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Healthcare professionals and dual loyalty: technical proficiency is not enough.

Professional proficiency, and the societal expectations that go with it, include far more than technical skills. Professionals ask questions not only about means, but also about ends: What is the purpose of what we are doing here? Should I deploy my knowledge and skills for this effort? Recent attention to the problem of detainee abuse during “the war on terror[1–5]” illustrates the profound importance of professionals asking themselves, and one another, fundamental questions about the purposes for which they will allow their technical expertise to be used. 
 
In 2004, Steven Miles wrote the whistle-blowing article that appeared in The Lancet, in which he alleged that military physicians had been complicit with abuse and torture at Abu Ghraib in Iraq, in Afghanistan, and at Guantanamo.[1] His review of government documents and other evidence suggests that military physicians violated the Geneva Conventions,[6] the World Medical Association guidelines,[7] and basic principles of international humanitarian law[8] in at least 4 ways: by sharing medical records of detainees with interrogators; providing advice to interrogators about how to perform interrogations; failing to report witnessed or suspected abuse; and delaying, inadequately completing, or falsifying death certificates. 
 
In a more recent article, published on July 5, 2005 in MedGenMed, Miles[9] zeros in on the last of these 4 types of violations. He provides a detailed description of late and/or incomplete death certificates for 6 detainees in Afghanistan and 11 in Iraq, who died, or appear to have died, as a result of torture. Miles[9] asserts that, because some of these cases were labeled “natural deaths,” the death certificates concealed what were actually homicides by torture. He also concludes that other cases were so incompletely investigated that it is impossible to tell whether the trauma was purposefully inflicted or accidental. In all the cases, the death records fall short of the requirements laid out in the Geneva Conventions and in official US Army policy itself for properly documenting the deaths of detainees. 
 
In the 1990s, the Armed Forces Institute of Pathology, Washington, DC, set up the Armed Forces Office of the Medical Examiner (AFME) “to conduct autopsies of soldiers and civilians (including prisoners) who died while in the Armed Forces or under their jurisdiction.[9]” Miles holds that both the Institute of Pathology and its AFME were derelict in their duties, in that they mishandled forensic medical evidence, managed the death certification process poorly, and “did not properly and forcefully assert the need for field commanders to follow Defense Department policies for reporting prisoners' deaths for investigation.[9]” Had the AFME done a better job, Miles suggests that there would have been an “early warning system” of the abuse going on within these facilities, which might have brought the issue to public attention much earlier and could have saved lives.