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Medical Complicity in Interrogative Procedures at Guantánamo Bay andAbu Ghraib

In a review of unclassified United States government data, Denbeaux et al. (2006) concluded that, of the 517 "unlawful combatants" detained at the Guantánamo Bay detention camp for more than four years, 55% had not been charged with engaging in hostilities against the United States or its coalition allies and 60% are detained for being "associated with" one or more terrorist organizations. Additionally, "[o]nly 8% of the detainees were characterized as al Qaeda fighters. Of the remaining detainees, 40% have no definitive connection with al Qaeda at all and 18%...have no definitive affiliation with either al Qaeda or the Taliban" (Denbeaux et al., 2006, p. 2).

In 2005, a small group of civilian medical professionals, which included New England Journal of Medicine contributing editor Dr. Susan Okie, visited the Camp Delta to be briefed by the commander of Guantánamo Bay, Major General Jay W. Hood, on the current state of the medical and mental health care provided to the detainees. Because of safety and privacy concerns, the group was not permitted to see or talk to the detainees (Okie, 2005). Of main concern to the group was the possible involvement of medical personnel in the mistreatment of the detainees. Specifically, the group was curious about the Behavior Science Consultation Team (BSCT, pronounced "Biscuit") program.

The BSCT program began in 2002 and was approved for use at Guantánamo Bay by then commander Major General Geoffrey Miller to develop behavioral and psychological strategies that would expedite the gathering of intelligence from the "more than 100 detainees considered to have high intelligence value" (Okie, 2005, p. 2532). The BSCT at Guantánamo Bay included a psychiatrist and a psychologist who "prepared psychological profiles for use by interrogators [and]...sat in on some interrogations, observed other from behind one-way mirrors, and offered feedback to interrogator" (Bloche & Marks, 2005a, p. 7). The role of the BSCT medical personnel in the abuse of Mohammed al-Qahtani, a detainee determined to be of high intelligence value, is well documented (Miles, 2007)

The abuse of Mohammed al-Qahtani

In a review of declassified interrogation logs and other documents connected to an investigation conducted by the United States Army, Miles (2007) found that, between November 23, 2002, and January 11, 2003, al-Qahtani was interrogated 20 hours a day. After nearly two weeks, al-Qahtani's first break came in the form of a 42-hour hospitalization for hypothermia due to prolonged exposure to an air conditioner and edema likely due to malnutrition and prolonged restraint and recumbence. Medical personnel regularly administered intravenous fluids for dehydration and, on at least one occasion, inserted a shunt to permit the infusion of intravenous fluids. Between December 12 and 14, 2002, al-Qahtani's weight increased 11 pounds after he was administered a total of six bags of intravenous fluids. Although al-Qahtani experienced bradycardia (his heat rate measured 42 beats per minute) after his precipitous weight gain, a physician cleared al-Qahtani for continued interrogation.

The role of medical personal was not limited to intravenous fluid infusions and determinations of interrogative "fitness." Miles (2007) reports that Major John Leo, the first psychologist to chair the Guantánamo Bay BSCT, recommended that al-Qahtani be placed in a swivel chair "to prevent him from fixing his eyes on one spot" (¶ 11). Additionally, after he asked to be allowed to sleep in an area away from his interrogation room, the BSCT advised al-Qahtani's interrogators that his request was a ploy for sympathy and control.

Throughout his detention, al-Qahtani was forced to endure abusive psychological manipulation predicated upon behaviors proscribed by Islam: He stood naked in the midst of female soldiers during repeated strip searches, he wore a bra and a woman's thong on his head, he was dressed as a woman and made to dance with a male soldier, he witnessed desecration of the Qur'an, he was forced to wear pictures of women dressed in bikinis, he was told that he had homosexual tendencies and that his mother and sister were whores, and he was not allowed to pray most days. Additionally, "[al-Qahtani] was leashed [and]....told to bark like a happy dog at photographs of 9/11 victims and growl at pictures of terrorists" (Miles, 2007, ¶ 14). His interrogators advised him that behaving like a dog elevated his social status.

Was it torture?

The rationale for al-Qahtani's abusive treatment came from the highest level of the United States Government. President George W. Bush (2002, February 7) declared that the protections afforded to detainees by Geneva Conventions do not apply to al Qaeda and Taliban affiliated "unlawful combatants." In a memorandum to then presidential counsel and current attorney general Alberto Gonzalez, Justice Department lawyer Jay C. Bybee (2002, August 1) asserted the following:
[F]or an act to constitute torture...it must inflict pain that is difficult to endure. Physical pain amounting to torture must be equivalent to intensity to the pain accompanying serious physical injury, such as organ failure, impairment of bodily function, or even death. For purely mental pain or suffering to amount to torture...it must result in significant psychological harm of significant duration, e.g., lasting for months or even years. We conclude that the mental harm also must result from...threats of imminent death; threats of infliction of the kind of pain that would amount to physical torture; infliction of such physical pain as a means of psychological torture; use of drugs or other procedures designed to deeply disrupt the senses, or fundamentally alter an individual's personality; or threatening to do any of these things to a third party. 1 (¶ 2)
According to the objectively worded and practical definition of torture set forth by this brief, although physically and mentally abusive, humiliating, and degrading, the documented treatment of al-Qahtani and the undocumented treatment of an untold number of detainees do not constitute torture.

In the 2004 investigation of the Abu Ghraib prison in Baghdad, the former chief of military intelligence at Abu Ghraib, Colonel Thomas M. Pappas, testified that the Abu Ghraib BSCT medical personnel reviewed detainee "interrogation plans" and advised military personnel as to what parts of the plan could be implemented based on a determination of the detainee's interrogative "fitness" (Bloche & Marks, 2005b). In a declassified memorandum, commander Lieutenant General Ricardo S. Sanchez (2003, September 14) approved the following interrogation techniques (presented in abbreviated form), modeled on those used at Camp Delta, for use at Abu Ghraib:
  1. Interrogators may significantly increase a detainee's fear level. 
  2. Interrogators may invoke feelings of futility in a detainee. 
  3. Interrogators may isolate a detainee for no more than 30 days. If a longer isolation is desired, a commanding officer must be briefed before it is implemented. 
  4. Interrogators must provide a detainee with a minimum of 4 hours of sleep per day for no more than three consecutive days. 
  5. Interrogators may use stress positions such as sitting, standing, kneeling, and prone for no more than 60 consecutive minutes and for no more than 4 hours a day.
The interrogation techniques could be used provided that "the detainee is medically and operationally evaluated as suitable" (Sanchez, 2003, September 14, General Safeguards section, ¶ 1).

Unfortunately, these interrogation techniques were not followed by practical guidelines. How to increase a detainee's fear level significantly, invoke feelings of futility, or force a detainee into a sustained stress position were at the discretion of military personnel. This latitude significantly increased the risk of detainee abuse. In a leaked report, the International Committee of the Red Cross (ICRC; 2004) determined that the most frequent allegations regarding methods of abuse throughout their 29 visits to 14 detention facilities included:
  1. Periods of "hooding" ranging from a few hours to four consecutive hours in order to induce disorientation and obstruct breathing.
  2. Extended periods of handcuffing causing skin lesions and nerve damage.
  3. Beatings, slapping, punching, and kicking.
  4. Periods of isolation wherein the detainee was completely naked.
  5. Being displayed naked to military personnel and other detainees for the amusement of military personnel.
  6. Exposure to outdoor temperature possibly exceeding 122 °F.
The ICRC (2004) concluded that those detainees classified as high intelligence value "unlawful combatants" "were at high risk of being subjected to a variety of harsh treatments ranging from insults, threats and humiliations to both physical and psychological coercion, which in some cases was tantamount to torture [italics added], in order to force cooperation" (Executive Summary section, ¶ 5).

1After it became public, the Bybee (2002, August 1) memorandum was withdrawn. The superseding memorandum formally defined torture as the intentional infliction of "severe [italics added] physical or mental pain or suffering (other than pain or suffering incidental to lawful sanctions)" (Levin, 2004, December 30, Section I, ¶ 1). However, Levin (2004, December 30) does not take issue with Bybee's (2002, August 1) practical definition of torture.

Medical involvement in torture and interrogation: Then and now

Although "the confession" has long been held in high esteem by most religions and cultures, torture was likely begun as an abusive venture by those whose goal was to demarcate the free man from the slave and thereby ensure acquiescence to the security of the social hierarchy (Maio, 2001). The first reference to medical personnel as being complicit in torture was recorded in the 1532 German penal code known as the Constitutio Criminalis Carolina in which physicians were to determine "fitness" for torture (Aggrawal, 2001). After 1532, the recorded history of torture indicates that medical personnel determined "fitness," assessed malingering, advised the doles of dolor when to stop in order to prevent a premature termination of the torture through death, and treated subsequent injuries so that the torture could recommence (Maio, 2001).

Currently, medical personnel of all stripes are strictly forbidden by ethical protocol from engaging in the interrogative practices of their historical counterparts. According to the American Medical Association (2006):
Physicians must neither conduct nor directly participate in an interrogation, because a role as physician-interrogator undermines the physician's role as healer and thereby erodes trust in the individual physician-interrogator and in the medical profession. Physicians must not monitor interrogations with the intentionof intervening in the process, because this constitutes direct participation in interrogation. (¶ 3-4)
In a closely worded statement specifically addressing the role of psychiatrists in interrogative procedures, the American Psychiatric Association (2006) put forth that "[n]o psychiatrist should participate directly in the interrogation of persons held in custody....Direct participation includes being present in the interrogation room, asking or suggesting questions, or advising authorities on the use of specific techniques of interrogation with particular detainees" (¶ 3). The American Psychological Association, on the other hand, does not explicitly forbid psychologists from direct participation in interrogation that is legal (Miles, 2007, ¶ 19).

The full extent to which medical personnel participated in the documented and undocumented abuses at Guantánamo Bay and Abu Ghraib (see Walsh, 2006) is unknown. However, what is known is disturbing. Zernike (2004) reports that, at Abu Ghraib:
Much of the evidence of abuse at the prison came from medical documents. Records and statements show doctors and medics reporting to the area of the prison where the abuse occurred several times to stitch wounds, tend to collapsed prisoners or see patients with bruised or reddened genitals. (¶ 11)
It is likely that the medical personnel knew that the injuries resulted from abuse yet failed to report them and thereby strengthened the unfortunate wall of military silence that enabled the abuse. In addition to the previously mentioned ways that BSCT medical personnel were complicit in abusive interrogative procedures, charges leveled against the medical personnel include advising military personnel on how to exploit the fear and phobias of detainees, giving detainee medical records to military personnel in order to maximize interrogative effectiveness, participating in the abuse, failing to investigate detainee deaths, and falsifying detainee death certificates (Keram, 2006; Lifton, 2004; Miles, 2004).

The rationale for the direct involvement by medical personnel in interrogation is that the ethics inherent to the relationship between patient and provider did not apply the medical members of BSCT. Referring to the BSCT medical personnel, Pentagon spokesman Bryan Whitman "suggested that the doctors advising interrogators were not covered by ethics strictures because they were not treating patients but rather were acting as behavioral scientists" (Lewis, 2005, ¶ 6). This medical acquiescence to this "dual oath" meme is illustrated by Cohen (2005) who argued that "I consider myself to be a compassionate doctor, yet...my responsibilities as a human being and an American citizen take precedence over any doctrine, professional or otherwise" (p. 1633). Georgetown University professor Dr. Nancy Sherman, a member of the small group who visited Camp Delta, concluded that the "dual oath" argument "is a red herring. It is hair-splitting that detracts from the real issue of whether health professionals of any stripe can ethically be involved in interrogations that may involve coercive techniques or torture. The answer is clearly no" (Sherman, 2005, ¶ 10).

The Tao of false confessions

Based on a review of relevant literature, Meissner and Albrechtsen (in press) concluded that coercive interrogation techniques that include physical torture and psychological manipulation are likely to engender both true and false confessions. Kassin and Gudjonsson (2004) described three forms of false confessions: voluntary, compliant, and internalized. Although detainees may voluntarily make false confessions to gain notoriety (see Novak, 2003), of main concern are the two latter forms of false confessions. The compliant false confession occurs when the accused believes that the short-term rewards, such as eating or sleeping, gained by confessing outweigh the long-term consequences. The internalized false confession, which is usually elicited from juvenile and mentally retarded individuals, occurs when the accused develops a profound distrust of his memory (Kassin & Gudjonsson, 2004).

Fatigue, the result of interrogative techniques such as the sleep deprivation, isolation, and forced stress positions, increase the likelihood of obtaining a false confession. Blagrove (1996) found that participants who were deprived of sleep for 43 hours yielded to leading questions at a significantly rate than controls. Harrison and Horne (2000) determined that sleep deprivation impairs decision-making and communication and increases distractibility. Prolonged interrogations may elicit false confessions. In a study of false confessions in which length of interrogation was documented, Drizin and Leo (2004) found that "16% lasted less than six hours; 34% between six and twelve hours; 39% between twelve and twenty-four hours; 7% between twenty-four to forty-eight hours; 2% between forty-eight and seventy-two hours; and 2% between seventy-two and ninety-six hours" (p. 946).

Conclusion

Although the ratio of accurate to inaccurate intelligence gathered at the detention facilities governed by the United States and its coalition allies will never be known, it is easy to determine that the abusive interrogative procedures employed at Guantánamo Bay and Abu Ghraib were ineffective and likely failed to yield diagnostic intelligence. Rapport-based interrogative procedures, customarily employed in the United States, are more reliable (Kassin & Gudjonsson, 2004). After the investigations into treatment of detainees at Guantánamo Bay and Abu Ghraib, it is likely that BSCT medical personnel have received better training on how, when, and where to report abusive interrogation techniques. This assertion is slightly substantiated by Okie (2005) who reported that, during her visit, Major General Jay W. Hood stated that the abusive interrogation techniques that had once been used at Camp Delta had been replaced by an interrogative procedure that employs rapport-based techniques.

Lifton (2004) argued that, because medical professionals are "seen by others...as possessing special magic in connection with life and death" (p. 416), medical professionals should abide by the highest ethical standards whether they are considered behavioral scientists or are practicing within the traditional patient-provider framework. Similarly, Bloche and Marks (2005b) concluded that "physicianhood...encompass[es] technical skill, scientific understanding, a caring ethos, and cultural authority" (p. 5). Indeed, the best way that medical professionals can apply their "physicianhood" is constructively and caringly.

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