AMA Journal of Ethics. October 2015, Volume 17, Number 10: 924-930.
In the Literature
Professionalism and Conflicting Interests: The American Psychological Association’s Involvement in Torture
The American Psychological Association’s ethical guidelines condoning psychologists’ participation in torture, which were motivated by professional self-interest, constitute a violation of medical ethics and international law.
Nikhil A. Patel, MS, and G. David Elkin, MD
Hoffman DH, Carter DJ, Viglucci Lopez CR, et al. Report to the Special Committee of the Board of Directors of the American Psychological Association: Independent Review Relating to APA Ethics Guidelines, National Security Interrogations, and Torture. Chicago, IL: Sidley Austin; July 2, 2015.
On July 2, 2015, a 542-page report, “Independent Review Relating to APA Ethics Guidelines, National Security Interrogations, and Torture,” was submitted to the Special Committee of the Board of Directors of the American Psychological Association (APA) . This review was commissioned after a decade of intense scrutiny, principally by journalists and activist groups such as the Coalition for an Ethical Psychology, of the APA’s unethical involvement with governmental agencies, particularly the Department of Defense (DoD) and the Central Intelligence Agency (CIA) .
The review highlights that the ethical guidelines on interrogation issued by the APA were intentionally ambiguous in the interest of currying favor with the DoD and CIA . Given that the APA represents the interests of professional psychology, its condoning psychologists’ participation in “enhanced interrogation” or torture had significant consequences. The report details how an APA ethics task force obfuscated the language of its ethical guidelines and de facto allowed psychologists to play a role in “enhanced interrogations” and torture.
The 2002 White House Office of Legal Counsel’s “torture memos” [3-5] laid the groundwork for the Bush Administration’s approval of the CIA’s use of “enhanced interrogation” methods. Central to the memos was a narrow definition of “torture” as acts that cause pain and “serious physical injury such as organ failure, impairment of bodily function, or even death” . The temporary or long-lasting mental distress and psychological harm that detainees faced would not be considered torture if the interrogators had not “specifically intended to cause severe…mental pain or suffering” . The argument was that interrogators would safeguard against potential abuses by “consulting with experts or reviewing evidence gained in past experience” . Because the American Medical Association  and American Psychiatric Association  prohibited their members from participating in torture, “experts” meant psychologists. Thus the American Psychological Association’s statements on ethical matters are not merely abstract ideals, but instructions for psychologists, including those working in the government sector.
Conflicts of Interest at the APA
In 2005, the APA’s “Presidential Task Force on Ethics and National Security” (PENS) was convened by then-APA President Ronald F. Levant, EdD. The mandate of the task force, led by APA Ethics Director Stephen Behnke, PhD, JD, was to functionally define ethical practice for psychologists working in interrogation of detainees. There was a conflict of interest in the formation of the commission, inasmuch as six of ten participants were DoD psychologists and only three were not, and the report asserts that this was intentional .
Although the PENS Task Force was ostensibly responding to criticism of its involvement in intelligence activities in a serious manner , the report reveals that Dr. Behnke crafted much of the language ahead of time and kept it vague and nondescript . A major objective was to produce guidelines that minimally constrained DoD psychologists .
As a profession that is involved in the provision of vital mental health care, why would the APA want to cooperate with the DoD? The principal motives, as outlined in the report, were twofold. First, the DoD has endowed psychologists with benefits such as grants and contracts, and there was even a small program in the 1990s that allowed DoD psychologists to have prescribing privileges—a contentious, long-standing scope-of-practice issue between psychologists and psychiatrists. The report surmised that APA officials wanted to ensure that psychology stayed relevant to DoD intelligence activities. While the 2005 PENS Task Force was also intended to demonstrate to the public that the APA was introspective and thoughtful about issues of professionalism and ethics, one of the motives behind it was to cultivate and support military psychologists’ work and avoid placing concrete constraints on what was “right” for its members to do.
The Task Force and the Creation of Dual Loyalties
“Safe, legal, ethical, effective” was the framework that the PENS task force approved to guide psychologist participation in interrogations . Only two of the criteria created by a group formed to analyze “ethics” addressed ethical issues, and the criteria seem to be at odds with each other. “Enhanced interrogations” are purportedly intended to extract essential information to protect the homeland from nefarious elements. The torture memos argued that mental health professionals would prevent abuse by monitoring the interrogations and making them safe. But how can psychologists safeguard against torture when they have loyalties not only to their “patients,” the detainees, but to their superiors within the DoD and the goal of obtaining information? Can one be hired to help exploit detainee psychological vulnerabilities, such as specific phobias, and at the same time ensure that the detainees are not tortured? The former makes interrogations more “effective,” but a more “effective” interrogation is probably not “safe” or in the best interests of the detainee. Standard 1.02 of the APA Ethics Code, revised the same year as the release of the torture memos, stated that, if there was conflict between a psychologist’s ethical obligations and legal authority, deference ought to be provided to the legal authority . Such guidance disrupts the tenuous balance in the notion of dual loyalties, instructing psychologists to put the government’s aims above those of the profession.
Even if there were not such extreme conflicts of interest, there is no evidence that psychologists or other professionals can prevent, or even remain immune to, abusive behavior in such a setting. The classic “Stanford Prison Experiment,” conducted by Philip Zimbardo (APA President in 2002) showed that, when college students were assigned to play the roles of “prisoners” receiving punishment and “guards” meting it out, the “prisoners” became passive and some of the “guards,” aggressive and dehumanizing . The prison guards were said to be experiencing “behavioral drift.” The argument made in the torture memos that psychologists could prevent this from happening does not pass muster. No evidence has surfaced in the literature to suggest that certain professionals are immune to behavioral drift or that they could mitigate the outcomes of it.
Psychologist Involvement with Torture: A Violation of Multiple Norms
A violation of medical ethics. “Primum non nocere” (first, do no harm) is a central ethical tenet that applies to all health care professionals, including psychologists. Society trusts us to provide high-quality, ethical care to those who seek our help. While we may not be able to heal all of our patients, this principle of nonmaleficence is a pillar of bioethics that must be considered in deciding whether we are doing “right” by those under our care. As the United Nations (UN) declares: “It is a contravention of medical ethics for health personnel, particularly physicians, to be involved in any professional relationship with prisoners or detainees the purpose of which is not solely to evaluate, protect or improve their physical and mental health” . The fact that the ethics leadership at the APA ensured that the ethical guidelines would be written with the operational interests of the DoD in mind is an affront to the independence and integrity of the profession of psychology.
The guidance that psychologists should defer to legal authority in conflict with professional norms has an alarming similarity to the “Nuremberg defense,” in which doctors on trial after the horrors of the Holocaust argued that they were simply following the orders of their commanding officers and that their actions were legal at the time . An action’s being legal for citizens in general or military officers does not make it ethically acceptable for members of a healing profession.
A violation of international law. Furthermore, psychologists’ and the US government’s role in condoning torture ultimately contravenes international law, such as the UN Convention Against Torture which outlines in article 1 that “torture” is:
any act by which severe pain or suffering, whether physical or mental, is intentionally inflicted on a person for such purposes as obtaining from him, or a third person, information or a confession, punishing him for an act he or a third person has committed or is suspected of having committed, or intimidating or coercing him or a third person, or for any reason based on discrimination of any kind, when such pain or suffering is inflicted by or at the instigation of or with the consent or acquiescence of a public official or other person acting in an official capacity [12; italics added].
Article 2 states specifically that there are “no exceptional circumstances whatsoever” .
The Geneva Conventions, created in response to the brutality of war, were wantonly disregarded. The Third Geneva convention was written to protect prisoners of war, as stated in Common Article 3:
Persons taking no active part in the hostilities, including members of armed forces who have laid down their arms and those placed hors de combat by sickness, wounds, detention, or any other cause, shall in all circumstances be treated humanely, without any adverse distinction founded on race, colour, religion or faith, sex, birth or wealth, or any other similar criteria .
It seems that, too easily, international law is perceived as a mere obstacle to ensuring national security. The United States position has been that those captured in combat are not prisoners of war but in fact detainees who are not entitled to the rights ensured by the Geneva Conventions. Arguments are often made that if we are following these codes and our enemy is not, we are leaving ourselves open for more brutal attacks. But, indeed, they are the codes and values we are fighting to protect.
The Way Forward: Individual Responsibility
As this piece was being written, the voting membership at the APA national meeting unanimously banned the involvement of psychologists in torture in no uncertain terms . Although activists may argue that this is too little, too late, progress can be made, and without reports like that of the Hoffman et al., this positive step forward would not have been possible.
Although the Special Committee report concerns only the APA’s involvement in torture, other professions have found themselves in similar positions or may do so in the future. The history of medicine is plagued with violations of human rights. Psychiatric asylums in the era prior to antipsychotics often violated the basic human dignity of individuals with severe mental illness . The Tuskegee experiments selectively targeted African American men and violated their human rights and dignity . Wartime abuses by physicians have been well-documented. Having once violated society’s trust, it may be difficult to regain it.
We must use critical thought to distinguish what is ethical from what is lawful and to consider what it means to be a professional. Therefore, we must continually question and re-question authority, whether it is the law or a code of ethics, or else we may be doomed to serve the interests of those who crafted the code, not necessarily the interests of those who need to embody the code or use it to guide their practice. Just because a principle is codified does not make it ethical. Ethics is not an abstract exercise but one of importance and consequence, as the Hoffman et al. report illustrates. It is our individual responsibility to safeguard the values of the profession.
Organs of power do not move easily—inertia is often the default—but individuals also have power: power of conscience, power of knowledge, and power of organizing. Professional education needs to ensure that the history of professional participation in human rights abuses is not forgotten but discussed and grappled with. Cycles of abuse need not be repeated. As custodians of mental and physical health care, it is our obligation to ensure that they are not.
Nikhil A. Patel, MS, is a fourth-year medical student at the Mayo Medical School in Rochester, Minnesota, who plans to pursue a career in psychiatry. He recently completed the requirements for an MPH in global health with interdisciplinary concentrations in public health leadership and in humanitarian studies, ethics, and human rights at the Harvard T.H. Chan School of Public Health. He hopes to build on his multidisciplinary training and on his experience working with refugees in the US and at the Thai-Burma border by developing and scaling models of mental health care delivery for vulnerable populations, locally and globally.
G. David Elkin, MD, is a clinical professor of psychiatry at the University of California, San Francisco, where he co-leads the coordination of clinical psychiatry rotations and leads seminars on psychiatric assessment, critical thinking, and medical humanities. He completed his MD at the University of Pennsylvania Perelman School of Medicine and a residency in internal medicine and psychiatry at the University of California, Davis. Dr. Elkin is the editor of Introduction to Clinical Psychiatry (Lange, 1999) and an upcoming book chapter on medical ethics.
Related in the AMA Journal of Ethics
The viewpoints expressed in this article are those of the author(s) and do not necessarily reflect the views and policies of the AMA.
© 2015 American Medical Association. All Rights Reserved. ISSN 2376-6980