Pulse
Miles to Go
University of Minnesota bioethicist Steven Miles, M.D., isn’t letting up in his quest to end the abuses at Abu Ghraib prison in Iraq.
Steven Miles, M.D., flashes a slide on the screen, and the small group assembled in a lecture hall at the University of St. Thomas in St. Paul grows quiet. The image is hard to look at: a pyramid of seven naked men, some of whom have visible bruises on their legs and buttocks. Behind them, two guards stand with their arms around each others’ shoulders, smiling.
Miles explains that the caption under the photo, which was published in the New York Times, said something about guards abusing prisoners at Abu Ghraib. He then turns to the audience and asks: “How would your feelings change if it said, ‘This is what the nurse saw at Abu Ghraib?’” Miles says that according to the military’s documentation, a nurse did witness the scene but failed to report it. And that, he says, is what’s amazing about the story.
It was the publication of that photo and others showing detainees being abused in Iraq’s Abu Ghraib prison in April of 2004 that prompted the University of Minnesota professor of medicine and bioethicist to investigate why medical personnel didn’t report or try to stop what was happening at prisons in Iraq and Afghanistan and at Guantánamo Bay—a quest that briefly landed him in the international spotlight. “Since health care professionals are frontline human rights monitors in any prison, and since the abuses had been going on for a while, why hadn’t the medical system blown the whistle? Why didn’t they serve as the early tripwire or the canary in the coal mine to say there was something wrong in the prisons?” Miles asks.
In his effort to unearth answers to those questions, Miles amassed more than 35,000 pages of government documents. Those documents became the basis of his article “Abu Ghraib: Its Legacy for Military Medicine,” which was published in the British journal The Lancet in August of 2004, and a book manuscript, Oath Betrayed: Military Medicine and the War on Terror, which was being shopped around to publishers early this year.
In the Lancet article, Miles asserts that medical personnel evaluated detainees to determine whether certain interrogation techniques were suitable; monitored coercive interrogation; allowed inter- rogators to use medical records to develop interrogation plans; falsified medical and death records; and failed to provide basic care, maintain records, provide proper care for disabled detainees, and report abuse, degradation, and signs of torture. Some of those actions, he says, violated the Geneva Conventions and the United Nations’ Principles of Medical Ethics Relevant to the Role of Health Personnel; others breached ethical codes including the World Medical Association’s Declaration of Tokyo, which forbids physician participation in torture, and the American Medical Association’s position on torture, which was adopted in 1999 and says that “physicians must oppose and must not participate in torture for any reason.”
So what would make physicians, as well as health care providers working under the supervision of a physician, look the other way?
Miles, who has spoken to groups around the country on the topic and whose Lancet article has been translated into five languages, ticks off the reasons: “First off, there’s institution-think that goes with anything. Secondly, human rights training was nearly nil. Third, there was not only no reporting mechanism, but when reports were made, they were ignored. Four, there was this very interesting innovation in that they essentially made the cell blocks part of the interrogation room.” Miles explains that all of prison life became part of the interrogation system. “So it’s not like the physicians or nurses ever got to see the patients outside of what the interrogation system was doing to them.”
Miles says the situation at Abu Ghraib represents a departure from military medicine in the United States, which he describes as having “an honorable history” in the treatment of prisoners, and he lays the blame at the feet of Defense Secretary Donald Rumsfeld, whom he says approved the policies that involved physicians and other medical personnel in the interrogation of detainees. “It wasn’t an accident. It wasn’t a form of institutional neglect; it was built into the system.”
He also blames physicians and other health care professionals working in the prisons for not recognizing their duty to buck the system. “I think it’s similar to a physician who fails to recognize the need to contest an HMO policy that’s injuring a patient,” he explains. “If an HMO says to a doc, ‘This beneficial therapy is too costly. Don’t tell the patient about it,’ and the doc did that, it’s a gag rule, and we wouldn’t have any trouble suing the doc for malpractice and saying the institutional environment or your desire to be promoted or get incentive pay in no way mitigates your responsibility to your patient.”
Connecting Documents and Dots
When asked if he ever thought he would one day investigate the role of medical providers in abuses that took place at a prison thousands of miles away, Miles shakes his head in disbelief. “If you told me two years ago that I would be doing this, I would have laughed,” he says.
But Miles couldn’t let go of the images of the detainees. After reading the early news reports, Miles began obtaining government documents through the Freedom of Information Act. Because the documents were photographed and, therefore, not searchable, he forced himself to read every page—an activity that allowed him to make connections he otherwise may have missed. “For example, in one org chart, I saw the term BSCT under military intelligence, but there was no definition of what BSCT stood for.” The term stands for Behavioral Science Consultation Team—a group of medical personnel who advise military interrogators. Miles says the documents indicated that BSCTs used clinical data to find ways to break down prisoners. After happening upon the name of the person in charge of a BSCT operating near Abu Ghraib in another document, Miles discovered he was a board-certified U.S. psychiatrist and thus was bound by the same ethical codes as other physicians. “If I had different people reading these documents, some of those connections would have been missed,” he says.
And had a physician not read them, other important details may have gone unnoticed as well, including questionable causes of medical problems. “What does it mean when a physician sees a patient who is hospitalized with a nearly lethal cardiac arrhythmia from hypothermia in Guantánamo? Guantánamo is not known for hypothermia. … Those kinds of questions a physician is best equipped to ask,” he says.
In addition to making such discrepancies known to the medical community, Miles is trying to make the military answer for its actions. He says he’s been having a running e-mail exchange with Army Surgeon General Lt. Gen. Kevin Kiley, M.D., about the Lancet article. “He disagrees with much of what I’m saying. … But he never really answers the critique; he just says it’s wrong. The nice thing about the paper,” Miles says, turning to the references section of his book manuscript, “is that if you look at the citations, these are not USA Today. This is the Army’s work, these are FBI documents. I’m not basing this on people who are not accountable. This is their own investigation and their own data.”
A Charge to Medicine
Miles says some changes have taken place since his report came out. The military has conducted three investigations into the abuses and the alleged involvement by medical personnel. “The problem,” he says, “is that they are not independent of the Defense Department, so it’s the Defense Department investigating itself.” Also, several policy reforms are addressing confidentiality of records and forensic investigations. Most recently, Congress approved, and President Bush agreed to endorse, Sen. John McCain’s torture ban, which prohibits the “cruel, inhuman, or degrading” treatment of any detainee in U.S. custody anywhere in the world—a move some say doesn’t go far enough to prevent the use of some coercive techniques such as exploiting phobias.
Miles believes the medical community needs to step up and demand accountability and change. The unabashedly outspoken professor praises Physicians for Human Rights and the American College of Physicians for being active on the issue from the beginning. At the same time, he criticizes the American Medical Association (AMA) for being what he calls “conspicuously silent.” Miles says he would like to see the AMA as well as other physician organizations demand an independent investigation of the abuses at the prisons and the involvement of medical professionals. “The AMA needs to put its muscle foursquare behind addressing what is essentially the largest human rights medical meltdown in the West since Nuremberg.”—K. Kiser