Does medical education make physicians susceptible to participating in torture?

Bioethics.net, 5 November, 2013
Reproduced with permission

Back in February 2013, Steven Miles, M.D. posted a blog on these pages titled "On Military Doctors and Deaths By Torture: When A Witness Becomes an Accessory" that was also published in the May issue of the American Journal of Bioethics. Dr. Miles has served as one of 20 members of the Taskforce on Preserving Medical Professionalism in National Security Detention Centers that examined the issue of physician involvement in torture and abuse. The independent review found that U.S. health care professionals allowed "cruel, inhumane and degrading treatment of prisoners while acting at the direction of military leaders under both President George W. Bush and President Barack Obama."

Released in November 2013, "Ethics Abandoned: Medical Professionalism and Detainee Abuse in the War on Terror" is a 156-page report. Among its conclusions is that "Military and intelligence-agency physicians and other health professionals, particularly psychologists, became involved in the design and administration of. . .harsh treatment and torture - in clear conflict with established international and national professional principles and laws."

The report states that the egregious actions on the part of health care providers were aided by three factors: (1) a government directive that individuals detained as part of the "war on terror" were not lawful combatants protected by the Geneva Convention; (2) both the Department of Defense and the CIA directed health care providers to violate their professional and ethical duties; and (3) secrecy allowed the unlawful detention and interrogation to continue outside of normative ethical and legal review.

Among the many disturbing claims are the use of physicians and psychologists to develop new interrogation techniques, the inadequate medical treatment of prisoners, DoD and CIA directives to contradict ethical medical standards (including changing the notion of "harm," limiting required reports of abuse, forcing breaking of hunger strikes through the use of restraints and feeding tubes) and more.

The report offers several recommendations for change including a thorough review of health care professionals’ role in the treatment of detainees, a cessation of the use of inhumane and cruel treatment, reinstatement of professional standards, following ethical standards regarding hunger strikes, including compliance with professional standards as part of quality assurance review, strengthening AMA and APA statements on professionals work with detainees, classifying participating in torture and mistreatment by health care professionals as "sanctionable misconduct" with licensure implications, and educating military health professionals on their professional ethical duties.

Reading the report is like a time warp, learning about the abuses conducted by physicians during the Nazi era. Except, that the issues in the report are recent and ongoing. During the Nuremburg trials, many physicians claimed they were simply "following orders." One would think that the experiences, which led to the establishment of professional ethics (AMA, APA, Hippocratic Oath), legal professional duties (laws and regulations), and international codes (Geneva Convention, Declaration of Helsinki) would have taught the world a lesson. Clearly, we learned very little. The very nation that wrote the Nuremburg Code has been behind a decade-long project to require health care professionals to assist in stripping human beings of their rights and common decency.

Putting aside that a federal government, which purports to support human rights and encourages democracy around the world sanctioned and even encouraged torture and human rights abuses, the notion that health care professionals in medicine and psychology would agree to follow those directives is infuriating. The Nuremburg trials demonstrates that following an unethical order that would be illegal for any other group is in itself unethical behavior. We expect health care professionals to do the right thing even when that requires a display of extraordinary moral courage.

And yet, Stanley Milgram demonstrated in the 1960s that when faced with the pressure of an authority, a majority of people will violate their own ethical standards and cause harm to others.  This begs the question if our expectations of health care professionals - who are, after all, simply well-educated human beings - are unrealistic. Knowing that a significant percent of humans will acquiesce in the face of an authority, is it too much to expect the physician to stand up and say "no?" I suggest that holding physicians to superhuman expectations may be part of the problem, overlooking components of medical education and practice that may encourage following such orders.

Medical education does not provide courses in moral courage, defying authority, or turning against the tide of one's peers. In fact, medical education encourages group think, keeping your head down and knowing your place in the hierarchy, and seeking out the approval of your peers. Medical education itself has often been accused of encouraging a culture of bullying and abuse of medical students. In 2012, the Association of American Medical Colleges surveyed medical students and found that 47% experienced mistreatment including public humiliation, degrading language, and abuse of power (such as being asked to run superior's personal errands). A 2012 study published in Academic Medicine found that over a 12-year period of time, a majority of students experienced mistreatment. That is enough time for the mistreated medical student to become the resident and even attending who mistreats her/his medical students. The bullied becomes the bully. The very traits that are ingrained into medical students through the hidden curriculum are the same ones that make them vulnerable to being used as instruments of the state to participate in torture and abuse.

I would suggest an additional recommendation to those in the report: A reformation of medical education to change its culture so that the skills that would allow a person to stand up and say "no" are encouraged. The hidden curriculum would have to offer lessons in distrusting authority, questioning superiors, and not seeking the approval of peers. Passing more laws and adopting new ethical codes are unlikely to change the chances of physician participation in abuse and torture from happening again (and continuing to happen now). We need to rethink how we choose students, how we educate them, and what character traits we value in our medical and psychological professionals to have a hope of changing the world and health care professionals in extraordinary times.