Medical ethics and interrogation at Guantanamo Bay

The American Journal of Bioethics carries an analysis of recently de-classified logs of an interrogation at Guantanamo Bay:

The interrogation and the involvement of a psychologist, physician and medics violate international and medical norms for the treatment of prisoners.

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For eleven days, beginning November 23, al-Qahtani was interrogated for twenty hours each day by interrogators working in shifts. He was kept awake with music, yelling, loud white noise or brief opportunities to stand. He then was subjected to eighty hours of nearly continuous interrogation until what was intended to be a 24-hour “recuperation.” This recuperation was entirely occupied by a hospitalization for hypothermia that had resulted from deliberately abusive use of an air conditioner. Army investigators reported that al-Qahtani’s body temperature had been cooled to 95 to 97 degrees Fahrenheit (35 to 36.1 degrees Celsius) and that his heart rate had slowed to thirty-five beats per minute. While hospitalized, his electrolytes were corrected and an ultrasound did not find venous thrombosis as a cause for the swelling of his leg. The prisoner slept through most of the 42-hour hospitalization after which he was hooded, shackled, put on a litter and taken by ambulance to an interrogation room for twelve more days of interrogation, punctuated by a few brief naps. He was then allowed to sleep for four hours before being interrogated for ten more days, except for naps of up to an hour. He was allowed 12 hours of sleep on January 1, but for the next eleven days, the exhausted and increasingly non-communicative prisoner was only allowed naps of one to four hours as he was interrogated. The log ends with a discharge for another “sleep period.”

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In October 2002, before the time covered by the log, Army investigators found that dogs were brought to the interrogation room to growl, bark and bare their teeth at al-Qahtani. The investigators noted that a BSCT psychologist witnessed the use of the dog, Zeus, during at least one such instance, an incident deemed properly authorized to “exploit individual phobias.” FBI agents, however, objected to the use of dogs and withdrew from at least one session in which dogs were used.

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Transgressions against Islamic and Arab mores for sexual modesty were employed. The prisoner was forced to wear photographs of “sexy females” and to study sets of such photographs to identify whether various pictures of bikini-clad women were of the same or a different person. He was told that his mother and sister were whores. He was forced to wear a bra, and a woman’s thong was put on his head. He was dressed as a woman and compelled to dance with a male interrogator. He was told that he had homosexual tendencies and that other prisoners knew this. Although continuously monitored, interrogators repeatedly strip-searched him as a “control measure.” On at least one occasion, he was forced to stand naked with women soldiers present. Female interrogators seductively touched the prisoner under the authorized use of approaches called “Invasion of Personal Space” and “Futility.” On one occasion, a female interrogator straddled the prisoner as he was held down on the floor.

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He was leashed (a detail omitted in the log but recorded by investigators) and made to “stay, come, and bark to elevate his social status up to a dog.” He was told to bark like a happy dog at photographs of 9/11 victims and growl at pictures of terrorists.

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Clinicians were integral to this abusive interrogation. Medics regularly assessed al-Qahtani’s vital signs, hydration, skin integrity and constipation. They attended to edema that appears to have resulted from a combination of prolonged restraint, recumbency and (perhaps) nutritional insufficiency. Physicians came to the interrogation cell to assess or treat dehydration, inanition, pain, edema and potential trauma from prolonged restraint to a metal chair. A physician told interrogators over the telephone that interrogation could continue despite bradycardia. Inpatient clinicians treated hypothermia-induced bradycardia and returned him to the interrogators. The Behavioral Science Consultation Team and its psychologist Chair oversaw the interrogation, including the use of a military dog to threaten the prisoner, and directly suggested responses to the prisoner’s requests and actions.

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The Army investigation, instigated by an FBI complaint rather than by clinicians, focused on whether the interrogation techniques were authorized by Defense Department policy. The investigators found that the prolonged sleep deprivation was authorized. Cooling with an air conditioner was authorized “environmental manipulation.” Notwithstanding bradycardia requiring hospitalization, the investigators asserted, “There are no medical entries indicating the subject . . . ever experienced medical problems related to low body temperature” (Bashour, Gualberto and Ryan 1989). Investigators noted a second episode of bradycardia in February 2003 after the period covered by interrogation log. Army investigators found no evidence that al-Qahtani was ever physically assaulted and pointed out that medical records did not find evidence of physical assault or “medical conditions of note.” They concluded that there was “no evidence that [al-Qahtani] . . . was subjected to humiliation intentionally directed at his religion.” They found that the cumulative effect of this “creative, aggressive, and persistent” interrogation was “degrading and abusive” but did not constitute “torture” or “inhumane” treatment but did not define distinctions between these words. Not finding torture or inhumane treatment, the Army recommended closing the investigation.

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International law squarely prohibits this kind of interrogation. The Geneva Convention relative to the Treatment of Prisoners of War states,

"Persons . . . placed hors de combat by . . . detention shall in all circumstances be treated humanely ... To this end the following acts are and shall remain prohibited at any time and in any place whatsoever . . . (c) 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" (Geneva Convention 1949).

Similarly, the United Nations’ Convention Against Torture defines “torture” as “any act by which severe pain or suffering, whether physical or mental, is intentionally inflicted on a person for such purposes as obtaining from him or a third person information or a confession, ... at the instigation of . . . a public official” (United Nations General Assembly 1984). Although the United States Supreme Court upheld the Geneva Convention in its Hamdan decision (Hamdi v. Rumsfeld, 124 S. Ct. 2633 [2004]), the recently enacted Military Commissions Act denies prisoners the right to invoke the Geneva provisions (Military Commissions Act of 2006).

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Numerous ethics codes proscribe medical complicity with harsh interrogation. In response to public outcry against clinical participation in coercive interrogations at war on terror prisons, the American Medical Association and the American Psychiatric Association have endorsed more stringent codes for military clinicians who are asked to participate in interrogation (Table 1).

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Table 1. Selected Excerpts from Medical Ethics Codes and Conventions Addressing Clinicians Roles in Interrogation.

United Nations General Assembly. Principles of Medical Ethics Relevant to the Protection of Prisoners Against Torture (1982).

"It is a gross contravention of medical ethics, . . . for health personnel, particularly physicians, to [1] engage, actively or passively, in acts which constitute participation in, complicity in, incitement to or attempts to commit torture or other cruel, inhuman or degrading treatment or punishment, . . . [2] be involved in any professional relationship with prisoners or detainees the purpose of which is not solely to evaluate, protect or improve their physical and mental health, . . . [3] (a) apply their knowledge and skills in order to assist in the interrogation of prisoners . . . in a manner that may adversely affect the physical or mental health or condition of such prisoners . . . ; (b) certify, or to participate in the certification of, the fitness of prisoners . . . for any form of treatment or punishment that may adversely affect their physical or mental health . . . or to participate in any way in the infliction of any such treatment or punishment . . . , [4] participate in any procedure for restraining a prisoner . . . unless such a procedure is determined in accordance with purely medical criteria as being necessary for the protection of the physical or mental health or the safety of the prisoner or detainee himself . . . and presents no hazard to his physical or mental health."