Bioethics Discussion Blog has an interesting post about the new AMA guidelines for physician participation in law enforcement or intelligence interrogation practices. The AMA apparently feels they are taking a strong stand, but I’m not sure that they are. The relevant policy is quoted below:

Physicians who engage in any activity that relies on their medical knowledge and skills must continue to uphold ethical principles. Questions about the propriety of physician participation in interrogations and in the development of interrogation strategies may be addressed by balancing obligations to individuals with obligations to protect third parties and the public. The further removed the physician is from direct involvement with a detainee, the more justifiable is a role serving the public interest. Applying this general approach, physician involvement with interrogations during law enforcement or intelligence gathering should be guided by the following:

(1) Physicians may perform physical and mental assessments of detainees to determine the need for and to provide medical care. When so doing, physicians must disclose to the detainee the extent to which others have access to information included in medical records. Treatment must never be conditional on a patient’s participation in an interrogation. (2) 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.

(3) Physicians must not monitor interrogations with the intention of intervening in the process, because this constitutes direct participation in interrogation.

(4) Physicians may participate in developing effective interrogation strategies for general training purposes. These strategies must not threaten or cause physical injury or mental suffering and must be humane and respect the rights of individuals.

(5) When physicians have reason to believe that interrogations are coercive, they must report their observations to the appropriate authorities. . . .

Though this appears to put strict limits on doctors’ participation in interrogation, it also appears to have a lot of loopholes, and it appears to me to rest on questionable moral premises.

The general statement of obligations seems especially problematic. It is almost a blanket endorsement of the utilitarian rationale for torture, with a nod to professional ethics thrown in. It’s reassuring to be told that “Physicians who engage in any activity that relies on their medical knowledge and skills must continue to uphold ethical principles”, but that hardly constitutes taking a firm moral stance. In fact, it constitutes taking the most minimum possible moral stance – namely, that one must have ethical principles at all. How did the AMA believe it was setting limits on participation in interrogation by affirming that physicians must behave ethically? Since, in promulgating a policy on how to participate in interrogation, the AMA has thereby endorsed participation in some form, it adds no measure of protection to say that doctors must do so ethically. Did they believe they were standing strongly in opposition to the claim that, while participating in torture, physicians were authorized to behave unethically? That would appear to be the only claim to which this vague and vapid assertion of moral principle would be a response. What appears, then, to be a bold statement of ethical obligation is nothing more than a reiteration of the inescapable obligation all persons have to behave with minimal decency at all times. The AMA has here given away the game on the salient moral question – is it ethical to participate in interrogations in the first place? – by asserting the weakest possible endorsement of moral principle while doing so. Their putative moral stance on interrogating people “ethically” is actually an evasion of the question whether to interrogate people at all.

The starkest departure from traditional medical ethics, perhaps, comes in the next sentence: “Questions about the propriety of physician participation in interrogations and in the development of interrogation strategies may be addressed by balancing obligations to individuals with obligations to protect third parties and the public.” Medicine has always recognized public need as a constraint upon the treatment of individual patients, but it has been chary of intruding the welfare of a specific third party into decisions about that treatment. Public-need considerations have usually been broad-based parametric principles – limiting factors – addressing health concerns, such as prioritizing the use of limited health resources, imposing population-wide public health measures, and the like. Only where one individual posed a specific threat to others’ health, as in cases of infectious disease, were the liberties of individuals directly subsumed to the needs of particular others. And except in cases such as the above, it has been understood that it was never permissible to directly take advantage of one person for the benefit of another: no one is required to donate an organ for another’s welfare (unless that organ was the uterus, in which case donation was once, and is again becoming, mandatory); no one is required to undergo medical experimentation; no one may be subject to medical mistreatment, or their rights infringed, due to such characteristics as race, creed, or national origin. Until now. Now, the interests of “third parties” (presumably the hypothetical victims of the storied “ticking time bomb scenarios” so beloved of torture defenders) may be invoked to justify action by medical professionals against the interests of their own patients. This vacates any role of the profession, or of medical ethics, in standing for those patients’ interests unequivocally and uncompromisingly – the sum and substance of traditional medical ethics. Now patients are simply one individual to take into account, in the balance with others, as having interests, but no special interests, in their caregivers’ eyes, arising from their relationship with that caregiver.

You can actually make an argument for a strictly neutral, utilitarian ethic of medicine. Perhaps patients do hold no special relationship to their caregivers. If “each is to count for one, and none for more than one”, perhaps patients, or the interests of patients, have no more claim on their caregivers’ loyalty than any other individual in a more distant relationship to the caregiver. But that is a radical departure from the physician-as-guardian ethic that the AMA, in one way or another, has always endorsed. Did the AMA really believe it was adopting a completely new ethic of medicine, and jettisoning the traditional relationship between doctors and patients, in endorsing the Bush administration’s torture protocol? Is the interrogation policy of such importance that it is worth changing the entire moral stance of the medical profession itself? Or is this a one-time compromise that only unwittingly undermines the traditional role of the physician? Either way, it seems both poorly thought-out and very ill-advised.

The claim that “The further removed the physician is from direct involvement with a detainee, the more justifiable is a role serving the public interest” is equally startling. I don’t know where this “principle” comes from, but it sounds very suspicious. For one thing, it is misstatement of the clearly utilitarian ethic driving the interrogation policy generally. Though the immediacy of one’s actions or their consequences are of concern to utilitarians, it is only by way of the attenuating effect that “distance”, or indirectness of contribution, has on those actions and consequences. The less influence a doctor has over the interrogation policy, the less responsible they are for abuses under it – that is obvious. But that fact does not make those contributions more justifiable – only less directly a source of what is not justifiable. To the extent that a doctor is contributing to, or participating in, the interrogations at all, that doctor is proportionately culpable for their outcome – no more, no less. Adding a degree of “remove” from the procedure does not make that procedure any better, it only makes it someone else’s fault – and if that procedure is itself unjustifiable, participation in it is unjustifiable no matter how far “removed” that participation may be. There is no general moral principle that holds that some certain number of “degrees of separation” absolves one of moral responsibility for what is done at the end of that chain of connection. Finally, the rhetorical shift from “involvement with detainees” to “serving the public interest” is the most obvious semantic manipulation; it is unworthy in this context, and from this source.

Given this level of moral befuddlement in the very opening paragraph, it is no wonder that the actual policies are similarly worrisome.

Rules 1, 2, and 3 seem correct (though note that Rule 1 voids the protection of medical privacy for prisoners). One wishes the AMA had stopped there. Rule 4, however, and especially in the light of the loopholes and evasions contained in the opening paragraph, seems to erase whatever barriers or prohibitions the preceding rules impose.

Obviously, the AMA anticipates that doctors will be participating in intelligence interrogations in some capacity – else they would not have needed these rules in the first place (or at least could have settled for a clear, unambiguous, blanket prohibition that would have left these various loopholes closed). Taken together, the directives that physicians may not “conduct, directly participate in, or monitor” interrogations, but may “develop effective interrogation strategies”, seems merely to mean that they may not be physically present during interrogations, but may guide or control them, offer advice on breaking prisoners’ resistance, or give interrogators medical knowledge and advice that will assist them in doing so. They may indirectly participate in them – and it is apparently up to their own discretion, and that of the other interrogators, what is “indirect” about that participation. The caveat about “general training purposes” is clearly meaningless also, since there is no definition of what constitutes “general” training, or how it differs from . . . well, whatever kind of training this rule pretends to prohibit. Especially given our state torture services’ well-established propensity for making up their own rules, and then breaking even those, there is little hope that these restrictions will have any effect. Whatever “training” a doctor wishes to do will be construed as “general” training, and whatever participation they offer will be “indirect”, at least as long as they are not conducted directly in the training room.

So what limitations, then, does this policy actually put on doctors? It appears they may contribute to interrogations in any capacity other than that of actually questioning the prisoners or physically mistreating them. But those are not the particular skills that doctors would be expected to offer in an interrogation setting. It is their medical and psychological knowledge – useful for tricking, pressuring, wearing down, tripping up, and weakening the subject – that interrogators want from doctors, and it is precisely this “general, indirect training” role that the AMA endorses. The AMA prohibits doctors from actually questioning prisoners, but that is not how doctors participate in interrogations; doctors are not trained for that role, while experts who have been so trained are easily available. To whatever degree that doctors actually can contribute usefully to interrogation, it would seem, the AMA policy offers no barrier. Like the insistence that doctors must only interrogate involuntarily-held prisoners ethically, these rules for interrogation procedure seem to constrain doctors only to do so using their special professional skills. In both respects, the policy endorses precisely what it should be questioning, while imposing supposed limits that are so nominal they have no practical consequence.

And, finally, what are we to make of the declaration that “[interrogation] strategies must not threaten or cause physical injury or mental suffering and must be humane and respect the rights of individuals”? Leaving aside the beatings, torture, sexual abuse, and murders that have been widespread in US interrogation centers – much of it officially sanctioned by Bush administration policy – how is this final, high-minded and pathetically weak moral principle supposed to be employed even in “ordinary” interrogations? The entire thrust of the policy is that physicians may act against their patients’ interests, may reveal patient medical information specifically so that others may act against their interests, may advise others on acting against patients’ interests (“in general”), may train others to use medical knowledge in doing so, and may offer (“general”, “indirect”) guidance on doing so. And it goes without saying that all of this occurs in a context which, in a more normal treatment setting, could not possibly be regarded as ethical. That is to say, nothing that goes into the type of participation in interrogation that the AMA endorses could conceivably be construed as normal medical treatment in keeping with the bounds of ordinary ethical practice – so in what was is it imaginable that all this could be done with “respect the rights of individuals”? How is violation of privacy, abuse of the medical treatment relationship to reduce the patient’s autonomy and mental and physical stamina, violation of the patient’s desire to control their own giving of information, and the use of medical and psychological knowledge to do so, not “causing physical or mental suffering”?

Consider again some of the things the government famously does not consider “torture”, precisely because they do not cause what is in the Bush administration’s eyes an unacceptable level of suffering: sleep deprivation, near-drownings, suffocation, “stress positions”, and “mild” physical abuse. Can any doctor do such things to their patients? If not, how is the provision of “general” and “indirect” “training” that will allow others to do them not a form of participation in interrogation that causes physical and mental suffering? Does the “remove” the doctor enjoys, by being in the next room, or the next building, somehow make the consequences of these procedures something other than suffering? And again, if not, how is it possible both to provide the assistance with interrogations – the assistance with the waterboardings, dog attacks, shaking, harsh lights and sounds, and all the rest – that the AMA endorses, while simultaneously remaining innocent of “causing physical injury or mental suffering”, and “being humane and respect the rights of individuals”?

I think the AMA has stumbled badly, and I presume unwittingly, though that is small comfort.