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.]

Extending the Zadroga Act

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

Thirteen years ago today, Americans watched in horror as planes hijacked by Al Qaeda-backed terrorists slammed into the World Trade Center, the Pentagon and a vacant field outside of Shanksville, Pennsylvania.

Many of us lost friends and family. Nearly 3,000 people were killed that day, including 2,753 who died when the World Trade Center’s Twin Towers fell. The actual death toll associated with 9/11, however, is much higher.

When the Towers fell, they released a cloud of pulverized cement, shards of glass, asbestos, mercury, lead, PCBs, and other carcinogenic and poisonous materials into the air. That cloud lingered for months, with hundreds of rescue workers, thousands of construction workers and millions of New York City residents breathing in a witches’ brew of cancer-causing chemicals.

Rates of asthma, obstructive pulmonary disease and other respiratory illnesses are sky high among those who were exposed to the foul air or toxic dust that lingered over Lower Manhattan in the days and weeks the followed 9/11. A study of police who responded to the terror attacks found that more half have diminished lung function and chronic shortness of breath.

Rates of prostate cancer, thyroid cancer, and multiple myeloma are also elevated; one study looking at nearly 10,000 firefighters found that those who were at the World Trade Center were 20% more likely to develop cancer than those who were not there. Over 2,900 people who worked or lived near the World Trade Center on 9/11 have been diagnosed with cancer, including nearly 900 fire fighters and 600 police. Many of these cancers are likely associated with exposure to chemicals in the air and debris at Ground Zero.

Under the James Zadroga 9/11 Health and Compensation Act, passed by Congress in 2010 after a prolonged partisan fight, first responders, recovery workers, and survivors of the terror attacks can seek free testing and treatment for 9/11-related illnesses. Nearly 50,000 people are currently being monitored and over 30,000 are receiving medical treatment or compensation for illnesses and injuries associated with the World Trade Center’s collapse.

These numbers are expected to rise in the coming years. The incidence of cancer and chronic respiratory illnesses continues to increase at an alarming rate among survivors and responders of the terror attacks. At the same time, two of the key programs created by the Zadroga Act are due to expire. Unless Congress extends the Act, the World Trade Center Health Program, which provides free screening and treatment for 9/11-related illnesses, will end in October 2015. The September 11th Victim Compensation Fund, which provides financial support to the victims of 9/11 and their families, will close in October 2016. Desperately needed medical care and social services will be cut off for thousands of sick patients whose only crime was to survive the attacks or to provide care and aid for those who did.

A bipartisan group of New York politicians – including New York City Mayor Bill de Blasio, US Senator Kirsten Gillibrand, and US Representatives Peter King and Carolyn Maloney – want to prevent this. Just this week, they called upon Congress to extend the Zadroga Act for another 25 years. But they and other supporters of the Act face an uphill battle.

One of the key reasons that it took nearly 10 years to get this legislation passed in the first place is that many prominent (largely conservative) Congressmen opposed its passage, including Representatives Michele Bachmann and Paul Ryan. House Speaker John Boehner and Majority Whip Kevin McCarthy voted against it repeatedly. Senator Tom Coburn also filibustered its passage, arguing that the federal government simply cannot afford provide treatment and care for the victims of 9/11 in an era of record budget deficits. Should the deficit hawks of the Republican Party retain control of the House and recapture the Senate in the upcoming mid-term elections, the fate of the Zadroga Act is likely sealed.

The heroes and victims of 9/11 deserve better. I believe that we have a moral obligation to provide lifelong medical care and treatment for illnesses linked to the terror attacks. It is shameful that the same politicians who used these attacks to justify hundreds of billions of dollars in military expenditures are suddenly crying poor when asked to help the victims themselves. I urge you to call your Senator and Representative and urge them to support the Zadroga Act. More importantly, I urge you to use the power of the ballot box in the upcoming midterm elections to send a message to those who do not support an extension of the James Zadroga 9/11 Health and Compensation Act.

[This blog entry was originally presented as an oral commentary on Northeast Public Radio on September 11, 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.]

Will Bioethicists Support Hunger Strike Death? A response to Wesley J. Smith

by Jacob Dahlke, Bioethics Program Alum (MSBioethics 2012)

I came across a post from Wesley J. Smith at National Review Online regarding a recent ruling about force feeding prisoners at Guantanamo Bay. (Credit to Art Caplan for the tweet that brought this to my attention.) I would like to take some time and craft a reply to his question.

In short my position is this: Bioethicists ought not support the forced feeding of prisoners engaged in hunger strikes. Note that this does not directly answer Mr. Smith’s question, which is deftly written to bait someone who is opposed to his view into supporting the death of these prisoners. That is at best an inaccurate characterization of the opposing view. This is an attempt to more accurate characterize that view, with full acknowledgement that there is likely room for many disparate views.

Citizens, within the context of healthcare, are afforded particular rights with regards to medical treatments. One such right is that to refuse such treatments, a violation of which could constitute battery. There are landmark legal (and ethical) cases that highlight this right, most notably Nancy Cruzan and Dax Shephard. They provide a framework for discussing other persons, free or imprisoned, who decide to refuse medical treatments that may or will result in their deaths. The person at the center of this discussion, Jihad Ahmed Mujstafa Diyab, has an otherwise ambiguous role in American society.

To see Mr. Diyab as a prisoner – and thus eligible for a comparison to a prisoner in Kentucky who died following a purported hunger strike – ignores the fact that he has not actually been convicted of any crime to consider him as a criminal or felon. (It also ignores that the Kentucky death was not a clear hunger strike in protest, but rather a possible suicide or, even worse, a result of untreated mental illness.) Indeed, Mr. Diyab has not even been charged with any crime, he has only been detained (for an incredible 12 years). Were he charged, tried, and convicted, we would likely have a very different discussion on our hands. But this man is not yet a convicted criminal, so we are left to consider him ‘something else’. We must also leave Mr. Smith’s assertion that since Mr. Diyab is a criminal he is eligible to lose such rights as other convicted criminals, such as in the Kentucky prisoner death.

If we ignore all of the above, however, and presume that Mr. Diyab is actually a prisoner then we can ask what I assume is at the heart of Mr. Smith’s question: is a prisoner permitted to risk their health and potential life by undergoing a hunger strike? And, do medical ethical principles support the actions of the involved physician to treat only the symptoms associated with malnutrition and dehydration, fully aware that failing to treat the cause will eventually lead to death?

I will begin with the latter question. Mr. Smith wrote in a previous post that physicians who do not intervene to reverse the effects of the hunger strike are engaging in political activism, not medical ethics, and that “helping hunger strikers strike is not a doctor’s job.” He also writes that such an “intervention is only necessary because of self-inflicted harm and the feeding seeks to prevent death and destruction of health, not cause it. In this sense, it is not the same thing at all as a cancer patient refusing chemotherapy.” On this I  disagree. This implies several professional obligations of a physician, including:

  1. intervening in the health-altering behavior of a patient (“helping hunger strikers strike”, and the “destruction of health”). If this were actually a physician’s professional obligation, then physicians would be compelled to intervene to keep patients from knowingly risking their health and life from smoking cigarettes, eating high calorie diets, and leading sedentary lives. All three of these behaviors are known to put a person’s health at risk, albeit drawn out over a longer period of time than a hunger strike. Instead, I propose that the physician’s obligation in this case is to ensure that the patient is aware of all of the risks to their behavior, and to offer alternatives with better known benefits. To say that the physician decides that a patient with full autonomy is simply making the wrong choice and that the physician will instead make a ‘better’ decision on behalf of the patient smacks of paternalism.
  2. the prevention of death. While the avoidance of death can be celebrated as an outcome of medical interventions, it is only the byproduct of the underlying professional obligation of minimizing harms. It should be self-evident that minimizing harm can include avoiding death, but they are not synonymous. If they were identical, a single professional obligation, then the entire field of hospice and palliative care would not exist, since those professions (employed by physicians) do not seek to prevent death even though it may be a known prognosis, and instead it seeks to manage pain and other symptoms associated with the dying process.

Regarding the former question, regarding whether the rights lost by prisoners include that of medical autonomy, that should also be an irrelevant point since the status of the patient within the physician-patient relationship should not be a determinative factor. That is, a prisoner, detainee, or inmate should not receive an alternative level of care once that relationship has been begun, lest we begin a tiered system of patient and physician interactions.

Physicians that manage the health of detainees, whether on hunger strike or not, are working to maintain patient autonomy while still attempting to manage a balance between promoting patient benefits and minimizing harm. They are not engaging in political discourse; rather, they are simply doing their jobs as outlined by their profession.

[This blog entry was originally posted in a slightly different form on Mr. Dahlke’s blog on May 19, 2014. Its contents are solely the responsibility of the author alone and do not represent the views of the Bioethics Program or Union Graduate College.]

Hunger Games: Guantanamo Bay

by Theresa Spranger, Bioethics Program Alumna (MSBioethics 2012)

Guantanamo Bay is back in the news.  It seems that several of the inmates are currently participating in a hunger strike that began in February of this year.  It was started to draw attention to the camp and make a political statement that it should be closed as President Obama promised it would be during his 2008 campaign.

The hunger strike started with just a few prisoners and has expanded to over 100 of the 166 detainees.  About 45 of them have lost a significant amount of weight and require forced feeding to keep them alive.

So, what does “forced feeding” entail exactly?  Twice each day the prisoner is restrained at the hands, feet, and head, in a chair, a feeding tube is inserted into the stomach though the nose, and a protein shake (Ensure, or the like) fed to the prisoner through this tube.  The process can take up to 2 hours per person, per feeding.  With 45 people on feedings, each twice a day, this is no small operation for the Guantanamo Bay medical staff.

Some activist groups consider the forced feedings to be torture.  To back up their claim they look to the world of medical ethics.  The World Medical Association and American Medical Association, among other organizations, accept that patients have the right to refuse life sustaining treatment, including tube feedings.  This has been established through cases like that of Terri Schiavo, the Florida woman in a vegetative state whose story made headline news in the early 2000s.

Reprieve, a human rights group, recently released a video of Hip-hop artist/actor, Yasiin Bey (also known as Mos Def) undergoing the same forced feeding procedure that is happening in Guantanamo Bay.  In the video, Mr. Bey is unable to complete the procedure and it is stopped before the tube is even completely lowered into his stomach.  For much of the 4 minute video he is seen screaming and crying in an orange jumpsuit while being restrained in a chair, with people in white lab coats attempting to place the tube in his nose.  He continues to scream and struggle, until an off screen voice tells them to stop the procedure.

The video was made to illustrate the painful nature of the forced feeding procedure; the group considers the procedure a form of torture and has openly called for the feedings to be stopped.  The tag on the Reprieve website is, “Reprieve delivers justice and saves lives, from death row to Guantanamo Bay.”   Given their current argument about the forced feedings I find this tag line to be ironic.

It seems Reprieve has missed a major memo, so let me break it down here:

If we stop the forced feedings and the prisoners still refuse nourishment, they WILL die!

So, the question becomes: can you live with that?

If you will please look to the left of our military you will see a rock and to the right a hard place…now choose.

The military defends their decision to pursue the forced feedings saying they don’t allow suicide by any other means, so they choose not to allow it in the form of starvation.  I understand their position and that they are trying to prevent the loss of life.

My personal feelings however, are against the forced feedings.  Not because they are torturous or painful, though I’m sure the procedure is less than pleasant.  I am against them because I think our military and our country are being manipulated by the prisoners at Guantanamo Bay.  They stop eating and what has been the American reaction?

  • The New York Times printed an editorial about the horrors of Guantanamo Bay in a prisoner’s own words.
  • We discuss how the forced feedings could interfere with Ramadan, therefore violating the prisoners’ right to freedom of religion.  (Side note: The feedings are currently being performed at night to respect the religious traditions of the prisoners.)
  • Human rights activist groups, like Reprieve, take up the cause and renew the fight for the camp to be closed.

I don’t think the men of Guantanamo Bay actually want to die the miserable death of starvation, but rather they have found a captive audience for this new game of theirs.  If the feedings continue the hunger strike will never end.  The only way I can see to convince the men to start eating again is to let them see their decisions play out in some of their comrades.

I understand that my opinion is probably not a popular one, I don’t even like it myself to be honest, but what choice do we have?  Many will certainly say, “Close Guantanamo Bay…there is your choice.”  To them I say:

Whether you choose to believe it or not, there is a reason these men are being held in Guantanamo Bay and a reason that our current President, like the last one, has not closed the facility.

[This blog entry was originally posted in a slightly edited form on Ms. Spranger’s blog on July 15, 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.]