Medical ethics at Guantánamo

...But this would suggest that a doctor or staff member's prior obligation ought to be to promote, to the degree possible, circumstances that enable autonomous choice, such as consultation with trusted persons, whether family members or clergy...

...For military doctors, psychologists, and psychiatrists serve in U.S...

...Thus, even if the institutional role of treatment is on paper separate from the interrogation role, those who treat can still cede their professional responsibility to those who interrogate...

...THE VERY DISCUSSION about which kind of health care provider ought to support interrogation should raise red flags...

...Medical questionnaires, evaluations, and statistical analysis under professorial leadership and management—in short, the stuff of institutionalized science and academe, all added to the legitimization of the process...

...It is not clear if these steps have been taken at Guantanamo...

...Among the unspoken reasons for the invitation was a steep rise in hunger strikes in mid-June 2005, as well as the bruising criticism the administration had received, over that summer and fall, for its use of psychiatrists and psychologists in interrogation procedures...

...There he saw a pool of blood...

...Yet saving life at Guantanamo has often seemed more a politically motivated concern than a humanitarian one...

...Lifton reports his defense of lethal injection as "a completely painless method," and his noting that "the term euthanasia comes from the Greek eu, which means beautiful...

...Let the world know of the agony of the detainees in Cuba...

...One of those detainees, Jumah al-Dossari, had been in Camp 5, the maximum-security facility, for extended periods...

...He looked up to find a gaunt figure hanging from the mesh wall on the cell side, face covered in blood, body limp, eyes rolled back in his head, his lips and mouth swollen and protruded...

...And there was concern about largescale force-feeding of hunger strikers through stomach tubes...

...After alDossari's October 15 attempt, his attorney asked for transfer to a less isolating camp, some meaningful social interaction, a few books, and one telephone call with his family...

...Five months later, I replayed that scene as I listened to the account of a detainee lawyer, Joshua Colangelo-Bryan...

...The charges, delivered by Brigadier General Telford Taylor on December 9, 1946, form a seminal chapter in the history of medical ethics and, specifically, medical ethics in war...

...During my visit, one of the pressing questions posed to the visiting team was not if psychologists or psychiatrists should consult on interrogation plans, but which professional should...

...DISSENT / Winter 2007 •13...

...He called in the MPs who cut down al-Dossari from the mesh wall and, at the attorney's request, began CPR...

...Still, two scenes involving inmates made my moral worries concrete...

...freezing experiments...

...Though we were invited as observers, we saw none of the 505 inmates during the whole day, save for one stolen glimpse of two bearded prisoners in white tunics and loose pants behind screens and barbed wire...

...If the "ought" is a moral one, then no health professional of any stripe ought to be involved in interrogation where there is strong institutional pressure to use coercive techniques and torture...

...and five years after its erection, there have been no trials of doctors and no charges brought...

...So, in this case, at least, clinicians seemed aware of 12 n DISSENT / Winter 2007 COMMENTS & OPINIONS a detainee's reports of suicidal depression, yet subordinated treatment to security...

...At the time of their meeting, al-Dossari told Colangelo-Bryan not to bother with the note...

...Behavioral Science Consultation Teams, BSCTs (pronounced DISSENT / Winter 2007 n I I COMMENTS & OPINIONS "biscuits," and their members, "BSCs," behavioral science consultants) are typically military psychologists who help tailor individual interrogation plans...

...Actions are perceived as beyond one's own doing, making, or stopping...

...sterilization experiments...

...experiments with poison and with incendiary bombs...

...A couple of minutes went by, and then a few more...

...And they serve in top positions in the Pentagon, as civilian and military heads of chains of command, who pass orders and regulations to military doctors in the field, in charge of the health of enemy combatants, as well as U. S. soldiers...

...Are they typically involved in such decisions...

...Remember that our governments let us down...

...Not irrelevant, perhaps, is that the American Psychological Association has been less explicit in its condemnations of participation at Guantanamo than the American Psychiatric Association...

...These may be circumstances where a patient lacks adequate autonomy to make an informed choice...

...The patient's rights or their life...

...This article is adapted from a paper given at a conference, "Judgment at Nuremberg," held at the Washington University School of Law in September 2006...

...And some, including one medical official to whom I spoke, may be eager to discount it for just that reason, as a clever appeal for sympathy by a welleducated terrorist...

...Surgeon General Richard Carmona, Army Surgeon General Kevin Kiley, Joint Staff Surgeon Joseph Kelly, as well as top civilian physicians who work for Undersecretary of Defense for Health Affairs William Winkenwerder) a tube used for feeding—a thin nasogastric tube, a 10-French Dobhoff—and explained that lubrication and anesthesia were routinely used before insertion...

...But the absence of the spotlight makes it all the more imperative to sketch the current involvement of doctors and health workers in the operation of the Guantanamo center and to shed some light on their professional roles and on the psychological distancing mechanisms at work...

...The acronyms insert psychological distance between mental health and interrogation, as does the fact that a "biscuit" is never physically present in an interrogation room with a detainee, but on the other side of a two-way mirror...

...It is a place where, by design, morality is made to recede...

...Show the world my letters...

...In what follows I want to isolate several psychological mechanisms that enable doctors and health care workers, both sixty years ago and now, to insulate their moral consciences...

...Also unclear is the toll our policies will take on the interrogators and health care providers themselves...

...I present these vignettes in order to pinpoint morally troubling medical issues that remain part of our detention policy at Guantanamo...

...NANCY SHERMAN is author of Stoic Warriors (Oxford University Press, 2005...

...The questions about moral distancing Lifton raised then (though not the questions about criminal experiments) have immediate urgency for us now...

...But they have been torture centers, and euphemisms and medicalized terms have helped insulate practitioners from moral conflict...

...But I have one last request...

...Still, it ought to worry us...

...In October 2005 I visited the center with a small group of civilian psychiatrists, psychologists, top military doctors, and Department of Defense civilian health affairs officials to observe detainee medical and mental health care...

...Arguably, force-feeding is, in certain circumstances, the humane response of a doctor to a hunger striker...

...When he took on the representation of several Bahrainee detainees at Guantanamo in 2004, he took their concerns with an even "bigger grain of salt" than he would in a typical case of commercial litigation...

...The result was that they I 0 n DISSENT / Winter 2007 urinated and defecated on themselves...

...Thus, killing "life unworthy of life" (whether the term came to denote Jews, homosexuals, Roma, Catholic critics, the mentally ill, the physically feeble, or other "impure" strains) was a matter of "euthanasia...

...The attorney then walked out of the room and the MPs took al-Dossari to a small cell with a toilet, located on the other side of the meeting area and separated from it by a steel mesh wall...

...According to his attorney, their reply was that they could do nothing and that he had to speak to his interrogator...

...Al-Dossari survived this suicide attempt, but during his time at Guantanamo he has tried to commit suicide eleven other times...

...Colangelo-Bryan called in the military police so that they could remove the shackles holding al-Dossari to the floor in the meeting area...

...In his 1981 work, The Nazi Doctors, Robert Jay Lifton took up that question, interviewing doctors, many of whom for forty years continued to distance themselves psychologically from their deeds...

...Indeed, in al-Dossari's case, as his psychological conditions worsened, he requested help from mental health clinicians with both his release from the extreme isolation of Camp 5 and with access to more meaningful social contact...

...If diuretics and laxatives were used, who approved their use...

...She is University Professor at Georgetown University and a fellow this year at the Woodrow Wilson International Center for Scholars...

...Remember the unreasonable delay of the courts in looking to our case and deciding the victims of justice . . . . I thank you for everything you have done for me...

...A hunger striker, according to officials with whom I spoke at Guantanamo, is a detainee who misses nine meals...

...Also, psychologists have a strong tradition of working in forensics, where the client is not the patient...

...In the Nazi period, euphemistic and scientific language played a critical role in the medicalization of killing...

...sulfanilamide experiments...

...The voices of the detainees need to be heard...

...More specifically, there were well-publicized allegations that "resilience training" for our own soldiers at Fort Bragg was "reverse engineered" at DISSENT / Winter 2007 n 9 COMMENTS & OPINIONS Guantanamo for the infliction of torture...

...The follow-up story of the medical and mental health personnel who are part of the Guantanamo detention center has not yet been told...

...During COMMENTS & OPINIONS the interview, al-Dossari said he needed to go to the bathroom...

...Unfortunately, the methods by which morality disappears at Guantanamo are not novel...

...In Tim Golden's New York Times Magazine article on Guantanamo, of September 17, 2006, Edmonson, the senior medical doctor at the base when I was there, reflected candidly, "Anytime you're doing a procedure that the patient doesn't want, it's not a place you want to be . . . .What takes precedence...

...Those who showed reluctance were threatened with removal of guardianship...

...It remains unclear how, if at all, the recently passed Military Commissions Act will affect medical and interrogation practices at Guantánamo...

...Coerced consent of victims is an explicit feature of the Nazi period...

...Litton's research is, in part, a follow-up study...

...Legal issues aside, the case raises concerns about the role of psychiatrists and behavioral therapists at Guantanamo: in particular, were mental health workers involved in decisions about al-Dossari's isolation and restrictions...

...But Guantanamo is also a moral black hole...

...Not one doctor asked about the consequences of not acquiescing to the tube...

...they would talk about it later...

...Because we recently marked the sixtieth anniversary of the judgment at Nuremberg, I want to awaken our collective memory to the ways in which doctors in war, even in a war very different from the one the Nazis fought, can insulate themselves from their moral and professional consciences...

...0n October 25, 1946, three weeks after the handing down of the verdicts of the International Military Tribunal at Nuremberg, the United States established Military Tribunal I for the trial of twenty-three Nazi physicians...

...There were reports of the breach of confidential psychiatric records used in tailoring interrogation tactics...

...Psychological and moral numbing is, in part, a result of seeing oneself as not really "in charge" of decisions...

...I raised this question with a senior medical official in the Pentagon, but have not received an answer...

...Not surprisingly, al-Dossari suffered from the psychological stress of isolation...

...The detention center is still in operation...

...This point is by now a well-documented part of the working of Nazi machinery...

...We were assured that the hunger strikers were being treated humanely...

...I have drawn on lessons from the past not in order to shock or hyperbolize but to alert us to an aspect of our current detention largely occluded by focus on legal issues...

...The list of noxious experiments condemned as war crimes and crimes against humanity on civilians and prisoners of war is by now more or less familiar—high-altitude experiments...

...WE HEAR MUCH about Guantanamo as a legal black hole—one that falls between the cracks of the laws of armed conflict and the federal criminal law system...

...The sign is still in place, despite the growing desperation of the inmates about their treatment...

...All four requests were denied...

...Lifton's study makes clear how a highly bureaucratic division of labor and roles diffuses a sense of individual responsibility for one's actions...

...In the T4 prototype for the final solution, the policy was to gain "consent" from the parents of mentally ill children for the transfer of their children to the "Children's Specialty Departments," also euphemistically known as "Therapeutic Convalescent Institutions...

...But in remembrance of Nuremberg and the international moral law it set in place, this is no time to let cynicism of fear best our humanity...

...Seven detainees were on hunger strike, a steep drop from the escalated numbers over the summer...

...none openly worried that acquiescence might not be the same thing as consent...

...none voiced the concern that pulling out a nose tube funneled down the back of one's throat to the top of one's stomach might, in some circumstances, be painful, and that failure to do that might at best be a weak form of consent...

...The majority of those who have already been released have been returned to their home countries...

...Colangelo-Bryan is a young lawyer who, in his own words, is "cynical by nature" and takes all his clients' reports with "a grain of salt...

...There were three successful suicides at Guantanamo by other detainees in June of 2006...

...The blocks in Camp 5 have solid walls, with the only access to the outside world being a food-tray slot on a door that opens to a hall where large industrial fans drown out any attempt at conversation...

...Nor is it clear that there should be charges and trials...

...We were taken to the psychiatric wing of the hospital and introduced to two young female army psychiatrists...

...It is about the conflict and moral residue that linger, close to a half a century later...

...Moreover, the institutional separation of psychiatrists from interrogation does not itself excuse them from complicity while serving in non-interrogational roles, because it is unlikely that clinicians at Guantanamo remain ignorant of the actual conditions of interrogation and confinement...

...One reason seemed to be that psychologists, as non-physicians, are not perceived as strictly bound by the Hippocratic maxim, do no harm, as are physicians...

...ASECOND SCENE has returned to me often...

...Colangelo-Bryan was ordered to leave, but as he left he heard al-Dossari gasp for air...

...The Greek word, to the ears of some Nazi doctors, retained the positive overtones of its etymological root, as Adolf Wahlmann, medical director at the killing institution Hadamar, was eager to insist in legal testimony...

...Let the world read them...

...The Court argued that he was not isolated because he had been interrogated twenty-nine times over the past two years—"a novel legal position," his attorney commented (though perhaps in line with the notion that rapport building is, as I was told by Hood, the preferred method of interrogation at Guantanamo...

...The coercion implicit in force-feeding at Guantanamo is very different, more nuanced in its attitude toward the moral subject, and aimed at keeping people alive...

...The senior military and civilian doctors listened attentively as they were told that there was overall "complicity," in that most strikers did not forcibly resist insertion of the tubes or remove them once they were in place...

...Because of the Graham-Levin Amendment stripping detainee cases of habeas corpus (upheld recently in the Military Commissions Act), al-Dossari's team has not been able to obtain legal relief...

...sea water experiments...

...The attorney had a sense that something might be wrong and peeked into the door to the meeting area...

...But what remains clear is that more than four hundred individuals are still serving indefinite sentences at Guantánamo...

...What remains less familiar is the moral mind of doctors or health care workers who ply their medical skill for morally questionable uses in war...

...Al-Dossari then filed a motion with the court that was also denied...

...malaria experiments...

...The allegations raise serious questions about the role of doctors in authorizing the procedure...

...The preference among some Pentagon advisers was to use psychologists rather than psychiatrists for intelligence gathering...

...On October 15, 2005, Colangelo-Bryan went down to Guantanamo to consult with him...

...bone, muscle, and nerve regeneration and bone transplantation experiments...

...It's not an easy question...

...In the spring of 2005, while al-Dossari was still in Camp 5, he asked his attorney in a quiet voice, "What can I do from going crazy...

...The commanding doctor at the time, Captain John Edmonson, showed our group (which included U.S...

...As one enters the Guantanamo center, one passes under a gateway that reads "Honor Bound...

...The scene is disturbing in light of confirmed reports, just four months after my visit, that striking detainees had been strapped into restraint chairs during and immediately after force-feeding in order to prevent, according to officials, purging and asphyxiation that might result from being fed in a prostrate position...

...About four months later, the government declassified the suicide note: I know it is an awful and horrible scene, but there is no other alternative to make our voice heard by the world from the depths of the detention centers except this way in order for the world to reexamine its standing and for the fair people of America to look again at the situation and try to have a moment of truth with themselves . . . .When you remember me .. . remember that the world let us down and let our case down...

...The attorney was initially skeptical of some of the statements until he later read FBI memos and a book by a military officer that detailed exactly the same interrogation techniques his client had described, including the menstrual blood tactic...

...I conclude with the voice of Jumah alDossari from a note passed to his attorney in a sealed envelope, as they began their meeting on October 15, 2005...

...Some detainees alleged that while in the chair they were force-fed not only nutrients but also diuretics and laxatives...

...Guantanamo, too, divides labor in a way that aims at professional insulation...

...During their consultations, al-Dossari said that in interrogation sessions he was wrapped in an Israeli flag, chained to a floor while a female interrogator put on his face what he believed to be menstrual blood, and beaten unconscious by guards...

...jaundice and spotted fever experiments...

...military prisons in Guantanamo, Abu Ghraib, Kandahar, and until very recently, in undisclosed CIA locations throughout the world, where medical ethics are again at issue...

...Al-Dossari's voice is eloquent...

...Institutions such as Guantanamo are not killing centers like Hadamar was—that's not the comparison I want to make...

...Imageries of "therapeutic killing," "killing as healing and cure," "killing for the sake of the strong and the healthy," helped to further promote the myth of "special treatment" as therapeutic...

...The presiding commander of Guantanamo at the time, General Jay W. Hood, praised them highly for their dedication in the face of resistance from detainees...

...Consent to being force-fed is expressed, according to the base doctors, by the absence of active resistance...