Psychiatrists and other physicians must not take part in interrogations of
persons detained by military authorities, according to both an APA position
statement and AMA ethics guidelines, but a recently revealed Department of
Defense policy memorandum "seeks to undermine the positions taken by the
AMA and APA concerning physicians' monitoring of interrogations,"
said a Perspective in the September 11 New England Journal of
The memorandum was signed by the then-Army Surgeon General Lt. Gen. Kevin
Kiley, M.C., in October 2006, but it applies to all branches of the armed
The Army memo "fails to mention the APA statement and provides a
permissive gloss on the AMA's policy, at some points contradicting it
outright," wrote Jonathan H. Marks, M.A., B.C.L., and M. Gregg Bloche,
M.D., J.D. Marks is an associate professor of bioethics, humanities, and law
at the Pennsylvania State University at University Park and at the College of
Medicine in Hershey, and a barrister and academic member of Matrix Chambers,
London. Bloche is a professor of law at Georgetown University and a
nonresident senior fellow at the Brookings Institution in Washington, D.C.,
and an adjunct professor at the Bloomberg School of Public Health at Johns
The APA statement, approved by APA's Board of Trustees in May 2006,
states, in part: "No psychiatrist should participate directly in the
interrogation of persons held in custody by military or civilian investigative
or law enforcement authorities, whether in the United States or elsewhere.
Direct participation includes being present in the interrogation room, asking
or suggesting questions, or advising authorities on the use of specific
techniques of interrogation with particular detainees."
While Marks and Bloche credited the Army with prohibiting torture or other
illegal treatment of detainees, they argued that the Army memo's wording
introduces confusion about the ethical obligations of health
professionals—including psychiatrists—who function as consultants
during interrogations (see Army Document at Odds With Ethics).
The confusion is most explicit in the contrast between the
organizations' statements against involvement in interrogation and the
Army memo, which says: "[Psychologists and psychiatrists] must regularly
monitor their behavior and remain within professional ethical boundaries as
established by their professional associations, by their licensing State, and
by the military."
"Such consulting undermines their role as physicians," said
Marks in an interview.
Through a Freedom of Information Act request, the authors asked the Army to
provide documents relating to health professionals' role on Behavioral
Science Consultation Teams, the military term for "operational
psychologists and psychiatrists ... essential in developing integrated
interrogation strategies and assessing interrogation intelligence
Among those documents was the Army memo, which the authors did not know
existed prior to receiving it. The document is not classified.
The Army contends that it avoids any conflict of interest or violation of
professional ethics by separating psychiatrists and psychologists who provide
clinical care for detainees or U.S. personnel from those who serve as
behavioral science consultants, said Col. Elspeth Cameron Ritchie, M.C., a
psychiatrist and medical director of strategic communication in the Army
Medical Department, in an interview.
"The Army uses only experienced forensic psychiatrists specially
trained for this role, and then only if a psychologist is not
available," said Ritchie.
An American Psychological Association resolution passed in 2007 does not
prevent psychologists from taking part in interrogations in which torture is
not used (Psychiatric News, December 21, 2007). However, at press
time, that organization passed a measure prohibiting psychologists from taking
part in interrogations in settings where "persons are held outside of,
or in violation of, either International Law (e.g., the U.N. Convention
Against Torture and the Geneva Conventions) or the U.S. Constitution, where
appropriate," unless they represent a detainee or an independent third
The Army requires psychiatrists to complete a 136-hour course before taking
part in interrogations. Ritchie has taught parts of that program and said that
four psychiatrists have attended it so far.
"The big question is, Should forensic psychiatrists participate as
subject-matter experts and not in a treatment role, like they do in the
civilian world?" said Ritchie.
The Army may be pinning too much emphasis on this distinction, according to
APA experts on the matter.
"We should not be a part of interrogation under any
conditions," said former APA President Steven Sharfstein, M.D.,
president and chief executive officer of the Sheppard Pratt Health System in
Baltimore. "Taking part in interrogations is just not part of our
medical ethics." Sharfstein was APA president when APA's position
statement on interrogation of detainees was approved.
At APA's 2006 annual meeting in Toronto, Kiley appeared on a panel
with members to discuss the Association's statement.
"He said unequivocally that the Army would abide by APA's
position and not put psychiatrists in situations where they would have to go
against APA's position unless there was absolutely no alternative,"
said Paul Appelbaum, M.D., another former APA president and former chair of
the Council on Law and Psychiatry. "The Army memo appears to violate the
assurances we were given then."
The Army policy was developed after the expansion of Guantanamo Bay as a
detention center and the exposure of mistreatment of prisoners at the Abu
Ghraib prison in Iraq, said Ritchie.
"We needed to be explicit about what the rules should be," she
said. She cited the value of health professionals' assisting
"Psychologists and psychiatrists are experts at enhancing
rapport," she said. "They also can counteract behavioral drift,
the spiraling down of interrogation into a culture of coercion" that can
lead to mistreatment of detainees.
Such interrogations have revealed weapons caches, identified the remains of U.S.
troops, and have saved the lives of American soldiers, she said.
While Ritchie envisions these specially trained psychiatrists putting the
brakes on illegal or unethical treatment of detainees, others see an
inevitable pressure to remain in step with one's unit.
"The Army is being naïve in thinking that physicians will
magically be able to resist the tendencies that everyone else is susceptible
to," said Appelbaum.
Marks agreed it would be hard for a member of an interrogation team to act
independently and report colleagues who go beyond the bounds of professional
"You don't want to seem unpatriotic or to be crying wolf,"
he said in an interview. "So you wait for egregious cases, but that
signals that other cases are OK."
The Army memo does not refer to APA's statement of May 2006, although
it does refer to an AMA report by the Council on Ethical and Judicial Action
issued a month later. The AMA does not distinguish between treating and
nontreating physicians, and the report became a part the AMA's code of
ethics in November 2006.
APA members are bound by the nine principles of the AMA's ethics code
but not by its more specific set of opinions.
The lack of reference to APA's statement was no oversight, said
"APA's was a position statement, not an ethical
guideline," she said. "My understanding is that if you violate
ethical guidelines, there are measures that the Association can take, but not
if it's a position statement."
That may be where things stand at the moment, said Spencer Eth, M.D., who
was chair of APA's Ethics Committee when it developed its annotation
addressing torture. The annotation prohibits psychiatrists from participating
in "cruel and degrading treatment" of prisoners, that is,
"However, the position statement opposing a role in interrogation
binds APA as an organization, but is not actionable against individual
members," said Eth in an interview.
Only if the position statement against interrogation were passed as an
ethics annotation could action be taken against a psychiatrist who was found
to have violated it, he said. That is unlikely to happen soon.
"There is a real clash of values between military convenience and
professional ethics," said Lawrence Hartmann, M.D., chair of APA's
Council on Global Psychiatry. "The Army should embrace the [APA and AMA]
statements, but let's be realistic: we don't have the power to
enforce our views on the government and the military. We can influence but not
The Army is now reviewing the 2006 memo, which expires on October 20, and
it may be revised before it is reissued. Changes are possible, said Ritchie."
But we expect there will continue to be differences of
"The Ethics of Interrogation—The U.S. Military's
Ongoing Use of Psychiatrists" is posted at:<http://content.nejm.org/cgi/content/full/359/11/1090>.
The Department of the Army's "Behavioral Science Consultation
Policy" is posted at the New England Journal of Medicine's
Web site at<http://content.nejm.org/cgi/data/359/11/1090/DC1/1>.▪