AMA Journal of Ethics^®

Reis C, Ahmed AT, Amowitz LL, Kushner AL, Elahi M, Iacopino V. Physician participation in human rights abuses in southern Iraq. JAMA. 2004;291(12):1480-1486 (Erratum, JAMA. 2004;291(19):2316).

As reports of conditions in prewar Iraq remind us, state-sponsored human rights abuses still occur in many parts of the world. Torture continues to be employed by more than 100 governments and by non-state players such as armed militia in 40 countries.¹ A recent study, "Physician Participation in Human Rights Abuses in Southern Iraq,"² by Physicians for Human Rights (PHR) seeks to clarify the nature and extent of physician complicity with state-sponsored torture during Saddam Hussein's reign in Iraq The authors' findings should be read in the context of the medical community's long and complicated history with torture.

According to physician and ethicist Giovanni Maio, the medical establishment's involvement in torture dates back to ancient Greece.³ The first official reference to medical activity in the practice is in the Constitutio Criminalis Carolina of 1532 in the time of Charles V, emperor of the Holy Roman Empire, which established the European legal roots of the physician's presence during torture.⁴ Torture was thought of as necessary to prevent criminal activity, so it was enshrined in the legal system and widely acknowledged.

As representatives of the state, physicians were expected to carry out the law. Their cooperation was not a consequence of coercion or fear of reprisal. Surprisingly, in light of this legal situation, much of the criticism of torture beginning in the 16th century came from the very physicians who participated in it. Doctors did not at first argue on moral or ethical grounds, condemning the cruelty of torment or the infliction of pain. Rather, Maio contends, they questioned the reliability of the testimony given under torture by those who were persecuted.

Still, physicians provided medical certificates that documented the defendant's state of health and mind and his or her ability to survive torture. If the accused was weak or ill, doctors recommended different methods of torment that could be endured. Physicians also determined when the pain had to be stopped in order to prevent sudden death, assessed whether the accused was truly unconscious or not, and treated injuries to allow the persecution to continue. But, Maio concludes that prior to the 20th century, the physician's role in torture was always passive. Medical doctors never took an active part in the ordeal. By contrast, he contends that as modern torture became progressively more scientific, physicians became actively involved by inventing new technical possibilities and by administering, for example, psychiatric-pharmacological and psychological forms of torture. Even as their participation went from passive to active, physicians paradoxically became unwilling to endorse the practice the way their early counterparts had done—a difference that reflects the change in society's attitude toward torture over the centuries.

It was the questionable reliability of testimony made under torture that prompted the first ban of the practice in Austria in 1776.⁵ Torture was eventually repudiated by most "civilized" societies, exiled to isolated torture chambers, denied and suppressed. International declarations and statements forbidding torture were established first after the French Revolution and again after World War II.⁶ And international declarations condemning medical personnel's participation in torture began to appear. Among the most important of these are the Declaration of Geneva and the Declaration of Tokyo, which were adopted by the World Medical Association in 1968 and 1975, respectively. These declarations state that physicians must maintain the "utmost respect for human life" even under threat,⁷ and any medical participation in torture is proscribed. Similarly, the United Nations' resolution on Principles of Medical Ethics, 1983, forbids physician abuse of the patient-doctor relationship to aid in torture or interrogation of suspects.⁸

The current participation of physicians in torture around the world exposes the ineffectiveness of such codes. During Saddam Hussein's reign in Iraq from 1979-2003, his regime systematically inflicted widespread human rights violations. The nature and scope of physician participation in these abuses are ambiguous. On the belief that identifying and confronting past evils will prevent history from repeating itself and is crucial for the successful reconstruction of Iraq, Physicians for Human Rights (PHR) conducted a self-administered survey of medical doctors in 2 major cities in southern Iraq. Its three objectives were: (1) to outline the system of physician participation in state-sponsored torture; (2) to ascertain structural factors that aided doctors' involvement in the abuses; and (3) to assess physician attitudes toward human rights violations and identify actions for preventing future compliance.⁹

The study's findings indicate that Iraqi medical doctors performed partial or complete amputation of ears as a form of punishment, falsified medical and legal reports of alleged torture, and misrepresented or fabricated death certificates. These practices breach internationally accepted declarations like those made by the World Medical Association, as well as international codes or principles of medical ethics. Iraq is a party to The International Covenant on Civil and Political Rights, which bans torture. Although the Baath regime decreed participation of physicians in human rights abuses, these acts also violated Iraq's Interim Constitution of 1990 and the Iraqi Penal Code.¹⁰ Despite the ethical ideals and legal measures, physicians assisted in carrying out orders of violence and cruelty of the state.

The absolute control wielded by the Baath regime must be taken into consideration when attempting to understand the medical community's obedience in executing torture, Reis et al argue. Repressive regimes generally involve physicians to spread fear, permit officials to deny responsibility, and allow perpetrators to detach themselves morally. The physicians' complicity in the state's system of oppression in turn, encourages them to support the regime. Their widely known complicity undermines not only patient trust but also trust among the physicians themselves. The survey findings suggest that the web of involvement and cover-up ensures that physicians will continue to comply with the wishes of the authorities. This explains why no independent national medical institutions were able to develop and become powerful enough to speak out against the government and protect individual physicians and their families from harm. The authors further assert that Iraqi physicians who unwillingly performed human rights violations may themselves be viewed as survivors of the regime and should not be judged in the same manner as their willing peers.

The authors advise that reforming the Iraqi legal system, restructuring and strengthening medical institutions and associations, and establishing the medical community's independence from state authorities are crucial steps toward the goal of averting future physician involvement in violence, cruelty, and persecution by the state. Effective monitoring of the authorities' compliance with civil liberties and constitutional rights is necessary to achieving that goal. Ethics education for medical professionals should be designed to promote awareness and understanding of the devastating effects of torture and to explore the roles doctors commonly play in oppressive authoritarian systems. Finally, physicians must be given strategies for dealing with the threatening situations in which they find themselves if they do not comply in executing torture. These include the use of established networks or arrangements with international governments that can then exert external pressures on the abusive regime.

As it rebuilds, Iraq's success as a democratic state will depend on its readiness to confront its past evils and take actions to prevent their recurrence. However, as Vincent Iacopino, Director of Research for Physicians for Human Rights (PHR), writes, "torture is a profound concern for the world community. It concerns all members of the human family because it impugns the very meaning of our existence and our hopes for a brighter future."¹¹

Questions for Discussion

1. Why should physicians care about state-sponsored torture employed in different parts of the world? What are possible implications of not taking a collective stand against torture and not protecting physicians from being forced to participate?
2. How can a physician in a regime that employs torture and abuse confront the government's demand to participate in these practices? What lessons can be learned from the study of Iraqi doctors by physicians in other countries?