Leonard S. Rubenstein

Medical ethics at Guantanamo Bay detention centre and in the US military: a time for reform

President Obama has pledged to close the US detention centre at Guantanamo Bay, Cuba, by Jan 23, 2010. Physicians have a special interest in how this pledge is going to be accomplished since the use of brutal interrogation and force-feeding of prisoners as sanctioned by George Bush’s administration has damaged the integrity of the physicians working for the military and the Central Intelligence Agency (CIA). These physicians had a conflict of loyalty because of their ethical obligations to their imprisoned patients and the Bush administration’s demands to further the goals and interests of military commanders and intelligence officials. A declassified congressional report shows that military physicians developed and implemented interrogation methods, including sleep deprivation, isolation, threats, nakedness, and stress positions. The release of previously secret memoranda from the US Justice Department shows the involvement of physicians working for the CIA in designing, using, and monitoring interrogation methods, including water boarding. The International Committee of the Red Cross has established that these methods amount to torture. In January, 2009, President Obama directed Robert Gates, the Secretary of Defense, to review the current practices at the detention centre in Guantanamo Bay to determine whether the prisoners were being held in accordance with Common Article 3 of the Geneva Conventions. Admiral Patrick Walsh, Vice Chief of Naval Operations, led the review team that produced an 81 page report including subjects of special interest to the medical community, such as the health and medical treatment of the prisoners, and the role of medical personnel in hunger strikes and in interrogation support. Military physicians have been important in stopping hunger strikes at the detention centre in Guantanamo Bay from the outset. At least since 2005, they have used restraint chairs to put hundreds of prisoners in eight-point restraints (ie, both ankles, wrists, and shoulders, one lap belt, and one head restraint) before, during, and after the placement of a nasogastric tube so that the prisoners can be force-fed. The use of coercion, physical force, or physical restraints to force-feed competent individuals on hunger strike has been condemned by the World Medical Association as a form of “inhuman and degrading treatment” that is prohibited according to Common Article 3. The report, although noting the World Medical Association’s application of the prohibitions of Common Article 3 of the Geneva Conventions to force-feed prisoners, relies instead on the 2006 medical instruction of the Department of Defense, and the regulations of the US Bureau of Prisons, both of which permit force-feeding to prevent self-harm. Admiral Walsh’s team—in summarising current practice—perhaps inadvertently, draws attention to some of the main ethical challenges associated with the involvement of physicians in forcefeeding prisoners. The first is that the decision alone to force-feed is made on the basis of a classified medical protocol. Second, the physician does not make the decision since “a medical recommendation for intervention with involuntarily intravenous therapy or enteral feeding must be approved by the CJTF [Commander Joint Task Force].” Third, prisoners often refuse to be taken to be force-fed and then must be forcibly removed from their cells and transported by the non-medical forced-cell-extraction team, consisting of five security personnel in riot gear, a member of the medical staff, and a videographer. Fourth, restraints are used “to protect both the detainee and staff.” Fifth, “time in the feeding chair may not exceed two hours”. The team concluded first, that the policy of forcefeeding is designed “to preserve the life and health” of the prisoners; second, the policy is similar to that used by the US Bureau of Prisons; third, the “feeding program is being conducted solely as a medical procedure to sustain the life and health” of individuals on hunger strikes; fourth, the process is “lawful and is being administered in a humane manner”; and fifth, is “in accordance with Common Article 3 and Department of Defense policy.” 2 years before physician-assisted force-feeding of individuals on hunger strike at the centre in Guantanamo Bay began, President Bush’s Bioethics Council had described the force-feeding of competent prisoners on hunger strike with the use of restraints and a nasogastric tube as a form of torture. The opinions expressed by the Bioethics Council were ignored by the Bush administration, which also ignored the statements of the World Medical Association, American Medical Association, and other organisations that condemned the involvement of physicians in force-feeding and the use of restraint chairs as unethical. Walsh’s team did not question the ethics of the use of a classified medical protocol; a non-physician (the base commander) making a medical treatment decision and the decision to use forced-cell extraction of individuals on hunger strike; the unlikelihood of a prisoner who is strong enough to pose a safety and security danger to the guards needing forced-feeding to save his life or protect his health (force-feeding is routinely started long before it could reasonably be considered medically necessary); the Lancet 2009; 374: 353–55

Dual loyalty and human rights

FOR CENTURIES health care professionals worldwide have been expected to abide by an ethic of undivided loyalty to the patient—first codified by the Hippocratic Oath and later updated by the World Medical Association Declaration of Geneva, which asks physicians to pledge “the health of my patient shall be my first consideration.”While there is a rich history of universally accepted standards invoking fidelity to the patient as a cornerstone of health care ethics, in practice physicians, nurses, and health professionals often have competing obligations to third parties—family members, employers, and governments—that may conflict with the undivided devotion to the patient. Such a conflict presents the health care professional with the problem of dual loyalty. Increasingly, health care professionals around the world are called upon to subordinate the patient’s interest to achieve a social objective that may be incompatible with protecting the human rights of the patient. The most insidious human rights violations stemming from dual loyalty arise in the health professions under repressive governments, where pervasive human rights abuses occur by health professionals at the behest of the state. Some glaring examples are direct participation in torture in Chile, making sure prisoners are fit for torture, or covering up torture by falsifying medical records; using surgical skills in Iraq to conduct amputations at the state’s request; and subjecting Falun Gong practitioners in

Punishing health care providers for treating terrorists

Imagine that an American physician volunteered to treat wounded children through the Ministry of Health in Gaza, controlled by Hamas. Or that a Palestinian nurse attending to injured fighters in Gaza spoke out against the firing of rockets into Israel, was threatened with arrest, and sought asylum in the United States. Under U.S. law, the doctor could be subject to prosecution, and the nurse could be denied asylum -- in the first case, because she provided medical care under the direction or control of a designated terrorist organization; in the second, because he knowingly provided care to a member of a terrorist organization. The question of whether a terrorist is entitled to medical care, though largely theoretical, has generated considerable discussion, with near unanimity that there is no moral basis to refuse to treat. But whether a health professional can be punished for providing medical care either to terrorists or under the auspices of a terrorist organization has received little attention from either a moral or legal perspective, although such situations arise throughout the world. Language: en