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Last Updated: Tuesday, 31 August, 2004, 10:09 GMT 11:09 UK
Brought to heal or heel?
By Daniel Sokol

Doctors have always learned lessons on the battlefield - not least how to operate successfully. But in the Iraq war, a medical ethicist says, the big lessons were about how to balance the duties to their patients and their country.

It is a curious but well-known paradox that medicine has gained much from the horrors of war. Amputations, antisepsis, skin transplants and the treatment of gunshot wounds were all greatly improved through observing and treating casualties of war.

Wars naturally provide opportunities for doctors to perform heroic acts. Braving enemy fire in Napoleonic times, the French military surgeon Dominique Larrey rode into the battlefield to treat and evacuate wounded soldiers, performing dozens of emergency amputations.

In times of war, military doctors have fulfilled two obligations: to treat patients and to serve their country.

In the current war in Iraq, for American medics, these two obligations have come into conflict.

New claims have surfaced alleging military doctors were asked to participate in acts of torture and humiliation during interrogations at the now notorious Abu Ghraib prison in Baghdad. The persons before them were both patients and enemies.

The US military has dismissed the claims, saying there is no evidence.

Prisoner in Iraq
The bond between doctor and patient is tighter than the impersonal, abstract relationship between a doctor and military objectives of commanders
Daniel Sokol

According to the interrogation manual issued to the US military, doctors were required to supervise techniques such as food deprivation, and to ensure that prisoners were fit for interrogation.

One Iraqi woman who, according to Amnesty International, was tortured in Abu Ghraib, said prisoners were often unconscious after interrogation sessions. Two doctors, usually one American and one Iraqi, then examined the prisoners.

On one occasion, it's claimed, a doctor was ordered to insert an intravenous catheter into the corpse of a prisoner killed under interrogation to disguise the cause and time of death.

If true, this means military doctors faced a conflict between their ethical duties to patients and their obligation to obey the orders of those higher in command.

The primary aim - or telos - of medicine is the alleviation of suffering. The Hippocratic Oath, written in the 5th Century BC, is clear on this: "I will use my power to help the sick to the best of my ability and judgment; I will abstain from harming or wronging any man by it."

This consequent prohibition of torture is echoed by many contemporary codes of ethics, such as the World Medical Association's Declaration of Tokyo, the United Nations Convention Against Torture, and the European Convention on Human Rights.

Dual obligation

Principle 2 of the UN's Principles of Medical Ethics states it is a "gross contravention of medical ethics... for health personnel to engage, actively or passively, in acts which constitute participation in, complicity in, incitement to or attempts to commit torture or other cruel, inhuman or degrading treatment or punishment".

Medical doctors, both civilian and military, have a dual obligation to benefit their patients and to avoid causing them harm. Involvement in torture, even passively, infringes both these obligations. No other activity so violates the fundamental tenets of the medical profession.

In such situations, the line separating doctors from torturers is blurred.

There is little moral difference between starving a prisoner by withholding food and supervising the starvation of a prisoner, or between electrocuting a prisoner and ensuring that the prisoner can be "safely" electrocuted. Only a credible threat to one's own life, or the life of loved ones, may arguably justify participating in torture. This was the case for many Iraqi doctors under Saddam Hussein. Western military doctors, however, were not acting under such duress.

The Oath refers not only to doctors' ability, but also their judgment. Both these skills are required for the safe and ethical practice of medicine. While doctors who possess only technical ability are a threat to their patients, so too are doctors of sound judgment but inadequate knowledge.

It is judgment that the military doctors in Iraq most needed when faced with their conflict of duties. How should they have balanced the duty of care to their patients with the duty to fulfil military objectives?

Credibility at risk

In a speech to newly trained army surgeons in 1894, William Osler, a renowned doctor, issued some precautionary advice to his audience: "Do not forget that, though army officers, you owe allegiance to an honourable profession, to the members of which you are linked by ties of a most binding character."

Dead prisoner
A dead prisoner, wrapped in ice, is removed from Abu Ghraib
For Osler, the ethical scales with patients on one side and country on the other tip to the side of the patients. Deliberately mistreating patients, for whatever noble reason, is so contrary to the telos of medicine that it risks dishonouring the entire medical profession.

The bond between doctor and patient is tighter than the impersonal, abstract relationship between a doctor and the military objectives of those in command.

The objectives of a doctor caring for a patient will always be laudable. No hindsight will ever cast scorn or criticism on a doctor's efforts to reduce suffering, but the objectives of military commanders may be, and historically often have been, misguided.

Daniel K. Sokol is a medical ethicist at the Imperial College Faculty of Medicine, London and the author of the forthcoming book Medical Ethics for Medics. He can be contacted at daniel.sokol@imperial.ac.uk

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