The Role of Health Professionals in Bush-Era Torture

On Wednesday, just after the Senate Armed Services Committee released its report on the Bush Administration's torture program, Firedoglake hosted a live online chat with Nathaniel Raymond, Director of PHR's Campaign Against Torture. Firedoglake's Christy Hardin Smith introduced the online discussion, saying:

As the details spill out, again and again two names keep appearing—James Mitchell and Bruce Jessen. But it wasn't just those two. There were medical professionals involved in all aspects of these policies, from their initial development and inception, to overseeing and potentially participating in the interrogations themselvesAnd that participation led to this sort of twisted, unsupported policy:

At the direction of an accompanying psychologist, the team planned to conduct a psychic demolition in which they'd get Zubaydah to reveal everything by severing his sense of personality and scaring him almost to death.

PHR has been on the forefront of calling out the ethical and medical ramifications of this, as well as detailing the physical, mental and legal implications of torture by physician complicity.The question now is: will there be true accountability for these actions? Or are we to be forever haunted by the ghosts of justice at Nuremberg?

Below the cut I've excerpted all of Raymond's direct exchanges with participants in the discussion. For the complete chat, see the original post on Firedoglake.jhutson: With the declassification last week of the four Office of Legal Counsel memos and the declassification last night of the Senate Armed Services Committee report on its 2-year investigation, what’s the biggest surprise to come to light?Nathaniel Raymond: One of the most startling revelations from the recently released Office of Legal Counsel memos is the extreme involvement of medical professionals–one specifically was identified as a physician–serving as “safety officers” during the use of waterboarding and other tactics used on detainees in CIA custody. The monitoring of vital signs and giving instructions to interrogators to start and stop are some of the most severe abuses of the Hippocratic Oath and medical ethics imaginable. They also violate US anti-torture law. Strangely, the memos and the statements of former senior Bush Administration officials use the presence of medical professionals in contravention of their professional ethics as a defense, when it is in fact, itself, a crime.Christy Hardin Smith: I’ve been wondering about the licensing and professional organizations of which a lot of these folks are members. How are licensing boards likely to deal with a lot of this.As a lawyer, I’ve been wondering the same about various lawyers who were involved in this process. Professional organizations are going to have a very rough road ahead of them in sorting through conduct, intent and involvement, I’d bet. Would love your thoughts from the medical perspective.Nathaniel Raymond: Good question, Christy. As the White House, Congress, and the American public debate how and whether to hold those who authorized and use torture to account, one important front in the fight for accountability is the question of what do about members of specific professions—i.e. lawyers and health professionals (psychologists and physicians)—who were the handmaidens of torture.There has been only one case, to my knowledge, of a doctor who faced ethics charges because of his role in detainee abuse (he is licensed in CA) and that case was thrown out due to a supposed lack of juridstiction by the licensing board. However, there is in effort underway in NY state to pass legislation that would criminalize med ethics violations on the state level, called the “Gottfried Bill,” which PHR supports and is working with many groups to pass.What is needed now, additionally, besides legislation like the NY bill, is the swift action of the AMA, the APA, and the American Psychiatric Association to investigate their members and push licensing boards to sanction those found to have broken their oaths.laughingchimp: Today Binyam Mohamed’s lawyers were back at the British High Court arguing that evidence of his maiming by Moroccan agents, supervised by the CIA should be released. There was no mention of rendition in the OLC memos which leads one to conclude that it may still be illegal.The OLC memos may end up being most significant for what they don’t excuse. It would appear that when the CIA wanted to inflict lasting psychological or physical harm (as was also the case with Maher Arar) they sought to have interrogations completed by foreign agents. Would you agree?Nathaniel Raymond: You raise an important point, Mr. Laughingchimp. The cases of Binyam Mohamed and Maher Arar raise a troubling question that the release of the OLC memos and the SASC (Senate Armed Services Report) does not answer. What other secret memos exist that relate to detainee treatment (esp. rendition and transfer to third party intelligence services) that we don’t know about? While the OLC memos cover the use of the SERE tactics, we still don’t know what other aspects of detainee treatment and torture law were mangled in other, still classified directives.Christy Hardin Smith: It’s almost as though the medical professionals were used as the plausible deniability already factored into the mix. “See, we had doctor’s there, so everything was on the up and up.”Which, incidentally, is not an excuse with regard to conduct, but more of a PR ploy, I think. That they thought of it up front is bizarre enough, but that physicians would allow themselves to be used in that way? Appalling.Nathaniel Raymond: It is shameful that health professionals were put in a position of making an inherently damaging process “safe”… In fact, to quote my colleague Leonard Rubenstein, they became calibrators of harm.The use of doctors in this way, sadly, is identical to how other governments who have employed torture deployed health professionals as “legitimizers” and “sanitizers” of torture and abuse. Regardless of whether prosecutions occur, the US needs a non-partisan commission, with specific capacity to investigate health professionals, to get the full story.Jane Hamsher: Also curious to know how you think the medical community comes down on all of this—where do you think the AMA and others will stand?Nathaniel Raymond: The AMA recently released a letter to President Obama saying that they stand ready to support next steps, incl. a commission of inquiry. While this is positive, and PHR supports the AMA’s statement of support for accountability, it is essential that the AMA and the American Psychological Association, in conjunction with state licensure boards—the one’s who have the real power to impose strong sanction—tell their colleagues and the American people how they will ensure that those who assisted or directed torture will lose their licenses and never practice again.Hugh: There are several medical issues here.First, you have medical determinations made by the likes of Yoo, Bybee, Bradbury, and others has to what kinds of techniques caused what kinds of physical and psychological damage. They simply didn’t have the backgrounds to say anything about any of this.Second, you have medical personnel who either monitored detainees during torture, gave counsel to facilitate torture, or patched up detainees so that they could be further tortured. Personally, I feel the whole lot of them should have their professional credentials pulled. But aren’t these some of the well meaning people Obama has vowed to protect? How can the identities of any of them be established so that even if they aren’t pursued criminally they could be professionally.But even if their names were known, I foresee problems. If they are military physicians and nurses, couldn’t they continue to practice in that system? Mightn’t they be able to transfer at some point to VA facilities? I know in theory that the VA has certain standards but I could see these circumvented.Nathaniel Raymond: In response to your salient points, Hugh, I think it might be helpful to lay out what types of health professionals, from what branches of the national security community, and in what roles they were involved.Based on PHR’s investigations, the landmark report released by SASC yesterday, and other government documents and official statements in the public record, we know the following:

  • psychologists and other mental health professionals with the US military and CIA supervised torture at the “black sites,” GTMO, and elsewhere.
  • health professionals, including medics, patched up detainees so they could be returned to interrogation to face torture.
  • clinical psychologists and doctors did not adequately report in med records how torture caused mental and physical harm to their patients. In one report analyzed by PHR, a psychologist says that the severe mental suffering of a detainee being held in prolonged isolation is due to “routine stressors of confinement.”
  • And physicians and other members of the CIA’s Office of Medical Services were monitoring vitals and doing other diagnostics at CIA black sites during torture.

These varied roles, specialties, and branches and locations require a holistic approach to the med ethics violations that occurred as part of detainee abuse. A commission of inquiry is the best place to start in tackling what to do about these crimes by health professionals.Loo Hoo: Thanks for being here Nathanial. Did you ever get a sense of how these people could watch these procedures, much less participate in them? I absolutely cannot imagine.I couldn't watch someone "wall" a cat without making them stop.Nathaniel Raymond: One thing that continues to astound me, Loo Hoo, in the three years I have been ivestigating these issues is that there were many heroes in this story. Col. Steve Kleinman, USAF-Ret. objected to the use of SERE techniques on detainees in Iraq by the Special Mission Units (see amazing section on this in SASC report). My friend and personal hero Maj. General Tony Taguba, USA, Ret. told the truth to Congress. Alberto Mora. And many unnamed people of conscious at CIA.They all stood up.But I have yet to see a health professional involved in the use of these tactics be shown to have displayed real courage in the face of the unlawful orders they were given and, according to SASC, carried out. It is ironic that the healing professions appears to have been more compliant with gross violations of the Geneva Convention and US law then combat veterans and intelligence professionals. It says a lot about how social and institutional pressures can overwhelm people who are specifically trained to follow a higher code.Kirk James Murphy, MD: Though I agree state licensure boards have the final power, in CA and many other states, the state legislature has the power to direct the med baords via legislation (where they’re not cursed with govs who’d veto the new law). Might well-disposed legislatures in some states be able to advance the process by ordering their (captive) med licensure agency to wall out the torture docs?Nathaniel Raymond: Yes, Kirk. I think there needs to be citizen pressure on state legs to move (following the lead of NY State Rep. Gottfried) quickly to take exactly the type of action you are suggesting. “Juridstictional” issues and the ilk should not be used as an excuse to keep licensing boards from taking punitive action against those who violated the core principle of their professional ethics—"DO NO HARM"Christy Hardin Smith: Nathaniel—there is also mention in at least a couple of OLC memos of “outside providers” of psych or other contracted medical services. Do we have ideas who these were? Is that where Mitchell and Jessen’s firm comes in—or were there a lot of others as well?And, if you know, in what capacity were they contracting: advice, research or hands-on treatment? Or all of the above?Nathaniel Raymond: While we do not fully know exactly who those "outside providers" were, SASC’s investigation, hearings and report sheds some light on this question, potentially. SASC has discovered that consultations were made by DoD General Counsel Jim Haynes to SERE personnel in WA state in 2001 and 2002. It is likely that these consultations were used in some way to justify the authorization and twisted legal rationale for these tactics.To be a broken record, a commission in required to fill in these holes, wipe out the remaining redactions, and put all the principle players—good, bad and ugly—on the stand and before the American people to make sure that we know—once and for all—what was done in our name.BTW, I want to express here my great gratitude and respect for the hard working and committed investigators at Senate Armed Services. Senator Levin and his team released yesterday the most definitive record thus far of America’s descent into torture. We should all be proud of the work they have done to uphold our values and restore our nation’s reputation as a defender of human rights and the rule of law. My hat is officially off to them.Peterr: In the civilian world, medical professionals are licensed by and are accountable to state boards. How does it work for folks who are serving in the military?Are they required to be licensed in *some* state, though perhaps not where they are currently based/posted, or is there some DOD equivalent to a state licensing board that supersedes any state board?Nathaniel Raymond: In the US military, all health professionals in uniform, as part of post-Vietnam era reforms, are required to be state-licensed–psychiatrists, psychologists, nurses, physicians, etc. Another important point to note about military med ethics is that any health professional given an order that violates their professional ethics is required by military code to not obey it. That professional, military and moral directive was clearly not followed here by the psychologists, physicians and other health personnel involved.ondelette: Nathaniel,Thank you and all of PHR for all you do.In 2006, Gerald Gray (Santa Clara University Institute for Redress and Recovery) wrote for the journal Torture that he believed that a regime had been deliberately set up to cause abuse and torture on a massive scale, by using the precepts learned in the Stanford Prison Experiment—anonymity (secrecy), control, and encouragement from authority, to facilitate having prisoners abused by those controlling them, at places like Abu Ghraib, for instance. Given that the techniques listed in the torture memoes include nudity, isolation, cold/dousing, loud noise, 24/7 lights, dietary manipulation, and sleep deprivation, which are well known to cause profound disruption of the personality and senses, and given that most of those techniques were propagated to Bagram and Abu Ghraib according to the SASC document released today, is it worth revisiting Gray’s accusations? The jailers were told to ’soften people up’ and given free reign in some cases, while the above mentioned techniques were SOP.Specifically, do you think those in charge—both the lawyers and administration and the medical and psychological professionals who advised them—should be held accountable for the treatments seen in Broken Laws, Broken Lives, some of which go well beyond anything in any specific memoes?Nathaniel Raymond: Inspired by your mention of SPE (Stanford Prison Experiment), I want to quote Phil Zimbardo who said about Abu Ghraib (to paraphrase):

It wasn’t a case of bad apples. It was bad barrel makers.

The cause of accountability for torture is not served by prosecuting and convicting the next round of Ivan Fredericks… Those who designed, justified, and authorized this regime of psychological and physical torture at the top levels–and in violation of their professional ethics, for lawyers and health professionals—must be held to account if the “bedrock principle of command accountability,” to quote ret. Brig. General David Irvine, is to be restored.For me and many military/intel professionals who I have spoken to, one of the most tragic casualties of this dark chapter is that “command accountability,” a core characteristic of our armed forces, has been so severely damaged. We cannot have reform of our military and intelligence services without accountability.Hugh: I am less a fan of Levin. My view is better late than never, but he could have used his position as a Senator to raise this issue and explore on his own before 2006. Certainly, since the Democratic takeover of the Senate in January 2007, he could have put out a report two years ago.Nathaniel Raymond: I hear you, Hugh. All of us concerned about torture wanted the truth out years ago—and wanted Congress to robustly execute its oversight obligations at the time—as opposed to after the fact. However, the SASC investigation only began in early 07 due to the Dems taking over the majority in the Senate. For the amount of ground that SASC has covered in just under two years, I think that they should be given credit, and they deserve applause for their efforts to ensure almost total declassification of their report.But as good as the report is…it is not enough. Even the SSCI (Senate Select Committee on Intelligence) probe recently begun by the Chair, Senator Diane Feinstein (D-CA) is not enough. There needs to be a commission–non-partisan and outside Congress–and AG Eric Holder should be allowed to freely follow the evidence where it leads him and the rest of DoJ.MrToad: While I wouldn’t be in the least surprised to have more, and more detailed, memos turn up, it seems to me that what we have is more than sufficient. The techniques as described are surely well able to get anybody to say, or agree to, anything and everything. We’ve seen this all before, of course, and the ability of people to set aside their morals and ethics (if any) is well-known. I think the most appalling thing for me, on reading the released memos, was the detailed, clinical list of how and how much these “techniques of harsh interrogation” were to be used. Change the names and print it in German with a 1940 publication date, and people would be properly shocked. So, I wonder—why bother with the comforting fiction that the Nuremberg trials matter any more, or that the medical or legal professions have any inherent ethical standards? Certainly there’s plenty of after-the-fact wringing of hands, but what’s in these memos is not news. With all due respect, what I expect to see from these professional societies amounts to a few harsh words followed by some hearty handshakes all around and then some well-deserved drinks in celebration of their fine efforts. I’d be interested in speculation on whether losing our national sense of community has cost us our sense of empathy or whether we as people and as a nation ever had any sense that we were part of a larger group than simply our special tribe. How are we different from any other nation that has eagerly set foot on the road to dictatorship?Nathaniel Raymond: Mr. Toad—to address your eloquent closing question, “how are we different from any other nation that set foot on the road to dictatorship,” the answer to it is in all of our hands. Seriously. As cliche as it sounds, the question of accountability now at the center of the public debate will only be answered the right way if the American people in a unified, non-partisan way clearly articulate their demand for it.PHR has a petition on our website ( calling on President Obama to support a commission. Call the White House. Call your member of Congress. Write a letter to the editor. Tell your neighbors.Demand it. Demand it. Demand it.bgrothus: Nathaniel,It is true that in the past, doctors have been trained not to have their authority challenged by patients or other health care providers. I think this is changing as new medical personnel are being encouraged to be more responsive to the needs and questions of patients.Do you think that we can hope for more doctors to stand against this kind of behavior in the future? I am astonished to hear that none seemed to have stood up for what was right, as least as far as we know now.Nathaniel Raymond: There are several components that need to be in place to ensure that these types of abuses by health professionals never occur in US military/intel settings again.The American Psychological Association needs to amend their ethics code to take out section 1.02—a provision which allows contravention of the ethics code when faced with a conflicting “lawful” order. It is tantamount to the Nuremberg defense.

  • Ethics training—both in mil institutions and at med schools—needs to be strengthened and revamped in light of the detainee abuse scandal to learn the lessons and close the gaps in training.
  • All associations—state and national—need to send the message in their statements and actions: “You engage in this behavior and you will lose your ability to ever practice again.”
  • State legislatures need to pass legislation, as Kirk mentioned earlier, to strengthen the law as it relates to these abuses.
  • And a commission, which the AMA and APA should support publicly, is required to really examine how the strong codes of military medical ethics, that have distinguished our military at so many moments in the past, were short-circuited and undermined in such a tragic way.

Peterr: There’s also the yet-to-be-delivered report by the DOJ’s Office of Professional Responsibility. It’s not a congressional committee, but given what folks like Sheldon Whitehouse are saying, it could be quite stunning.Nathaniel Raymond: Those of us who work on detainee abuse issues are waiting with baited breath for the DOJ-OPR report about what it says about many things, most notably the roles of Yoo, Bybee and Bradbury. There is much speculation about what it allegedly says and recommends. We will just have to wait for its release and push for DoJ and the American Bar Association, among other bodies, to act in response.Christy Hardin Smith: Nathaniel—do you have any thoughts you can share on the destruction of those CIA interrogation tapes and the investigation into that?Nathaniel Raymond: The investigation by US Attorney John Durham into the alleged destruction of black site interrogation tapes by the CIA could potentially be a “game changer” in terms of the question of prosecutions. Durham’s report, expected some time relatively soon, according to news reports, could cause additional legal action against former US officials. Regardless of its outcome, the Durham probe is important because it represents the first major investigation of its kind on these issues. We should all watch closely to see where it leads.Kirk James Murphy, MD: Mr. Raymond, thanks to you and PHR for fighting the good fight. I hope one day America’s values on torture will return to what they were after WW II.Nathaniel Raymond: Thanks, Kirk, for your kind words and insightful comments about med practice and ethics. It is heartening for wonks like me to see that people like you are concerned about these issues. Years ago, when the detainee abuse scandal was just becoming apparent, it was easy to despair about whether many other people cared enough to act, to get educated, to get involved. I don’t feel that anymore. Though we have a tough row to hoe in the fight for accountability, I am hopeful that enough people, such as yourself, are outraged enough to make their voices heard.bluejeanstshirt: Thank you Nathaniel, The level of violence in film, teevee and video games seem to have hit ridiculous levels. Reality shows depicting degrading acts would have to have an effect not only on the participants but also viewers. I was raised in front of the teevee and I know something is afoot. Any thoughts as to the overall effect on the nations psyche?Nathaniel Raymond: Programs such as 24, etc have distorted, I think, the reality of interrogation in counter-terrorism settings. To read a more accurate account, Matt Alexander’s book: “How to Break a Terrorist” is a compelling insider’s account of interrogation.But I am not fully answering your question. I think books, TV, etc that seems to countenance or promote torture or “gloves off” approaches to the complex multitude of real national security threats our country faces are reflections of the national trauma of 9/11 and the ensuing years of war in Aghanistan and Iraq. To quote the Japanese Nobel Laureate, author Kenzaburo Oe, who was writing about the aftermath of atrocities, we need to “outgrow our madness,” so to speak and recommit ourselves to the defense of our nation through the defense of our values.A commission will be, I think, a key component of that process. By being able to present the facts of how our government ended up doing what it did, we can begin to not only heal the damage nationally and internationally, the US can see how it can change course and operationalize that change.hackworth: NPR’s Robert Segal suggested that since Lyndie England and the other Abu Ghraib soldier were prosecuted, this issue should be over. Levin’s rebuttal was excellent.Segal suggested further that waterboarding is not a big issue. Levin’s rebuttal was also excellent.Nathaniel Raymond: Thanks for the play by play. I look forward to hearing what the Senator has to say.Thank you, Christy and everyone for listening this afternoon to a policy wonk who largely speaks in acronyms. It has been a true treat. Anymore questions before we finish up?Christy Hardin Smith: Nathaniel, as Gregg said above, this really has been a great discussion—and a disturbing one as well. I was saying this morning that we already knew so much of this from other memos and news reports the last few years, but reading it in compacted form with the serial e-mail and memos to fill in some of the gaps makes it that much more disturbing when you see how any dissent was cleanly cut out of the mix with policymaking.I can’t thank you enough for being here to discuss this today. But also for all of the work that you and PHR have done on these issues for so long.Nathaniel Raymond: Much appreciated, Christy. I look forward to joining you all again. And thanks to FDL for having a forum to talk about these important issues in a reasoned way.Valtin: Great work by you and everyone at PHR, and by SASC.I want to reiterate Jane’s question earlier:

Can you talk about the memo of Dr. Jerald Ogrisseg, whose memo on waterboarding in the SERE project was forwarded by Lt Col Baumgartner to the General Counsel’s office? It’s my understanding that this was used in order to provide proof of the “safety” of waterboarding by Yoo/Bybee, though Dr. Ogrisseg claims that his memo had no application to actual real-world waterboarding outside the SERE program.

As you know, it’s my contention that the OLC memo by Bybee shows clear evidence of cherry-picking Ogrisseg’s report, proving they had different info on waterboarding and ignored it. There apparently is a lot more in the SASC report as well.Also, it’s my contention that the Haynes’ approach to JRPA prior to any determination of different status treatment of “enemy combatants” from Al Qaeda/Taliban demonstrates conspiracy to torture, and one for which the administration has NO defense.Any comments on this? Also, do you see the rewrite of the Army Field Manual, with its abusive interrogation techniques written into it, as connected to the material in the SASC report?Nathaniel Raymond: Valtin—you raise a series of important points. I will address one of them briefly. The current Army Field Manual must be amended because several of the tactics identified by SASC report and by PHR’s investigations as being used on detainees (i.e. isolation, sleep dep, sensory dep) are still in the manual in Appendix M. No SERE tactic should be allowed to remain in the AFM in any form.

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