Doctor’s Orders -- Spill Your Guts

Credit the folks who ran Abu Ghraib for their wit. “The database is lonely,” says a smiley face in a slide show for new interrogators prepared a year ago. “You can help! Visit the database every time you spend time with any of our esteemed guests. Tell the database about what fun conversation you and your guests had.” The last slide is a cartoon of an interrogation session. “I realize it sounds rather cliche, but we have ways of making you talk,” its caption reads.

At Abu Ghraib, Guantanamo Bay, Cuba, and “undisclosed locations,” some U.S. military interrogators used troubling methods to try to get their captives to talk. Many of their efforts have been widely reported; some may have risen to the level of torture under international law. What is less known -- but equally disturbing -- is that military doctors become arbiters, even planners, of aggressive interrogation practice, including prolonged isolation, sleep deprivation and exposure to temperature extremes.

An August 2002 Justice Department memo, sought by White House Counsel Alberto R. Gonzales to protect interrogators against prosecution for employing such methods as sleep deprivation, defined torture in medical terms. Coercive measures, the memo stated, don’t constitute torture unless they bring about “death, organ failure ... serious impairment of bodily functions” or prolonged and severe mental illness. Use of mind-altering drugs is OK, so long as it doesn’t “disrupt profoundly the senses or the personality.” Even when these lines are crossed, the memo held, interrogators aren’t torturers if they act “in good faith” by “surveying professional literature” or “consulting with experts.”

The International Committee of the Red Cross, which monitors wartime detention practices, alleges that medical personnel at Guantanamo shared clinical information with interrogators, in “flagrant violation of medical ethics,” to extract more information from detainees. The Pentagon says the charge is false. But our inquiry into the role that health professionals played in military intelligence-gathering in Iraq and Guantanamo has found a pattern of reliance on medical input. Not only did caregivers pass clinical data to interrogators, physicians and other health professionals helped craft and carry out coercive interrogation plans.

Such conduct violated U.S. obligations under the Geneva Convention, which bar threatening, insulting and other abusive treatment of prisoners. There is also probable cause to suspect that some physicians were complicit in the use of interrogation methods that constitute torture under international law.

Piercing the veil of silence surrounding Abu Ghraib and Guantanamo poses unusual difficulties. Military personnel knowledgeable about interrogation practices or medical care at these sites were reluctant to speak with us. Some cited orders not to discuss their service; others pointed to a general understanding, not expressed as an order, that public discussion of their experiences was ill advised. One, Maj. David Auch, commander of the clinical unit that staffed Abu Ghraib when the notorious photos of Iraqi prisoners were taken, said a military intelligence officer told his medics not to talk about deaths that occurred in detention.

Yet multiple interviews with military medical personnel, often on a not-for-attribution basis, made it possible to “connect the dots.” Documents made public through Freedom of Information Act litigation brought by the American Civil Liberties Union also contributed.

Critical to understanding the medical role is the change in interrogation doctrine introduced by Maj. Gen. Geoffrey Miller and his team, first at Guantanamo, then at Abu Ghraib. A classified memo, prepared by Miller in late 2003, made the case for “fusion” of all prison functions to support the “interrogation mission.”

Miller argued that “Behavioral psychologists and psychiatrists” were needed to “develop ... integrated interrogation strategies and assess ... interrogation intelligence production.” To this end, he called for creation of “Behavioral Science Consultation Teams,” known as “Biscuits,” made up of psychologists and psychiatrists.

Desperate for some edge against a worsening insurgency in Iraq in November 2003, U.S. commanders implemented Miller’s design at Abu Ghraib. In one example that came to our attention, Maj. Scott Uithol, a psychiatrist, arrived in Iraq expecting to serve with a combat stress-control unit. He was deployed instead to Abu Ghraib’s newly formed Biscuit.

Uithol declined to talk to us, but other sources, including Abu Ghraib’s chief of military intelligence, Col. Thomas Pappas, shed light on what at least some Biscuit members did. In testimony taken last February for an internal report but made public in October, Pappas described how physicians helped devise and execute interrogation strategies. Military intelligence teams, he said, prepared individualized “interrogation plans” for detainees, including a “sleep plan” and “medical standards.” A physician and a psychiatrist monitored what went on.

What was in these interrogation plans? None have become public, but a classified January 2004 memo (prepared by unnamed military intelligence personnel at Abu Ghraib and made public in October) sets out an “interrogation and counter-resistance policy” calling for harsh measures. These include “dietary manipulation -- minimum bread and water, monitored by medics”; temperature extremes; sensory and sleep deprivation “monitored by medics”; prolonged isolation; and “stress positions.” Pappas’ testimony refers to a written “sleep management plan” that instructs guards to wake a detainee “every X-amount of hours.”

Doctors collaborated with guards and interrogators in applying these approaches. “The doctor and psychiatrist,” Pappas said, “look at the files to see what the interrogation plan recommends; they have the final say as to what is implemented.” A psychiatrist also went with interrogators to the Abu Ghraib prison, “review[ed] all those people under a management plan” and provided “feedback as to whether they were being medically and physically taken care of.”

At both Abu Ghraib and Guantanamo, interrogation teams also had access to clinical caregivers and medical records, a practice defended by Deputy Assistant Secretary of Defense for Clinical and Program Policy David Tornberg. There is “not a doctor-patient relationship in the traditional sense between a military healthcare provider and an enemy prisoner of war,” he told us. “Medical information will not be protected ... to the extent it is military relevant.”

Tornberg’s sweeping claim is at odds with the Geneva Convention’s promise of adequate medical care to people detained in armed conflicts. When a caregiver learns of an imminent threat to the life of others (for example, a prisoner who tells his doctor about an impending terror attack), breach of doctor-patient confidentiality to save life is appropriate. But revealing health information to interrogators undermines detainees’ trust in their doctors, a prerequisite for adequate care.

How did military physicians who advised or served with Biscuits justify this role to themselves? Some may have conflated Geneva protections with the ban on torture. So long as interrogation strategies didn’t rise to the level of torture, they could see their conduct as lawful. Other physicians feared prosecution for disobeying orders more than they worried about the consequences of following illegal orders.

Some military doctors advanced another rationalization: Whatever their obligations under the international human rights law and the laws of war, medical ethics do not apply when they devote their skills to intelligence-gathering and other war-fighting functions. In such cases, these physicians say, they are combatants, not physicians, because they apply their knowledge to achieve military ends. A medical degree, Tornberg told us, isn’t a “sacramental vow.” When a doctor participates in interrogation, “he’s not functioning as a physician,” and the Hippocratic ideal of fidelity to patients is beside the point.

The Hippocratic ideal does fail to capture the breadth of the profession’s social role. Doctors routinely serve criminal justice, public health and other social purposes, sometimes at the expense of individuals’ well-being. But the proposition that, in so doing, they don’t act as physicians is self-contradictory. It is their mix of technical skill, caring ethos and moral authority that qualifies them to assume these roles. It is why the architects of the United States’ post-9/11 detainee counter-resistance policy looked to medicine.

To their credit, some military physicians in leadership roles seek a larger public discussion of their profession’s moral dilemmas in the war on terrorism. So far, the Pentagon’s civilian leadership has stymied these efforts by telling doctors not to go public with their ethics concerns. This has left them isolated from their civilian peers.

The therapeutic mission is medicine’s primary role, whether or not doctors wear their country’s uniform. But military physicians make a national service commitment that is sometimes at odds with Hippocratic ideals. We owe them gratitude for making this commitment -- and for their courage and sacrifice in Iraq and other post-9/11 theaters of war. But Abu Ghraib and Guantanamo should remind us that there are some things doctors must not do.