Doctors and Torture
http://www.100md.com
《新英格兰医药杂志》
To the Editor: The Perspective article on doctors and torture by Lifton (July 29 issue)1 illustrates serious and ongoing failures within the Army and the Army Medical Department. As a retired Army Reserve Medical Services Corps officer, a former combat medic, and a combat veteran, I find the actions as reported in this article to be absolutely unacceptable yet obviously representative of a prevalent attitude. Military medics are obligated to provide optimal medical care to all persons. This means that even if they have to shoot an enemy combatant, if that persons survives, then they must provide that person with prompt and effective medical care. Military medics absolutely must ensure optimal medical care for those in custody. Today, enemy troops, our own troops, and our veterans are not receiving prompt and effective medical care. It is time for us to remember what medicine is all about.
Doug L. Rokke, Ph.D.
2737 CR 1200 E
Rantoul, IL 61866
dlind49@aol.com
References
Lifton RJ. Doctors and torture. N Engl J Med 2004;351:415-416.
To the Editor: As one of the first military physicians deployed to Afghanistan in 2001, I believe Dr. Lifton's discussion of the alleged role of military physicians in the abuse of prisoners is incomplete. I assert that inadequate training in wartime medical ethics can contribute to confusion and immoral behavior among military medical personnel.
My experience with detainees and prisoners of war (POWs) in Afghanistan did not include any complicity in torture of the prisoners. Unfortunately, this was not because of medical command training in military medical ethics or because of the Geneva Convention relative to the Treatment of Prisoners of War. A lack of clear command guidance and of "in-country" resources resulted in confusion regarding medical care of the detainees and POWs and the ethics of such care. Data from Operation Desert Storm1 corroborate this uncertainty: although the Geneva Convention was familiar to 84 percent of those surveyed, only 60 percent read the rules for the medical treatment of POWs, and one third disagreed with the Convention's tenets.
In view of the patient's unclear legal status and the limited resources available, treatment of severe injuries incurred before confinement would be difficult even with expertise in legal and moral statutes. Insufficient education and an unclear interpretation of norms undoubtedly contribute to wartime situations in which unethical medical behavior may occur.
Edward J. Miller, M.D., M.C., U.S. Navy Reserve
Yale University School of Medicine
New Haven, CT 06520
edward.j.miller@yale.edu
References
Carter BS. Ethical concerns for physicians deployed to Operation Desert Storm. Mil Med 1994;159:55-59.
To the Editor: Lifton's excellent commentary on the subversion of doctors and other medical staff under the conditions of war brings to mind other medical conundrums. For example, psychiatrists working for the Department of Veterans Affairs often hear from their patients about various atrocities and abuses committed by military personnel against enemies and true innocents, and occasionally on one another. There appears to be no mechanism and — because of concern about confidentiality and the patients' apprehensions — no possibility of reporting or revealing accounts of the abuses. Also, Dr. Lifton failed to mention perhaps the most notorious psychiatrist of modern times, Dr. Radovan Karadzic of Bosnia, who was responsible for uncountable acts of torture and deaths. A pervasive sense of cynicism and futility seems to be the military and medical order of the day.
Steve O. Marzicola, M.D.
Department of Veterans Affairs
Santa Barbara, CA 93110
steveorestemarzicola@yahoo.com
To the Editor: Lifton rightly calls on all medical professionals with first-hand knowledge of torture or abuse at Abu Ghraib and other prisons to speak out. However, this call does not go far enough. The success of the National Commission on Terrorist Attacks on the United States (the 9/11 Commission) illustrates the power of an organized investigation of difficult issues. The medical community should take similar steps. Major medical organizations such as the American Medical Association should establish a commission for the investigation of abuses by medical professionals, and it should be charged with responsibility for the development of specific recommendations to prevent further abuses. If we fail to take this active stance regarding our own professional activities, we invite appropriate criticism of our professional ethics and, even worse, fail to exhibit solidarity with those who most need our help.
Daniel Jacoby, M.D.
Columbia Presbyterian Medical Center
New York, NY 10032
To the Editor: With regard to Dr. Lifton's concern about the provision of prisoners' medical records to military interrogators, it is worth noting that military administrative personnel, not military physicians themselves, have custody of military medical records and are responsible for decisions regarding their use. In a larger context, however, long-standing government policy provides that the confidentiality of all military medical records is much less well protected than that of civilian medical records. Even though the government rules regarding the privacy of these records have just been revised to increase confidentiality, the new regulations still state that "Patient medical information or medical records may be disclosed to officers and employees of DOD who have an official need for access to the record in the performance of their duties. Consent of the patient is not required."1 This rather nebulous statement has been the focus of ongoing discussions regarding the privacy of all military medical records, and it is perhaps in this broader context that Dr. Lifton's concern about the privacy of prisoners' medical records should be considered.
Allan R. Glass, M.D.
4853 Cordell Ave. #614
Bethesda, MD 20814
References
Army Regulation 40-66, section 2-4a1. Washington, D.C.: Department of the Army, 2003.
To the Editor: The forensic pathologists of the Armed Forces Medical Examiner System (AFMES) strongly object to Dr. Lifton's allegations in his article. The AFMES identifies and investigates the causes and manner of death of U.S. military personnel and also of detainees who die while in military custody. In the past two years, we have investigated 26 deaths of detainees in Iraq and Afghanistan. At the time of the deaths, there was no recognized organization in Iraq with which to file death certificates nor were there families able to receive them. Consequently, death certificates were not prepared.
Later, when allegations of abuse arose, we recognized immediately that the deaths of detainees were a subject of very legitimate public interest. On the basis of completed autopsy reports, we prepared death certificates and made them available to the public. The AFMES did not delay the production of these documents and most certainly did not falsify them. We stand by our findings with regard to the scientifically and objectively determined causes and manner of death of the detainees.
Craig T. Mallak, M.D., J.D. Cmdr., M.C., U.S. Navy
Office of the Armed Forces Medical Examiner
Rockville, MD 20850
craig.mallak@afip.osd.mil
To the Editor: The assertions made by Dr. Lifton are ill considered and irresponsible. His criticism of U.S. military medical personnel, stated with such certainty yet based purely on newspaper articles, astounds us. We are also disturbed by the decision to publish this article without checking with the Department of Defense to determine the accuracy of such highly charged allegations.
Investigations addressing all aspects of prison and detainee operations are under way. At present, we are unaware of any instance in which medical personnel failed to report wounds that were clearly caused by torture. If transgressions of the Geneva Conventions, Department of Defense directives, or Army regulations governing the care of patients have occurred, those responsible will be held accountable. We believe in finding the facts before declaring guilt. We do not see a broadening scandal, and we do not have "increasing evidence" that military medical personnel have been complicit in torture. There is absolutely no evidence that final death certificates were falsified.
Current policies and regulations of the Department of Defense implement the "law of war" and the Geneva Conventions. They require humane treatment of all prisoners and detainees. To protect or save the lives of others, it is absolutely appropriate to interrogate prisoners and detainees. However, they must be protected from acts of violence or reprisal, and from bodily injury. The confidentiality of prisoners' medical records is maintained in a manner that is consistent with applicable laws and regulations. When medical information is legally shared for justifiable reasons, the prisoner or detainee is informed in advance in his or her own language.
Medical personnel examine prisoners upon their incarceration and clear them as fit for confinement. If a prisoner is found not to be fit, medical personnel notify their chain of command, and the prisoner receives appropriate medical treatment in accordance with the standards of care for all patients — including those for military personnel. Military medical personnel are obliged to report to the proper authorities when they suspect that a prisoner is being mistreated or harmed at any time, including during interrogation.
The medical care provided to all prisoners and detainees held in U.S. custody is reliant on professional judgment and standards similar to those used in the care of U.S. personnel. The lives of dozens, if not hundreds, of insurgent Iraqis and terrorist detainees have been saved by the superior care and treatment provided by military medical personnel. It is a little-reported fact that roughly 50 percent of the beds in U.S. field hospitals are routinely filled with such persons and Iraqi civilians.
Lifton's discussion of the atrocities committed by Nazi doctors, in the context of what is known about the current situation, is out of place and inappropriate. He asserts that physicians are no more or less moral than other people. We agree. The ethical behavior of physicians is best promoted and upheld by clear and high standards of ethical conduct, moral leadership, open societies, and democratic government. Physicians in Saddam Hussein's Iraq were forced to perpetrate truly horrifying atrocities. We urge Lifton, if he is seriously interested in pursuing the topic of doctors and torture, to investigate fully the emerging facts of this terrible and sad situation. In the meantime, and until it is proved otherwise, we believe that the men and women serving as military medical personnel deserve everyone's support and respect.
William Winkenwerder, Jr., M.D.
Assistant Secretary of Defense for Health Affairs, Department of Defense
The Pentagon
Washington, DC 20301
Kevin C. Kiley, M.D., Maj. Gen.
Commander, U.S. Army Medical Command
San Antonio, TX 78234
Donald C. Arthur, M.D., Vice Adm.
Surgeon General of the Navy
Washington, DC 20372
George P. Taylor, Jr., M.D., Lt. Gen.
Surgeon General, U.S. Air Force
The Pentagon
Washington, DC 20301
Darrel R. Porr, M.D., Maj. Gen.
Joint Staff Surgeon
The Pentagon
Washington, DC 20301
Dr. Lifton replies: My article has two central themes: evidence of medical complicity in torture and the psychological environment in which medical complicity is most likely to occur. Dr. Rokke finds the actions and attitudes I describe to be "prevalent," but I am sure he would agree that they occur most frequently under certain kinds of military and psychological pressure. The same holds true for Dr. Miller's important stress on inadequate ethical training and lack of command guidance. Dr. Marzicola's point about the absence of any mechanism for "reporting or revealing" abuses is consistent with my emphasis on collective psychological influence.
Dr. Glass makes the important point that military administrative personnel, rather than physicians, have actual "custody" of prisoners' medical records. This is a structural expression of military physicians' ethical struggle between their medical role and their relationship to the command hierarchy.
Two of the letters vehemently defend military medical institutions. Dr. Winkenwerder and his colleagues call my commentary "ill considered and irresponsible," when, if anything, it is cautious and understated. A more recent article in the Lancet, by Dr. Steven H. Miles, a professor of bioethics, confirms and extends my observations, citing a "breakdown" of medical responsibility toward detainees.1 And the official report by Major General George R. Fay, issued in August, details a series of shameful transgressions by medical personnel.2
Contrary to the claim of Winkenwerder et al. that my statements are "based purely on newspaper articles," evidence comes from a wide variety of sources, including the International Committee of the Red Cross; Amnesty International; Human Rights Watch; official American military investigations, notably those headed by Major General Antonio M. Taguba and by Major General Fay; testimony before the Senate and House Armed Services Committees; and sworn statements of American officers, medics, and former detainees. I do not doubt the good work of military medical personnel in treating Iraqi civilians, or their often heroic care of wounded American soldiers, as mentioned by Winkenwerder and his colleagues. But listing military medical policies and regulations — including the obligation to report wounds apparently caused by mistreatment and the confidentiality of prisoners' medical records — only serves to highlight their violation.
Both Miles and the Fay team record not only the failure of medical personnel to report wounds caused by torture but also refusals of treatment when it was indicated. Miles also details the collaboration of the "medical system" in implementing coercive forms of interrogation, referring to statements by Army officials.
Winkenwerder et al. deny any evidence of "final" death certificates being falsified. But Human Rights Watch has documented changes made in death certificates, in one case from an initial attribution of death to "natural causes" to a more accurate reference to "asphyxia due to smothering and chest compression" with "evidence of blunt force trauma to the chest and legs."3 Similarly, Dr. Mallak may be correct about the accuracy of death certificates issued by the AFMES, but there is more to be learned about the initial falsifications, changes, and delays surrounding these documents.
I raise the subject of Nazi doctors in my article not to equate American medical personnel with them but to suggest that we can learn from the most extreme examples of doctors' vulnerability to being socialized to abusive environments and to engage in destructive behavior. We need to learn all that we can about abuses by doctors everywhere, as a means of strengthening the healing commitment of medical institutions in a democratic society.
I strongly concur with Dr. Jacoby's call for a full-scale investigation by a commission that would include prominent medical representatives. Any such investigation should also have a strong psychological component with regard to atrocity-producing medical environments that can emerge in war in general and have emerged in this war in particular.
Robert Jay Lifton, M.D.
Harvard Medical School
Boston, MA 02115
References
Miles SH. Abu Ghraib: its legacy for military medicine. Lancet 2004;364:725-729.
Fay GR. AR 15-6 investigation of the Abu Ghraib detention facility and 205th Military Intelligence Brigade. Mountain View, Calif.: FindLaw, 2004:34-176. (Accessed September 17, 2004, at http://news.findlaw.com/nytimes/docs/dod/fay82504rpt.pdf.)
Human Rights Watch. The road to Abu Ghraib. June 2004. (Accessed September 17, 2004, at http://hrw.org/reports/2004/usa0604/.)
Doug L. Rokke, Ph.D.
2737 CR 1200 E
Rantoul, IL 61866
dlind49@aol.com
References
Lifton RJ. Doctors and torture. N Engl J Med 2004;351:415-416.
To the Editor: As one of the first military physicians deployed to Afghanistan in 2001, I believe Dr. Lifton's discussion of the alleged role of military physicians in the abuse of prisoners is incomplete. I assert that inadequate training in wartime medical ethics can contribute to confusion and immoral behavior among military medical personnel.
My experience with detainees and prisoners of war (POWs) in Afghanistan did not include any complicity in torture of the prisoners. Unfortunately, this was not because of medical command training in military medical ethics or because of the Geneva Convention relative to the Treatment of Prisoners of War. A lack of clear command guidance and of "in-country" resources resulted in confusion regarding medical care of the detainees and POWs and the ethics of such care. Data from Operation Desert Storm1 corroborate this uncertainty: although the Geneva Convention was familiar to 84 percent of those surveyed, only 60 percent read the rules for the medical treatment of POWs, and one third disagreed with the Convention's tenets.
In view of the patient's unclear legal status and the limited resources available, treatment of severe injuries incurred before confinement would be difficult even with expertise in legal and moral statutes. Insufficient education and an unclear interpretation of norms undoubtedly contribute to wartime situations in which unethical medical behavior may occur.
Edward J. Miller, M.D., M.C., U.S. Navy Reserve
Yale University School of Medicine
New Haven, CT 06520
edward.j.miller@yale.edu
References
Carter BS. Ethical concerns for physicians deployed to Operation Desert Storm. Mil Med 1994;159:55-59.
To the Editor: Lifton's excellent commentary on the subversion of doctors and other medical staff under the conditions of war brings to mind other medical conundrums. For example, psychiatrists working for the Department of Veterans Affairs often hear from their patients about various atrocities and abuses committed by military personnel against enemies and true innocents, and occasionally on one another. There appears to be no mechanism and — because of concern about confidentiality and the patients' apprehensions — no possibility of reporting or revealing accounts of the abuses. Also, Dr. Lifton failed to mention perhaps the most notorious psychiatrist of modern times, Dr. Radovan Karadzic of Bosnia, who was responsible for uncountable acts of torture and deaths. A pervasive sense of cynicism and futility seems to be the military and medical order of the day.
Steve O. Marzicola, M.D.
Department of Veterans Affairs
Santa Barbara, CA 93110
steveorestemarzicola@yahoo.com
To the Editor: Lifton rightly calls on all medical professionals with first-hand knowledge of torture or abuse at Abu Ghraib and other prisons to speak out. However, this call does not go far enough. The success of the National Commission on Terrorist Attacks on the United States (the 9/11 Commission) illustrates the power of an organized investigation of difficult issues. The medical community should take similar steps. Major medical organizations such as the American Medical Association should establish a commission for the investigation of abuses by medical professionals, and it should be charged with responsibility for the development of specific recommendations to prevent further abuses. If we fail to take this active stance regarding our own professional activities, we invite appropriate criticism of our professional ethics and, even worse, fail to exhibit solidarity with those who most need our help.
Daniel Jacoby, M.D.
Columbia Presbyterian Medical Center
New York, NY 10032
To the Editor: With regard to Dr. Lifton's concern about the provision of prisoners' medical records to military interrogators, it is worth noting that military administrative personnel, not military physicians themselves, have custody of military medical records and are responsible for decisions regarding their use. In a larger context, however, long-standing government policy provides that the confidentiality of all military medical records is much less well protected than that of civilian medical records. Even though the government rules regarding the privacy of these records have just been revised to increase confidentiality, the new regulations still state that "Patient medical information or medical records may be disclosed to officers and employees of DOD who have an official need for access to the record in the performance of their duties. Consent of the patient is not required."1 This rather nebulous statement has been the focus of ongoing discussions regarding the privacy of all military medical records, and it is perhaps in this broader context that Dr. Lifton's concern about the privacy of prisoners' medical records should be considered.
Allan R. Glass, M.D.
4853 Cordell Ave. #614
Bethesda, MD 20814
References
Army Regulation 40-66, section 2-4a1. Washington, D.C.: Department of the Army, 2003.
To the Editor: The forensic pathologists of the Armed Forces Medical Examiner System (AFMES) strongly object to Dr. Lifton's allegations in his article. The AFMES identifies and investigates the causes and manner of death of U.S. military personnel and also of detainees who die while in military custody. In the past two years, we have investigated 26 deaths of detainees in Iraq and Afghanistan. At the time of the deaths, there was no recognized organization in Iraq with which to file death certificates nor were there families able to receive them. Consequently, death certificates were not prepared.
Later, when allegations of abuse arose, we recognized immediately that the deaths of detainees were a subject of very legitimate public interest. On the basis of completed autopsy reports, we prepared death certificates and made them available to the public. The AFMES did not delay the production of these documents and most certainly did not falsify them. We stand by our findings with regard to the scientifically and objectively determined causes and manner of death of the detainees.
Craig T. Mallak, M.D., J.D. Cmdr., M.C., U.S. Navy
Office of the Armed Forces Medical Examiner
Rockville, MD 20850
craig.mallak@afip.osd.mil
To the Editor: The assertions made by Dr. Lifton are ill considered and irresponsible. His criticism of U.S. military medical personnel, stated with such certainty yet based purely on newspaper articles, astounds us. We are also disturbed by the decision to publish this article without checking with the Department of Defense to determine the accuracy of such highly charged allegations.
Investigations addressing all aspects of prison and detainee operations are under way. At present, we are unaware of any instance in which medical personnel failed to report wounds that were clearly caused by torture. If transgressions of the Geneva Conventions, Department of Defense directives, or Army regulations governing the care of patients have occurred, those responsible will be held accountable. We believe in finding the facts before declaring guilt. We do not see a broadening scandal, and we do not have "increasing evidence" that military medical personnel have been complicit in torture. There is absolutely no evidence that final death certificates were falsified.
Current policies and regulations of the Department of Defense implement the "law of war" and the Geneva Conventions. They require humane treatment of all prisoners and detainees. To protect or save the lives of others, it is absolutely appropriate to interrogate prisoners and detainees. However, they must be protected from acts of violence or reprisal, and from bodily injury. The confidentiality of prisoners' medical records is maintained in a manner that is consistent with applicable laws and regulations. When medical information is legally shared for justifiable reasons, the prisoner or detainee is informed in advance in his or her own language.
Medical personnel examine prisoners upon their incarceration and clear them as fit for confinement. If a prisoner is found not to be fit, medical personnel notify their chain of command, and the prisoner receives appropriate medical treatment in accordance with the standards of care for all patients — including those for military personnel. Military medical personnel are obliged to report to the proper authorities when they suspect that a prisoner is being mistreated or harmed at any time, including during interrogation.
The medical care provided to all prisoners and detainees held in U.S. custody is reliant on professional judgment and standards similar to those used in the care of U.S. personnel. The lives of dozens, if not hundreds, of insurgent Iraqis and terrorist detainees have been saved by the superior care and treatment provided by military medical personnel. It is a little-reported fact that roughly 50 percent of the beds in U.S. field hospitals are routinely filled with such persons and Iraqi civilians.
Lifton's discussion of the atrocities committed by Nazi doctors, in the context of what is known about the current situation, is out of place and inappropriate. He asserts that physicians are no more or less moral than other people. We agree. The ethical behavior of physicians is best promoted and upheld by clear and high standards of ethical conduct, moral leadership, open societies, and democratic government. Physicians in Saddam Hussein's Iraq were forced to perpetrate truly horrifying atrocities. We urge Lifton, if he is seriously interested in pursuing the topic of doctors and torture, to investigate fully the emerging facts of this terrible and sad situation. In the meantime, and until it is proved otherwise, we believe that the men and women serving as military medical personnel deserve everyone's support and respect.
William Winkenwerder, Jr., M.D.
Assistant Secretary of Defense for Health Affairs, Department of Defense
The Pentagon
Washington, DC 20301
Kevin C. Kiley, M.D., Maj. Gen.
Commander, U.S. Army Medical Command
San Antonio, TX 78234
Donald C. Arthur, M.D., Vice Adm.
Surgeon General of the Navy
Washington, DC 20372
George P. Taylor, Jr., M.D., Lt. Gen.
Surgeon General, U.S. Air Force
The Pentagon
Washington, DC 20301
Darrel R. Porr, M.D., Maj. Gen.
Joint Staff Surgeon
The Pentagon
Washington, DC 20301
Dr. Lifton replies: My article has two central themes: evidence of medical complicity in torture and the psychological environment in which medical complicity is most likely to occur. Dr. Rokke finds the actions and attitudes I describe to be "prevalent," but I am sure he would agree that they occur most frequently under certain kinds of military and psychological pressure. The same holds true for Dr. Miller's important stress on inadequate ethical training and lack of command guidance. Dr. Marzicola's point about the absence of any mechanism for "reporting or revealing" abuses is consistent with my emphasis on collective psychological influence.
Dr. Glass makes the important point that military administrative personnel, rather than physicians, have actual "custody" of prisoners' medical records. This is a structural expression of military physicians' ethical struggle between their medical role and their relationship to the command hierarchy.
Two of the letters vehemently defend military medical institutions. Dr. Winkenwerder and his colleagues call my commentary "ill considered and irresponsible," when, if anything, it is cautious and understated. A more recent article in the Lancet, by Dr. Steven H. Miles, a professor of bioethics, confirms and extends my observations, citing a "breakdown" of medical responsibility toward detainees.1 And the official report by Major General George R. Fay, issued in August, details a series of shameful transgressions by medical personnel.2
Contrary to the claim of Winkenwerder et al. that my statements are "based purely on newspaper articles," evidence comes from a wide variety of sources, including the International Committee of the Red Cross; Amnesty International; Human Rights Watch; official American military investigations, notably those headed by Major General Antonio M. Taguba and by Major General Fay; testimony before the Senate and House Armed Services Committees; and sworn statements of American officers, medics, and former detainees. I do not doubt the good work of military medical personnel in treating Iraqi civilians, or their often heroic care of wounded American soldiers, as mentioned by Winkenwerder and his colleagues. But listing military medical policies and regulations — including the obligation to report wounds apparently caused by mistreatment and the confidentiality of prisoners' medical records — only serves to highlight their violation.
Both Miles and the Fay team record not only the failure of medical personnel to report wounds caused by torture but also refusals of treatment when it was indicated. Miles also details the collaboration of the "medical system" in implementing coercive forms of interrogation, referring to statements by Army officials.
Winkenwerder et al. deny any evidence of "final" death certificates being falsified. But Human Rights Watch has documented changes made in death certificates, in one case from an initial attribution of death to "natural causes" to a more accurate reference to "asphyxia due to smothering and chest compression" with "evidence of blunt force trauma to the chest and legs."3 Similarly, Dr. Mallak may be correct about the accuracy of death certificates issued by the AFMES, but there is more to be learned about the initial falsifications, changes, and delays surrounding these documents.
I raise the subject of Nazi doctors in my article not to equate American medical personnel with them but to suggest that we can learn from the most extreme examples of doctors' vulnerability to being socialized to abusive environments and to engage in destructive behavior. We need to learn all that we can about abuses by doctors everywhere, as a means of strengthening the healing commitment of medical institutions in a democratic society.
I strongly concur with Dr. Jacoby's call for a full-scale investigation by a commission that would include prominent medical representatives. Any such investigation should also have a strong psychological component with regard to atrocity-producing medical environments that can emerge in war in general and have emerged in this war in particular.
Robert Jay Lifton, M.D.
Harvard Medical School
Boston, MA 02115
References
Miles SH. Abu Ghraib: its legacy for military medicine. Lancet 2004;364:725-729.
Fay GR. AR 15-6 investigation of the Abu Ghraib detention facility and 205th Military Intelligence Brigade. Mountain View, Calif.: FindLaw, 2004:34-176. (Accessed September 17, 2004, at http://news.findlaw.com/nytimes/docs/dod/fay82504rpt.pdf.)
Human Rights Watch. The road to Abu Ghraib. June 2004. (Accessed September 17, 2004, at http://hrw.org/reports/2004/usa0604/.)