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Previous Volume 359:1090-1092 September 11, 2008 Number 11 Next

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In May 2006, the American Psychiatric Association (APA) adopted a position statement prohibiting psychiatrists from "direct participation" in the interrogation of any person in military or civilian detention — including "being present in the interrogation room, asking or suggesting questions, or advising authorities on the use of specific techniques of interrogation with particular detainees."¹ A few weeks later, the Council on Ethical and Judicial Affairs of the American Medical Association (AMA) issued a similar opinion, stating that "physicians must neither conduct nor directly participate in an interrogation, because a role as physician–interrogator undermines the physician's role as healer."² The opinion defines direct participation as including "monitoring interrogations with the intention of intervening." Although the AMA and APA conceded that physicians could participate in general training of interrogation personnel, both organizations firmly opposed physicians' helping to devise interrogation plans for individual detainees. The World Medical Association also revised its Declaration of Tokyo in May 2006 in firm terms, asserting that "the physician shall not use nor allow to be used, as far as he or she can, medical knowledge or skills, or health information specific to individuals, to facilitate or otherwise aid any interrogation, legal or illegal, of those individuals."³

Yet documents recently provided to us by the U.S. Army in response to requests under the Freedom of Information Act (FOIA) make clear that the Department of Defense still wants doctors to be involved and continues to resist the positions taken by medicine's professional associations. An October 2006 memo entitled "Behavioral Science Consultation Policy" (see the Supplementary Appendix, available with the full text of this article at www.nejm.org) fails to mention the APA statement and provides a permissive gloss on the AMA's policy, at some points contradicting it outright. The memo appears to claim that psychiatrists should be able to provide advice regarding the interrogation of individual detainees if they are not providing medical care to detainees, their advice is not based on medical information they originally obtained for medical purposes, and their input is "warranted by compelling national security interests." The advice envisaged by the memo includes "evaluat[ing] the psychological strengths and vulnerabilities of detainees" and "assist[ing] in integrating these factors into a successful interrogation."

The new Army field manual issued in September 2006 allayed some concerns about the use of coercive interrogation tactics by the military (though not by the Central Intelligence Agency [CIA]). The manual prohibits some aggressive techniques, such as waterboarding, hooding, and the use of military dogs. However, it still permits "physical separation" for an initial period of up to 30 days, which may be renewed. Given that prolonged isolation has serious psychological consequences and can cause post-traumatic stress, the prospect that physicians might still be advising interrogators on its effective use for "conditioning" detainees should be cause for concern.

The policy memo also states that a "behavioral science consultant" may not be a "medical monitor during interrogation" and suggests that this is a "healthcare function." However, it appears to authorize monitoring as part of consultants' intelligence functions, since "physicians may protect interrogatees if, by monitoring, they prevent coercive interrogations." It asserts, more specifically, that "the presence of a physician at an interrogation, particularly an appropriately trained psychiatrist, may benefit the interrogatees because of the belief held by many psychiatrists that kind and compassionate treatment of detainees can establish rapport that may result in eliciting more useful information."

This statement is troubling. First, it seeks to undermine the positions taken by the AMA and APA concerning physicians' monitoring of interrogations. Second, it suggests that the officials who signed off on this memo (the Army's former surgeon general and former assistant surgeon general for force protection) were skeptical about the merits of rapport-building detainee interviews. It also hints at the rationale that the military may be using to encourage psychiatrists to reject the positions of their professional associations.

To their credit, the memo's authors instruct physicians to report coercive interrogations to "the appropriate authorities" and, if necessary, to "independent authorities that have the power to investigate or adjudicate such allegations." But physicians' reporting obligations do not in themselves require that they adopt a direct monitoring function, and this role creates the potential moral hazard that interrogators will "push the envelope" while waiting for the physician to intervene.

Other documents obtained under FOIA indicate that between July 2006 and October 2007, five Army psychiatrists were put through the "behavioral science consultation" training course. The policy memo raises critical questions about that course, among them, Why are consultants receiving training in "learned helplessness" — a term that invokes the work of psychologist Martin Seligman, who used electric shocks to induce passive behavior in dogs and destroy their will to escape? As Jane Mayer has revealed, Seligman was invited by the CIA to give a lecture in learned helplessness at the Navy's Survival, Evasion, Resistance, and Escape school in 2002, purportedly to help U.S. soldiers to resist torture rather than enable them to inflict it.⁴ According to Mayer, at least one experienced interrogator has claimed that learned helplessness was the paradigm for some of the most aggressive interrogations in the war on terror. If coercive interrogations are supposed to be off the table, why teach this theory to behavioral science consultants?

Although the authors of the 2006 policy memo should be credited for requiring behavioral science consultants not to "perform any duties they believe are illegal, immoral or unethical," the value of such a mandate is undermined by the confusion the memo introduces regarding the ethical obligations of health professionals who serve as consultants. The memo is set to expire this October 20. The Army should take this opportunity to clarify the guidance and to embrace the positions of the AMA and the APA. In a high-pressure interrogation environment, unnecessary uncertainty about ethical constraints can only lead to mischief.

No potential conflict of interest relevant to this article was reported.

Source Information

Mr. Marks is an associate professor of bioethics, humanities, and law at the Pennsylvania State University at University Park and at the College of Medicine in Hershey, and a barrister and academic member of Matrix Chambers, London. Dr. Bloche is a professor of law at Georgetown University and a Nonresident Senior Fellow at the Brookings Institution, Washington, DC, and an adjunct professor at the Bloomberg School of Public Health, Johns Hopkins University, Baltimore.

References

1. American Psychiatric Association. Psychiatric participation in interrogation of detainees: position statement. May 2006. (Accessed August 22, 2008, at http://archive.psych.org/edu/other_res/lib_archives/archives/200601.pdf.)
2. American Medical Association. Physician participation in interrogation: report 10-A-06 of the Council on Ethical and Judicial Affairs. (Accessed August 22, 2008, at http://www.ama-assn.org/ama1/pub/upload/mm/369/ceja_recs_10a06.pdf.)
3. World Medical Association. Declaration of Tokyo (as amended, May 2006). (Accessed August 22, 2008, at http://www.wma.net/e/policy/c18.htm.)
4. Mayer J. The dark side: the inside story of how the war on terror turned into a war on American ideals. New York: Doubleday, 2008.

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