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Abu Ghraib: its legacy for
military medicine
The Lancet (UK Medical Journal) Steven H.
Miles
21 August 2004
The complicity of US military medical personnel during abuses
of detainees in Iraq, Afghanistan, and Guantanamo Bay is of great
importance to human rights, medical ethics, and military
medicine. Government documents show that the US military medical
system failed to protect detainees' human rights, sometimes
collaborated with interrogators or abusive guards, and failed to
properly report injuries or deaths caused by beatings.1-23 An
inquiry into the behaviour of medical personnel in places such as
Abu Ghraib could lead to valuable reforms within military
medicine.
The policies
As the Bush administration planned to retaliate against
al-Qaeda's terrorist attacks on the USA, it was reluctant to
accept that the Geneva Convention Relative to the Treatment of
Prisoners of War would apply to al-Qaeda detainees.24 In January,
2002, a memorandum from the US Department of Justice to the
Department of Defense concluded that since al-Qaeda was not a
national signatory to international conventions and treaties,
these obligations did not apply.4 It also concluded that the
Convention did not apply to Taliban detainees because al-Qaeda's
influence over Afghanistan's government meant that it could not
be a party to treaties. In February, 2002, the US president
signed an executive order stating that although the Geneva
Conventions did not apply to al-Qaeda or Taliban detainees, "our
nation . . . will continue to be a strong supporter of Geneva and
its principles . . . the United States Armed Forces shall
continue to treat detainees humanely and, to the extent
appropriate and consistent with military necessity in a manner
consistent with the principles of Geneva."5 This phrasing
subordinates US compliance to the Geneva Convention to undefined
"military necessity."
An August, 2002 Justice Department memorandum to the President
and a March, 2003 Defense Department Working Group distinguished
cruel, inhumane, or degrading treatment, which could be permitted
in US military detention centres, from torture, which was
ordinarily banned except when the President set aside the US
commitment to the Convention in exercising his discretionary
war-making powers.3,7 These memoranda semantically analysed the
words "harm" or "profound disruption of the personality" in legal
definitions of torture without grounding the terms on references
to research showing the prevalence, severity, or duration of harm
from abusing detainees.25-30 Also, the memoranda do not
distinguish between coercive interrogation involving soldiers
from those employing medical personnel or expertise. For example,
both documents excuse the use of drugs during interrogation.3,7
Neither document mentions medical ethics codes or the history of
medical or psychiatric complicity with torture or inhumane
treatment.25,26,31,32
In late 2002, the Secretary of Defense approved "Counter
Resistance Techniques" including nudity, isolation, and
exploiting fear of dogs for interrogating al-Qaeda suspects at
Guantanamo.6 In April, he revised those techniques and advised
those devising interrogation plans to give consideration to the
view of other countries that some of the authorised techniques
such as threats, insults, or intimidation violate the Geneva
Convention. He added, "Nothing in this memorandum in any way
restricts your existing authority to maintain good order and
discipline among detainees."6 .
The Interrogation Rules of Engagement posted at Abu Ghraib
stated: "[Interrogation] Approaches must always be humane . . .
Detainees will NEVER be touched in a malicious or unwanted manner
. . . the Geneva Conven-tions apply."11 These rules were imported
from the US operation in Afghanistan and echoed the 2003 memo by
the Secretary of Defense. They stated: "Wounded or medically
burdened detainees must be medically cleared prior to
interrogation" and approved "Dietary mani-pulation (monitored by
med)" for interrogation.11 Defense Department memoranda define
the latter as substituting hot meals to cold field rations rather
than food deprivation but there are credible reports of food
deprivation.6,19,33
Although US military personnel receive at least 36 minutes of
basic training on human rights, Abu Ghraib military personnel did
not receive additional human rights training and did not train
civilian interrogators working there.1,15,17 Military medical
personnel in charge of detainees in Iraq and Afghanistan denied
being trained in Army human rights policies.17 Local commanding
officers were unfamiliar with the Geneva Convention or Army
Regulations regarding abuses.13-15 Arab language synopses of
Geneva protections were not posted in the cellblocks in Iraq and
Afghanistan as required by Army regulation.2,10,13,17
The offences
Confirmed or reliably reported abuses of detainees in Iraq and
Afghanistan include beatings, burns, shocks, bodily suspensions,
asphyxia, threats against detainees and their relatives, sexual
humiliation, isolation, prolonged hooding and shackling, and
exposure to heat, cold, and loud noise.1,14,19,24,33,34 These
include deprivation of sleep, food, clothing, and material for
personal hygiene, and denigration of Islam and forced violation
of its rites.19 Detainees were forced to work in areas that were
not de-mined and seriously injured.34 Abuses of women detainees
are less well documented but include credible allegations of
sexual humiliation and rape.13,14,35
US Army investigators concluded that Abu Ghraib's medical
system for detainees was inadequately staffed and
equipped.8,11,13,16,17 The International Committee of the Red
Cross (ICRC) found that the medical system failed to maintain
internment cards with medical information necessary to protect
the detainees' health as required by the Geneva Convention; this
reportedly was due to a policy of not officially processing (ie,
recording their presence in the prison) new detainees.16,34 Few
units in Iraq and Afghanistan complied with the Geneva obligation
to provide monthly health inspections.17 The medical system also
failed to assure that prisoners could request proper medical care
as required by the Geneva Convention. For example, an Abu Ghraib
detainee's sworn document says that a purulent hand injury caused
by torture went untreated. The individual was also told by an
Iraqi physician working for the US that bleeding of his ear (from
a separate beating) could not be treated in a clinic; he was
treated instead in a prison hallway.20
The medical system failed to establish procedures, as called
for by Article 30 of the Geneva Convention, to ensure proper
treatment of prisoners with disabilities. An Abu Ghraib
prisoner's deposition reports the crutch that he used because of
a broken leg was taken from him and his leg was beaten as he was
ordered to renounce Islam. The same detainee told a guard that
the prison doctor had told him to immobilise a badly injured
shoulder; the guard's response was to suspend him from the
shoulder.21
The medical system collaborated with designing and
implementing psychologically and physically coercive
interrogations. Army officials stated that a physician and a
psychiatrist helped design, approve, and monitor interrogations
at Abu Ghraib.15 This echoes the Secretary of Defense's 2003 memo
ordering interrogators to ensure that detainees are "medically
and operationally evaluated as suitable" for interrogation
plans.6 In one example of a compromised medically monitored
interrogation, a detainee collapsed and was apparently
unconscious after a beating, medical staff revived the detainee
and left, and the abuse continued.22 There are isolated reports
that medical personnel directly abused detainees. Two detainees'
depositions describe an incident where a doctor allowed a
medically untrained guard to suture a prisoner's lacertation from
being beaten.22,23
The medical system failed to accurately report illnesses and
injuries.34 Abu Ghraib authorities did not notify families of
deaths, sicknesses, or transfers to medical facilities as
required by the Convention.34,36 A medic inserted a intravenous
catheter into the corpse of a detainee who died under torture in
order to create evidence that he was alive at the hospital.37 In
another case, an Iraqi man, taken into custody by US soldiers was
found months later by his family in an Iraqi hospital. He was
comatose, had three skull fractures, a severe thumb fracture, and
burns on the bottoms of his feet. An accompanying US medical
report stated that heat stroke had triggered a heart attack that
put him in a coma; it did not mention the injuries.38
Death certificates of detainees in Afghanistan and Iraq were
falsified or their release or completion was delayed for
months.24,39 Medical investigators either failed to investigate
unexpected deaths of detainees in Iraq and Afghanistan or
performed cursory evaluations and physicians routinely attributed
detainee deaths on death certificates to heart attacks, heat
stroke, or natural causes without noting the unnatural aetiology
of the death.40,41 In one example, soldiers tied a beaten
detainee to the top of his cell door and gagged him. The death
certificate indicated that he died of "natural causes . . .
during his sleep." After news media coverage, the Pentagon
revised the certificate to say that the death was a "homicide"
caused by "blunt force injuries and asphyxia."24
In November, 2003, Iraqi Major General Mowhoush's head was
pushed into a sleeping bag while interrogators sat on his chest.
He died; medics could not resuscitate him, and a surgeon stated
that he died of natural causes.42 6 months later, the Pentagon
released a death certificate calling the death a homicide by
asphyxia.42 Medical authorities allowed misleading information
released by military authorities to go unchallenged for many
months.24 In 2004, the US Secretary of Defense issued a stringent
policy for death investigations.43
Finally, although knowledge of torture and degrading treatment
was widespread at Abu Ghraib and known to medical
personnel,13,41,44 there is no report before the January 2004
Army investigation of military health personnel reporting abuse,
degradation, or signs of torture.
The legacy
Pentagon officials offer many reasons for these abuses
including poor training, understaffing, overcrowding of detainees
and military personnel, anti-Islamic prejudice, racism, pressure
to procure intelligence, a few criminally-inclined guards, the
stress of war, and uncertain lengths of deployment.1,2,13,16,17
Fundamentally however, the stage for these offences was set by
policies that were lax or permissive with regard to human rights
abuses, and a military command that was inattentive to human
rights.
Legal arguments as to whether detainees were prisoners of war,
soldiers, enemy combatants, terrorists, citizens of a failed
state, insurgents, or criminals miss an essential point. The US
has signed or enacted numerous instruments including the UN
Universal Declaration of Human Rights,45 the UN Body of
Principles for the Protection of All Persons under Any Form of
Detention or Imprisonment,46 UN Standard Minimum Rules for the
Treatment of Prisoners,36 the Convention Against Torture and
Other Cruel, Inhuman, or Degrading Treatment or Punishment,47 and
US military internment and inter-rogation policies,8-10
collectively containing mandatory and voluntary standards barring
US armed forces from practicing torture or degrading treatments
of all persons.
For example, the Universal Declaration of Human Rights states:
"No one shall be subjected to torture or to cruel, inhuman or
degrading treatment or punishment."45 The Geneva Convention
states: "Persons taking no active part in the hostilities,
including members of armed forces who have laid down their arms
and those placed hors de combat by sickness, wounds, detention,
or any other cause, shall in all circumstances be treated
humanely, without any adverse distinction . . . The following
acts are and shall remain prohibited at any time and in any place
whatsoever with respect to the above-mentioned persons: Violence
to life and person, in particular murder of all kinds,
mutilation, cruel treatment and torture; . . . Outrages upon
personal dignity, in particular, humiliating and degrading
treatment . . . No physical or mental torture, nor any other form
of coercion, may be inflicted on prisoners of war to secure from
them information of any kind whatever. Prisoners of war who
refuse to answer may not be threatened, insulted, or exposed to
any unpleasant or disadvantageous treatment of any kind."48
Furthermore, the US War Crimes Act says that US forces will
comply with the Annex to the Hague Convention Respecting the Laws
and Customs of War on Land and the Geneva Convention Relative to
the Treatment of Prisoners of War both of which bar torture or
inhumane treatment.48-50
Pentagon leaders testified that military officials did not
investigate or act on reports by Amnesty International and the
ICRC of abuses at Abu Ghraib and other coalition detention
facilities throughout 2002 and 2003.1,24,33,34 The command at Abu
Ghraib and in Iraq was inattentive to human rights organisations'
and soldiers' oral and written reports of abuses.51 After the
ICRC criticised the treatment of Abu Ghraib detainees, its access
to detainees was curtailed.1
The role of military medicine in these abuses merits special
attention because of the moral obligations of medical
professionals with regard to torture and because of horror at
health professionals who are silently or actively complicit with
torture. Active medical complicity with torture has occurred
throughout the world. Physicians collaborated with torture during
Saddam Hussein's regime.52 Physicians' and nurses' professional
organisations have created codes against participation in
torture.25-26,31,53,54 Physicians in Chile, Egypt, Turkey and
other nations have taken great personal risks to expose
state-sponsored torture.25,26,55 Health professionals have
created organisations including Physicians for Human Rights and
Amnesty International's Health Professionals Network. Numerous
non-medical groups have asserted that healers must be advocates
for persons at risk of torture.25,26,31,32,56
Military personnel treating prisoners of war face a "dual
loyalty conflict".57 The Geneva Convention addresses this ethical
dilemma squarely: "Although [medical personnel] shall be subject
to the internal discipline of the camp . . . such personnel may
not be compelled to carry out any work other than that concerned
with their medical . . . duties."48 By this standard, the moral
advocacy of military medicine for the detainees of the war on
terror broke down.
If Abu Ghraib is to leave a legacy of reform, it will be
important to clarify how the breakdown occurred. The emerging
evidence points to policy and operational failures. High-level
Defense Department policies were inattentive to human rights and
to the ethical obligations of medical care for detainees.6 One
policy empowered interrogators to evaluate and refuse the request
of a person under interrogation for medical evaluation. Another
directed clinicians to authorise and monitor interrogations
which, although proposed as a safeguard, allowed medical judgment
to determine the harshness of interrogation.57 It will be
important to establish whether and how, senior military medical
officers reviewed, challenged, or tempered those policies.
At the operational level, medical personnel evaluated
detainees for interrogation, and monitored coercive
interrogation, allowed interrogators to use medical records to
develop interrogation approaches, falsified medical records and
death certificates, and failed to provide provide basic health
care.58,59
Which medical professionals were responsible for this
misconduct? The US Armed Forces deploy physicians, physicians'
assistants, nurses, medics (with several months of training), and
various command and administrative staff. International
statements assert that every health-care worker has an ethical
duty to oppose torture. For example, the UN Principles of Medical
Ethics Relevant to the Protection of Prisoners Against Torture
refers to "health personnel," "particularly physicians" but it
also names physicians' assistants, paramedics, physical
therapists and nurse practitioners.32 Likewise, the Geneva
Convention refers to the duties of physicians, surgeons,
dentists, nurses, and medical orderlies.48 Furthermore, the US
Armed Forces medical services are under physician commanders and
each medic, as with civilian physicians' assistants, is
personally accountable to a physician. Thus, physicians are
responsible for the policies of the medical system; military
medical personnel are should abide by the ethics of medicine
regarding torture.41
Abu Ghraib will leave a substantial legacy. Medical personnel
prescribed anti-depressants to and addressed alcohol abuse and
sexual misconduct in US soldiers in the psychologically
destructive prison milieu.44 The reputation of military medicine,
the US Armed Forces, and the USA was damaged. The eroded status
of international law has increased the risk to individuals who
become detainees of war since Abu Ghraib because it has decreased
the credibility of international appeals on their behalf.
Although the US Armed Forces' medical services are mainly
staffed by humane and skilled personnel, the described offences
do not merely fall short of medical ideals; some constitute grave
breaches of international or US law. Various voices call for
courts martial, a special prosecutor, or compensation. Such
measures will be inadequate if unaccompanied by even more
ardently pursued reform.
Such reform must begin with a comprehensive investigation. At
this time, it is not possible to know the absolute or relative
prevalence of the various abuses or fully assess the performance
of military medical personnel with regard to human rights abuses.
Army investigations have looked at a small set of human rights
abuses, but have not investigated reports from human rights
organisations, nor have they focused on the role of medical
personnel or examined detention centres that were not operated by
the Army.13-17 Six more investigations are underway.59 The Army's
Miller and Ryder Investigations remain classified.17 Several
thousand pages of the Army's Taguba Investigation appendices are
unavailable.13 Several secret detention centres that remain
unmonitored. The US military medical services, human rights
groups, legal and medical academics, and health professional
associations should jointly and comprehensively review this
material in light of US and international law, medical ethics,
the military code of justice, military training, the system for
handling reports of human rights abuses, and standards for the
treatment of detainees. Reforms stemming from such an inquiry
could yet create a valuable legacy from the ruins of Abu
Ghraib.
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