Physician, Torture Thyself

by Sean Philpott-Jones, Director of the Center for Bioethics and Clinical Leadership

Last week, the US Senate Intelligence Committee released its long awaited report describing the techniques that the Central Intelligence Agency (CIA) used to interrogate suspected terrorists and other combatants captured during our long running War on Terror.

The so-called Torture Report, the product of a five-year investigation by the Democrat-led Senate, described in harrowing detail the methods used by CIA agents to extract information from detainees, including: waterboarding; sleep deprivation; light deprivation; threats to physically harm or sexually assault individuals, their children or their adult relatives; and “rectal feeding”. Many of these techniques blatantly violated the Geneva Conventions and other international agreements on humanitarian treatment of prisoners of war.

Not surprisingly, the political firestorm that release of this 6,700-page report ignited has been fierce. Many Republican politicians and conservative pundits have condemned the investigation as flawed, biased, and potentially damaging to US interests.

Others, including former Vice President Dick Cheney and key architects of the War on Terror, have defended the use of enhanced interrogation techniques, claiming that countless lives were saved and disputing allegations that any US laws or international treaties were violated. Only a few politicians and pundits on the right, most notably Arizona Senator John McCain (himself a former POW who was tortured), have stood up to defend the report.

On the other side of the political aisle, the response has been fairly muted. While progressive organizations and advocacy groups like Human Rights Watch have called for criminal investigation of senior Bush Administration officials and CIA operatives involved in the interrogation of prisoners, Democratic politicians and the Obama Administration have largely rejected calls to prosecute those involved. This is, I believe, a rather shrewd and calculated political move.

For this commentary, however, I don’t want dwell on the issue of whether or not the activities described in the Senate’s report question long-standing notions of American exceptionalism: the idea our country stands as a moral exemplar for the rest of the world. Instead, I want to focus on a more practical question: what does the fact that hundreds of doctors, nurses, and psychologists participated in the interrogation of CIA prisoners say about the healthcare profession as a whole?

We now know that CIA staff physicians and psychologists were involved in almost every interrogation session. This is in direct violation of all known codes of medical ethics, including the Hippocratic Oath, the American Medical Association’s (AMA) Code of Medical Ethics, the American Psychological Association’s (APA) Ethical Principles of Psychologists and Code of Conduct, and the World Medical Association’s Declaration of Tokyo. Despite a primary duty to “do no harm” (primum non nocere), a number of medical professionals have been directly involved in helping the US government, the CIA, and other military and intelligence agencies come up with new and creative ways of torturing prisoners.

For some healthcare professionals, torture is also a lucrative business. Two psychologists, Jim Mitchell and Bruce Jessen, helped the CIA develop its interrogation program. In exchange, they received more than $80 million from the US government.

Consider a few examples of physician involvement in torture outlined in the Senate report: Clinicians with the CIA’s Office of Medical Services, which provides healthcare to Agency employees, decided when detainees’ injuries were sufficiently healed such that agents could again interrogating them. A team of physicians determined which prisoners should be waterboarded, an interrogation technique that simulates drowning.

At one detention site, even though a prisoner’s feet were badly broken, the examining doctor nevertheless recommended that he be forced to stand for nearly 52 hours in order to extract information. Nurses and doctors also used rectal feeding and hydration — forcible injection of water, saline and even a pureed mix of hummus, nuts and pasta through the anus — despite the fact there is no physiological benefit or medical purpose to rectal feeding.

Few of these healthcare professionals are likely to face any consequences. To date, only one clinician has ever been sanctioned for their involvement in torture: a Navy nurse who refused to force-feed prisoners who were on an extended hunger strike at Guantanamo. He will probably be discharged from the military. He may also face criminal prosecution for failing to obey orders.

He will likely be the only medical professional prosecuted. The Obama Administration has largely given a “Get Out of Jail Free” card to everyone involved. In a briefing given by the White House following the release of the Torture Report, for example, a senior official with the US Department of Justice concluded that the CIA’s enhanced interrogation activities were “authorized” and “reviewed as legal” at the time they occurred.

While the AMA and the APA have condemned the actions of the clinicians and psychologists mentioned in the report, as professional organizations with no legal or licensing authority, there is little they can do to punish those involved. State medical licensing boards could suspect or revoke permission to practice, they probably won’t.

It is sad that the perpetrators of these crimes will face no sanction. It is sadder still that politicians, policymakers and the general public will largely ignore the Senate’s report. I can only hope that outrage in the medical community over these and other acts (such as physician involvement in state-sanctioned executions) leads to a change in the way healthcare workers treat suspected terrorists and other prisoners.

[This blog entry was originally presented as an oral commentary on Northeast Public Radio on December 18, 2014, and is available on the WAMC website. The contents of this post are solely the responsibility of the author alone and do not represent the views of the Bioethics Program or Union Graduate College.]

Forgiving Fred Phelps

by Sean Philpott, Director of the Center for Bioethics and Clinical Leadership

Fred Phelps, one of the most reviled men in the United States, died last week. Mr. Phelps was the founder of the Westboro Baptist Church, a virulently homophobic organization known for its “God Hates Fags” slogan.

Members of the Westboro Baptist Church have been conducting anti-gay protests since 1991, but the group gained national prominence in 1998 when it picketed the funeral of Matthew Shepard. As most people know, Mr. Shepard was a young man from Wyoming who was robbed and beaten to death by two men who targeted him because he was gay. His murder and the subsequent trial of his assailants, dramatized in the award-winning play The Laramie Project, helped to raise public consciousness about anti-gay bullying and hate crimes against sexual minorities.

The Westboro Baptist Church now conducts an average of six or more protests a day. Church members routinely picket the funerals of other gay men, particularly those who were the victims of hate crimes or who died of HIV/AIDS. They also protest at performances of The Laramie Project, at concerts given by musicians deemed to be LGBT-friendly, at Jewish and Muslim religious services, and even at the funerals of soldiers killed in Iraq or Afghanistan. Those wars, Church members believe, are divine punishment for “[our] evil nation for abandoning all moral imperatives that are worth a dime.”

Despite the fact that Mr. Phelps and his followers believe that my husband and I are directly responsible for all of the ill fortune that befalls Americans, I do not celebrate his death. While I am not going to mourn the passing of a hate-filled man such as Fred Phelps, I’m not going to take perverse happiness in it either. In fact, I find it sad that he left this world without a chance to find peace, love, redemption and forgiveness.

Many of my friends and family find this a bit shocking. When I posted this sentiment on Facebook, for example, one colleague commented that she’d have a hard time finding forgiveness for a guy who, by picketing the funerals of combat soldiers, put grieving families through so much additional pain.

I see it quite differently. People like Fred Phelps are exactly the ones that need our forgiveness. Moreover, forgiving those who have hurt us — particularly those who have done nothing to deserve forgiveness — gives us great power and strength. This is a lesson that I learned several years ago after having lunch with a remarkable woman named Eva Mozes Kor.

Ms. Kor is a Holocaust survivor. At the age of 6, Romania-born Eva and the other members of her family were sent to the infamous Auschwitz concentration camp. While there, Eva and her twin sister Miriam were the subjects of horrific medical experiments by Dr. Josef Mengele. Despite this, they both survived and were liberated by Allied forces near the end of the war. Eva eventually emigrated to the US while her sister moved to Israel. Together, they founded an organization called CANDLES (Children of Auschwitz Nazi Deadly Lab Experiments Survivors), through which they began to locate other survivors of Dr. Mengele’s research and to publicize the experiences of Holocaust survivors.

But Ms. Kor also did something completely unexpected and extremely controversial. Fifty years after the liberation of Auschwitz, on the very site where so many died, Eva announced publicly that she forgave the Nazi’s for what they had done to her. She didn’t deny that inhumane atrocities had occurred in the camps, nor did she believe that these crimes should be forgotten. She simply forgave those that had wronged her, freeing herself from decades of victimhood and suffering.

Hearing this story from Ms. Kor inspired me to do the same in my life. I forgave a former employer for a myriad of wrongs, letting go of my anger while still embracing the management lessons that I learned. I even forgave my former stepfather for a decade of mental and physical abuse, recognizing that my own compassion is a direct response to his lack of caring and concern.

I believe that Fred Phelps deserves the same. In fact, we should even thank Mr. Phelps and his followers for their hate-filled rhetoric. By taking the same rhetoric and opinions spouted by many ‘good Christians’ to the extreme — through slogans like “God Hates Fags” and “Thank God for Dead Soldiers” — the Westboro Baptist Church showed just how pervasive and perverse homophobic attitudes are. It’s even possible that many of the recent advances in gay rights wouldn’t have been achieved without Fred.

Thank you, Mr. Phelps, for being a role model for kind and caring people around the world. You and the others like you teach us what we should strive not to be. I only hope that you find the love and compassion in the next life that you so sorely lacked in this one.

[This blog entry was originally presented as an oral commentary on Northeast Public Radio on March 27, 2014. It is also available on the WAMC website. Its contents are solely the responsibility of the author alone and do not represent the views of the Bioethics Program or Union Graduate College.]

Safety Shutdown

by Sean Philpott, Director of the Center for Bioethics and Clinical Leadership

Unless a miracle happens, by the time this commentary airs on Northeast Public Radio the US federal government will enter its tenth day of shutdown. Nearly 800,000 workers will remain furloughed, important social service and educational programs will remain unfunded, national parks and monuments will remain closed, and the National Zoo’s panda cam will remain offline.

Some already have been directly affected by the shutdown — the furloughed workers, the disadvantaged children whose Head Start programs were forced to close due to a lack of funds, the grieving widows of fallen soldiers whose death benefits were delayed, and the desperate cancer patients whose enrollment in NIH-run clinical trials has been postponed. For most of us, however, the impact of the shutdown has been fairly minimal. Our mail is still being delivered, our courts of law are still open and our prisons are still full, our police and firemen remain on duty, and our social security checks continue to arrive.

For the average American then, all is currently okay in the land of the free and the home of the brave. And it will stay that way, so long as you don’t eat anything, drink anything, take any new medications, or fly anywhere. Unbeknownst to many, the very safety of the public is at risk during the shutdown.Consider the issue of food safety. Locally produced meat, poultry and seafood should remain safe, no matter the length of the shutdown. The United States Department of Agriculture (USDA) continues to inspect domestic meat and poultry plants. The National Oceanic and Atmospheric Administration’s (NOAA) domestic seafood inspection program is also up and running.

But the US Food and Drug Administration (FDA), which is responsible for monitoring the remaining 80% of domestic food production, as well as ensuring the safety of all food imports (including meat and seafood), has been largely shuttered. Given that 10% of the beef, 20% of the vegetables, 50% of the fruit and 90% of the seafood eaten by Americans comes from overseas, that’s a lot of uninspected food. So be sure to wash your fruits and vegetables carefully in the coming weeks.

Moreover, if an outbreak of food-borne illness should happen, the government response is likely to be tepid. When such outbreaks occur — particularly those that cross state lines, such as the current outbreak of Salmonella that has sickened over 300 people in 18 states — the FDA, USDA and the US Centers for Disease Control and Prevention (CDC) work with local and state health agencies to trace the source of the contamination and stop any further cases of illness. For the most part, that’s no longer happening.

In fact, the government shutdown poses a myriad of threats to the health and safety of all Americans. Not only is the CDC no longer actively investigating outbreaks of foodborne illness, it has also suspended its flu surveillance and vaccination program. The emergence of a new strain of influenza — such as the H1N1 strain that caused a global pandemic in 2009 — could go largely unnoticed until it is too late to prevent its deadly spread.

Similarly, not only have food inspections stopped at the FDA, so have drug approval and safety inspections. New drugs to treat deadly diseases like hepatitis C may be delayed, and unsafe drugs that pose a danger to US consumers may remain on the market. Thousands of Federal Aviation Administration (FAA) employees have also been furloughed, including air safety inspectors. As a result, in the past week safety inspections of planes and pilots have largely ceased. Most of the staff of the federal Occupational Safety and Health Administration (OSHA) have also been sent home. They are no longer conducting workplace safety inspections, except in cases where there is “a high risk of death or serious physical harm”.

The only Americans who remain safe during this government shutdown are the politicians themselves, most of who are comfortably ensconced in gerrymandered districts that ensure continued re-election despite universal disgust with their partisan hijinks. The rest of us are at risk, whether we know it or not. And it seems that is little that we can do to combat the continued political posturing that prevents our Congressmen from working together to address our nation’s pressing needs … at least, that is, until the 2014 midterm elections.

[This blog entry was originally presented as an oral commentary on Northeast Public Radio on October 10, 2013. It is also available on the WAMC website. Its contents are solely the responsibility of the author alone and do not represent the views of the Bioethics Program or Union Graduate College.]

Sweeping Sand Under the Rug

by Sean Philpott, Acting Director of the Center for Bioethics and Clinical Leadership

This past weekend was the Memorial Day holiday, traditionally marking the official start of the summer season. But Memorial Day is more than just barbeques with friends and three-day sales at local department stores. Memorial Day is also the day when we honor the more than one million men and women who have died in combat or from injuries received while serving in the US armed forces. Among those we honor are the nearly 75,000 who have died since serving in the 1991 Persian Gulf War (also known as Operation Desert Storm).

Now, that number may seem surprising. After all, coalition forces suffered few casualties during the liberation of Kuwait.  Less than 300 American soldiers were killed on the battlefield, and only 114 of those were caused by enemy fire. The rest were accidents or friendly fire.

In the two decades since the Persian Gulf War, however, many of those who served  (as well as many of the civilian contractors who supported the war effort) have been come down with a chronic disorder known as Gulf War Syndrome. Characterized by a diffuse set of symptoms — fatigue, headache, memory loss, muscle pain and weakness, arthritis and joint pain, and respiratory problems — the disease now appears to afflict over a quarter of a million Gulf War veterans, or nearly a third of those who served in Operation Desert Storm. Of those affected, activists estimate, over 70,000 have died.

The disease itself is somewhat controversial. Several studies published in the mid-1990s found no evidence that those who served in the Gulf had increased rates of illness, hospitalization or death, at least when compared with veterans who served in other theaters of operation. Based on these and other data, in 1996 the Institute of Medicine (the clinical arm of the US National Academies of Science) concluded that there was no evidence of a unique chronic illness associated with military service in the Gulf. Despite this, and armed with an additional twelve years of data, in 2008 a federal panel known as the Research Advisory Committee on Gulf War Veterans’ Illnesses announced that Gulf War Syndrome is indeed a distinct physical condition.

The cause of Gulf War Syndrome is also unclear. Some blame exposure to Sarin gas or other chemical weapons stockpiled by the Iraqi government. While there is no evidence that Saddam Hussein’s troops ever used chemical weapons against the coalition forces, many soldiers may have been inadvertently exposed during demolition of these weapons during and after the war.

Others suspect that the cause of Gulf War Syndrome is exposure to organophosphate pesticides used to prevent the spread of insect-borne diseases common in the Gulf.  Still others blame the pyridostigmine bromide pills given to troops to protect against nerve gas, or the depleted uranium ammunition used by troops, or the toxic smoke produced when Iraqi troops set the oil fields on fire.

We may never know the cause of Gulf War Syndrome. This is particularly true since the US Veterans Administration (the VA) seems reluctant to study the disease or its causes. Doing so could put the Agency on the hook for billions of dollars in treatment costs. Not surprising then that the Agency is keen to prevent or suppress such research, at least according to testimony presented by former VA epidemiologist-turned-whistleblower Dr. Stephen Coughlin at a recent Congressional hearing.

According to Dr. Coughlin, the Agency prevents VA-supported researchers from publishing “anything that supports the position that Gulf War Illness is a neurological condition.” It also refuses to release data from the ten-year National Health Study of a New Generation of U.S. Veterans, a multimillion dollar study of nearly 60,000 Gulf, Iraq and Afghan war vets.

Similarly, the Agency has also never published the results of the National Cohort of Gulf War and Gulf War Veterans study, a medical survey of some 30,000 Desert Storm vets. Finally, in an act that is either the height of hubris or the height of incompetence, the Agency “lost” over ten years of data from the Gulf War family registry, a Congressionally-mandated study to look for congenital disorders among the children of vets, birth defects that may have been caused by exposure to chemical weapons or other wartime environmental hazards.

What’s surprising to me that Dr. Coughlin’s explosive testimony has not engendered more anger on Capitol Hill. His allegations that officials at the VA — the very federal agency whose job it is to provide treatment and care for veterans and their dependents — may have deliberately suppressed research into the causes of Gulf War Syndrome are shocking. This accusation deserves to be investigated and, if proven to be true, immediate action to correct the grave harm to those suffering from Gulf War Syndrome, those who have died of the disease, and their families needs to be taken.

For 22 years now, sick veterans have been told that they are crazy, accused of being hypochondriacs, or denied benefits because their condition is not related to wartime service. It may turn out, however, that none of that is true. Rather, as has happened too many times before, the government may have sacrificed the health and well-being of military veterans in order to save a couple of bucks. That’s not only shameful, it goes against everything those soldiers fought and died for.

[This blog entry was originally presented as an oral commentary on Northeast Public Radio on May 30, 2013. It is also available on the WAMC website. Its contents are solely the responsibility of the author alone and do not represent the views of the Bioethics Program or Union Graduate College.]

On Hunger Strikes

by Jacob Dahlke, Bioethics Program Alum (MSBioethics 2012)

“We will not allow a detainee to starve themselves to death and we will continue to treat each person humanely.” Lt. Col. Samuel House.

Under what circumstances can physicians treat their patients over their objections? Do prisoners (or more accurately in this case detainees) have a right to refuse medical intervention? How might a military physician reconcile a situation in which the two professional obligations directly conflict with each other?

Questions like these have arisen in the news recently in which military officials have dispatched medical officers to manage the treatment of detainees at Guantanamo Bay. I personally am troubled by my initial reading of these headlines, but upon my realization that it may have been a purely visceral response, I decided to evaluate the situation a bit more objectively, if possible.

Good ethics begins with good facts; one way to organize those facts is to compile them into four quadrants: medical indications, patient preferences, quality of life considerations, and other contextual features.

Lt. Col. House has indicated that 100 of the 166 current detainees are participating in the strike, although lawyers for some of the detainees said that the number was around 130. Let’s be clear on this: the lowest estimate is that 60% of the detainees are voluntarily withholding nutrition, or nutrition and hydration. The high estimate indicates 78% participation.  21 detainees are currently being fed with nasogastric tubes over their objections. Five of the participants are currently hospitalized, likely due to side effects of malnutrition.

The detainees have not been evaluated for decisional capacity. In a case where that has not taken place, one would presume that a person has the capacity to make their own decisions. Regardless of a person’s capacity to make medical decisions, all persons retain the right to refuse treatments. If a person refuses a treatment, then the physician (or other medical professional) has two choices: they can honor the person’s refusal and manage the person’s side effects of the refusal (malnutrition in this case), or the professional can treat the person over their objection. This is technically medical assault or battery, so a special provision must be made in order to ethically justify it. That provision is that the person is suffering from a psychological, psychiatric, or somatic illness that is interfering with the person’s ability to properly evaluate the medical decision. That is, if the person is too ill to appropriately refuse (they lack capacity), then we can be justified in treating this person over their objection in order to achieve their greater goal of survival or life prolongation. (Since they have not be sufficiently been evaluated for their capacity, one cannot determine whether their goal is to prolong their lives.)

If we cannot make a definitive assessment based upon the first two categories, we must use the latter two. First, a caveat: I am making assumptions and judgments. I try to make them as objectively as possible, but due the general lack of good facts in this case, it will likely be overall inadequate.

These persons are currently detained in a military prison. They have been there for the better part of a decade (many for longer). While they are technically in a legal limbo of awaiting a trial, there are many indications that there is no intent to ever do that. Translated: this is their life, for the rest of their life. The only other prospect is that they get transferred to another prison. For all other practical purposes, they can be considered prisoners convicted of any other crime: they are treated for illness, provided limited access to personal belongings, etc.

There are likely many cultural biases at play in this case, and probably too many to begin to consider. To some Americans the detainees represent the antagonists to our global goals and achievements. “They” attacked “us”, and therefore in this course “we” captured “them”. To others, the detainees represent all that is wrong with America’s relationship with the rest of the world. Muslim v. Christian. American v. the “Middle East”. Us v. them. I contend that all of these cultural biases, while real and present in this case, are irrelevant. What I find interesting instead is the cultural clash among the health care professionals. There is a culture associated with being a health care professional, one that highlights a fiduciary responsibility to reduce suffering, treat illness, and respect individuals. There is a culture associated with being in the military, one that highlights a fiduciary responsibility to provide security, to reduce or eliminated harm or threat of harm. The structures, processes, and outcomes of these two cultures directly conflict here. It is relevant to note that the news has indicated the arrival of Navy medical personnel included “nurses, specialists, and hospital corpsmen who are trained to provide basic medical care“, which indicates to me that the medical personnel did not include physicians. This is an important distinction, particularly if one wanted to criticize AMA president Lazarus’s letter to Secretary of Defense Hagel on the subject. Translated: Lazarus is opposed specifically to treating over objections if it is physicians who are asked to do it, but will not commit to objecting to the practice in general, since the medical personnel are not technically physicians (and therefore technically beyond the AMA’s scope). Classy. But I digress.

One partial justification for the feeding tubes is that some of the detainees (being force fed) have occasionally voluntarily eaten, when removed from the general population of other detainees participating in the hunger strike. A relevant question then is at what point does peer pressure- which still represents an individual’s autonomous decision- change to coercion, which includes a threat of harm to the person? And what if the situation were reversed, and there was peer pressure on detainees to stop their hunger strike? Would the military intervene in that case of ‘peer pressure’? Likely no, because it’s not the peer pressure that matters; it’s that the detainees are doing something (hunger strike) that the military doesn’t want them to.

Ethical principles to consider

For me, this situation abounds in contrasting ethical principles. The first surrounds the right of a patient to express their autonomy, balanced with the health care professional’s obligations to beneficence (doing good- like treating illness or reducing suffering) and non-maleficence (avoiding doing harm, such as standing idly by while a person’s decisions reduces the quality of their health). I repeat my interest in noting that the military personnel are not physicians. (It is surely worth exploring the professional ethical codes for the personnel, but not for this dialogue.)

There is an apparent conflict between beneficence and non-maleficence. This is only perceived however, because we don’t actually know what the detainee’s goals are. If the goal is to minimize suffering, and if living this way is worse than death itself, then it would be beneficent to allow this and harmful to prevent it. It would thus be an ethical violation to treat this patient over their objection. Thus, the military is keeping these people alive, against their wishes… do what with them? Keep them in this limbo state, presumably.

If however, the detainee’s goal is to protest their treatment, to highlight the numerous abuses and illegal that are being imposed upon them, then the detainee’s goal is indeed life prolongation. Their refusal of food and overall nutrition and hydration, then, represents an irrational decision. How can one want to live, and yet refuse nutrition which will prolong your life? Here is a well-written article on the perceived noble explanation by the military that they are preventing suicide.

There is additionally the role that justice plays in this case. If the goal is to prosecute these individuals for their presumed crimes, then I can see an argument to treating them over their objections in order to see them through their course of justice.

In a strictly medical setting, if a patient refuses a treatment, there is a medically ethical obligation to pause and reconsider patient’s goals; if he has capacity, we should honor patient’s right to refuse. To treat the patient with capacity is to violate his rights, thus conducting battery on the person (doing something to him that he doesn’t want). If the patient doesn’t have capacity, we still can’t do something to someone that doesn’t want it. We must go to court, and get special permission to break the law (do something to someone that they don’t want us to do).

But let’s face it, it won’t. This is Guantanamo Bay. The whole place is one big quagmire of questionably dubious if not full-on illegal activity. Its very existence is questioned by the UN as a breach of international law. But I have drawn enough breath for tonight, and clearly I am not the only one thinking about this.

[This blog entry was originally posted on Mr. Dahlke’s blog on May 2, 2013. Its contents are solely the responsibility of the author alone and do not represent the views of the Bioethics Program or Union Graduate College.]