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Medical Ethics and the Detainees At Guantanamo Bay

On October 19 at 8 a.m., I climbed aboard a Navy jet with the surgeon general of the United States, the surgeon general of the Army, the assistant secretary of defense for health affairs, and a small group of U.S. medical and psychological leaders. Our destination was the detention camp for suspected terrorists at the U.S. Naval Station at Guantanamo Bay, Cuba.

This visit, in part, came about as a result of a letter I wrote last July to the Department of Defense expressing APA's significant concern about the participation of psychiatrists in providing consultation to military interrogators. I wrote that this participation "could be construed as facilitating treatment of prisoners in a manner inappropriate to psychiatry and possibly in violation of medical ethics." To its credit, the military responded by inviting me and other medical leaders to tour the detention camp firsthand and to have a frank discussion about medical ethics.

Our plane landed at 11 a.m. After a 20-minute boat ride to the naval installation at Camp Delta (a newly constructed prison for 505 detainees from Afghanistan, Iraq, and other Middle Eastern countries), we had a two-hour briefing and a question/answer period with the commander of the Joint Task Force at the base and other base leaders. We then walked through the prison complex, observed the detainee hospital, and viewed the newly opened, almost $3 million psychiatric wing. The med/surg hospital looked like a community hospital, and we met with the highly qualified staff. The psychiatric wing looked "state of the art" for a short-term psychiatric unit. We did not interview any detainees, speak to any detainees' lawyers, or witness any interrogations. We left Guantanamo by 5 p.m.

At 8 p.m. we returned to Andrews Air Force Base and began a spirited three-hour discussion over dinner. I distributed an APA position statement that is awaiting action by the Assembly regarding psychiatric participation on interrogation of detainees. This statement was developed by our Council of Psychiatry and Law, chaired by Paul Appelbaum, M.D., with input from the APA Ethics Committee, the Committee on Judicial Action, the Committee on Misuse and Abuse of Psychiatry, and representatives of military psychiatry. I read aloud from the third paragraph, "Psychiatrists should not participate in the interrogation of persons held in custody by military or civilian investigative or law enforcement authorities, whether in the United States or elsewhere, nor should they provide information or advice to military or civilian investigative or law enforcement authorities regarding the likely consequences of specific techniques of interrogation that are in any way particularized in its application to an individual detainee."

The role of Behavioral Science Consultation Teams in interrogation was a focus of widely read articles in the New Yorker and New England Journal of Medicine earlier this year.

It quickly became apparent that the APA position (supported by colleagues from the AMA) contrasted with the view of the American Psychological Association. The other APA has taken the position that "[p]sychologists may serve in various national security roles, such as consultant to interrogation, in a manner that is consistent with the ethics code, and, when doing so, psychologists are mindful of factors unique to these roles and contexts that require ethical consideration."

The military health leaders asked us to explain the difference. Why, they asked, might psychiatrists object to participating in interrogations but not psychologists?

In responding for psychiatry, I emphasized our Hippocratic training, our profound ethical obligation to patients, and our abiding concern that such consultation can involve psychiatrists in facilitating deception and cruel and degrading treatment. I argued that the other APA is wrong in permitting skills developed for healing to be used for gaining intelligence. (As the discussion wore on, I thought—but did not say—that such ethical differences between psychiatrists and psychologists are why limits are needed on the scope of practice of nonmedical professions.)

The surgeons general and other distinguished medical military leaders appeared to listen carefully. They were clearly not of the same mind on this subject. Their job is difficult, and they struggle under conflicting pressures. Yet, I continued to urge them to respect medical ethics and bar psychiatrists from interrogation teams as soon as possible.

The other issue we discussed at length was the handling of detainees, called "enemy combatants," who were on a hunger strike. Eleven of these were being fed via NG tubes and were being closely monitored medically. The ethics of forced feeding, the life-and-death issues being confronted, and the status of the detainees were all issues raised and debated.

I made it home at midnight. Soon after closing my eyes, I began to dream of a day when the detention center at Guantanamo Bay could close for good.

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