BMJ 2004;329:66 (10 July)
Doctors and the war on terrorism
Everyone must understand—doctors don't "do" torture
Members of coalition forces are reported to have tortured Iraqis and other nationals in detention centres in Iraq and elsewhere. These crimes followed the development of an enhanced role for the US military in collecting intelligence in the war on terrorism.1 So severe were the violations of international humanitarian law at Abu Ghraib Prison, Baghdad, that the acting United Nations high commissioner for human rights has said they possibly amount to crimes against humanity.2
When in late 2002 the Guantanamo Bay detainees became less susceptible to the then menu of coercive interrogation methods, the US secretary of defense, Donald Rumsfeld, approved 17 new techniques including stress positions, isolation, 20 hour interrogations, and nakedness.3 4 The solicitor acting for British men released without charge after two years at Guantanamo Bay has described their experiences—of being repeatedly shackled to the floor in painful positions during prolonged interrogations, stripped naked in public, and photographed in degrading situations (G Peirce, conference in London, June 2004). Tellingly, in an April 2003 revision of interrogation instructions the US defense secretary specified general safeguards to include "being medically evaluated as suitable" for interrogation.5
The health professionals with a responsibility for the physical and mental health of detainees who have been tortured are the dogs that did not bark. The 1949 Geneva Conventions protect imprisoned combatants and civilians against intimidation and torture. The doctors of the detaining powers must be ready to defend medical ethics when confronted by a conflicting military imperative. The International Committee of the Red Cross is sometimes surprised by how defensive doctors can be in favouring detaining authorities against the interest of their patients (J Stroun, Conference in London, October 1993).
Even if the Geneva Conventions are inapplicable in Guantanamo Bay—and the International Committee of the Red Cross vigorously disputes President Bush's interpretation—both the United States and United Kingdom are parties to the UN Convention against Torture, from which there can be no derogation.6 This convention proscribes not only torture but other practices along a continuum—equally forbidding cruel, inhuman, and degrading treatment. In May 1997 the UN Committee against Torture determined that interrogation methods known as "moderate physical pressure" employed by one party to the convention (Israel) constituted torture. These included restraint in very painful positions, handcuffing during interrogation, death threats, and head covering.7
Several international ethical codes prohibit doctors' involvement in torture, including the World Medical Association (WMA) declarations of Tokyo and of Geneva. Nathanson, while acknowledging it to be received wisdom that doctors have an important role in detecting, documenting, and prosecuting torture, speculated that ignorance might be a factor when they fail.8 But it is a doctor's responsibility to recognise when a conflation of risk factors increases the probability of a diagnosis—child abuse being an apposite example. The Istanbul protocol, which provides guidelines on the assessment of torture and ill treatment and on reporting the findings of such investigations, was published more than four years ago.9
Torture is the antithesis of ethical medical care, yet doctors have a long association with it.10 They may be involved involuntarily when treating someone who has been tortured; have an advisory role in monitoring a victim's fitness for torture; and, unusually, take an active part. In 1996 Physicians for Human Rights-UK stopped a leader of the genocide in Rwanda, who had fled to Bordeaux, from practising as an obstetrician. This incident provided the impetus for the WMA statement on the licensing of doctors fleeing prosecution for serious offences. The statement requires licensing authorities to ensure that doctors accused of participation in torture, war crimes, or crimes against humanity are denied a licence to practise until the allegations have been dealt with.
All doctors need to be educated to recognise torture, to treat it appropriately, and to report it. Doctors who ignore existing human rights standards can expect to be sanctioned. In the United Kingdom, section 134 of the Criminal Justice Act 1988, which incorporates the convention against torture, provides for the prosecution of anyone complicit in torture within the jurisdiction of the United Kingdom. Whether they be British or foreign and regardless of the nationality of the victim or where the violation took place, doctors who participate in torture can and should expect to be prosecuted.
Peter Hall, chair
Physicians for Human Rights-UK, Abbots Langley, Hertfordshire WD5 0BE (email@example.com)
Competing interests: None declared.
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