Clinical care and complicity with torture
BMJ 2018; 360 doi: https://doi.org/10.1136/bmj.k449 (Published 02 February 2018) Cite this as: BMJ 2018;360:k449
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Berger’s review of the CIA Guidelines on medical practice in secret detention facilities makes disturbing, but not surprising reading. That healthcare professionals forcibly hydrated hunger strikers per rectum is particularly shocking, and a clear breach of the Tokyo Convention.
In Northern Ireland in 1980 and 1981 Republican prisoners went on hunger strike. At no point did the medical staff or prison authorities even contemplate force feeding. The prisoners were provided with first class medical care. A surviving hunger striker was quoted by Dr. James Mc Kenna, the Chief Medical Officer for N.Ireland in ‘ Candles in the Dark’ ( Nuffield Trust 2005) : ‘ They spent hours and hours trying to get this right in terms of ethics....they were in touch with the GMC...they couldn’t have done more to handle it properly’.
Perhaps our United States colleagues could take note!
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This important article addresses a world problem, but in essence it concentrates on the recently unclassified USA documents. As in many other cases we see the problem not in every place where it is but in the place where there is enough light.
An example is the widespread use of torture in Russia (not only in Moscow, but everywhere). The most famous case is the death of lawyer Sergey Magnitskii (2009), which led to the imposition of sanctions by USA under special law to some Russian people. The most recent case is the long term retention of former Governor Nikita Belykh with very limited access to health care.
I believe that we have to keep in mind that in most countries doctors are not united by strong professional associations and are very vulnerable before the state.
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I would also worry about the torturers, their psychological condition is extremely damaged.
Reference
http://www.bmj.com/content/340/bmj.c124/rr-0
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I really feel that it is a cornerstone of Medical ethics that Doctors do not behave in a way that contributes towards actions that ultimately endanger an individual patient's health.
The actions that the U.N. regards as torture include arbitrary violence and the withdrawal of drugs from an addict (1). Confessions that are obtained from a withdrawing opioid addict, for example, may be seen as confessions obtained under torture. Doctors need to think very hard about how the work that they are doing may impact on a patient's human rights.
The same principle may apply to the sport of boxing(2). This sport has been recently legalised in Norway. The BMA has ran a long standing campaign to forbid an activity that often leads to contusive head trauma. Recent research (3) has demonstrated the role that sub concussive trauma may play in the development of chronic traumatic encephalopathy.
With a greater evidence base about the harmful effects of such activities, it remains to be seen what sanctions may be available for Doctors that act as conscientious objectors. What may be prohibited criminal activity, according to one country's law or government, may be in the better interests of wider society.
Doctors working today must not forget the origins of many accepted medical practices. Eugen Bleuler, for example- a noted eugenicist; still has a remarkable influence on modern psychiatry. It is very important that Doctors are able to retain a critical eye about the work that they are doing. It is important that Doctors learn to say "no", before they become complicit in practices that are inhumane and barbaric.
Bailes, J. E., Petraglia, A. L., Omalu, B. I., Nauman, E., & Talavage, T. (2013). Role of subconcussion in repetitive mild traumatic brain injury: a review. Journal of neurosurgery, 119(5), 1235-1245.
Hytten, K., & Tønsaker, S. K. (2017). Medical ethics in combat sports that permit knockouts. Tidsskrift for den Norske Laegeforening.
Melzer, Nils (2018). Leaders in Law Lecture: Professor Nils Melzer. Leaders in Law Lecture Series, 15th January, 2018. University of Birmingham. Lecture
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Re: Clinical care and complicity with torture
Clinical care and complicity with torture: Israel
Berger et al provide a telling description of the shocking involvement of US health professionals in the torture of detainees (“enhanced interrogation”) after 9/11, adding to the published literature on the active complicity of the American Psychological Association (APA). This has extended to the refusal of the APA to take ethical action against the individual psychologists involved (1).
We support the authors’ call for sanctions against health professionals in collusion with these practices. In this we point to a case of physician complicity with torture for which a mountain of incriminating evidence has accumulated over many years, and which has never been acted on. It is 22 years since Amnesty International concluded that Israeli doctors working with the security services “form part of a system in which detainees are tortured, ill-treated and humiliated in ways that place prison medical practice in conflict with medical ethics”. (2) Physicians for Human Rights-Israel (PHRI)/Public Committee Against Torture in Israel have since published exemplary studies, drawing in personal testimonies and often naming the Israeli doctors implicated (3-7). Doctors saw the prisoners at various points before, between, or after episodes of torture (which in one case led to spinal damage and disability), did not take a proper history or write up an honest medical record, made no protest on these men's behalf, and typically prescribed simple analgesia before returning them to their interrogators. Moreover the very presence of doctors as unit members conferred a sense of moral legitimacy to interrogators.
In 2009 an evidence-based appeal on behalf of 725 physicians from 43 countries to the World was submitted to Medical Association (WMA), pointing to the studied refusal of the Israeli Medical Association (IMA), a WMA member, to take action. As PHRI concluded in ‘Doctoring the Evidence, Abandoning the Victim: the Involvement of Medical Professionals in Torture and Ill-treatment in Israel’, “persistently repeated requests calling the IMA’s attention to cases arousing suspicion of doctors’ involvement in torture and cruel or degrading treatment, have not been dealt with substantively” (5). PHRI noted that IMA ethical codes privileged a duty to assist the security services ahead of duty to the patient. This is not consistent with the WMA Declaration of Tokyo, the seminal ethical code for doctors in relation to the practice of torture.
The IMA is a WMA member and at the time the WMA President was the IMA President Yoram Blachar. The WMA refused even to acknowledge our submission, and President Blachar began a libel suit in London against the convenor (DS). It became clear that the WMA would not act against the IMA under any circumstances, and this appears to remain true. Indeed the next WMA President will be IMA President Leonid Eidelman.
In 2016, 71 UK doctors made a fresh submission, with further published evidence, to the then WMA President Sir Michael Marmot, a well-known UK medical academic. He refused to submit it to WMA due process, nor reply to us, but claimed that past investigations had shown that the IMA had not been in ethical breach. Yet no proper investigation has ever occurred - all the evidence points the other way, as the PHRI quote above attests. Marmot’s exoneration of the IMA on behalf of the WMA granted them a propaganda coup widely reported in the Israeli media. He refused three requests by the BMJ for an explanation (8). We also approached the BMA, also an IMA member, but were told they could not assist.
Last December 11 I attended a public meeting at the Battersea Arts Centre at which the commentator Mark Thomas was interviewing Sir Michael Marmot. The event was being filmed. At question time I challenged Marmot about the role he had played in the events above. He responded by telling us all that he had spoken to PHRI who had informed him that they no longer had any medical ethical concerns. When I contacted PHRI they denied saying this, and confirmed that Israeli physicians and the IMA continue to be in breach of the Declaration of Tokyo (9).
We endorse the call by Berger et al that doctors should not allow themselves to be stationed in settings where torture is likely. Indeed PHRI has long noted that torture as state practice in Israel could not continue if doctors were withdrawn from service in interrogation units.
Berger et al do not address the question of the integrity and effectiveness of the WMA in policing medical ethics as commissioned to do when created in 1947 in the light of egregious abuses by German and Japanese doctors in World War 2. We note that others are calling for an overhaul of the WMA, which from the experience we relate above is not fit for purpose (10). The Israel case continues to be a standing reproach to the idea that global regulation of the ethical behaviour of doctors is even-handed and effective. As with the US case, the question is whether those with powerful friends continue to enjoy impunity.
1. Boulanger G. The American Psychological Association: from impunity to shame. Int J of Applied Psychoanalytic Studies 2017. https://doi.org/10.1002/aps.1518.
2. Amnesty International. “Under constant medical supervision”, torture, ill-treatment and the health professions in Israel and the Occupied Territories. London: Amnesty International, 1996.
3. Physicians for Human Rights-Israel. “Ticking Bombs”. Www.stoptorture.org.il/en/node/69.
4. Meyers A, Summerfield D. The campaign about doctors and torture in Israel two years on. BMJ 2011;343:d5223.
5. Public Committee Against Torture in Israel/ Physicians for Human Rights-Israel. Doctoring the Evidence, Abandoning the Victim: the Involvement of Medical Professionals in Torture and Ill-treatment in Israel. stoptorture.org.il 2011.
6. Gulland A. Doctors in Israeli detention facilities are complicit in torture, says report. BMJ 2011;343:d7200.
7. Weishut D. Sexual torture of Palestinian men by Israeli authorities. Reproductive Health Matters doi: 10.1016/j.rhm.2015.11.019.
8. Summerfield D, Burns-Cox C. Sir Michael Marmot, the World Medical Association and medical complicity with torture in Israel. www.bmj.com/content/349/bmj.g4386/rr
9. Ziv H. PHRI. email 7 Jan 2018.
10. Berger D. Time for an overhaul at the WMA. BMJ 2017;357:j1955.
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