the UN Special Rapporteur on Torture.
More than 3 years have passed, and despite many reminders, we have had no substantive response from Rapporteur Manfred Nowak or from his successor Juan Mendez. In March 2013 the Rapporteur’s Office informed us that the IMA and WMA were civil society organisations outside their mandate. To whom, then, are they accountable? However they added that they “will be willing to act on information that concerns the actions of Israeli state agents in specific cases”. This we sent, drawing on authoritative new documentation of actual cases, with named doctors in a report that has been reported on in the BMJ.(2 )(3 ) The presence of doctors in units where torture is routine offers legitimacy to the interrogators. Specific violations included: failure to document injuries in the medical notes, precluding victims from ever presenting evidence in court; returning the victim to the torturers despite evidence of torture; falsifying the medical record (eg recording torture injuries as resulting from falling down stairs); passing confidential medical information to the interrogators to assist their effectiveness. In not a single case did doctors act in accordance with the Declaration of Tokyo, showing that this was institutionalised malpractice. Repeated attempts to get the IMA to act have yielded nothing. Physicians for Human Rights-Israel say that the IMA sees itself as an institutional branch of the State and will not contest its practices. New cases continue to come to light.(4)
A further year on, and the Rapporteur on Torture has still not responded to the case material he invited us to send. Yet in 2009 he was tasked by the UN Human Rights Council to prioritise the issue of medical complicity. Elsewhere the signs are no more encouraging. Your editorial alludes to the contribution of US doctors and psychologists to the design and implementation of ‘enhanced’ torture techniques used on detainees in Afghanistan, Iraq and Guantanamo Bay.(4) Their names are known but the Ethics committees of the American Psychiatric and Psychological Associations have refused to act. Is the international regulation of the ethical behaviour of doctors as regards torture largely a dead letter? Our campaign continues.
Competing interest: None declared
1 Meyers A, Summerfield D. The campaign about doctors and torture in Israel two years on. BMJ 2022;343:d5223.
2 Physicians for Human Rights-Israel/Public Committee Against Torture in Israel. Doctoring the Evidence, Abandoning the Victim: The Involvement of Medical Professionals in Torture and Ill Treatment in Israel. www.stoptorture.org.il/en.
3 Gulland A. Doctors in Israeli detention facilities are complicit in torture, says report. BMJ 2011;343:d7200.
4 Devi S. Israeli doctors accused of collusion with torture. Lancet 2013;381:794.
5 Kimball S, Soldz S. Medical professionalism and abuse of detainees in war on terror.BMJ 2014;348:g2947.
Competing interests: No competing interests
I recommend anyone interested to read the report commented on in this editorial. The actual report is entitled Ethics Abandoned and covers many areas that our professional associations should attend to. It calls upon them to strengthen ethical guidance, to investigate abuses and speak out publicly against them and to aggressively discipline members found to have participated.
The BMA has told me that the workings of the International Committee are secret to ordinary BMA members so we cannot know what the BMA is or is not doing - shameful and hard to believe but true.
Competing interests: No competing interests
A Doctor should never be required to act against their ethical beliefs and must always stay within the boundaries of what a Doctor is and their contribution to the quality of Life for their patients. If the system is allowing for the misuse of their knowledge, then the system must be changed and the mistreatment of human beings must stop on all sides!
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Aesop's fable "Androcles and the Lion" tells the story of Androcles, who removed a thorn from a lion's paw, and was subsequently rescued by the very same lion. The moral of this story is that kindness can sometimes turn a dangerous enemy into a great friend. So let's not be too quick to hate our enemies. Instead, let's treat our enemies as potential friends, by demonstrating kindness and compassion. It's more humane to cure your enemies than to kill them.
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Dr Ahmed,
I appreciate your thoughtful comments on some of the challenges of balancing patient wellbeing with the safety of the staffing and community in taking care of psychiatric patients.
I agree with you that the there are many times when doctors face smaller scale challenges that pit the interests of a patient against the interests of the community. My hope is that, even in a forensic psychiatric unit, the main focus is on the patient’s wellbeing. One of the main differences between what you are describing and the situation in Guantanamo and Abu Gharaib is that there isn’t even the plausible deniability that the actions taken against prisoners were helpful to the prisoners themselves. There was no therapeutic alliance, only a non-therapeutic abuse of the power inherent in the role of the health care provider.
I don’t know that there is ever one answer to your final question, but it seems to be the right one to ask in any given situation where a physician or health care professional is asked to act against their ethical beliefs. In those situations (which I hope are few and far between), I think it is our responsibility to change something, rather than ignore the disquiet.
Dr. Mann,
I agree with you about the power of the language, particularly when it is used to portray and justify activities in an international arena. Thank you for putting it so eloquently.
Sarah Kimball, MD
Competing interests: SK is a volunteer medical asylum trainer for Physicians for Human Rights and a volunteer supporting legislative advocacy through the Massachusetts Coalition Against Torture, which promotes Massachusetts’ legislation to prevent the involvement of healthcare providers in torture.
As a CT3 in Psychiatry, having just completed a post in a medium secure unit, I found this article to be interesting and thought provoking. During my time as a doctor working in forensic psychiatry I often found myself being torn and confused between my duties, and the principles which are fundamental to being a doctor. When acutely unwell patients with horrific offending histories were transferred to seclusion following assaults on members of staff and other patients, and essentially deprived of any sunlight or real sensory stimulation for periods which could at times extend into months, my role was to ensure every 4 hours that the patient was physically stable. It often became confusing for both the patients and myself as to whether the seclusion was a form of punishment for their actions or a measure taken to ensure their safety and the safety of others. At times even when I felt the seclusion period was prolonged or harmful for the patient a multidisciplinary team decision would be made to continue. This is not a criticism of the unit where I worked, often we would be forced to manage a patient in this way due to lack of beds, difficult ward environments etc, but more an observation in the flaws in our system.
I believe most doctors at some point in their career have been faced with similar dilemmas, and have often been forced to carry out interventions which went against the fundamentals of being a doctor i.e ‘does no harm’ and ‘acts in the patients best interest’. I guess the question I’m asking is do we have rights as doctors to object to carrying out our roles and responsibilities as highlighted in our job description if it does not sit with us ethically or morally, and if so should what should we change; the system, our job or ourselves?
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War has become a popular but unfortunate metaphor and euphemism for society's failures. The "wars" on drugs, illiteracy, and poverty have all been lost, and the war on terrorism seems endless. Since war connotes conflict, violence, and death, we should dispense with this malevolent metaphor, and instead find beneficent metaphors that are more conducive to peace and health. Words have power and meaning, and they should be chosen carefully.
Competing interests: No competing interests
Re: Medical professionalism and abuse of detainees in the war on terror
26 June 2014
To the Editor of the British Medical Journal,
In my capacity as Special Rapporteur on the question of torture and other cruel, inhuman or degrading treatment or punishment in accordance with Human Rights Council resolution 25/13, I thank you for giving me this opportunity to respond to the article by Dr. Summerfield.
The jurisdiction of my mandate is worldwide and I respond to hundreds of cases a year by engaging with States who may be responsible for alleged violations. The working methods of independent experts of Special Procedures, which govern all thematic and country specific mandates, provide for a confidential exchange of information between Special Rapporteurs and States. The official communication, the Government’s reply, if any, and my observations on each case are reflected in my annual Observations report to the Human Rights Council.
In March 2013, I communicated a response, via the Office of the High Commissioner for Human Rights, with regard to the allegations brought to the attention of my mandate by Dr. Summerfield. These and additional allegations provided were not taken up because they referred to the conduct of the Israeli Medical Association (IMA) and the World Medical Association (WMA), entities that are civil society organizations. My mandate is responsible for addressing State responsibility for torture and indeed, on several occasions, I have held the State of Israel responsible where appropriate, specifically when State agents (including doctors) have been determined by me to have been complicit in torture.[1]
The IMA’s decision not to comment on policies of its Government may well be a breach of medical ethics if the result is to cover up torture. But that does not turn its leaders into State agents for purposes of the definition of torture or for purposes of my mandate.
I take this opportunity to restate that my mandate does not extend to relations between professional organizations and parts of their membership, e.g. a campaign to seek action by the WMA to expel the IMA.
In my capacity as Special Rapporteur, I have dealt with medical complicity amounting to torture in a variety of situations, including in Israel. My 2013 thematic report to the Human Rights Council focused on torture in the health-care context in which I noted that “a State’s obligation to prevent torture applies not only to public officials, such as law enforcement agents, but also to doctors, health-care professionals and social workers, including those working in private hospitals, other institutions and detention centres.[2]
I welcome a forum to discuss issues that fall within my mandate and -- in follow up to my thematic report -- I invited leading experts to share their views in a compilation on “Torture in Healthcare Settings: Reflections on the Special Rapporteur on Torture’s 2013 Thematic Report” [3] which was published in February 2014.
Earlier this week, in a joint press statement with the Special Rapporteur on health, I urged the Parliament of Israel not to amend the Prisons Act to authorise the force-feeding and medical treatment of prisoners on hunger strike against their will and referred to the ethical obligations of medical professionals.[4]
Contacting my mandate does not preclude Dr. Summerfield from seeking advice from other sources. In fact, regarding the accountability for IMA or WMA actions or inaction, it is not up to my mandate to provide legal advice as to which legal avenue should be pursued; this is a question that he should pose to the numerous legal counsel in the United Kingdom who are experts on international law in this specific field.
With best regards,
Juan E. Méndez
Special Rapporteur on the question of torture and other cruel,
inhuman or degrading treatment or punishment
1 For example, U.N. Doc. A/HRC/25/60/Add.2 at pg. 59-60, JAL 10/04/2013 Case No. ISR 3/2013
2 U.N. Doc. A/HRC/22/53 (Feb. 1, 2013), para. 24
3 http://antitorture.org/wp-content/uploads/2014/03/PDF_Torture_in_Healthc...
4 http://www.ohchr.org/en/NewsEvents/Pages/DisplayNews.aspx?NewsID=14770&L...
Competing interests: No competing interests