Robert Jay Lifton, M.D, New England Journal of Medicine, 8/6/2004

New England Journal of Medicine, Volume 351, No. 5

July 29, 2004

There is increasing evidence that U.S. doctors, nurses, and medics have been complicit in torture and other illegal procedures in Iraq, Afghanistan, and Guantanamo Bay. Such medical complicity suggests still another disturbing dimension of this broadening scandal.

We know that medical personnel have failed to report to higher authorities wounds that were clearly caused by torture and that they have neglected to take steps to interrupt this torture. In addition, they have turned over prisoners' medical records to interrogators who could use them to exploit the prisoners' weaknesses or vulnerabilities. We have not yet learned the extent of medical involvement in delaying and possibly falsifying the death certificates of prisoners who have been killed by torturers.

A May 22 article on Abu Ghraib in the New York Times states that "much of the evidence of abuse at the prison came from medical documents" and that records and statements "showed doctors and medics reporting to the area of the prison where the abuse occurred several times to stitch wounds, tend to collapsed prisoners or see patients with bruised or reddened genitals."1 According to the article, two doctors who gave a painkiller to a prisoner for a dislocated shoulder and sent him to an outside hospital recognized that the injury was caused by his arms being handcuffed and held over his head for "a long period," but they did not report any suspicions of abuse. A staff sergeantmedic who had seen the prisoner in that position later told investigators that he had instructed a military policeman to free the man but that he did not do so. A nurse, when called to attend to a prisoner who was having a panic attack, saw naked Iraqis in a human pyramid with sandbags over their heads but did not report it until an investigation was held several months later.

A June 10 article in the Washington Post tells of a long-standing policy at the Guantanamo Bay facility whereby military interrogators were given access to the medical records of individual prisoners.2 The policy was maintained despite complaints by the Red Cross that such records "are being used by interrogators to gain information in developing an interrogation plan." A civilian psychiatrist who was part of a medical review team was "disturbed" about not having been told about the practice and said that it would give interrogators "tremendous power" over prisoners.

Other reports, though sketchier, suggest that the death certificates of prisoners who might have been killed by various forms of mistreatment have not only been delayed but may have camouflaged the fatal abuse by attributing deaths to conditions such as cardiovascular disease.3

Various medical protocols notably, the World Medical Association Declaration of Tokyo in 1975 prohibit all three of these forms of medical complicity in torture. Moreover, the Hippocratic Oath declares, "I will use treatment to help the sick according to my ability and judgment, but never with a view to injury and wrongdoing."

To be a military physician is to be subject to potential moral conflict between commitment to the healing of individual people, on the one hand, and responsibility to the military hierarchy and the command structure, on the other. I experienced that conflict myself as an Air Force psychiatrist assigned to Japan and Korea some decades ago: I was required to decide whether to send psychologically disturbed men back to the United States, where they could best receive treatment, or to return them to their units, where they could best serve combat needs. There were, of course, other factors, such as a soldier's pride in not letting his buddies down, but for physicians this basic conflict remained.

American doctors at Abu Ghraib and elsewhere have undoubtedly been aware of their medical responsibility to document injuries and raise questions about their possible source in abuse. But those doctors and other medical personnel were part of a command structure that permitted, encouraged, and sometimes orchestrated torture to a degree that it became the norm with which they were expected to comply in the immediate prison environment.

The doctors thus brought a medical component to what I call an "atrocity-producing situation" one so structured, psychologically and militarily, that ordinary people can readily engage in atrocities. Even without directly participating in the abuse, doctors may have become socialized to an environment of torture and by virtue of their medical authority helped sustain it. In studying various forms of medical abuse, I have found that the participation of doctors can confer an aura of legitimacy and can even create an illusion of therapy and healing.

The Nazis provided the most extreme example of doctors' becoming socialized to atrocity.4 In addition to cruel medical experiments, many Nazi doctors, as part of military units, were directly involved in killing. To reach that point, they underwent a sequence of socialization: first to the medical profession, always a self-protective guild; then to the military, where they adapted to the requirements of command; and finally to camps such as Auschwitz, where adaptation included assuming leadership roles in the existing death factory. The great majority of these doctors were ordinary people who had killed no one before joining murderous Nazi institutions. They were corruptible and certainly responsible for what they did, but they became murderers mainly in atrocity-producing settings.

When I presented my work on Nazi doctors to U.S. medical groups, I received many thoughtful responses, including expressions of concern about much less extreme situations in which American doctors might be exposed to institutional pressures to violate their medical conscience. Frequently mentioned examples were prison doctors who administered or guided others in giving lethal injections to carry out the death penalty and military doctors in Vietnam who helped soldiers to become strong enough to resume their assignments in atrocity-producing situations.

Physicians are no more or less moral than other people. But as heirs to shamans and witch doctors, we may be seen by others and sometimes by ourselves as possessing special magic in connection with life and death. Various regimes have sought to harness that magic to their own despotic ends. Physicians have served as actual torturers in Chile and elsewhere; have surgically removed ears as punishment for desertion in Saddam Hussein's Iraq; have incarcerated political dissenters in mental hospitals, notably in the Soviet Union; have, as whites in South Africa, falsified medical reports on blacks who were tortured or killed; and have, as Americans associated with the Central Intelligence Agency, conducted harmful, sometimes fatal, experiments involving drugs and mind control.

With the possible exception of the altering of death certificates, the recent transgressions of U.S. military doctors have apparently not been of this order. But these examples help us to recognize what doctors are capable of when placed in atrocity- producing situations. A recent statement by the Physicians for Human Rights addresses this vulnerability in declaring that "torture can also compromise the integrity of health professionals."5

To understand the full scope of American torture and abuse at Abu Ghraib and other prisons, we need to look more closely at the behavior of doctors and other medical personnel, as well as at the pressures created by the war in Iraq that produced this behavior. It is possible that some doctors, nurses, or medics took steps, of which we are not yet aware, to oppose the torture. It is certain that many more did not. But all those involved could nonetheless reveal, in valuable medical detail, much of what actually took place. By speaking out, they would take an important step toward reclaiming their role as healers.Doctors and Torture

Robert Jay Lifton, M.D

New England Journal of Medicine, Volume 351, No. 5

July 29, 2004