6But then came the stories about Cuba… Not only questions of legality at GTMOMedical complicity?Breech of trust?Medical support of interrogations?
7Questions to Address Why are we in this predicament? What is in place to guide physicians?What is unique about military physicians?What is in place to guide us?What can we do to better prepare physicians for ethical quagmires?
8Why are we in this predicament? United States: Higher moral authorityBelieve we are just and rightJust war, just causeOpen society; free pressWe air our dirty laundryUsually come to the right answerAllegation of medical complicityWorld-wide press
9Don’t always believe what you read! 'Newsweek' retracts Koran desecration storyBy Bill Nichols, USA TODAYWASHINGTON — Newsweek magazine formally retracted on Monday a story published last week that said U.S. interrogators of Muslim prisoners at Guantanamo Bay desecrated the Koran."Based on what we know now, we are retracting our original story," Editor Mark Whitaker said in a statement. Whitaker had written in the magazine's latest issue that the May 9 report might not be true but had stopped short of a retraction. (Video: Newsweek apologizes)Newsweek articleRetractionFalsify records?Must wait for the full reportThe investigative ball is rolling
10What I do know about GTMO? Receiving top notch medical careBetter care than prisoners in USAccess to physicians including mental healthNutrition and appropriate medicationsDetainee with pancreatic massDetainee with cardiac disease
12What is in place to guide all physicians? --Hippocratic Oath--System of Medical Ethics--ACP Ethics Manual--Geneva Conventions
13Hippocratic Oath Original (ancient version) Modern version Most medical schools in U.S. still give some form of this oath at graduation
14Hippocratic Oath “exercise my art solely for the cure of patients, and will give no drug,perform no operation fora criminal purpose, evenif solicited…”
15Framework of Ethics Respect for autonomy Beneficence An obligation to act for the benefit of othersIntentionally take positive steps to help others.Non-maleficenceAn obligation not to inflict harm on othersIntentionally refrain from actions that cause harmJustice
16Framework for Ethical Research Respect for PersonsBeneficenceJusticeThe Belmont Report, 1979
17ACP Ethics Manual 2005; 5th Edition Relation of the Physician to GovernmentPhysicians must not be a party to and must speak outagainst torture or other abuses of human rights. Participationby physicians in the execution of prisoners except tocertify death is unethical. Under no circumstances is itethical for a physician to be used as an instrument of government to weaken the physical or mental resistance of ahuman being, nor should a physician participate in or toleratecruel or unusual punishment or disciplinary activitiesbeyond those permitted by the United Nations StandardMinimum Rules for the Treatment of Prisoners (90).Ann Intern Med. 2005;142:
19Geneva ConventionsArose from the need to maintain some “humanity” during war in the 1800sPrisoners, woundedCivilians, displacedEstablished definitions and codified conductAccepted throughout Europe and U.S.
20Geneva Conventions Major revision after each World War. Most recent version signed by majority of world in 1949.US ratified this convention in 1955It applies within the US military for…“…all cases of declared war or of any other armed conflict…even if the state of war is not recognized by one of [the parties to the conflict].”
22Modern Four Conventions (1949) Convention IFor the Amelioration of the Condition of the Wounded and Sick in Armed Forces in the Field, Geneva, 12 August 1949: Sets forth the protections for members of the armed forces who become wounded or sick.Convention II For the Amelioration of the Condition of Wounded, Sick and Shipwrecked Members of Armed Forces at Sea,Geneva, 12 August 1949: Extends these protections to wounded, sick and shipwrecked members of naval forces.Convention III Relative to the Treatment of Prisoners of War, Geneva, 12 August 1949 lists the rights of prisoners of war.Convention IV Relative to the Protection of Civilian Persons in Time of War, Geneva, 12 August 1949: Deals with the protection of the civilian population in times of war.
23The Two Protocols (1977) Protocol I Additional to the Geneva Conventions of 12 August 1949, and relating to the Protection of Victims of International Armed Conflicts, 8 June 1977: Extends protection to victims of wars against racist regimes, wars of self determination, and against alien oppression.Protocol II Additional to the Geneva Conventions of 12 August 1949, and relating to the Protection of Victims of Non-International Armed Conflicts, 8 June 1977: Extends protection to victims of internal conflicts in which an armed opposition controls enough territory to enable them to carry out sustained military operations.
24Protected Persons under the Conventions “Non-Combatants”CiviliansMedical PersonnelThe Wounded, Sick, or DeadEnemy Prisoners of WarParachutists Escaping CraftChaplainsShipwrecked sailors
25Civilians Treat Civilians Humanely Respect their customs and religion Do not use them as hostages or shieldsProtect Civilians from…Violence and InsultSexual AssaultPillage or reprisalsNo displacementexcept in extreme cases and for protectionGC Article 8, Article 54, and others
26Medical Personnel Article 10: General Protection of Medical Duties “Under no circumstances shall any person be punished for carrying out medical duties compatible with medical ethics, regardless of the person benefiting therefrom.”Geneva Conventions
27Geneva Convention Emblems Red Cross on White BackgroundRed Crescent on White backgroundRed Star of David on White Background
28International Committee of the Red Cross ( ICRC ) The ICRC is an international humanitarian organization based in Switzerland whose role is formally recognized within the Geneva Conventions.The ICRC must be permitted to visit EPWs to monitor their treatment.Geneva Conventions
29Duties Owed to Enemy Prisoners of War (EPWs) Duty to Respect:Do not attack, kill, mistreat, or in any way harm a fallen and unarmed combatant.Duty to Protect:Render care as the combatant’s condition requires.Duty to provide humane treatment:Treat fallen combatants as one’s own wounded.There should be no adverse distinctions:based on factors of gender, race, nationality, religion, or political opinions.
30Obligations for humane treatment of EPWs Removal from combat zoneAllow surrenderDo not kill; and do safeguard from harmNo coercionProvide medical careDon’t take personal propertyAllow religious practiceDo not force EPWs to perform dangerous, humiliating, or war-related labor.
31The core of obligations for all armed conflict Common Article 3Regarding treatment of Prisoners of War“The following acts are and shall remain prohibited at any time and in any place whatsoever:Violence to life and person, in particular murder of all kindsMutilationCruel treatment and tortureOutrages upon personal dignityIn particular, humiliating and degrading treatment”
32Detainee Medical Care EPWs: Retained Personnel: Civilian Internees: We must provide medical and dental careRetained Personnel:Civilian Internees:Civilian Internees will, if possible, be moved to a civilian hospital, where treatment must be as good as that provided to the general populationBased on Geneva Conventions
33Detainee Medical Care EPWs: We must provide medical and dental care Retained Personnel:Civilian Internees:Civilian Internees will, if possible, be moved to a civilian hospital, where treatment must be as good as that provided to the general populationGeneva Conventions
34Commander and Chief“I hereby reaffirm the order previously issued by the Secretary of Defense to the United States Armed Forces requiring that the detainees be treated humanely and, to the extent appropriate and consistent with the military necessity, in a manner consistent with the principles of Geneva.”White House Memorandum,Washington, DC, 7 Feb 2002
35Article 17No physical or mental torture, nor any other form of coercion, may be inflicted on prisoners of war to secure from them information of any kind whatsoeverPrisoners who refuse to answer questions may not be threatened, insulted, or exposed to any unpleasant or disadvantageous treatment of any kind.
36Torture“The deliberate, systematic, or wanton infliction of physical or mental suffering by one or more persons acting alone or on the orders of any authority, to force another person to yield information, to make a confession, or for any other reason.”Tokyo Declaration, 1985World Medical Association
37Investigation of Detainee Deaths and Injuries A camp or hospital commander must appoint an officer to investigate and report each death or serious injury caused, or suspected to be caused, by “guards or sentries, another civilian internee, or any other person”.Geneva Conventions
38What is unique about military physicians? Dual loyaltyConflict resolution?New guidelines from Health Affairs
39Military Medical Ethics Dual LoyaltyMedical OathMilitary Oath“State-employed” physiciansOccupational HealthPrisonsComrades in ArmsNational securityInsert picture
40DUAL LOYALTY“When physicians have responsibilities and are accountable both totheir patients and to a third party and when these responsibilities andaccountabilities are incompatible,they find themselves in a situationof ‘dual loyalty ’.”WMA Ethics Manual, 2005
42Dual Loyalty Working Group “Military health professionals should refrain from direct, indirect, and administrative forms of cooperation in cruel, inhuman, and degrading treatment and punishment at all times, including in wartime and during interrogation of prisoners.”A health professional passively participates by permitting his or her clinical findings or treatment to be used by authorities to aid in the process of torture.
43A health professional… “…should not authorize, approve, or participate in punishment in any form, in any way, including being present when such procedures are being used or threatened.”“Indirect participation includes examinations to declare an individual “fit” for caning, shackles, solitary confinement, or any other kind of abuse or dietary restriction.”Dual Loyalty Working Group
44Dual Loyalty Working Group If a health provider experiences a conflict of interest between the duty to care for, and protect, an arguably legally unprotected "unlawful combatant" against abusive treatment, and the patriotic duty to protect and serve the interests of one's country, he or she should consider it their legal and ethical obligation to report or actively protest against such treatment to appropriate authorities.
46ASD-HA Principles:1.Health care personnel charged with the medical care of detainees have a duty to protect their physical and mental health and provide appropriate treatment for disease. To the extent practicable, treatment of detainees should be guided by professional judgment and standards similar to those that would be applied to personnel of the US Armed Forces.2. All health care personnel have a duty in all matters affecting the physical and mental health of detainees to perform, encourage, and support, directly and indirectly, actions to uphold the humane treatment of detainees.3. It is a contravention of DoD policy for health care personnel to be involved in any profession al provider-patient treatment relationship with detainees the purpose of which is not solely to evaluate, protect, or improve their physical and mental health.
47ASD-HA Principles:It is a contravention of DoD policy for health care personnel: (a) To apply their knowledge and skills in order to assist in the interrogation of detainees in a manner that is not in accordance with applicable law; (b) To certify, or to participate in the certification of, the fitness of detainees for any form of treatment or punishment that is not in accordance with applicable law, or to participate in any way in the infliction of any such treatment or punishment. 5. It is a contravention of DoD policy for health care personnel to participate in any procedure for applying physical restraints to the person of a detainee unless such a procedure is determined in accordance with medical criteria as being necessary for the protection of the physical or mental health of the safety of the detainee himself or herself, or is determined to be necessary for the protection of his or her guardians or fellow detainees, and is determined to present no serious hazard to his or her physical or mental health.
48ASD-HA Principles:1. Medical Records: Accurate and complete medical records on all detainees shall be created and maintained in accordance with reference (b).2. Treatment Purpose: Health care personnel engaged in a professional provider-patient treatment relationship with detainees shall not undertake detainee-related activities for purposes other than health care purposes. Such health care personnel shall not actively solicit information from detainees for purposes other than health care purposes. Health care personnel engaged in non-treatment activities, such as forensic psychology or psychiatry, behavioral science consultation, forensic pathology, or similar disciplines, shall not also engage in any professional provider-patient treatment relationship with detainees.
49What can we do to better prepare physicians for ethical quagmires?
50Preparation Read Be Informed Plan scenarios EPWs, civilians, refugees, etc…Discuss issues with other physiciansDiscuss issues with non-physiciansChaplainsCommanding Officer / XO
51World Medical Association Established in 1947; response to WWIIIndependent organizationOver eighty member organizationsAMA, BMA, etc…Created to ensure the independence of physiciansWork for the highest possible standards of ethical behavior and care by physicians
52World Medical Association --Published in 2005--Free download on web--Free copies by mail
53The Borden Institute Military Medical Ethics Free 2-volume set Worth readingOrder on website.
58ACP Ethics Manual 2005 5th Edition Ann Intern Med. 2005;142:
59Up and coming… Web-based teaching on ethics More rigorous ethical curriculum at USUHSMore exposure to Military Medical Ethics in OIS
60Summary Military medical ethics Longstanding problem Tougher than good medical careKnow the guidelinesDo your homeworkSeek adviceDo the right thing (if not sure, advise what is best for the patient, detainee, EPW, etc…)