We're living through a time when our nations are flexing
their muscles in ways we haven't seen for a long time.
Stephen Harper has just returned from Afghanistan, where
he promised Canada will not "cut and run." Canadian troops
are moving into areas where serious combat is taking place
— not as part of the International Security Assistance
Force (ISAF), but as part of America's Operation Enduring
Freedom. The troubled region around Kandahar is now the
responsibility of a Canadian general.
And where the army goes, its doctors
must follow. That's where medical ethics and military
duty can collide.
In war, detention camps are built
and prisoners taken; military doctors are often asked
to do things that contravene established medical ethics
at these camps. Everywhere we look, military doctors
are having to make tough choices, and sometimes they
are making the wrong ones. Some of these physicians
have travelled a long way from the Hippocratic principle
of "first, do no harm."
Take for instance the force-feeding
of hunger strikers in Guantanamo Bay. The Lancet
recently carried a letter from 262 international doctors
protesting the policy. A BMJ editorial made the
same point.
Medical ethics on this point are
clear. The Tokyo and Malta declarations, both endorsed
by the American Medical Association (AMA), prohibit
the force-feeding of mentally competent prisoners who
make the informed decision to hunger strike. This rule
is endorsed by the British government, which allowed
IRA hunger strikers to die rather than force-feed them.
It's also followed in Canadian prisons, which have an
official ban on force-feeding competent prisoners.
In December , after months spent
sitting on the fence, the AMA emerged to state its unequivocal
opposition to force-feeding at Guantanamo. The American
Psychiatric Association had already condemned the practices
of military psychiatrists at Guantanamo, who used their
insights into prisoners' states of mind to help develop
interrogation plans that exploited their vulnerabilities.
Yet American state medical boards
argue that in the absence of a complaint from the military
itself, they cannot proceed against a military doctor.
Not surprisingly, no such complaint has been forthcoming.
Canada's own big test is surely
coming. Our involvement in Afghanistan has been relatively
painless so far, but with the increased responsibility
it's unlikely to remain that way. And again, doctors
will be caught in the middle.
The temptation to treat prisoner-patients
as enemies can overwhelm a good physician. I learned
this first-hand while working on a story about detainee
deaths in Iraq. I saw a number of military death certificates
of prisoners who had died in detention or during interrogation
by the British and Americans. Despite accompanying photos
showing bruised and bloodstained bodies, not one of
these certificates mentioned violence as a cause of
death. None were even remotely properly filled out,
according to a panel of pathologists who studied them.
In fact, dozens were signed by physicians who had never
come within 5,000 miles of the deceased.
After Abu Ghraib there was widespread
condemnation of doctors' failure to either halt the
abuse or blow the whistle. There were calls for reforms
that would make it official that physicians' duty to
their patients comes before duty to their commander.
So far that hasn't happened.
We would all like to think that
Canada's soldier-doctors will be firmer in upholding
the profession's principles. It would be nice to believe
that Canadian soldiers generally will not succumb to
the temptations that have led some of our allies astray.
But Canadian forces do not necessarily operate on a
higher moral plane. Our experience in Somalia proves
that.
History suggests that some will
put military expediency before medical ethics. The least
we can do is ensure that those who resist the debasement
of the profession have the unqualified support of doctors
and medical associations at home because these refusers
may get precious little support from their comrades
in the field.
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