By Annette M. Boyle
NEW YORK — A controversial report about medical ethics violations at Guantanamo Bay and Central Intelligence Agency secret prisons has gotten wide play in the general media, but at least one member of the task force creating the document emphasizes that the violations discussed are in the past and that the situation is much improved.
Retired Capt. Albert J. Shimkus, Jr., an associate professor, national security affairs, at the Naval War College in Newport, RI, spoke to U.S. Medicine about the report from the Task Force on Preserving Medical Professionalism in National Security Detention Centers and the Institute for Medicine as a Profession (IMAP).
“I don’t think the violations are continuing. What occurred in the past is past. The Department of Defense is a resilient organization that understands what is right and has internally corrected the kinds of things that needed correction,” he said.
Shimkus was the former commanding officer and chief surgeon for the Naval Hospital and Joint Task Force 160, which was responsible for administering healthcare to detainees.
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The New York-based task force reviewed public records over a two-year period and wrote, in a report entitled, Ethics Abandoned: Medical Professionalism and Detainee Abuse in the War on Terror, that, starting in 2001, “DoD and CIA policies institutionalized a variety of interventions by military and intelligence agency doctors and psychologists that breach ethical standards to promote well-being and avoid harm.”
It added that policies which “undermine standards of professional conduct” are continuing.
The DoD directly refuted the allegations. “We’re aware of the nearly comically absurd allegations trotted out in this IMAP report. However, it’s worth noting that the allegations made in the report are not new. They have been subject to numerous investigations over the years, and those investigations — which had access to more information than the authors of this report — have never substantiated these claims,” said DoD Spokesman Lt. Col. Todd Breasseale.
The report focuses on alleged violations at CIA secret prisons and Guantanamo Bay. The Obama Administration shuttered CIA prisons and banned use of many of the interrogation procedures outlined in the report in 2009, which the report acknowledges.
Shimkus does not contend that violations never occurred, just that the situation has largely been remedied. “My overall sense is that is [with] what has occurred at Guantanamo, we have lost the moral high ground in eyes of the world. I wouldn’t want to be living in that environment again. It’s a very difficult situation where each medical professional has to make an individual decision that impacts national security.”
Shimkus wrote in an op-ed piece in the Miami Herald earlier this year that “it is time to stop placing our dedicated military healthcare providers who serve in Guantanamo in the middle of a national security dilemma. It is not possible for the military healthcare professional to ethically serve both detainee patients and the state in the unique circumstances presented by Guantanamo.”
The challenge lies in the dual loyalties of military healthcare professionals, Shimkus said in an interview from AMSUS, the annual meeting of The Society of Federal Health Professionals, held this year in Seattle. “They are sworn to uphold the Constitution and the Hippocratic Oath or other pledges to do no harm. Each provider in uniform must balance both oaths and decide who he or she is as an individual and an officer.”
Providers in uniform took an oath of office when they accepted their commissions. “Essentially, this means that the medical officer will follow the legal orders of those who are of a senior rank, even though that officer is not a subject matter expert in medicine,” Shimkus wrote.
At the same time, they must meet certain state requirements to hold a license to practice in their field of healthcare, and state requirements may conflict with military demands. And, as healthcare providers, most would feel the need to “err on the side of the patient, the individual human being,” creating extremely difficult choices for providers in some circumstances.
Still, during his time at Guantanamo, Shimkus said “we gave detainees the best care they ever received.”
Breasseale maintained that that quality of care continues. “Task Force Guantanamo routinely provides comprehensive and humane medical care to the detainees held at Guantanamo. They are consummate professionals working under incredibly stressful conditions.”
The report specifically notes force-feeding of hunger strikers as a violation of international medical ethical standards.
While a number of medical associations oppose force-feeding of prisoners, U.S. federal and state courts have long upheld the practice as a means to prevent prisoner suicides and maintain order in prisons. Breasseale said that the DoD considers enteral feeding of hunger strikers part of its charge to protect the life and health of detainees by “humane and appropriate clinical means, and in accordance with all applicable law and policy.” He noted the procedure follows guidelines used in hospitals and nursing homes as well as prisons throughout the U.S.
In July, U.S. District Judge Rosemary Collyer ruled in a case brought by three detainees that the United States cannot allow a person in custody to die of self-inflicted starvation and that the military is obligated to preserve the health of detainees. Further, she noted, “there is nothing so shocking or inhumane in the treatment of petitioners — which they can avoid at will — to create a constitutional concern that might otherwise necessitate review.”
The number of hunger strikers in Guantanamo reached a high of 106 this summer. Just 14 continue the strike today. Breasseale said that detainees on the enteral feed list do not always require tube feeding. “Frequently they will drink the supplement or eat a meal out of sight of their peers.”
To address actual or potential future ethical conflicts, the task force recommended ongoing military medical training programs on human rights and professional ethics, stronger professional standards regarding treatment of prisoners or detainees on the part of medical associations and disciplinary action against violators, and state disciplinary action against health professionals who participate in interrogations or degrading treatments.
Shimkus said the recommendations of the task force “are exactly what’s needed” and that the DoD has already incorporated some of those changes.
Further, he and Breasseale agreed that shutting down the detention center at Guantanamo is in the interest of both the medical professionals who serve there and the DoD.
“We remain committed to President Obama’s goal of closing the detention facility at Guantanamo Bay, Cuba. It is wildly expensive, it is inefficient and it operates outside America’s best interests. However, until Congress changes the law, we will continue to humanely safeguard those held in our charge there,” Breasseale said.
The process for tracking the DoD’s most serious adverse medical events is “fragmented, impeding the Defense Health Agency’s (DHA) ability to ensure that it has received complete information,” according to a new review.
With a long history of point of care testing at both of its predecessor organizations, the Walter Reed National Military Medical Center (WRNMMC) laboratory services staff were keenly aware of the advantages of using portable testing devices to obtain rapid patient assessments.