The Tortured Patient: A Medical Dilemma

Torture is unethical and usually counter-productive. It is prohibited by international and national laws, and by a panoply of professional codes. Yet it persists: according to Amnesty International, torture is widespread in more than a third of countries. ¹ Physicians and other medical professionals are frequently asked to assist with torture. For example, a recently de-classified CIA report on interrogation at Guantanamo Bay states: "OMS (Office of Medical Services) provided comprehensive medical attention to detainees ... where Enhanced Interrogation Techniques were employed with high value detainees". ² Such "high value detainees" were exposed to death threats with handguns and power drills, water boarded more than 180 consecutive times, and subjected to lifting "off the floor by arms, while arms were bound behind his back with a belt", ³ a mediaeval form of torture known as Strappado.

The medical professionals described in this extract might not have actually engaged in torture. But by providing medical attention to prisoners subjected to practices that the Inspector General defined as "un-authorized and inappropriate", ⁴ and that most commentators consider torture, ⁵ some were surely complicit in it.

Medical complicity in torture, like other forms of involvement, is prohibited by international law and codes of professional ethics. However, when the victims of torture are also patients in need of treatment, doctors can find themselves torn. To accede to the requests of the torturers may entail assisting or condoning terrible acts. But to refuse care to someone in medical need may seem like abandoning a patient and thereby fail to exhibit the beneficence expected of physicians.

In this paper, we argue that this dilemma is real and that sometimes the right thing for a doctor to do requires complicity in torture. Though complicity in a wrongful act is itself prima facie wrongful, this judgement may be outweighed by other factors. We propose the following criteria for analysing how those factors apply to particular cases of medical complicity in torture.

• • First, doctors should assess the consequences of the different options open to them, including for themselves, for the patient, and the possible wider social effects, such as encouraging or discouraging policies that permit torture.

• • Second, doctors should attempt to discern and follow the requests of the patient regarding his or her care.

• • Finally, doctors should weigh the degree to which the act would be complicit in torture.

Where complicity is justified, it should also be minimised and we provide some analysis of how this can be achieved. As with other difficult ethical dilemmas, there is no formula for determining the right course of action; careful judgement must be used to weigh these moral factors in different situations. Our analysis provides a way to think through such dilemmas, and takes them seriously, in a way that blanket prohibitions on medical complicity in torture fail to do.

We should make two preliminary points about the scope of our argument. First, throughout we assume that the acts of torture with which doctors are asked to be involved are unethical. Though there remains some debate over the permissibility of torture in narrowly specified, extreme cases, ⁶ the vast majority of real acts of torture do not fit these specifications. ⁷ For those who do think that torture could be justified in some circumstances, we ask that they restrict themselves here to consideration of cases they believe to be unethical. Second, while we generally use the example of doctors, our arguments apply equally to other medical professionals, such as nurses and psychologists, who may also be asked to involve themselves in torture.

Physicians and Torture

According to the UN Convention against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment:

the term "torture" means 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...