Salus aegroti suprema lex is Latin for the ‘wellbeing of the patient is the most important law’.

Beneficence is a core value of medical ethics that may have been compromised by health care personnel that failed to inquire about or document causes of injuries and psychological symptoms they observed in Guantanamo Bay (GTMO), according to a paper published this week in PLoS Medicine.

After the September 11th attacks, the US government authorized use of ‘enhanced interrogation techniques’ (EIT), including waterboarding, forced nudity, sleep deprivation, temperature extremes, and stress positions. Evidence of these practices and other ill treatment of detainees in GTMO was revealed via inspection of medical records, case files, and legal affidavits by non-governmental experts, led by Vincent Iacopino, Senior Medical Advisor for Physician for Human Rights, and Brigadier General (Ret) Stephen Xenakis, U.S. Army. their study of 9 cases of male detainees from GTMO included the following allegations:

In addition to the use of authorized EITs, each of the nine detainees reported being subjected to ‘unauthorized’ acts or torture including: severe beatings, often associated with loss of consciousness and/or bone fractures, sexual assault and/or the threat of rape, mock execution, mock disappearance, and near asphyxiation from water (i.e., hose forced into the detainee’s mouth) or being choked. other allegations included forcing the detainee’s head into the toilet, being used as a human sponge to wipe the floor…

The authors write that the GTMO medical records do not mention the causes of physical injuries that are consistent with detainee allegations of abuse in 3 cases: “contusions (2), bone fractures (3), lacerations (2), peripheral nerve damage (1), and sciatica (2).” another detainee alleged that he saw an interrogator with his medical records and that his “chronic back pain was exploited by interrogators through prolonged, painful stress positions.”

According to the study, GTMO medical records indicate that none of the detainees had a past psychological history, prior to detainment at GTMO, but 8 of 9 cases were later documented as having significant psychological symptoms, including nightmares (5), suicidal ideation (4), audiovisual hallucinations (3), suicide attempts (2); and Department of Defense mental health providers with the Behavioral Health Service (BHS) evaluated 6 of 9 detainees and made the following diagnoses: “depression (4), passive aggressive personality (4), borderline personality (2), adjustment disorder (3), routine stressors of confinement (2), narcissistic traits (1), psychosis or depression with psychotic features (2), and anxiety NOS (not otherwise specified) (2).”

The authors wrote about BHS notes describing 7 detainees having symptoms supporting a diagnosis of PTSD, but “BHS clinicians did not indicate inquiring about or documenting possible causes of these symptoms and/or the diagnosis of PTSD.”

One of the limitations of this study is that the cases reviewed were those for which the authors were consulted, increasing the possibility of selection bias. the psychological assessments are potentially subject to bias from both the detainee and interviewer. the results from 9 cases may not be generalizable to other GTMO detainees, but there are other reports documenting US endorsement of harsh interrogation techniques.

The United Nations Convention against Torture has prohibited torture and previously recognized waterboarding, sleep deprivation, and prolonged isolation, as torture. Nations participating in the Geneva Convention agreed not to torture prisoners, but after 9/11, the US government redefined some of these practices as EITs and approved their use, putting health care providers working in detention camps like GTMO in potentially compromising situations.

Health care professionals have been complicit with the design and monitoring of EITs, as called for in the memos that authorized their use. It was not until 2005 that Department of Defense providers mentioned a duty to document abuse. in 2007, the New York Times reported that President Bush signed an order allowing the CIA to resume the use of harsh interrogation methods.

In one of his first acts of office, President Obama ordered that no one from the US government could rely upon any interpretation of the law governing interrogation issued by the Department of Justice between September 11th 2001 and January 20, 2009. in April of 2009, the President allowed the release of interrogation memos and issued a statement from the White House that was published in the New York Times:

In releasing these memos, it is our intention to assure those who carrying out their duties relying in good faith upon the legal advice from the Department of Justice that they will not be subject to prosecution.

It seems only fair that this statement should apply to similarly involved physicians and mental health workers, but raises the question of whether health care personnel are bound to the ethics of their profession or federal duty. these 9 cases illustrate a situation where it was hard to do both.

UPDATE: an organization called the Center for Justice & Accountability (CJA) is taking a step forward in attempting to hold health care professionals accountable for their roles in Guantanamo.

Kathy Roberts is a UC Berkeley Law School graduate and lead attorney for a professional misconduct complaint filed by the CJA against a psychologist alleged to have had a role in abusive interrogation at Guantanamo. She told me that no U.S. official involved, including health care professionals, has ever been held accountable for the cruel treatment of detainees at Guantanamo. She shared some details:

The Center for Justice & Accountability and the New York Civil Liberties Union represent New York psychologist Dr. Steven Reisner in this proceeding against the New York Department of Education’s Office of Professional Discipline (OPD) for its failure to investigate his fellow New York psychologist Dr. John Leso for his role in the abusive interrogation program at Guantanamo Bay, Cuba.

Dr. Reisner and CJA filed a professional misconduct complaint against Dr. Leso last July, alleging that while Dr. Leso served as a clinical psychologist at Guantanamo, he recommended a series of escalating physically and psychologically abusive interrogation tactics to be used on detainees and personally supervised and participated in interrogations where his tactics were used. the OPD declined jurisdiction, claiming that Dr. Leso’s alleged conduct at Guantanamo did not qualify as the practice of psychology as defined by New York law.

Posted by: Winston Chung MD (Email) | April 26 2011 at 11:10 AM

Combat and post-traumatic stress disorders in military veterans are not new, though the conditions have been called many other names throughout the years: “insanity” and “melancholia” during the Civil War, “shell-shock” during World War I and “combat fatigue” during World War II.

Top military leaders are now addressing the lingering effects of post-traumatic stress disorder, (PTSD) which were ignored for many years because they were seen as a sign of weakness. Last week, Gen. George Casey, the chief of staff of the U.S. Army, called PTSD “the defining military health issue of our era.”

Consider that statement alongside the much-recounted story from World War II, when Gen. George S. Patton infamously slapped a solider suffering from “nervous exhaustion” in a military hospital and ordered him back to the front.

That story, and others from wars stretching from the Civil War to the current battles in Afghanistan and Iraq are chronicled in a new HBO documentary, Wartorn 1861-2010, which combines footage, interviews and documents to examine the effects of PTSD on soldiers returning from the battlefield.

Directors Jon Alpert and Ellen Goosenberg Kent joined Fresh Air’s Terry Gross for a discussion about the film, which features interviews with veterans of World War II, the Vietnam War, Operation Desert Storm and Operation Iraqi Freedom.

One difficulty the two directors encountered, Kent says, was trying to find information about combat trauma in the Civil War. Unlike today, there was little documentation of combat trauma. instead, the filmmakers sifted through pension files to learn what soldiers’ families said about them when they came home from the war.

“Those were really the only recognition that there would be something wrong with [the soldiers],” Kent says. “Their family would attempt to get a pension because their breadwinner came home from the war and wasn’t able to function psychologically. going through these really unsexy legal documents led to individual stories from Civil War servicemen.”

One solider, Angelo Crapsey, wrote letters and kept a diary during his time in the service, allowing Goosenberg and Alpert to chart changes in his mental status. during his initial letters to family and friends in 1861, Crapsey sounds hopeful and confident. But by 1863, the tone of Crapsey’s letters had changed.

“His father gets a call from the hospital that he needs to come pick him up and visit him because he’s declining physically,” Kent says. “But when Crapsey [eventually comes home,] everyone notices he’s a completely different person than the one who left. He’s paranoid, he’s in and out of reality. he feels hated. he feels like he’s a killer. and he attempts suicide several times and doesn’t complete the suicide.”

On a hunting trip several weeks later, Crapsey shot and killed himself. In order to collect his pension money, his family had to prove that he killed himself as a result of being at war. The incident, Kent says, parallels what many veterans face today when struggling to prove they have PTSD in order to obtain health benefits.

“It’s really what the essence of the film is,” Kent says. “If you have any doubt that PTSD is a real thing or you wonder what causes it or you think PTSD happens because the war is good or it’s bad or you come home a hero or villain, it’s really irrelevant. What’s really relevant is that the experience of war — and experiencing man’s inhumanity to man — causes psychological damage. and that’s really what we wanted to show.”

It was not until World War I and World War II, Alpert says, that military officials began to realize that soldiers were coming home with psychological ailments that weren’t predicted.

“They didn’t know what to do about it,” he says. “They didn’t know what to call it [and] they didn’t understand completely why people were suffering like this.”

And military veterans stayed quiet about the after-effects that lingered.

“Having battle fatigue was something nobody wanted to own up to,” Kent says. “Because you were a coward. you were a malingerer. … it was absolutely not okay to be unwell psychologically when you came home. and when you came home, you were expected to be a hero and you were expected to be somebody who marched forward in life. nobody wanted to talk about it and the VA, as one of the veterans described in the film, was absolutely overwhelmed.”

Some World War II veterans were not diagnosed with PTSD until decades later, when the symptoms of PTSD were finally recognized as a real psychological illness.

“Some [World War II veterans] were beginning to enter retirement age and they were starting to re-experience symptoms,” says Kent. “And so they were kicked back to the VA and all of a sudden the VA said ‘Maybe you have PTSD’ and they were, in some degree, incredibly grateful for that diagnosis. They finally understood what the hell was wrong.”

Today’s military is trying to address the mental disorders and high suicide rates that have climbed since 2001, Alpert says.

“The military’s made it easier to get diagnosed with PTSD. you don’t have to prove that it was a specific traumatic incident. it could be the cumulative effects of being in a war zone,” Alpert says. “That also means that many, many people are in need of treatment and the cost of treatment that society’s going to bear is really going to be quite substantial.”

Alpert explains that the military is trying to change the perception of PTSD from the top down.

“The generals — for the first time — are talking about this. you don’t have somebody like General Patton” [any more] he says. “They’re saying the right things. But this is something that’s very difficult to deal with in a martial atmosphere, where you’re supposed to be tough, you’re supposed to be resilient and things aren’t supposed to affect you like this. But they’re saying ‘It’s okay to be wounded. It’s okay to be psychologically damaged. We’re going to try to treat you and send you back.’”

Jon Alpert and Ellen Goosenberg Kent previously worked together on the HBO documentary Addiction. Alpert has made films for NBC, PBS and HBO and received 15 Emmy Awards and three DuPont-Columbia Awards. Kent has received three Primetime Emmy Awards, a Peabody Award and other honors for her work on films for HBO, A&E and children’s television.