Paul Appelbaum, M.D.: "We always need to think carefully about
[psychiatrists'] nonpatient care roles and whether they so compromise that
perceived allegiance to patients' interests that they ought not to be
Alan Stone, M.D.: "I am unprepared to say that in a situation of
great consequence, a psychiatrist who might have some ability to help our
military should claim some ethical obligation that transcends all other
Can a psychiatrist ethically participate in the interrogation of a detainee
who may have information vital to the safety and security of the nation? If
so, what is an appropriate role for a psychiatrist in such a
setting—advisor on overall strategy? behind-the-scenes consultant on
individual cases? active participant in questioning?
And when does "psychological pressure" cross the line into
Those are just some of the ethical and professional dilemmas raised by
recent allegations that behavioral health professionals, including
psychiatrists, have participated in interrogation of detainees at the U.S.
naval station at Guantanamo Bay, Cuba. Worldwide attention has been focused on
allegations of abuse during interrogation of detainees there, as well as in
Iraq and Afghanistan.
The nature and extent of involvement by psychiatrists in interrogations are
not clear, but the charges have galvanized an effort to clarify ethical and
professional boundaries and establish guidelines for psychiatrists' conduct in
APA is "troubled by recent reports regarding alleged violations of
professional medical ethics by psychiatrists at Guantanamo Bay," the
Association said in a statement issued at the end of June. "APA is not
neutral on physician practices and clearly recommends that psychiatric
physicians practice in accordance with the APA ethics guidelines, which are
also in accordance with the medical code of ethics set forth in the American
Medical Association's Principles of Medical Ethics."
The statement noted that APA's Principles of Medical Ethics With
Annotations Especially Applicable to Psychiatry states the following:
Past APA President Paul Appelbaum, M.D., chair of the Council on Psychiatry
and Law, told Psychiatric News that APA leaders began delineating the
issues last year, before allegations about psychiatrists at Guantanamo had
This is an interrogation room at Camp Delta at Guatanamo Bay, Cuba, for
detainees from the war in Afghanistan. Approximately 600 prisoners remain in
detention. Photo by Joe Raedle/Getty Images
"The council and the Committee on Judicial Action met with a number
of psychiatrists who have relationships with the military or with national
security to talk about their experiences and the kinds of ethical issues they
perceive in their work and how they deal with them," he said. "It
was aimed at educating ourselves about these issues and trying to determine
whether an APA statement was needed, and what form it should take."
Appelbaum said that at next month's fall component meetings the council and
the committee, as well as representatives from the APA Committee on Ethics and
the Committee on Misuse and Abuse of Psychiatry, will begin the process of
developing guidelines for psychiatric involvement in national security
"The issues we will need to address include whether it is legitimate
for a psychiatrist to be involved in an investigative process and, if so, in
what ways," Appelbaum said. "As part of the interrogation itself?
Providing advice in real time behind a one-way mirror? Advising in advance on
interrogation techniques, including the vulnerabilities of a particular
suspect? Or advising more generally? Those seem to be key questions raised by
the Guantanamo experience that we will have to come to grips with."
He echoed other APA leaders in saying that the controversy had launched the
profession into uncharted territory.
"The current APA ethical principles and annotations certainly have
elements that can be drawn on to answer those questions," Appelbaum
said. "But never having been faced so starkly with these issues, I think
the Association has not had an opportunity to formulate relevant
Spencer Eth, M.D., chair of APA's Ethics Committee, agreed. "This is
a relatively new issue," he said. "Making a statement is itself an
important step, rather than simply saying our existing guidelines cover it.
Military practice is very different from civilian practice, just as is
correctional psychiatry. We need to be mindful of the variety of types of
practice our members are engaged in and not jump to conclusions."
APA leaders declined to comment on specific allegations of psychiatrist
involvement at Guantanamo given the difficulty of determining the veracity of
accounts and the extent and nature of psychiatric involvement.
A Department of Defense report on the subject of detainee abuse, led by
Vice Admiral Albert Church III, director of Navy staff, was ordered by Defense
Secretary Donald Rumsfeld last year and released in March.
Predictably, that report downplayed reports of widespread abuse, but the
investigation did find inconsistencies regarding the development,
promulgation, and dissemination of interrogation techniques. These techniques"
migrated" from Guantanamo Bay to Afghanistan, and then to Iraq,
the report stated.
The Church report stated that "behavioral science personnel"
assisted in interrogations.
"[I]t is a growing trend in the Global War on Terror for behavioral
science personnel to work with and support interrogators," the report
stated. "These personnel observe interrogations, assess detainee
behavior and motivations, review interrogation techniques, and offer advice to
interrogators. This advice can be effective in helping interrogators collect
intelligence from detainees; however, it must be done within proper
"We found that behavioral science personnel were not involved in
detainee medical care (thus avoiding any inherent conflict between caring for
detainees and crafting interrogation strategies) nor were they permitted
access to detainee medical records," the Church report concluded."
However, since neither the Geneva Convention[s] nor U.S. military
medical doctrine specifically addresses the issue of behavioral science
personnel assisting interrogators in developing interrogation strategies, this
practice has evolved in an ad hoc manner."
More recently, a report in the July 7 New England Journal of
Medicine stated that a psychiatrist and a psychologist had each headed
Behavioral Science Consultation Teams (BSCT, pronounced "biscuit")
to assist interrogators in questioning Guantanamo detainees.
"BSCT consultants prepared psychological profiles for use by
interrogators," according to article. "They also sat in on some
interrogations, observed others from behind one-way mirrors, and offered
feedback to interrogators."
Moreover, the journal report stated—in a contradiction to the Church
report—that BSCT teams did have access to medical records.
"An internal, May 24, 2005, memo from the Army Medical Command,
offering guidance to caregivers responsible for detainees, refers to the
`interpretation of relevant excerpts from medical records' for the purpose of
`assistance with the interrogation process,' " said the journal article."
The memo, provided to us by a military source, acknowledges this
nontherapeutic role, urging health professionals who serve in this capacity to
avoid involvement in detainee care, absent an emergency. This acknowledgment
is consistent with other accounts of information flow from caregivers to
behavioral science consultants to interrogators."
APA leaders say the issue is fraught with implications for medicine
"From a broader perspective, physicians in general retain the trust
of the general population because of a perception that they are committed to
the well-being of their patients," Appelbaum said. "We always need
to think carefully about other nonpatient care roles and whether they so
compromise that perceived allegiance to patients' interests that they ought
not to be considered legitimate."
At the same time, the ethics of psychiatric participation in interrogation
of detainees who may have information vital to the security of the nation are
"I am unprepared to say that in a situation of great consequence, a
psychiatrist who might have some ability to help our military should claim
some ethical obligation that transcends all other obligations," said
Alan Stone, M.D., a past APA President and current member of the Committee on
Judicial Action. "There could come a time when I thought a person knows
something, and I could help find out what that is. I would certainly think it
strange for me to rest on an ethical principle when there is so much greater
harm [at stake]."
Stone, a professor of law and psychiatry at Harvard, has written
extensively about issues related to the misuse of psychiatry. He said the
issue of psychiatric involvement in nonpatient care roles has surfaced
before—as in the case of clinicians who provide the government"
profiles" of foreign leaders—but the professional and
ethical boundaries of such conduct have not been clarified.
The current controversy about Guantanamo interrogations adds the dilemma of
determining when psychological pressure turns into torture. "These are
issues that psychiatry hasn't faced up to or resolved," Stone said.
The American Psychological Association has issued detailed guidelines on
the subject that allow for the involvement of psychologists in interrogations
Appelbaum noted that in contrast to psychiatry, psychology has a history of
participation in a range of nontherapeutic functions and that there are
distinct differences between the two professions.
"It's fair to say that psychology and psychiatry have a different
ontogeny," he said. "Psychology has historically played many roles
other than direct patient care, including consulting to organizations and
businesses and the like, to a much greater extent than psychiatry has. So
practices that we might as physicians find more problematic may seem
acceptable to psychologists who are coming from this alternative