Guantanamo Medical Role Likened to South Africa Under Apartheid

MINNEAPOLIS, Sept. 7 -- American military physicians at Guantanamo are acting in ways that seem reminiscent of those of doctors who fronted for the South African apartheid regime a generation ago, alleged 266 doctors and ethicists.

In a letter to The Lancet, the group saw "strong parallels" to the case of South African activist Steven Biko, who was beaten to death in police custody 30 years ago this week only to have South African doctors say he died of the effects of a hunger strike.

The U.S. medical establishment is turning a blind eye to abuses similar to those committed by the doctors involved in Biko's death, alleged the letter, citing reported suicides and suicide attempts at Guantanamo.

For example, medical authorities at Guantanamo "misclassified" suicide attempts, assigning them "a number of non-medical definitions," according to Steven Miles, M.D., of the University of Minnesota, one of the lead signers of the letter.

Also, said the letter, there is as yet no formal report into three suicides last year at the facility at Guantanamo, where about 460 prisoners of the war on terror are being held.

Dr. Miles, the author of Oath Betrayed: Torture, Medical Complicity and the War on Terror, accused the American Medical Association and state licensing boards of falling down on the job.

"The AMA has refused to call for an investigation into the role of military medicine in these events," he said. "And licensing boards have declined to act." One state board found insufficient evidence of the allegations and another cited a lack of jurisdiction.

The authors argued that "the failure of the U.S. regulatory authorities to act is damaging the reputation of U.S. military medicine."

The AMA denied the accusations, pointing out that the U.S. military in Guantanamo put roadblocks in the way of an association fact-finding mission.

"Since the questions of detainee abuse first surfaced, AMA leaders have met on several occasions with high-ranking officials at the United States Department of Defense to advocate for the treatment of detainees that is consistent with AMA ethics policy," said Edward Langston, M.D., a family physician in Lafayette, Ind., and chairman of the AMA's board of trustees.

Dr. Langston said in an e-mail that AMA representatives have visited Guantanamo, "but our access was limited and at no time did we have a chance to speak with the detainees."

Because of those obstacles, he said, "we are unable to determine with any certainty if ethical policies prohibiting physician involvement in torture are being adhered to."

The association will continue to monitor the situation and "advocate" for ethical treatment of detainees, he said

The AMA has said that doctors should not take part in interrogations and force-feeding, commented George Annas, J.D., an ethicist at Boston University, but overall "the silence of American medicine has been overwhelming." He was not a signer of the letter.

The military has said publicly that doctors involved in force-feeding prisoners feel they are acting ethically, Dr. Annas said. But he added that such a process - especially when prisoners are strong enough that they must be restrained to make it possible - is contrary to what most ethicists would regard as permissible.

But it's "not on the same level" as the case of Biko, an anti-apartheid activist who died of head trauma after he was beaten in custody. "It's in the same category, but it's way at the other extreme," Dr. Annas said.

Force-feeding is "not going to rise to the level of murder," he said, because the motivation is different, but that doesn't justify it.

In The Lancet, Dr. Miles and colleagues noted that there were "gross inadequacies" in the medical care Biko received, including falsification of records. Yet it was not until several years later that the physicians involved were disciplined for their role in the death.

The AMA's House of Delegates last year adopted a report saying it's unethical for doctors to take part in prisoner interrogation. The report, by the association's Council on Ethical and Judicial Affairs (CEJA), said doctors:

• "Must neither conduct nor directly participate in an interrogation."
• "Must not monitor interrogations with the intention of intervening in the process, because this constitutes direct participation in an interrogation."

Also, when physicians "have reason to believe that interrogations are coercive, they must report their observations to appropriate authorities," the report said.

"If authorities are aware of coercive interrogations but have not intervened, physicians are ethically obligated to report the offenses to independent authorities that have the power to investigate or adjudicate such allegations." (AMA: Prisoner Interrogation Unethical for Physicians, Declares AMA Panel)

The CEJA report is "an important advance," Dr. Miles said, although he added it should have been stronger, specifically by proposing sanctions for doctors who disobey the rules.

The American College of Physicians in 2004 called for a broad government investigation into allegations of mistreatment of prisoners, both at Guantanamo and elsewhere, and urged the AMA to join that push.

The ACP had no immediate comment on The Lancet letter.

Dr. Miles said that American medicine has had a history of opposing torture in other lands and of supporting doctors overseas who fight against torture.

The current situation, he said, is "undermining" the ability to take strong stands against torture. "How do we restore the moral authority of American medicine," he asked.

There was no immediate comment from the U.S. Army Medical Department.