Do no harm?
One Christian-Hippocratic position pertaining to the essentials of ethical medical practice has been unequivocal. There should be total separation between “black and white” medicine as described through the pregnant admonition: “do no harm.” Originally, the “black” side of medicine could be summarized neatly by two activities proscribed within the body of the Hippocratic Oath itself, abortion and euthanasia (or assisted suicide). Unfortunately, as distance between the precepts of the Oath and the realities of contemporary practice diverged, the list of prohibitions arguably qualifying as harm have increased. For example, bacteriological weapons became a sinister reality through the cooperation of physicians, initially in the Japanese Empire.1 Service to nation superseded the tenets of Christian-Hippocratism and fatal harm was thereby visited upon countless persons. Physicians became patriots and soldiers first. Similar harms were accomplished with human research—performed by physicians again—in Nazi death camps. That was then, what about now? How broadly should “harm” be defined in the context of the war on terror? The argument advanced here is that in contemporary, troubles times, it is imperative for physicians that harm be encompassed by the broadest of definitions.
A number of recent sources specifically attest to “medically-assisted torture” directed against detainees. 2 The reports are in response to a study by the International Committee of the Red Cross. It has been alleged that various prisoners and detainees accused of terrorism have been tortured by the CIA. Most of us are familiar with recent administration decisions to reverse government policy on torture of suspected terrorists. However, that the events transpired under the supervision of medical personnel, some of whom may have been physicians, is rather disconcerting. One report alleged a waterboarding session supervised by medical personnel; they were recording oxygen saturations during the procedure.3 Such assistance would allow incrementing levels of torture that could be stopped before a dangerous lack of oxygen occurred. Another vignette described prolonged shackling of a prisoner’s arms with medical examinations to ensure only judicious amounts of edema. The goal was torture just short of limb loss.
There are a number of disturbing aspects to these reports. The consistent perspective offered by the press for the events in question is dead wrong. If indeed physicians are cooperating with torture, using their expertise even to indirectly harm persons, the activity is not an opportunity for political football. Debates about the morality of the alleged behavior in the context of conservative versus liberal (or even Democrat versus Republican) miss a critical point. The purported behavior by physicians is ethically suspect in the same way it should have been for their prior complicity with bacteriological weapons development. The involved physicians, or other medical personnel, would have been using medical expertise not for the alleviation of pain and suffering, but rather, to harm. They would be doing the acts voluntarily with the assumption that the behaviors are not culpable in a military context. Say it is not so!
From the beginning, the telos of “black” medicine has been harm, in sizes big and small. The morality of such behaviors warrants its own unique ethical deliberation, a matter categorically separate from probing whether torture per se is right or wrong. If we as a culture valued the Oath and corpus of Christian-Hippocratism, this distinction would have been clarified already. For physicians, there is more to the story than country, president, and terrorism.
Therein lies the real rub. How can culture call upon the principle of “do no harm” to adjudicate contemporary physician complicity in torture, biological weapons, or human research? Margaret Mead’s characterization of doctors versus shamans offered precisely this sort of black and white analysis that eliminated shades of gray. All harm has to be proscribed for those who are called to heal, including abortion and assisted suicide, and these problematic recent additions. Always a doctor, never a patriot or soldier is how some have described the profession.4 Anything less opens a door to physicians that should never be opened. Just ask anyone who knows what horrors were punished at Nuremberg or discovered in the investigations of Unit 731’s germ warfare program. Torture of combatants by medical personnel is unethical, period. Let’s stop treating the errant professional behavior as a purely political or ethically abstract question; it must resonate at the very heart of physicians themselves. Their professional identity is at stake. They are the healers entrusted with those created in the divine image—whether their “patients” be friend or foe.
1 Gregory Rutecki, “From ‘Never to Harm’ to Harnessing Plague: A paradigm shift in Plague Ethics,” in Plague: Pathology, Diagnosis, and Treatment (Nova Science Publishers, forthcoming).
2 Mark Danner, “U.S. torture: Voices from the Black sites,” The New York Review of Books 56:6 (2009), accessed April 13, 2009. http://www.nybooks.com/articles/22530. Cf. “Medically-Assisted Torture,” New York Times April 8, 2009, accessed April 13, 2009. http://www.nytimes.com/2009/04/09/opinion/09thu3.html; Catharine Paddock, “Medics helped CIA torture terror suspects says secret Red Cross report,” Medical News Today April 8, 2009, accessed April 13, 2009. http://www.medicalnewstoday.com/articles/145532.php.
3 “Medically-Assisted Torture,” New York Times April 8, 2009, accessed April 13, 2009. http://www.nytimes.com/2009/04/09/opinion/09thu3.html
4 George Annas, “Military Medical Ethics: Physician first, last, always,” New England Journal of Medicine 359 (2008): 1087-1090.
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