The Bioethics of War

The demands of national security can place tremendous pressure on ethics. Since 9/11, professionals of all kinds—from doctors and lawyers to journalists and academics—have felt the need to reconsider and in some cases reformulate accepted understandings of their ethical responsibilities. Yet history shows that the urgent re-framing of ethical norms in order to serve the ends of national security can often be a matter of profound regret once the apparent threat subsides.

The recent publication of two books tackling the relationship between medical ethics and national security is therefore to be welcomed. These texts are not alternatives, but counterweights to each other. One, written by an American physician and well-known bioethicist, seeks to reaffirm the therapeutic and caring roles of medical professionals and to resist those who would subvert—and have subverted—those roles in the name of counterterrorism. The other, written by an Israeli political scientist who focuses on bioethics, seeks to challenge perceived wisdom regarding the ethical responsibilities of health professionals in the face of war and terrorism.

Steve Miles tells us that he was prompted to write Oath Betrayed by the nagging question: "Where were the doctors and nurses at Abu Ghraib?" To answer this question, however, one must look beyond the walls of the infamous prison. As Miles's book makes clear, the complicity of health care professionals in detainee abuse in the war on terror is not confined to Abu Ghraib, and it raises several legal and ethical questions of substantial import.

The book begins with a brief history of torture—both licit and illicit—and draws repeatedly on legal materials such as the Geneva Conventions and the Torture Convention. But Oath Betrayed is an avowedly ethical rather than legal account, albeit one that draws rhetorical force from legal materials as well as codes of medical ethics.

Examining the conduct of several military medical personnel through this lens, Miles finds his subjects—many of whom are named—more than wanting. He claims that physicians and psychologists may collaborate with those who torture or abuse prisoners in six ways: by certifying prisoners as fit for harsh interrogation; by monitoring and treating them during interrogation; by concealing evidence of abuse through the design of "nonscarifying techniques" or failure to record injuries in medical documents; by conducting abusive research; by overseeing the systematic neglect of prisoners' basic needs, including health care; and by keeping silent while abuse is ongoing (p. 31). Miles sought evidence of such complicity by perusing thousands of pages of documents obtained by the American Civil Liberties Union, together with press clippings, military reports, and already-published work. With the notable exception of abusive research, he finds incriminating material for most kinds of complicity in his taxonomy.

Complicity is, of course, more readily understood in some cases than in others. A physician at Abu Ghraib once told me, for example, that two of his platoon medics initially kept silent about the abuse of a prisoner when thinly veiled threats were made on their lives. (The same physician also described severely limited medical resources at the Abu Ghraib facility—a problem, he claimed, he had not been in a position to remedy.)

However, the systematic involvement of health professionals in aggressive interrogation is, for many, the most troubling form of complicity. Acting as behavioral science consultants, psychiatrists and psychologists at Guantanamo Bay and Abu Ghraib advised interrogators on how to conduct interrogations that exposed detainees to severe physical and psychological stressors. Miles's description of these techniques as "non-scarifying" is somewhat puzzling, since many psychological stressors were designed specifically to scare the detainees. Preexisting phobias—in one case, fear of the dark (recorded on a detainee's medical records)—were deliberately exploited.

Miles reserves some of his harshest criticisms for behavioral scientists. "It is one thing," he observes, for "clinicians to train an interrogator in rapport-building and cross-cultural communication. It is quite another to use psychological, medical and cultural information (especially when obtained in a clinical encounter) to degrade, frighten or inflict physical distress on a person" (p. 67). The Department of Defense has defended physicians acting as behavioral science...