One of the casualties of the 9/11 terrorist attacks has been the ethical corruption of some American doctors, nurses and psychologists serving on the front lines of the War on Terror.
Earlier this month, a searing report from the Taskforce on Preserving Medical Professionalism in National Security Detention Centers examined the issue of physician involvement in torture and abuse. The independent review found that US health care professionals had allowed “cruel, inhumane and degrading treatment of prisoners while acting at the direction of military leaders under both President George W. Bush and President Barack Obama”.
“Ethics Abandoned: Medical Professionalism and Detainee Abuse in the War on Terror” is a 156-page report. Among its conclusions is that “Military and intelligence-agency physicians and other health professionals, particularly psychologists, became involved in the design and administration of… harsh treatment and torture — in clear conflict with established international and national professional principles and laws.”
The report states that these egregious actions on the part of health care providers were aided by three factors: (1) a government directive stated that individuals detained as part of the “war on terror” were not lawful combatants protected by the Geneva Convention; (2) both the Department of Defense (DoD) and the CIA directed health care providers to violate their professional and ethical duties; and (3) secrecy allowed the unlawful detention and interrogation to continue outside of normative ethical and legal review.
Among the many disturbing claims were: the use of physicians and psychologists to develop new interrogation techniques, the inadequate medical treatment of prisoners, and DoD and CIA directives violated medical ethics standards (including changing the notion of “harm,” limiting required reports of abuse, forcing breaking of hunger strikes through the use of restraints and feeding tubes).
The report offers several recommendations for change. These include a thorough review of health care professionals’ role in the treatment of detainees, a cessation of the use of inhumane and cruel treatment, reinstatement of professional standards, following ethical standards regarding hunger strikes, including compliance with professional standards as part of quality assurance review, strengthening statements by the American Medical Association (AMA) and the American Psychological Association (APA) on professionals working with detainees, classifying participation in torture and mistreatment as “sanctionable misconduct” with licensure implications, and educating military health professionals on their professional ethical duties.
Reading the report is like entering a time warp and learning about the abuses conducted by physicians during the Nazi era. But the issues in this report are recent and ongoing.
During the Nuremburg trials, many physicians claimed they were simply “following orders.” The world responded to atrocities committed by Nazi doctors by establishing codes of professional ethics for the AMA and the APA (in addition to the Hippocratic Oath), legal professional duties, and international codes like the Declaration of Helsinki.
But clearly we have learned very little. The very nation that wrote the Nuremburg Code has been behind a decade-long project to require health care professionals to assist in stripping human beings of their rights and common decency.
Let us put to one side for a moment the appalling fact that an American government which purports to support human rights and encourages democracy around the world sanctioned and even encouraged torture and human rights abuses. The notion that health care professionals in medicine and psychology would agree to follow those directives is even more infuriating.
The Nuremburg trials demonstrated that following an order that would be illegal for any other group is in itself unethical behaviour. We expect health care professionals to do the right thing even when that requires a display of extraordinary moral courage.
And yet, as psychologist Stanley Milgram demonstrated in the 1960s, when faced with pressure from an authority, most people will violate their own ethical standards and cause harm to others. This raises the question of whether our expectations of health care professionals — who are, after all, simply well-educated human beings — are realistic.
Knowing that a significant proportion of humans will acquiesce to orders from an authority, is it too much to expect a physician to stand up and say “no?” I suggest that expecting superhuman moral strength of physicians may be part of the problem. We may be overlooking components of medical education and practice that actually encourage following such orders.
Medical education does not provide courses in moral courage, defying authority, or turning against the tide of one’s peers. In fact, medical education encourages group-think, keeping your head down, knowing your place in the hierarchy, and seeking the approval of your peers.
Medical education has often been accused of encouraging a culture of bullying and abuse of students. In 2012, the Association of American Medical Colleges surveyed medical students and found that 47 percent had experienced mistreatment, including public humiliation, degrading language, and abuse of power (such as being asked to run superior’s personal errands).
A 2012 study published in Academic Medicine found that over a 12-year period, a majority of students had experienced mistreatment. That is enough time for a mistreated medical student to become a resident who mistreats her/his medical students. The bullied becomes the bully. The very traits that are ingrained into medical students through the hidden curriculum are the ones that make them vulnerable to being used as instruments of the state to participate in torture and abuse.
I would suggest an additional recommendation to those already made in the report. We need to reform medical education to change its culture so that the skills that allow a person to stand up and say “no” are encouraged.
The hidden curriculum would have to offer lessons in distrusting authority, questioning superiors, and not seeking the approval of peers. Passing more laws and adopting new ethical codes are unlikely to change the chances of physician participation in abuse and torture from happening again (and continuing to happen now). So we need to rethink how we choose students, how we educate them, and what character traits we value in our medical and psychological professionals if we are to have a hope of changing the world and health care professionals in extraordinary times.
Professor Craig Klugman is a bioethicist and medical anthropologist who is chair of the Department of Health Sciences at DePaul University in Chicago. This article was first published in the blog of the American Journal of Bioethics.