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4 8 Physician facilitation of torture and coercive interrogation
The Case
A suspect informs police that he has buried a 5 year-old girl in a box with a limited air supply. Standard interrogation techniques have failed to ascertain the girl’s location and it is believed she may have only several hours to live. A judge authorizes torturing the suspect to obtain the girl’s location. The proposed method of torture is to have an anesthesiologist administer a paralytic drug to the awake prisoner, and then allow the prisoner to experience periods of awake paralysis without respiratory support. This will result in acute hypercarbia, severe dyspnea, and an experience of awake suffocation. After a period of time, time the anesthesiologist will be instructed to ventilate him with a bag and mask, reverse the paralytic, and allow him to answer questions. The technique will leave no lasting physical disfigurement or disabilities.
This type of scenario, known as the “ticking time bomb scenario” is often proposed as one in which torture might be justified. Some authors suggest that in cases of “ticking time bomb scenarios,” not only is torture possibly justified, but that it should be regulated by judicial warrant and oversight.1
Torture is the deliberate infliction of mental and physical suffering in order to overcome resistance or to sufficiently disorient prisoners so that the torturer can intimidate, extract information, and obtain confessions. Methods of physical torture include, but are by no means limited to, beating, choking, stressful positioning, “simulated drowning”a and use of electric shock. Methods of psychological torture involve sensory manipulation, sleep deprivation, exploitation of phobias, and humiliation. Torture is performed during peace and wartime – by state policy or by individual decision. “Participation in torture” is not necessarily confined to administration of the coercive technique itself. Historically, medical personnel have participated in torture by evaluating prisoners for interrogation, monitoring coercive interrogation, allowing interrogators access to medical records of the prisoners to develop their interrogative approaches, falsifying medical records and death certificates, and failing to provide even basic healthcare.2
All mainstream medical ethicists unwaveringly reject torture as an affront to the fundamental and absolute right of all humans to dignity. We shall consider the morally impermissible nature of torture (as well as of coercive interrogation), the ethical prohibition of physician participation in torture, and the dilemma of dual loyalties facing physicians requested or mandated to participate in such universally condemned activities.
International statements banning torture
Arguments prohibiting torture are straightforward and powerful. Perhaps the most potent argument is the psychological, emotional, cultural and legal prohibition to treat people inhumanely. For that reason, a number of agreements and statements ban torture.3 For example, the 1984 Convention Against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment from the United Nations4 states:
Torture and other cruel, inhuman or degrading treatment or punishment are particularly serious violations of human rights and, as such, are strictly condemned by international law.
The Convention declared that no “exceptional circumstances” and no legal authority may supersede this absolute prohibition.
For long periods of history, torture was legal, and physician participation was common. Following revelations about atrocities during World War II, Western nations condemned torture through documents such as the Geneva Conventions and statements from the international medical tribunal at Nuremberg. In 1982, the United Nations reiterated the foundational ethical medical principle of nonmaleficence (primum non nocere – first do no harm), imploring physicians to adhere to this dictum when requested – or ordered – to participate in medical interventions that are not intended to be beneficial:
It is a great contravention of medical ethics, as well as an offence under applicable international instruments, for health personnel, particularly physicians, to engage, actively or passively, in acts which constitute participation in, complicity in, incitement to, or attempts to commit torture or other cruel, inhuman or degrading treatment or punishment.5
The World Medical Association has repeatedly made declarations against physician participation in torture as well as in other cruel, inhumane or degrading practices. In particular, it iterated that:
Medical ethics in times of armed conflict is identical to medical ethics in times of peace … [and that] … if, in performing their professional duty, physicians have conflicting [dual] loyalties, their primary obligation is to their patients.
The American Medical Association lends even further support by calling upon physicians to support victims of torture, reject the use of torture, and endeavor to change situations in which torture is practiced.6
Treaties and statements prohibiting torture encourage states not to torture so that their enemies also will not torture. For example, the prohibition on gas warfare was effective in World War II because each side feared that initiating gas warfare would result in a similar enemy response. The moral clarity provided by statements may enable states to refrain from torture regardless of enemy actions. In addition, torture rents the fabric of both the torturer and the community. If torture were to become acceptable within society, it may become psychologically easier to permit other immoral acts.
Some commentators suggest that torture may be acceptable under certain conditions,7 but that torture should be a last resort only after other less intrusive measures have failed. They further declare that interrogators would need robust reasons for believing that the prisoner has the desired information, and that such information must have immediate benefits for reducing or preventing imminent harm. Under these specific conditions, they contend, torture may be worth its associated harms. However, these authors further opine that torture should not be used to force confessions or to uncover unspecified, future crimes. Other gross considerations may include the likelihood that the information is accurate and the potential benefits such as lives saved from the information.
No studies confirm or deny the relative accuracy of torture in extracting accurate information, or how often information obtained from torture has saved lives. Many experienced interrogators believe that torture is less likely to lead to accurate information than other techniques such as relationship building. If the rate of success is relevant in deciding whether to torture, however, this implies that the decision to torture should be based on risks and benefits. From an ethics point of view, if torture is wrong because it is an affront to human rights and dignity, then it is always wrong, regardless of the rate of success.
Returning to the case example at the beginning of this chapter, we find that the kidnapped girl in the box is an example of a scenario that fulfills many of these aforementioned requirements. The confessed perpetrator has provided sufficient evidence to prove his participation and knowledge of the crime (to help rule out coerced confession), less invasive methods have failed, and time-sensitive results will immediately benefit the kidnapped girl. Presumably acting in good faith, interrogators desired to avoid torture, but feel compelled by their obligation to help the girl. Importantly, the judge, a formal authority operating within her jurisdiction of protecting others, has approved proceeding, so there is no legal impediment. False leads will not cause a misallocation of limited resources that otherwise might expose society to other harms, and the information can be quickly confirmed or disproven.
Related posts:
Informed consent and the pediatric patient
The use of ethics consultation regarding consent and refusal
Revising the Uniform Anatomical Gift Act – the role of physicians in shaping legislation
Animal subjects research Part I: Do animals have rights?
Disclosure of medical errors in anesthesiology practice
Opioid therapy in addicted patients: background and perspective from the US
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