# Medical Ethics Set Aside?



## Armymedic (22 Aug 2004)

Possibly a case of Duty vs Ethics? 
Where do you just follow orders or deny orders because of medical ethics? This should raise some good debate....

http://www.signonsandiego.com/news/military/20040821-1019-doctors-abughraib.html

Doctors don't leave ethics behind when they join the military, experts say 

By Marilynn Marchione
ASSOCIATED PRESS
10:19 a.m. August 21, 2004

Suspected of having condoned the torture of Iraqi prisoners, some American military doctors now face ugly comparisons to soldier-physicians who conspired in abuses by Saddam Hussein, Adolf Hitler and other dictators. 

Although the Americans' alleged misconduct is far less severe, some say it is made worse because they did not have to fear being killed if they didn't cooperate. 

"I don't think there are shades of gray," said Dr. Vincent Iacopino, director of research for Physicians for Human Rights. "If they did not have the immediate threat of harm, they had the obligation if they witnessed abuses to say something about them." 

The Defense Department issued a statement Friday taking "strong exception" to allegations made last week in the British medical journal The Lancet. An article by an American professor said doctors at Baghdad's Abu Ghraib prison falsified death certificates to hide killings, hid evidence of beatings and revived a prisoner so he could be tortured more. 

The Defense Department says there is "no evidence" of that and objects to what it calls the "wholesale indictment" of U.S. medical personnel and care in Iraq. The statement says that if an ongoing investigation finds guilt, "those responsible will be held accountable." 

Medical ethicists say that being silent while patients are harmed is a profound breach of ethics and the oath that doctors take. They have called for reforms of military medicine, more training for doctors to recognize signs of torture, and an independent, non-military-led investigation of the scandal. 

The Lancet article was written by Steven Miles, a University of Minnesota professor who has researched human rights issues for 20 years. It was based on media reports, congressional testimony, sworn statements of detainees and soldiers, and medical journal accounts â â€œ not events he witnessed firsthand. 

Miles does not shed light on how many doctors were involved or how widespread the problem of medical complicity was, aspects he says he is now investigating. 

The Lancet report follows an essay in the July 29 New England Journal of Medicine by Dr. Robert Jay Lifton, a Harvard Medical School psychiatrist, noting mounting reports of abuses and urging military doctors to come forward with what they know. He alluded to incidents in the past where doctors had roles in torture or abuse, including the brutal experiments by Joseph Mengele and other Nazi doctors during World War II. 

Being a doctor and being a soldier are not conflicting duties, said Martha Huggins, an author, sociologist and longtime torture researcher from Tulane University who spoke in June at an American Association for the Advancement of Science conference on the topic. 

Even if officers or other military personnel were abusing prisoners and detainees, it doesn't mean the system expects a doctor to be complicit, she said. 

"They put you in that position. They have validated that they want you to be a doctor," and that means doing no harm, Huggins said. 

The American Medical Association has long had a policy against doctors joining in abuse "in any form," said Dr. Michael Goldrich, chairman of its council on ethical and judicial affairs. 

"Participation in torture by physicians is the most egregious concern, but there are other levels that can range from physicians caring for patients to facilitate their return to interrogation and torture, or just awareness of the ongoing presence of torture," he said. 

But written policies against abuse often fall away under the pressure of the kind of counterinsurgency war going on in Iraq, Lifton said. It's especially dangerous when the enemy is unclear and elusive, the war is on foreign and hostile territory, and involves non-whites, he said. 

"In that kind of situation, you're likely to get atrocities that can include doctors," he said. 

The messages doctors get from their leaders is important, Lifton said. 

"It's one thing to have principles. It's another to be in a particular situation where the command environment powerfully either endorses, promotes or at least does little to discourage torture or abuse of prisoners," he said. 

How this scandal is investigated and whether better monitoring and accountability come out of it are important, Iacopino said. 

"There needs to be leadership to enforce effective documentation (of abuses) and to send a clear signal that this is what's wanted from health professionals, not complicity," he said. 

Scandals like this also could undermine humanitarian work that many doctors do in war-torn countries for groups like the International Committee of the Red Cross and Doctors Without Borders. 

"A doctor in a military prison or a prisoner of war camp is the first and last defense against human rights abuse," Miles said. "It is very important the doctors take seriously their independent stature...from the prisoner's side, if the doctor is silent or actively complicit in abuses, it tells the prisoner that you are completely beyond human concern, that you are completely lost."


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## George Wallace (22 Aug 2004)

A scary dilemma for one to face.  Ethics should be followed, but even then, as seen in our Somalia Affair, one can see one's career end by doing the 'Right thing' and be ostracized by one's peers and associates.  Last I heard, that Dr. left the Forces for a Civilian practice in Kanora.

GW


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## Bruce Monkhouse (23 Aug 2004)

But written policies against abuse often fall away under the pressure of the kind of counterinsurgency war going on in Iraq, Lifton said. It's especially dangerous when the enemy is unclear and elusive, the war is on foreign and hostile territory, and involves non-whites, he said.

Anything in this article that this "person" stated is tainted by that ridiculous statement. Good article, was closely reading as seemed like a good discussion topic then.....BOOM..next!


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## Armymedic (23 Aug 2004)

Indeed George, the example I was thinking as I posted this thread....

Bruce, its much easier to set aside ethics when you feel the "patient" is not equal to you. Such is the case for German Doctors in WW2. The Jews were suitable test subjects because they could kill them duiring thier experiments because it was condoned by the gov't of the day as Jews were considered sub-human.

So racism has a place in this discussion.


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## Bruce Monkhouse (23 Aug 2004)

OK, good point, my friend. I guess I'm a little senstive to the racial thing as it seems to get used like a tar-brush,to paint everyone the same.
OK, back to topic,  to clue me in, what would be the" legal" repercussions of a doctor who saw, but did not partake in, this kind of torture or would there be any?


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## Brad Sallows (23 Aug 2004)

Has anyone read a print or on-line source which verifies any of the allegations (transcript of testimony, first-hand account)?  Everything I've read so far is hearsay.


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## Armymedic (23 Aug 2004)

I have yet to see anything but allegations. There have been rumors of this type since the story broke earlier this yr...

The problem for a Doctor who was witness to torture, IMHO, would be two fold. Before I go into this, I must qualify this with being a North American standard of ethics. 

First, being witness to the actual crime of torture, or something lesser such as mistreatment of prisoners with the purpose of gaining info. As per the case of the Airborne Bg MO in Somalia, you choice is cut and dry. You report it to your chain of command, as you any other crime.

Second, having to revive or treat the patient so that he is able to undergo more questioning...Intresting dilemma...Do you revive him quickly as to gain th informantion in a timely manner or do you protect the detainee from futher abuse at the risk that no info may cause the death of more of your soldiers? Or do you refuse to treat him, and act contrary to the need of the detainee in preserving his life?


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## ModlrMike (24 Aug 2004)

Bruce Monkhouse said:
			
		

> OK, back to topic,   to clue me in, what would be the" legal" repercussions of a doctor who saw, but did not partake in, this kind of torture or would there be any?


As Canadian Forces members are subject to the Criminal Code of Canada at all times (even when serving overseas), there are a number of potential charges. The NDA also has a number of charges, and then there is the section that deals with not following patently illegal orders.


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## Michael Dorosh (24 Aug 2004)

ModlrMike said:
			
		

> As Canadian Forces members are subject to the Criminal Code of Canada at all times (even when serving overseas), there are a number of potential charges. The NDA also has a number of charges, and then there is the section that deals with not following patently illegal orders.



I believe this is also all encapsulated by the Canadian Forces Code of Conduct.


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## Armymedic (24 Aug 2004)

ModlrMike said:
			
		

> As Canadian Forces members are subject to the Criminal Code of Canada at all times (even when serving overseas), there are a number of potential charges. The NDA also has a number of charges, and then there is the section that deals with not following patently illegal orders.





			
				Michael Dorosh said:
			
		

> I believe this is also all encapsulated by the Canadian Forces Code of Conduct.



Indeed there are reprecussions within the Code of Conduct for taking part. But what of knowing (but not actually witnessing) activites going on, what charges could be brought, what ethical guideliness are you bending?


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## Michael Dorosh (24 Aug 2004)

That sort of brings it down to the level of cheating in school, or something.   I would imagine the burden of proof would be on your accusers to prevent evidence that you knew.

If you admitted to knowing or it was proven you knew, I can only offer conjecture.   Has such a case ever been in the news?   Aside from Somalia (was Kenward his name?) I don't know of any Canadian examples.

I think an officer who knew _during the commission of the crimes_ would be guilty of not trying to prevent or stop the illegal actions, or of failing to report to his superiors.   As for _after the fact_, you could be found guilty of not reporting the crimes, but that would be about it, no?

If the guilty parties outranked you, you would still be reasonably expected to attempt to stop any illegal activities if you knew about during, or witnessed the actual commission, of the crimes themselves.


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## ModlrMike (24 Aug 2004)

Michael Dorosh said:
			
		

> I think an officer who knew _during the commission of the crimes_ would be guilty of not trying to prevent or stop the illegal actions, or of failing to report to his superiors.   As for _after the fact_, you could be found guilty of not reporting the crimes, but that would be about it, no?


This gets into the concept of "acts of ommission". Indeed, criminal negligence can be that you did something negligent (act of commission) or did not prevent something negligent (act of ommission). The determining factor in culpability would be that you knew, or should reasonably have known that you had a duty to stop the illegal actions.



			
				Michael Dorosh said:
			
		

> If the guilty parties outranked you, you would still be reasonably expected to attempt to stop any illegal activities if you knew about during, or witnessed the actual commission, of the crimes themselves.


Not only would you be reasonably expected to, you would be obliged by law. The rank of the individual committing the crime has nothing to do with your duty to report it, although it may have much to do with the way in which you report the crime.


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## Brad Sallows (24 Aug 2004)

From general principles, the moral and ethical duty is to provide the best possible care for the patient.  Whether the patient will be again subjected to mistreatment is a moral and ethical decision to be made by another.  A second duty is to inform the abuser that his behaviour was wrong, that it will be reported up the chain, and counsel him to not repeat it.  A third duty is to report the incident up the chain.

As a leader: once you know something, you must act.  You must not refuse information in the belief that you are not responsible if you don't know.  Not only must you neither ignore nor refuse information, you must take reasonable steps to pre-empt (education and demonstration) and interdict (supervision) misdeeds.

As a soldier and as a medic: you are professionally obligated to seek and learn the applicable ethical codes and legal strictures.

So much for the template.  It has to be fitted to each situation.  By definition a moral or ethical dilemma requires a choice between two unpalatable options.  When there is no conflict of duties, there is only one path which should be followed.


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## Armymedic (25 Aug 2004)

Well said, as usual Brad.

We, in the Cdn military medical services, have the example of Maj Barry Armstrong to follow as to the guidelines to follow when questionable actions may contravene the laws or armed conflict and Codes of Conduct. As much as people tried to discredit him, he stuck by his word and did what he felt (and by law was) right. 

I am sure, despite allegations and innuendo contrary, that American doctors would be as morally upstanding.


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