Why the College voiced its concerns on prison abuse
For the most part, ACP focuses on domestic health policy issues—such as reimbursement and medical liability reform, or the problems created by lack of health insurance for millions of Americans—that directly affect practicing internists and their patients. We tend to shy away from issues in which we have no particular expertise or standing. International and military affairs, in particular, are subjects that fall outside the College's usual scope of advocacy efforts.
Why then has ACP entered the debate about the treatment of prisoners and detainees abroad by U.S. governmental authorities?
In June, the College introduced an "emergency" resolution to the AMA's House of Delegates. We urged the AMA to join us in calling for a broad government inquiry into the allegations.
And in two letters sent over the past nine months, the College has asked President Bush to investigate reports of alleged mistreatment of prisoners in U.S.-controlled detention facilities in Iraq, Afghanistan and Guantanamo Bay. (The May 17 letter is online.)
Several ACP members have subsequently written to us, commenting on the College's decision to enter into the abuse controversy. While some internists argued that ACP has no legitimate interest in the prisoner abuse issue, others wrote and praised the College for its "courageous" stance.
To be clear, the College has heard from a very small number of members, so it is impossible to assess overall member reaction. It is likely, though, that both the negative and positive views expressed by those who took time to write are representative of the viewpoints of many other internists.
The strong reaction from some members is not surprising. The prisoner abuse scandal comes at a time when the nation is engaged in a very raw and partisan presidential election and a debate about the administration's handling of the war in Iraq.
No matter where they stand on the partisan issues, however, ACP members deserve an understanding of the policy basis and rationale for the College's involvement in the prisoner abuse issue.
College policies on abuse
The College's concern about treatment of prisoners is based on policies and ethical guidelines that pre-date by more than a decade the current abuse allegations.
The College's overall policy framework was adopted by the Board of Regents in July 1993 and published in the April 15, 1995, issue of Annals of Internal Medicine. The paper calls on medical professional organizations to speak out against torture of prisoners:
"The key to an effective response to torture," that policy paper states, "lies in concerted action on the part of the medical profession. Physicians, regardless of their specialty and the way in which they express their medical skills on a daily basis, can respond to torture through their affiliation with the medical profession. Medical associations can expand and magnify the effectiveness of an individual physician's work."
The Fourth Edition of ACP's Ethics Manual, approved by the Board of Regents in October 1997, similarly speaks of physicians' ethical obligation to oppose torture:
"Physicians must not be a party to and must speak out against torture or other abuses of human rights. Participation by physicians in the execution of prisoners except to certify death is unethical. Under no circumstances is it ethical for a physician to be used as an instrument of government to weaken the physical or mental resistance of a human being, nor should a physician participate in or tolerate cruel or unusual punishment or disciplinary activities beyond those permitted by the United Nations Standard Minimum Rules for the Treatment of Prisoners."
ACP is not alone in declaring the ethical obligation of physicians to oppose torture. "Physicians must oppose and must not participate in torture for any reason," AMA policy adopted in December 1999 states. It goes on to say that, "Physicians should help provide support for victims of torture and, whenever possible, strive to change situations in which torture is practiced or the potential for torture is great."
Relevance to the current debate
Even though the College's policies on prisoner abuse directs it to speak out about torture, why did ACP choose to enter the current debate, knowing that our views would likely be viewed by some as partisan criticism of President Bush? The College carefully considered the potential political fallout during an election year of taking a public position on alleged abuses. Because it did not want its views to be misused for political purposes, the College did not publicize its October 2003 letter to President Bush.
Instead, that letter privately communicated to the president the ACP's concerns about reports of alleged prisoner mistreatment by U.S. authorities in Afghanistan and other countries. The letter was prepared by the College's Ethics and Human Rights Committee and approved by then-President Munsey S. Wheby, MACP.
The timing of the letter, which was sent months before the revelations about the abuses in Abu Ghraib, clearly shows that the College's concerns were not generated by the Abu Ghraib headlines, but preceded them.
Because President Bush did not respond to the October letter, and in light of the subsequent revelations about Abu Ghraib, a second follow-up letter to the president was sent this May. We reiterated the College's call for a broader investigation of—and corrective actions to prevent—abuse of prisoners under the jurisdiction of U.S. authorities.
Because members and the public have a right to know about the College's continued concerns, ACP then released the two letters to the membership and the news media.
The College's communications to members and the media have emphasized that the organization is strictly nonpartisan. We have made it clear that our views are based on longstanding policies and ethical guidelines that obligate ACP to speak out against torture and other violations of human rights, no matter which political party occupies the White House.
ACP has a responsibility to speak out about abuse that directly affects the medical conditions of individuals under the government's jurisdiction.
There is little doubt that some ACP members would prefer that the College focus its attention exclusively on domestic economic and regulatory issues that directly affect their daily practice lives. But the College's policies and ethical guidelines are clear.
ACP has a continuing responsibility to speak out about the prisoner abuse scandal, precisely because it directly affects the medical conditions and human rights of individuals who are under the jurisdiction of the U.S. government. The issue also affects the ethical responsibilities of physicians (possibly including some College members in uniform) who may be required to treat prisoners who have been abused.
Because the College's interest in the prisoner abuse scandal is based on long-standing ethical positions that guide the actions of individual members and professional organizations, ACP has the stature and standing to contribute to a reasoned and nonpartisan discussion of what needs to be done to prevent further abuses.
Robert B. Doherty is ACP's Senior Vice President for Governmental Affairs and Public Policy.
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