- FROM BIOETHICS BRIEFINGS
Torture: The Bioethics Perspective
Framing the Issue
Torture occupies an odd position in that it is universally illegal and widely practiced. Despite many studies showing its inefficacy, more than half of the world’s nations systematically use torture, and medical personnel have a long history of involvement with torture. The word torture, like the word torque, derives from the Latin word tortūra meaning “twist.” The word captures an image of the bending a victim’s body as by a medieval rack or Abu Ghraib prison’s “stress positions.” Torture encompasses a universe of physical and psychological abuses, and it creates long lasting physical and psychological disabilities. Ethical concerns with torture consider the physical and psychological harms to people who are tortured, psychological harm to torturers, harms to civil society, and harms to health professions whose members explicitly or tacitly abet torture.
The Holocaust brought modern torture to public awareness and censure. Since World War II, torture has been condemned by the United Nations’ “Universal Declaration of Human Rights,” the Geneva Convention, the Convention Against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment, the United Nations’ “International Covenant on Civil And Political Rights,” and countless regional groups, such as the European Convention for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment. In 1977, the U.N. passed the “First Additional Protocol to the Geneva Conventions,” which specifically bars medical complicity with torture or the mistreatment of prisoners.
Medicine’s Involvement with Torture
During the Renaissance, physicians had legal roles in interrogational torture. The German Constitutio Criminalis Carolina of 1532 required that a physician certify that a person who is going to be interrogated by torture could survive, and that he or she was not blind, mute, or insane (and therefore incapable of giving the solicited testimony). By confirming pregnancies, midwives afforded women a temporary exemption from torture. Such medical and midwifery certificates were used throughout Europe until torture became illegal during the eighteenth century.
During the enlightenment, torture was radically reduced as public opinion concluded that it was barbaric, abused by those in power, and produced unreliable testimony. The most influential compilation of arguments against torture was in a 1764 book, On Crimes and Punishment, by Cesare Beccaria, an Italian lawyer and philosopher. A year later, the English jurist William Blackstone wrote, “It seems astonishing [to be] . . . rating a man’s virtue by the hardiness of his constitution and his guilt by the sensibility of his nerves.” Following these publications, torture abolitionist sentiment and legislation to end the practice rapidly escalated.
Nonetheless, torture–and medical involvement in it–persisted. Global revulsion at clinicians who participated in torture was ignited by revelations of the actions of Nazi physicians at death camps. In 1946, 23 physicians were tried and mostly convicted at Nuremberg for war crimes and crimes against humanity pertaining to their complicity with mass-murder and sadistic experiments on prisoners. After the war, the World Medical Association was founded and passed the Declaration of Geneva, the 1956 “Regulations in Time of Armed Conflict,” the 1975 Declaration of Tokyo (formerly known as “Guidelines for Medical Doctors Concerning Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment in Relation to Detention and Imprisonment,” and the 2007 “Resolution on the Responsibility of Physicians in the Documentation and Denunciation of Acts of Torture or Cruel or Inhuman or Degrading Treatment.” The Declaration of Tokyo explicitly defines direct or indirect medical complicity with torture as unprofessional conduct. Countless other medical societies have since passed medical codes against torture.
Despite medical association codes and the opposition of brave clinicians to torture, many more physicians abet torture compared with the few physicians who work in the sparse number of torture survivor treatment centers. Many torture survivors report that clinicians monitored their mistreatment. Of course, reports do not include the victims who never saw the doctor who falsified their death certificates to conceal torture. The presence of a physician during torture compounds the victim’s suffering by emphasizing that even the humanity of medicine is turned against the prisoner.
THE TORTURING CLINICIAN
Physicians, psychologists, and other clinicians who participate in torture do not have a characteristic psychological profile. Most have simply built their careers around the practice. Some are ardent political enthusiasts. Others separate their prison selves from their civilian professional identities.
Clinicians collaborate with torture by playing several roles. They certify prisoners fit for the planned regimen of torture. They devise techniques that do not leave evidentiary scars or other signs of trauma. This accounts for the increased use of methods such as prolonged asphyxia, drugs, or the infliction of severe psychotrauma. They monitor the torture of persons who are not supposed to die to assess whether the abuse can be increased without causing death or should be decreased to avoid killing the prisoner. They provide palliative treatments for torture-inflicted injuries while leaving the prisoner in the control of torturing officials. They fail to record signs of torture on medical reports and death certificates in order to conceal evidence of torture.
Physicians are accomplices to torture in Asia, Europe, Africa, and South America. Recent attention has focused on the complicity of physicians and psychologists with torture in United States’ military prisons at Guantanamo Bay, Iraq, and Afghanistan. Today, physicians have three major roles in torture: 1) devising methods that do not leave scars that might be used as evidence (e.g., asphyxiation and intra-rectal electrical shocks are harder to discover than the scars left by whipping), 2) keeping prisoners who are not supposed to die under torture alive by monitoring and titrating the severity of the torture, or by treating unexpectedly grave injuries, and 3) writing death certificates and medical records that falsely omit mention of torture-inflicted injuries.
All countries that use physicians to participate in torture protect them from professional or criminal accountability. But, in general, medical licensing boards are more active than criminal courts in punishing such physicians. Punishments are uncommon but are steadily increasing.
Bioethics and the “Ticking Time Bomb”
Given the prevalence of torture, it is not surprising that it has proponents, including some bioethicists. Recent arguments of bioethicists who are sympathetic to considering some instances of clinician involvement in torture, including Fritz Allhoff and Michael Gross (see Resources), align closely with the policies of torturing governments. These arguments ignore empirical evidence unequivocally showing that torture doesn’t work.
Proponents of torture rationalize its devastating effects on human dignity and well-being by appealing to its utilitarian value in specific cases. The “ticking time bomb” argument is central to their position. According to this argument, in the event of a time-critical threat to national interests, torture is justified as a way to obtain information expediously. To accept the argument, one must posit that the interrogator: 1) lacks one or a few pieces of key information, 2) knows that the information is time-critical, 3) knows that a prisoner has specific information, 4) knows that torture will break the prisoner, 4) knows that the odds are that torture will secure the information more quickly than other forms of interrogation, and 5) knows that the prisoner will reveal true information in response to torture. Any one of the hypotheticals in this moral syllogism is very doubtful.
There are numerous critiques of the ticking time bomb argument:
- Interrogators rarely know that a prisoner has specific information.
- They do not know how much pressure must be applied to break the prisoner.
- They usually obtain false information that can lead to disastrous consequences, such as the torture-acquired testimony used to support the invasion of Iraq. (This testimony claimed that Saddam Hussein and Al Qaeda were cooperating on bioweapons development, which has been roundly disproven.)
- Finally, a premise of the ticking time bomb hypothetical is the need to act fast, but intelligence services rarely have the capacity to act immediately on information.
By contrast, the implausibility of the ticking time bomb argument raises credible moral challenges, such as:
- Is it moral to use interrogational torture knowing that most of those questioned will be innocent or ignorant? About 85% of the persons at Abu Ghraib were innocent or ignorant of insurgency activity.
- If so, how should society balance the harms to those people with the good that allegedly comes from torture? Should society compensate and provide therapy to the innocent victims of torture?
- Is it moral to torture a culpable person who is unlikely to give useful information despite being tortured?
- Is it wise to torture when torture procures false information that swamps limited intelligence analysis resources?
- Is it prudent to employ torture, given that it destroys the ability to recruit human intelligence, makes our enemies more numerous and hardens them against us, and makes enemy soldiers more willing to fight to death rather than risk capture and torture?
Twentieth century torture has always spread far beyond ticking time bomb scenarios to the abuse of many innocent or ignorant persons. Societies that torture arm a real time bomb. Bioethicists should distinguish the instrumental purpose of torture (e.g., interrogation) from its social function. Torture is most often used against civil society. In this use, it is aimed against leaders in the press, religion, education, unions, student groups, and opposition political movements. Even where torture is not aimed to suppress civil society, as in Iraq, it destroys the political moral credibility of an authority that claims to want to build civil society.
Medical ethics is a form of social capital in civil society. Medical authorities who have spoken out in torturing societies against these practices have become highly vulnerable to being abused. Such was the case of physicians in the Chilean and Turkish Medical Associations who protested torture, as well as Dr. Anatoly Koryagin, a psychiatrist in the former Soviet Union who protested the arbitrary commitment and forced medication of dissidents. Those who support instances of clinician-abetted torture heighten the danger to colleagues in countries that practice torture. Appeals to laws against torture have been used by governments and groups like Amnesty International to protect friends of civil society and prisoners of war. The practice of torture erodes the foundation for such appeals anywhere.
Steven H. Miles, MD, is a professor of medicine at the Maas Family Foundation Professor of Bioethics at the University of Minnesota.