Malpractice

Steven H. Miles, University of Minnesota geriatrician, regularly and courageously brings ethical questions about health care into the political arena. One might even say he believes the practice of medicine is a political act. In 1991, when disputes were raging about whether physicians could withhold treatment from patients demanding interventions their physicians thought futile, Miles petitioned a court for permission to deny ventilator treatment to Helga Wanglie, who was in a persistent vegetative state. In 2000, he ran unsuccessfully in the Minnesota Democratic primary for U.S. Senate, campaigning for universal health insurance and against economic sanctions in foreign policy. In 2005, Miles quit the American Society for Bioethics and Humanities over its policy against making political statements. Torture has now become his focus. He has spoken to the media and medical societies, and written articles documenting allegations of physician complicity. Oath Betrayed is the culmination of this work.

The book is far more than an indictment of physicians. First and foremost, Miles accuses the whole of the American people. The United States is now a “torturing society,” Miles claims, which has aided other torturing societies and now tortures and kills prisoners systematically in the “war on terror.” In light of this premise, Oath Betrayed involves physicians secondarily because, as Miles puts it, “a torturing society must secure the passive assent or active complicity of its professions.” But his political views regarding medicine’s social responsibilities run even deeper than the question of complicity. “Civilian medical societies are a respected domestic constituency and part of an honored international community,” Miles writes. “They have a crucial responsibility in opposing torture.”

Oath Betrayed is thus more concerned with U.S. prisoner-interrogation policy since 9/11 than with physician participation in torture. Yes, some U.S. military personnel have tortured prisoners in the “war on terror.” Not even the Bush administration denies that. Yet whether these were isolated acts or part of a systematic policy remains a subject of controversy. Miles argues that the government—the elected representatives of our torturing society—set out to allow widespread torture, and that it progressed in three steps. First, the U.S. government denied that the Geneva Conventions applied to Al Qaeda and to the Taliban. Second, the Defense Department and Justice Department changed the definition of torture to cover “only extreme acts,” such as severe pain “akin to that which accompanies serious physical injury such as death or organ failure,” or lasting psychological damage. Third, the military implemented unprecedented interrogation policies in the field. In Miles’s view, these liberalizations were part of a systematic policy to permit abuses like those documented in the infamous Abu Ghraib photos.

Like a prosecuting district attorney, Miles presents an extensive list of indictments, including nineteen deaths in Afghanistan and Iraq he alleges are instances of prisoner homicide by torture. He details every accusation of torture in Afghanistan, Iraq, and Guantánamo Bay, and demands investigation and justice.

While Miles accuses the government of narrowing the definition of torture, he uses a very broad brush in his depiction of war crimes againist prisoners for which he holds the U.S. government guilty. Solitary confinement, loud noise, and American food seem to count as abuse every bit as much as beatings, sodomizing with blunt objects, and the desecration of the Qur’an.

There is little gray in Miles’s palate, while U.S. military physicians complain that they see nothing but gray. They wonder about how much moral certainty is possible in the situations they face in the field. Of course, military physicians should not participate in torture. Yet even in the abstract—let alone in practice—controversies surround the definitions and moral obligations associated with the terms “military physician,” “participate,” and “torture.”

Military physicians have a difficult role. Even in peacetime, their situation is akin to that of “company doctors” torn between advocating for patients and respecting the legitimate claims of their employers. Can the patient return to work? Is the patient malingering in order to make an insurance claim? Moral judgments in such circumstances do not come easily—and they are even thornier for military doctors. The latter must decide: Is the prisoner claiming to be sick to avoid interrogation? Is the prisoner hoarding medications so he can commit suicide as a political statement?

Whose definition of torture should the military physician accept? That of Dr. Miles? The Geneva Conventions? The World Health Organization? The U.S. Departments of Justice and Defense? The U.N. Convention Against Torture defines it this way:

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, punishing him for an act he or a third person has committed or is suspected of having committed, or intimidating or coercing him or a third person, or for any reason based on discrimination of any kind, when such pain or suffering is inflicted at the instigation of or with the consent or acquiescence of a public official or other person acting in an official capacity.

Pity the military physicians trying to apply this in the field. Does a weeklong bread-and-water diet count? What about failing to acquire the chemicals needed to test for tuberculosis within the first six months of opening a prison hospital?

And what constitutes participation? Miles reports no allegations that U.S. military physicians directly inflicted torture. But he does accuse them of involvement by failing to report evidence of torture. Still, making this judgment may not be as easy as he assumes it is. All the military physician sees at 3 a.m. is an injured patient. How easy is it to determine whether that patient’s wounds were caused in battle or as a result of interrogation?

Torture brings dishonor to our nation, undermines our arguments for waging the fight against terrorism, and raises serious questions about our integrity in the court of world opinion. It is certainly possible that some military physicians have participated in these atrocities, and, if true, it not only undermines our nation, it undermines the integrity of the medical profession. If, for instance, a U.S. medic inserted an IV line into the corpse of a prisoner who died as a result of torture in order to cover up the mistreatment, as Miles alleges, it would be a grave moral offense. One should not underestimate the courage it would take to disobey orders and “do the right thing” in these circumstances. We need military medical personnel who are trained to expose torture—and the highest levels of the military must support such whistle blowing. To the extent that Miles’s book reminds us of this moral requirement, it is worth reading. To the extent that it provides details concerning all the allegations that have been made regarding torture by U.S. personnel during the war on terror, it is worth reading. To the extent that Miles fails to see the morally gray areas military physicians face in their work, it is unlikely that his book will be of great help to them.