Ethics Experts Challenge Army's Interrogation Participation Memo

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 Medicine.

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 services.

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 Hopkins University.

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 Original article: 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 production.”

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 party.

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 interrogators.

“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 ethics.

“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 Ritchie.

“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, torture.

“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 enforce.”

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 opinion.”

“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>.▪