Molecular Biology
No Other Way Out for Iron

Infectious Disease
Milestone Reached, But Campaign Against Polio Continues

Developmental Biology
Stem Cell Niche Discovered in Placenta

Medical Practice
Dual Loyalties at Abu Ghraib: Squeezing Ethics out of Care

Leak-patching Protein Shuts Down Tumor Growth, Swelling

Specialization Seen in Chromatin Remodelers

Study Plays Cat and Mouse with Development of the Visual Cortex

Proceedings of the HMS Faculty Council

Donor Funds Labs for Aging Research

MassCURE to Advocate for Regenerative Medicine

Lemelson Prize Awarded for Innovations in Cancer and Stroke

Match Day Links One Third of Fourth-years to Internal Medicine Residencies

Honors and Advances

Consortium Formed for RNA Interference

AIDS and Isolation Among the Navajo

Front Page

Dual Loyalties at Abu Ghraib: Squeezing Ethics out of Care

Earlier, before the camera shutter snapped on a pile of naked men squirming and screaming under the grins of U.S. guards, a nurse was called into the room to examine one of the prisoners, a man who had collapsed during a violent interrogation. The nurse faced a dilemma: should she abide by Abu Ghraib’s unspoken strictures and say nothing about the beaten men or should she report the incident, going against her colleagues to lobby for her patients? The nurse, like many medical professionals at Abu Ghraib and Guantanamo Bay, chose to do nothing, remaining complicit in the guards’ abuses.

Robert Jay Lifton (left) and Leonard Rubenstein discuss ways to avoid dual loyalty conflicts in military prisons. (Photo by Liza Green, HMS Media Services)

At a forum sponsored by the HMS Division of Medical Ethics on March 1, three experts discussed why these professionals made the choices they did, and how to help future medical personnel choose differently.

The speakers asked the audience to envision the nurse and her colleagues, medical professionals who falsified medical records, tampered with corpses, and collaborated with violent and humiliating interrogations. “Imagine what it’s like to be a medical professional at Abu Ghraib or Guantanamo Bay,” said Leonard Rubenstein, executive director of Physicians for Human Rights. “You are alone, you’re surrounded by the military, the pressure can be enormous.”

This pressure was the result of dual loyalties, conflicts between obligations to patients and obligations to a third party, which Rubenstein, Steven Miles, and Robert Jay Lifton said existed in the military prisons. Medical workers were caught between their duties to their patients and their duties to the military.

Dual loyalty has historically been a problem, especially in relation to human rights. Doctors have been complicit with state-sponsored torture before, in Iraq under Saddam Hussein and in Nazi Germany, for instance, and have given inadequate treatment in South Africa. According to Rubenstein, traditional medical ethics models do not address dual loyalties.

“The doctors at Abu Ghraib were part of a military structure that orchestrated torture until it became normal.”

The loyalty conflicts in the detention centers were created by military orders, group pressure, and an atmosphere that thrived on dehumanizing prisoners. Miles, professor of medicine at the University of Minnesota Medical School, outlined a series of government memos and initiatives that helped create medical complicity. Among other things, the regulations required detainees to be declared physically fit for interrogation and gave interrogation leaders power over detainees’ medical treatment. “The doctors at Abu Ghraib were part of a military structure that orchestrated torture until it became normal,” said Lifton, HMS lecturer in psychiatry at Cambridge Hospital and distinguished professor emeritus of psychiatry and psychology at the City University of New York.

Medical abuses at Abu Ghraib ranged broadly in their significance. When Miles researched the prison’s medical treatment, he found that medical records and death certificates were falsified, clinicians had given interrogators their subjects’ medical histories, medical assistance was denied, and medical professionals had consistently failed to report injuries and deaths caused by torture. In some instances, health workers directly aided torture. Miles related one incident in which a doctor called to suture a beaten prisoner gave the suture materials to the man’s attacker, a guard, and allowed him to treat the wound unsupervised.

The speakers argued that health workers have a special duty to protect people. Lifton pointed to the unique respect accorded to medical professionals, and said that their presence can “medicalize a criminal event.” Rubenstein agreed, saying that “health personnel should never be instruments by which the state commits human rights violations.”

In collaboration with the International Dual Loyalty Working Group, Rubenstein came up with a series of proposals to deal with future dual-loyalty dilemmas. They proposed initiating a standard-setting authority to establish general guidelines on when doctors can allow other obligations, such as the health of a third party, to take priority over their patients’ health. “The decision of how to act [in a dual-loyalty situation] shouldn’t be made by a command authority or a doctor,” said Rubenstein.

As long as some doctors neglect to help their patients, like those at Abu Ghraib and Guantanamo Bay who failed to do so, Rubenstein sees an opportunity for medical professionals to make a difference. “Until [medical complicity in abuse] ends,” he said, “we need to mobilize people.”

—Rebecca Tinkelman

top