Editorial

Medical abuse at Guantanamo Bay Military Prison – what do

we do now?

Emmeline J. Buckley1, Sakib Rokadiya2, Anthony Kessel1, John Porter1 and Osman Dar3

1 London School of Hygiene and Tropical Medicine, London, UK2 University College London, UCLH NHS Trust, London, UK3 Chatham House Centre for Global Health Security, London, UK

keywords ethics, Guantanamo Bay

Ethics abandoned

In April 2013, the president of the American Medical

Association wrote to the US Defense Secretary expressing

concern over allegations of force-feeding of detainees at

Guantanamo Bay Military Prison and highlighting the

possible unethical participation of physicians in the pro-

cess (Lazarus 2013). The prison complex (hereafter

referred to as Guantanamo Bay) located within the Uni-

ted States Military Naval Base overlooking Guantanamo

Bay in Cuba was established in January 2002, for the

detention, interrogation and prosecution of prisoners sus-

pected of war crimes.

In November 2013, suspicions were confirmed with the

publication of a report supported by the Institute on

Medicine as a Profession (IMAP) and the Open Society

Foundations, entitled Ethics Abandoned: Medical Profes-

sionalism and Detainee Abuse in the War on Terror. This

report was the result of a 2-year review by a Task Force

comprising independent military, ethics, medical, public

health and legal experts (IMAP & OSF 2013).

The report did not only uphold allegations about phy-

sician involvement in force-feeding, but also showed that

US Department of Defense and CIA policies have institu-

tionalised a whole range of practices by military and

intelligence agency health workers that breach interna-

tional standards of medical ethics, as initially laid out by

the World Medical Association in 1975, and again in

2006 (World Medical Association 1949). These malprac-

tices include medical personnel involvement in abusive

interrogation designed to increase disorientation and anx-

iety of detainees, using medical information for interroga-

tion purposes, and the force-feeding of hunger strikers. In

the face of these accusations, the US government has

responded by stating that it is obliged to follow the laws

of war, not the international standards of medical ethics

(Cowley 2013). However, the laws of war – set out in

the additional protocols to the Geneva Convention in

1997 – explicitly state that health personnel should not

contravene medical ethics by carrying out medical proce-

dures not consistent with generally accepted medical stan-

dards (ICRC 1949; Goodman 2013).

The global medical community responds

Awareness of the ongoing breaches of ethical standards at

Guantanamo Bay among both the medical community

and the media is already present, thanks in large part to

the publication in May 2013 of an open letter from

detainees to their doctors, expressing pain and distress at

their treatment (Anonymous 2013a). The letter provoked

an immediate response from the medical community and

saw widespread calls for practical action. In June, The

Lancet published an open letter to President Obama writ-

ten on behalf of more than 150 doctors offering indepen-

dent medical services at Guantanamo Bay (Arnold et al.

2013). Shortly after, the New England Journal of Medi-

cine made an unequivocal statement on the need for the

medical community to be more vociferous in its opposi-

tion to unethical medical practices at Guantanamo and

urged support for military physicians who refuse to

comply with orders contrary to their ethical standards

(Annas et al. 2013). Back across the Atlantic, the British

Medical Journal called for the international medical

community to support military medics at Guantanamo

who speak out against ethical abuses. Furthermore, it

encouraged its readers to take practical steps, such as

writing to government ministers to publicly call for the

US to suspend immediately any medical involvement in

force-feeding and to allow detainees full access to

independent medical assessments (Chrispin & Nathanson

2013).

1000 © 2014 John Wiley & Sons Ltd

Tropical Medicine and International Health doi:10.1111/tmi.12348

volume 19 no 9 pp 1000–1002 september 2014

What do we do now?

The publication of the IMAP report must now galvanise

the medical community still further. The policy shift

away from force-feeding hunger strikers instituted in the

UK in the 1970s is a clear indicator of the influence that

the medical community can exert on decision makers

(Jacobs 2012). For what is of greatest concern now is

that even after the extensive efforts of the multidisciplin-

ary, independent, American team of experts that pro-

duced the IMAP report, there appears to have been little

change in US military policy relating to the medical treat-

ment of detainees. Indeed, detainees are perhaps worse

off, behind a barrier of increased secrecy: in December

2013, the US military declared it will no longer disclose

to the media and public whether prisoners at Guantana-

mo are on a hunger strike (Anonymous 2013c). Even the

terminology in use at Guantanamo Bay has been altered

to divert attention from controversy; documents released

by the Pentagon in March 2014 reveal that guidance on

the ‘Medical Management of Detainees on Hunger

Strike’ (written in March 2013) has been replaced by the

more palatably titled ‘Medical Management of Detainees

with Weight Loss’, and force-feeding is now referred to

as ‘involuntary enteral feeding’ (Joint Medical Group

Joint Task Force Guantanamo Bay 2013; Anonymous

2014).

More coherent action is thus needed from the global

medical community if we are to make a difference and

uphold the ethical values and standards we espouse.

There is little doubt that similar abuses by medical per-

sonnel in military and other detention facilities occur in

other countries around the world and should be con-

demned whenever they are brought to light. Ignoring

this particular blight on the global medical conscience is

not an option. It is now necessary to develop a coordi-

nated strategy which should include three elements:

keeping the protection of medical ethics at Guantanamo

Bay a ‘live issue’; mobilising interest groups from medi-

cal, legal and political spheres to develop enforceable

safeguards and solutions around prisoner rights and

treatment; and establishing sterner sanctions to be

applied to those contravening the principles of medical

ethics.

As part of the first strand of this strategy, statements

and actions to counter ethical breaches of medical practice

remain essential. Forums such as the World Health

Assembly and the General Assembly of the International

Federation of Red Cross and Red Crescent Societies could

provide an excellent platform for this. The latter is an

especially good forum in which to raise concerns, as the

ICRC is the sole independent human rights organisation

with access to the detention facility at Guantanamo Bay

(Anonymous 2013b). The second element of this strategy

could be achieved in part through targeted events that

serve to unite interest groups and provide a space in which

to formulate clear ideas for action. A recent conference on

Medical Care and Medical Ethics at Guantanamo brought

together international representatives from the medical,

military and legal professions who were able to identify

barriers to improving medical ethics at Guantanamo Bay

and set out solutions and next steps (Detainee Task Force

2013). Key to progress beyond this would be the inclusion

of policy makers and senior politicians in future events of

this kind. The third component of this strategy, develop-

ing processes for sterner definitive sanctions against those

contravening the principles of medical ethics, could

include boycotts of joint medical research and clinical

activity and other forms of collaborations with any insti-

tutions/facilities (military or otherwise) participating in

unethical practices. The impact of the international aca-

demic boycott of apartheid-era South Africa – supported

by the South African National Medical and Dental Associ-

ation (NAMDA) – suggests that this type of sanction can

be an effective tool in raising awareness and promoting a

positive policy change (Coovadia 1999).

The events at Guantanamo Bay require urgent atten-

tion, both for the benefit of the detainees whose human

rights are being ignored and for the sake of the wider

global medical community, whose reputation for indepen-

dence and ethical rigour is being compromised. To safe-

guard for future generations, the ethics and values that

underpin the medical profession, health professionals,

must take action now.

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Corresponding Author Emmeline J. Buckley, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E

7HT, UK. Tel.: +44 208 237 6395; E-mail: emmeline.buckley@lshtm.ac.uk

1002 © 2014 John Wiley & Sons Ltd

Tropical Medicine and International Health volume 19 no 9 pp 1000–1002 september 2014

E. J. Buckley et al. Editorial