It was called the "water cure." But it was dosed out liberally
to those who weren't sick. Unfortunate recipients were held by the neck beneath
a water tank. The tap was turned on, and they were forced to swallow the gushing
stream - or to choke within an inch of death while trying. Another variation
used tubing to siphon water from a kerosene can into a detainee's nostril. Sworn
testimony records the use of this tactic in the presence of a doctor. It was,
after all, a "cure." When the detainee still refused to talk, the
doctor would ratchet up the treatment, ordering a second tube to be placed in
the detainee's other nostril and a handful of salt to be thrown into the water.
Anyone who's ever had sea water up his or her nose will know just how pleasant
that would have been.
This interrogation tactic comes not from the "war on terror" but
from the war in the Philippines more than 100 years ago. There too the abuses
were justified by the need to combat troublesome local "insurgents."
The enemy was "not civilized" and did not deserve to be treated according
to the rules of civilized warfare. The water cure is, of course, the precursor
to a more recent interrogation technique known as "water boarding."
And the participation of the physician is an early example of American medical
personnel being co-opted into an egregious and unlawful military mission. The
doctor's presence did not restrain the interrogator's excesses; on the contrary,
he actively fueled them.
After 9/11 some American healthcare personnel were once again asked to step
into the breach and help Army interrogators conduct aggressive interrogations.
They have, among others, Maj. Gen. Geoffrey Miller - former camp commander at
Guantánamo Bay - to thank for this. Miller considered the participation
of Behavioral Science Consultation Teams - known colloquially as "Biscuits"
- to be an "essential" part of the interrogation process. Having introduced
the first Biscuit to the Guantánamo facility in late 2002, Miller urged
the deployment of a similar team at Abu Ghraib in late 2003. These Biscuits
were staffed at various times by psychologists and/or psychiatrists.
The Defense Department has acknowledged that several Biscuit staff were sent
to Fort Bragg, North Carolina, for training at SERE school - short for Survival,
Evasion, Resistance and Escape. This is where American soldiers are taught how
to resist their captors. Training is based on exposure to abusive tactics, some
tantamount to torture, delivered by fellow soldiers. (That these tactics are
designed to break detainees and procure false confessions - not to produce intelligence
- appears to have been overlooked by the Administration when it decided to deploy
them in the "war on terror.") At SERE school, Biscuit healthcare personnel
acquired a grounding in the now well-publicized techniques of hooding, prolonged
isolation, stress positions, sleep deprivation and exposure to loud noise and
temperature extremes - techniques often used in combination.
They brought this knowledge back to Guantánamo Bay, where - according
to an internal Army report - they offered opinions on the character and personalities
of detainees, advised on interrogation plans and approaches, and provided feedback
on interrogation technique. Army documents also record that Biscuit personnel
sometimes sat in on interrogations. Notably, the name of a Biscuit psychologist
appears in the interrogation log of Guantánamo detainee Mohammed al-Qahtani.
According to that log - a copy of which was obtained by Time magazine - Qahtani
was questioned for eighteen to twenty hours per day for forty-eight out of fifty-four
consecutive days in late 2002 and early 2003. During that time, he was subjected
to an array of tactics that included exposure to temperature extremes, barking
military dogs, strip searches, stress positions, being led around on a leash
and being forced to stand naked in front of women. In addition to these measures
- many of which were held "legally permissible" in a recent Army report
- a medical corpsman forcibly administered three and a half bags of intravenous
fluid. Qahtani was refused a promised bathroom break and, when he became desperate,
he was told to go in his pants.
Before this interrogation regime, Qahtani had been subjected to 160 days of
isolation and - according to a letter of complaint sent by the FBI to the Pentagon
- he was "evidencing behavior consistent with extreme psychological trauma."
Not surprisingly, this trauma was compounded by the deleterious impact the interrogation
tactics had on Qahtani's physical health. On one occasion, his heartbeat became
so slow - just thirty-five beats per minute instead of the normal sixty to 100
- that he had to be hospitalized. On at least two occasions, his temperature
dropped to a life-threatening ninety-five degrees.
Aggressive interrogations like those endured by Qahtani were based on a model
that seeks to employ extreme levels of stress in order to erode established
patterns of behavior, such as resistance to questioning. One of the functions
of Biscuit health professionals is to help interrogators tailor interrogation
"stressors" to the personality of each detainee - particularly "high-value
detainees." In one example - reported by Neil Lewis in the New York Times
- interrogators were told by a Biscuit that a detainee's medical files recorded
his severe phobia of the dark, and the Biscuit suggested ways that fear could
be manipulated to make the detainee cooperate.
Much ink has been spilled - by me and others - explaining why these practices
violate fundamental rules and protections found in both the laws of war and
international human rights law. These two bodies of law prohibit most of the
aggressive interrogation strategies deployed in the "war on terror"
- and mandate the humane treatment of detainees. The Administration has tried
its best to circumvent these laws. It argues, for example, that the ban on cruel,
inhuman and degrading treatment doesn't apply to foreigners outside the United
States - a position the McCain amendment seeks to overturn. This amendment is
all the more important in light of the Defense Department's new Interrogation
Directive. The directive was greeted warmly in the press with headlines like
"Pentagon: Detainees Must Be Treated Well" (AP). It prohibits the
use of military dogs and requires interrogations to be humane and in accordance
with "relevant" international law (whatever that may be). But read
the fine print: It also expressly provides that Defense Secretary Rumsfeld or
his deputies may authorize interrogations that do not meet either of these basic
When medical personnel are involved in interrogation, medical ethics should
also have something to say. And when the Administration plays around with legal
rules, it is all the more important for the medical establishment - and its
members - to take an ethical stand. Medical ethics should embrace and reflect
the fundamental protections found in human rights law and the laws of war, as
the UN has recognized. According to a resolution of the General Assembly adopted
without dissent in 1982, it is a "gross contravention of medical ethics"
for health professionals to be complicit in torture or cruel, inhuman or degrading
treatment. They are also required not to use their knowledge and skills to assist
with an interrogation that may adversely affect a detainee's health and is not
in accordance with international law. Medical personnel who helped design and
monitor aggressive interrogations like those of Qahtani have undoubtedly fallen
afoul of this ethical mandate.
But ethical constraints can and should go beyond the requirements of law.
The World Medical Association has acknowledged this and holds that - even in
times of armed conflict - it is unethical for physicians to weaken the physical
or mental health of a human being "without therapeutic justification."
Its codes also emphasize that detainee medical records are presumed to be confidential.
This presumption - universally acknowledged as being vital to patient trust
and effective medical care - was violated by the routine exploitation of medical
records during interrogations at Guantánamo. The association's rules
also prohibit force-feeding hunger-strikers - a rule now broken daily at Guantánamo.
Although the Defense Department has denied the shocking claim that a finger-thick
nasogastric tube was reused without sterilization in order to feed different
detainees at the facility, it readily admits that force-feeding is occurring.
The Pentagon has recently taken steps to alleviate concerns about the involvement
of medical personnel in abuse. In June it issued new medical "procedures"
for detainees in US custody. These prohibit healthcare personnel from participating
in interrogations not in accordance with "applicable law." But what
law is "applicable"? More pertinent, what law is applicable according
to an Administration that does not shy away from developing its own highly permissive
formulations of legal doctrine? In September the Defense Department issued a
further "special text" stating that Biscuit members should not have
access to medical records "except as needed to maintain safe, legal and
ethical interrogations." But anyone familiar with previous abuses must
have concerns about how that constraint will be enforced. In October the Pentagon
flew officials from several health professional organizations to Guantánamo.
Like the typical Defense Department tour of Guantánamo, it was a six-hour
visit. Guests were armed with packs of information and given multiple briefings,
but they were not permitted to talk to detainees - a prohibition that recently
led UN human rights experts to cancel their Guantánamo visit.
These measures may not have had the effect the Administration hoped for. Following
the Guantánamo trip, Dr. Steven Sharfstein, president of the American
Psychiatric Association, stated publicly that it was "inappropriate"
for psychiatrists to serve on Biscuits. The APA's board is soon expected to
adopt changes to its rules that will make this official policy. Sharfstein's
concerns extend beyond aggressive interrogations. In his view, all Guantánamo
interrogations are tainted by the detention of the subject in legal limbo and,
more than that, he doesn't want his members participating in or advising on
any inherently deceptive interrogation tactics.
Other groups - not least, Physicians for Human Rights and Physicians for Social
Responsibility - have also been vocal in their condemnations of medical participation
in abusive practices at Guantánamo Bay and elsewhere. The responses of
two of America's core medical professional organizations, the American Medical
Association and the American Psychological Association, however, raise serious
The performance of the AMA - the organization that spoke out so firmly in
response to the abuses of Nazi doctors - has been especially shocking. After
the Guantánamo tour, it declined to make its representative on that trip,
Dr. Audiey Kao, available to the New York Times for comment. The AMA was also
slow to express support for the anti-torture McCain amendment, doing so only
after other medical groups had spoken out and its silence became embarrassing.
One reason for the AMA's lack of resolve is its members' concerns about other
issues - topics more relevant to their daily practice. Hundreds of resolutions
are brought by members every year on issues ranging from tort "reform"
to Medicare. But only two resolutions in the past year addressed the interrogation
issue. The result was a decision in November to commission a report from the
AMA's ethics body, which won't appear until June 2006 at the earliest. That
concerns about the level of Medicare reimbursements - currently under consideration
on the Hill - are preventing the AMA from speaking out on an issue that goes
to the heart of what it means to be a physician (whether for fear of offending
the government or exhausting the group's political capital) should be a source
The American Psychological Association has been quicker to act, producing
guidance drafted by its Presidential Task Force in June. But the task force
was stacked predominantly with psychologists who work or have worked for the
military - in some cases at SERE school. Although the resulting guidelines require
psychologists not to facilitate torture or cruel, inhuman or degrading treatment,
they adopt as a "touchstone" US rules and regulations as "developed
and refined" in the "war on terror." Despite the association's
subsequent support of the McCain amendment, this makes psychologists' ethical
constraints appear dependent upon the Administration's manipulation of legal
doctrine and, in particular, on its views about the scope and content of the
ban on cruel, inhuman and degrading treatment. Just as important, the task force
also failed to require psychologists to respect the fundamental human rights
of detainees established in international law. Rather than giving psychologists
firm guidelines, the task force tells them to be mindful of factors that "require
special ethical consideration" when consulting on interrogation. But leaving
psychologists to make ad hoc decisions in military scenarios - when they are
dependent on others for information and have neither the time nor the competence
to assess it - is not a good recipe for preventing future abuses. Since the
Defense Department has deployed psychologists rather than psychiatrists on Biscuits
recently - sensing, perhaps, that their ethical constraints may not be as rigorous
- it is especially important that the shortcomings in these guidelines be addressed.
But all bodies within the medical establishment should lay down rules that
directly address the participation of their members in the design and monitoring
of interrogations. Clear rules drafted with real-world scenarios in mind are
vital if we are to empower medical personnel to say no when asked to participate
in future abuses.
Moving forward, however, also requires looking back. At least four Guantánamo
detainees have lodged a complaint against Dr. John Edmondson, head of the facility's
Naval hospital. They allege that physicians under Edmondson's supervision made
medical care contingent on cooperation with interrogators, that they witnessed
and participated in abuse and that they shared medical information with interrogators
to expose detainees' weaknesses. The Medical Board of California has refused
to entertain the complaint on procedural grounds. The board says it can't consider
the complaint because the alleged conduct occurred outside its jurisdiction,
on a military base. By that rationale, a lawyer could be guilty of serious misconduct
in California and still practice at the New York bar. This point has not escaped
Scott Sullivan, the attorney representing the detainees. He has asked the California
courts to compel the Medical Board to hear the complaint. That it should come
to this is more than unfortunate.
Although it is the job of the medical community to regulate its own, and to
call to account the few who threaten to tarnish the reputation of the many,
a full and independent investigation into detainee abuses and the role of medical
personnel in those abuses is also needed. An "assessment" report of
detainee medical activities made public by the Army Surgeon General in July
raised more questions than it answered. What did the seventy-four medical personnel
- in Iraq alone - who admitted witnessing interrogations actually see? What
do the detainees who were the subjects of those interrogations - and who were
not interviewed for the report - have to say about the involvement of those
personnel? More generally, how were some medical personnel co-opted into a policy
of detainee abuse after 9/11? Demanding answers to these questions is essential,
not just for the integrity of the medical community but for the health of our