1. PERSPE C T I V E doctors and interrogators at guantanamo bay
Doctors and Interrogators at Guantanamo Bay
M. Gregg Bloche, M.D., J.D., and Jonathan H. Marks, M.A., B.C.L.
M ounting evidence from many
sources, including Penta-
gon documents, indicates that
exceptions. Other Pentagon offi-
cials have reinforced this mes-
sage. In a memo made public last
tract actionable intelligence from
resistant captives.
A previously unreported U.S.
military interrogators at Guanta- month, announcing “Principles . . . Southern Command (SouthCom)
namo Bay have used aggressive for the Protection and Treatment policy statement, in effect since
counter-resistance measures in of Detainees,” William Winken- August 6, 2002, instructs health
systematic fashion to pressure werder, the Assistant Secretary of care providers that communica-
detainees to cooperate. These Defense for Health Affairs, said tions from “enemy persons un-
measures have reportedly includ- that limits on detainees’ medical der U.S. control” at Guantanamo
ed sleep deprivation, prolonged privacy are “analogous to legal “are not confidential and are not
isolation, painful body positions, standards applicable to U.S. citi- subject to the assertion of privi-
feigned suffocation, and beat- zens.” leges” by detainees. The state-
ings. Other stress-inducing tac- ment, from SouthCom’s chief of
tics have allegedly included sexu- staff, also instructs medical per-
al provocation and displays of sonnel to “convey any informa-
contempt for Islamic symbols.1 tion concerning . . . the accom-
The International Committee of plishment of a military or
the Red Cross (ICRC) and others national security mission . . .
charge that such tactics constitute obtained from detainees in the
cruel and inhuman treatment, course of treatment to non-med-
even torture. ical military or other United
To what extent did interroga- States personnel who have an
tors draw on detainees’ health apparent need to know the in-
information in designing and formation. Such information,” it
pursuing such approaches? The adds, “shall be communicated
Pentagon has persistently denied to other United States personnel
this practice. After the ICRC with an apparent need to know,
charged last year that interroga- whether the exchange of infor-
tors tapped clinical data to craft mation with the non-medical
interrogation strategies, Defense But this claim, our inquiry person is initiated by the pro-
Department officials issued a has determined, is sharply at vider or by the non-medical per-
statement denying “the allega- odds with orders given to mili- son.” The only limit this policy
tion that detainee medical files tary medical personnel — and imposes on caregivers’ role in
were used to harm detainees.”2 with actual practice at Guanta- intelligence gathering is that
This spring, an inquiry led by namo. Health information has they cannot act as interrogators.
Vice Admiral Albert T. Church, been routinely available to be- The statement, embedded —
the inspector general of the U.S. havioral science consultants and along with policies on parking
Navy, concluded: “While access others who are responsible for and alcohol — in the personnel
to medical information was crafting and carrying out inter- section of the SouthCom Web
carefully controlled at GTMO rogation strategies. Through site,4 not only requires caregiv-
[Guantanamo Bay], we found in early 2003 (and possibly later), ers to provide clinical informa-
Afghanistan and Iraq that inter- interrogators themselves had ac- tion to military and Central In-
rogators sometimes had easy ac- cess to medical records. And telligence Agency interrogation
cess to such information.”3 The since late 2002, psychiatrists teams on request; it calls on
implication is that interrogators and psychologists have been them to volunteer information
had no such access at Guantana- part of a strategy that employs that they believe might be of
mo and that medical confidenti- extreme stress, combined with value. It thereby makes them
ality was shielded, albeit with behavior-shaping rewards, to ex- part of Guantanamo’s surveil-
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2. PERSPECTIVE doctors and interrogators at guantanamo bay
lance network, dissolving the the United States, this principle late 2002, growing frustration
Pentagon’s purported separation has attained the status of cus- with the slow pace of intelligence
between intelligence gathering tomary international law. Inter- production at Guantanamo led
and patient care. national human rights law (most to calls from commanders for
Rather than being consistent important, the 1966 Interna- innovative tactics. Major General
with the presumption of confi- tional Covenant on Civil and Po- Geoffrey Miller, who took com-
dentiality that applies to Ameri- litical Rights) provides addition- mand of Guantanamo in late
cans even in prisons, the Guan- al protection for privacy in 2002, approved the creation of a
tanamo policy rejects this general — in wartime and “Behavioral Science Consultation
presumption. Within military peacetime. Although this pro- Team” (BSCT, pronounced “Bis-
prisons, personal health infor- tection isn’t absolute, exceptions cuit”) in order to develop new
mation cannot be given to cor- must be justified by pressing strategies and assess intelligence
rectional or law-enforcement of- public need, and they must rep- production. A principal BSCT
ficials unless they deem it resent the least restrictive way to function was to engineer the
necessary for health, safety, or meet this need. Wholesale aban- camp experiences of “priority”
security reasons. Confidentiality donment of medical confidenti- detainees to make interrogation
is also the starting point in fed- ality hardly qualifies, especially more productive.
eral and state prisons for civil- when the “need” invoked is the A psychiatrist and a psycholo-
ians, albeit with similar excep- crafting of counter-resistance gist staffed the Guantanamo
tions for health, safety, and measures that are prohibited by BSCT. Those initially assigned
security. (Federal law permits dis- international law. to this team both came from
closure of inmates’ health infor- In what ways did military in- health care backgrounds; nei-
mation “to authorized federal of- telligence personnel draw on ther had much training in be-
ficials for the conduct of lawful medical information for interro- havioral analysis of the sort that
intelligence, counter-intelligence, gation and counter-resistance pur- civilian psychologists perform for
and other national security ac- poses? Instructions to Guantana- law-enforcement agencies. Ac-
tivities.”) There is debate over mo veterans not to discuss their cording to Hood’s briefing, BSCT
the scope of these exceptions, service publicly have been an ob- consultants prepared psycholog-
but there is consensus about the stacle to answering this question. ical profiles for use by interroga-
basic presumption of medical But available documents, an ac- tors; they also sat in on some
privacy. count of a fall 2004 briefing by interrogations, observed others
Wholesale rejection of clinical the camp’s commander (Brigadier from behind one-way mirrors,
confidentiality at Guantanamo General Jay Hood), and interviews and offered feedback to interroga-
also runs contrary to settled with behavioral science profes- tors. The first BSCT psychologist,
ethical precepts. Medical privacy sionals enable us to assemble Major John Leso, a specialist in
is not an ethical absolute — parts of this picture. assessing aviators’ fitness to fly,
caregivers in civilian and military During the camp’s early attended part of the interroga-
settings have an obligation to re- months, interrogators could gain tion of Mohammed al-Qahtani,
port information to third parties access to personal health infor- thought by many to be the “20th
when doing so can avert threats mation (and did so to set limits hijacker.” (An extract from a log
to the health or safety of identifi- on practices that might put de- of this interrogation published
able persons — but confidential- tainees’ health at risk) but did in Time magazine last month re-
ity is the starting premise. not use psychological assessments fers to Leso as “Maj. L.”)
The laws of war defer to of individual subjects. Conven- There are strong indications
medical ethics. Additional Pro- tional army intelligence doctrine that the Guantanamo BSCT has
tocol I to the Geneva Conven- has been unsympathetic to such had access to personal health
tions provides that medical per- input: it has relied instead on a information. An internal, May 24,
sonnel “shall not be compelled mix of standard interrogation 2005, memo from the Army Medi-
to perform acts or to carry out methods meant to appeal vari- cal Command, offering guidance
work contrary to the rules of ously to subjects’ insecurities, to caregivers responsible for de-
medical ethics.” Although the pride, and fears, within constraints tainees, refers to the “interpre-
protocol has not been ratified by set by the laws of war.5 But by tation of relevant excerpts from
n engl j med 353;1 www.nejm.org july 7, 2005 7
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3. PERSPE C T I V E doctors and interrogators at guantanamo bay
medical records” for the purpose quelae of extreme stress — anx- if so, why not oversee isolation
of “assistance with the interro- iety, depressed mood, and disor- and sleep deprivation or monitor
gation process.” The memo, pro- dered thinking — impair the beatings to make sure nothing
vided to us by a military source, understanding of questions and terrible happens?
acknowledges this nontherapeu- produce incoherent answers. Rap- Wholesale disregard for clini-
tic role, urging health profes- port building, tailored to peo- cal confidentiality is a large leap
sionals who serve in this capacity ple’s cognitive styles and cultur- across the threshold, since it
to avoid involvement in detainee al beliefs, takes time but yields makes every caregiver into an
care, absent an emergency. This better information, its defenders accessory to intelligence gather-
acknowledgment is consistent contend. ing. Not only does this under-
with other accounts of informa- There is no scientific answer mine patient trust; it puts pris-
tion flow from caregivers to be- to the question of which inter- oners at greater risk for serious
havioral science consultants to rogation strategy is more effec- abuse. The global political fall-
interrogators. tive. For obvious ethical and legal out from such abuse may pose
Competing behavioral science reasons, there is unlikely to be more of a threat to U.S. security
models have influenced the ad- one. At Guantanamo, the fear- than any secrets still closely held
vice given to interrogators by and-anxiety approach was often by shackled internees at Guanta-
BSCT members. One approach favored. The cruel and degrad- namo Bay.
emphasizes fear and anxiety as ing measures taken by some, in
Dr. Bloche is professor of law at Georgetown
counter-resistance tools; another violation of international human University and a visiting fellow at the
favors rapport with detainees. rights law and the laws of war, Brookings Institution, both in Washington,
The former approach, supported have become a matter of nation- D.C., and adjunct professor at Bloomberg
School of Public Health, Johns Hopkins
by some associated with the John al shame. University, Baltimore. Mr. Marks is a barris-
F. Kennedy Special Warfare Cen- Clinical expertise has a lim- ter at Matrix Chambers, London, and
ter who have helped to formulate ited place in the planning and Greenwall Fellow in Bioethics at Georgetown
University Law Center and the Bloomberg
BSCT doctrine, builds on the oversight of lawful interroga- School of Public Health.
premise that acute, uncontrolla- tion. Psychologists play such a
ble stress erodes established be- role in criminal investigations, An interview with Mr. Marks can be heard at
www.nejm.org
havior (e.g., resistance to ques- and medical monitoring of de-
tioning), creating opportunities tainees is called for by interna- 1. Break them down: systematic use of psy-
to reshape behavior. Complex re- tional legal instruments. But chological torture by U.S. forces. Cambridge,
ward systems (e.g., the creation proximity of health professionals Mass.: Physicians for Human Rights, 2005.
2. Lewis NA. Red Cross finds detainees
of multiple camp “levels” with to interrogation settings, even abuse at Guantanamo. New York Times.
different privileges) promote co- when they act as caregivers, car- November 30, 2004:A1.
operation. Stressors tailored to ries risk. It may invite interroga- 3. Church report: unclassified executive
summary. (Accessed June 16, 2005, at http://
the psychological and cultural tors to be more aggressive, be- www.defenselink.mil/news/Mar2005/
vulnerabilities of individual de- cause they imagine that these d20050310exe.pdf.)
tainees (e.g., phobias, personal- professionals will set needed lim- 4. Huck RA. U.S. Southern Command confi-
dentiality policy for interactions between
ity features, and religious be- its. The logic of caregiver involve- health care providers and enemy persons un-
liefs) are key to this approach ment as a safeguard also risks der U.S. control, detained in conjunction
and can be devised on the basis pulling health professionals in with Operation Enduring Freedom. August
6, 2002 (memorandum). (Accessed June 16,
of detainee profiles. ever more deeply. Once caregiv- 2005, at http://www.southcom.mil/restrict/
Proponents of rapport-based ers share information with in- J1/new%20web%20page/New%20Web%
interrogation counter that an- terrogators, why should they re- 20Pages/AG/Policy/Current%20SC%
20Policies/SC%20Current_pols.htm.)
swers given under high stress frain from giving advice about 5. Department of the Army. Field manual
are unreliable. Not only are peo- how to best use the data? Won’t 34-52: intelligence interrogation. 1992.
ple in acute distress inclined to such advice better protect de- (Accessed June 21, 2005, at https://atiam.
train.army.mil/soldierPortal/atia/adlsc/
say whatever they think might tainees, while furthering the in- view/public/6999-1/FM/34-52/FM34_
bring relief; the psychiatric se- telligence-gathering mission? And 52.PDF.)
8 n engl j med 353;1 www.nejm.org july 7, 2005
The New England Journal of Medicine
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Copyright © 2005 Massachusetts Medical Society. All rights reserved.