More on “The Role and Responsibilities of Psychiatry in 21st Century Warfare”

The Journal published my lecture on “The Role and Responsibilities of Psychiatry in 21st Century Warfare” in 2014.¹ I noted that psychiatrists, other mental health professionals, and physicians have been drawn into the epicenter of the war on terrorism, particularly in confronting torture and abuse. I expressed my concern that politics and public sentiment had corrupted the ethics principles of the medical professions. My involvement with the detention camp on the Guantánamo Bay Naval Base and cases of terrorism in the United States has continued. Since 2008, I have spent cumulatively a full year in Guantánamo evaluating detainees. I have also advised attorneys on numerous cases of accused terrorists within our continental borders.

I traveled to Guantánamo in January 2020 to hear the testimony of James E. Mitchell, PhD, one of the psychologists and architects of the program of enhanced interrogation, also known as torture. The defense team that I advise had called Dr. Mitchell and his colleague, John Bruce Jessen, PhD, to testify on the development and implementation of the enhanced interrogation program. I wanted to listen first-hand to Dr. Mitchell's testimony. Over the past 15 years, I have participated reluctantly in the Guantánamo cases and related matters. As a retired Army Brigadier General, I have formulated opinions and promoted recommendations in consideration of my dual responsibility as a physician for individual welfare and for the safety and security of our nation. I endorse strategy and tactics that protect our country from foreign terrorist organizations and the recruitment of young Americans to fight on their behalf. I remain engaged because I cannot walk away from my professional and ethics principles, particularly in the face of increasing threats, both domestic and foreign.

At the time of the terrorist attacks on September 11, 2001, Dr. Mitchell and his business partner, Dr. Jessen, were psychologists assigned to a Department of Defense program known as SERE (Survival, Evasion, Resistance, and Escape) to train service members to resist torture if captured. Mark Fallon, a senior career official with Naval Criminal Investigative Service (NCIS), elegantly explains in his book Unjustifiable Means² that Dr. Mitchell and his colleagues sidestepped and ignored longstanding scholarship and documentation on conducting effective interrogations. They had worked in the Department of Defense training program for resisting torture and cruel treatment, but they had no experience in actually interrogating suspects. Their ideas should not have been viewed as credible.

Dr. Mitchell justified his role in inflicting waterboarding, walling, and a host of other cruel and harmful tactics on the detainees in support of the Central Intelligence Agency (CIA). He declared that his actions served to defend the country against future attacks. He emphatically and unapologetically declared that he “would do it again.”³ He was following orders from CIA headquarters and asserted that he was not the grand wizard behind the program.⁴ The CIA and senior U.S. government leadership feared another serious attack, and there was strong suspicion that Al Qaeda had nuclear capabilities and was planning to detonate a weapon inside the United States. The U.S. leadership felt sure that Khalid Sheik Mohammed and his fellow defendants knew the details of plans for many other future attacks. The American public now knows that there were no nuclear weapons and little, if any, evidence of another impending attack like 9/11.

Guidance from the Department of Defense recommended medical and operational evaluations of the detainees in support of interrogations. It stipulated that interrogation plans include reasonable safeguards, limits on duration, intervals between applications, termination criteria, presence or availability of qualified medical personnel, and appropriate supervision.⁵ Dr. Mitchell testified that a board-certified physician was in the room when he was waterboarding the detainees. The physicians' role had been to “carefully monitor” the waterboarding, to keep the subjects “safe,” and to revive the men subjected to these life-threatening acts if needed. He testified that the physicians did not object to inflicting the injuries of waterboarding, walling, sleep deprivation, painful shackling, and the other tactics. The idea that medical monitoring of interrogation provides any measure of safety is dubious because the presence of health professionals may serve to legitimize coercive interrogation rather than restrict it.⁵ The presence of physicians violated the fundamental principle of medical ethics to “first, do no harm.”

Dr. Mitchell gave what seemed to me a rehearsed explanation on “learned helplessness” to explain the application to interrogations. Learned helplessness is a phenomenon codified by Martin Seligman, PhD, based on studies of dogs subjected to electric shocks.⁶ Dr. Seligman induced a profound state of resignation and apathy by delivering the shocks in a way that the dogs could never escape. Applying the concept of learned helplessness to enhanced interrogations is bad science. Inducing a state of resignation and apathy does not in any way lead the subject to disclose useful intelligence. On the contrary, years of research on states of mind induced by stress, drugs, or other conditions has revealed that the subjects become profoundly depressed and learn to say whatever they think is expected of them.⁷ This tragic flaw in the program's design should have been obvious to physicians. As an interesting aside, based upon his research, Dr. Seligman marketed a program called Comprehensive Soldier Fitness that was implemented by the U.S. Army in 2010 for tens of millions of dollars.⁸ The purpose of the program was to train soldiers on “resilience” to protect them from posttraumatic stress disorder and suicide.

During his testimony, Dr. Mitchell reviewed the concepts of “moral disengagement” as developed by Albert Bandura, PhD.⁹ He pointedly accused the 9/11 defendants of reprehensible behavior and opined that they demonstrated critical elements of moral justification, euphemistic labeling, displacement of responsibility, and dehumanization. His logic is convoluted and self-serving. The perpetrators of torture and cruel, inhuman, and degrading treatment asserted moral justification for their behavior, dehumanized their subjects, and displaced responsibility onto them. “Radical jihadist” has become a euphemistic label and a catch-all term to rationalize the global war on terror.¹⁰ Dr. Mitchell and his colleagues indulged in the very same psychological maneuvers as their victims to justify their enhanced interrogation practices. He did not see the irony in this, boldly asserting that good, loyal Americans had to go to the dark side to protect the country, and he even teared up in sharing with the court the burden he and his colleagues endured.

Authorizing enhanced interrogation techniques pushed the country down a slippery slope. It eroded the rule of law and undermined democracy. My chapter with Claire Finkelstein, founder of the Center for Ethics and Rule of Law, in a recent publication elaborates on these implications.¹¹ President Obama announced immunity in 2009 to prosecution for anyone who had relied on the infamous Yoo-Bybee memorandum of 2002 from the Office of Legal Counsel on conducting harsh interrogations.¹² President Obama did not intend to pursue or even investigate the authors of the memorandum or the architects of the program that relied on the Office of Legal Counsel memoranda for justification. No actors linked to torture and related policies have been held accountable or removed from positions of responsibility and authority. The Yoo-Bybee memorandum was later withdrawn as legally flawed, but it laid out propositions concerning executive authority that have endured, essentially providing legal coverage to senior government officials for a personal necessity defense to justify questionable policies and practices. In the context of enhanced interrogations or torture, that kind of legal coverage placed doctors and other health care providers in a bind that compromised them. The health care providers and others on the front lines were advised that their actions, regarded by many as torture and violating human rights, had been legitimized by executive directives. In other words, doctors in federal service who objected to enhanced interrogation tactics on ethics principles were obliged to follow orders or risk adverse action. They risked being fired or sidelined for not following orders, or had to search for ingenious ways to object, such as exercising their rights as a whistleblower. As recent events have shown, even the whistleblower provision in federal law may not protect the reporting individual from retribution. This situation was unfair, and doctors and psychiatrists deserved the protection of their professional organizations to follow time-honored ethics principles.

It is well documented that senior U.S. government leaders made crucial mistakes in failing to prevent the attacks of 9/11.¹³ In this light, the torture program looks like vengeance. Leaders exploited the fear and shame that spread across the country in the wake of the deaths of 3,000 innocent Americans. They flexed muscles and shouted rhetoric about “holding the bad guys accountable.” But quite the opposite has happened.

The recent hearings at Guantánamo brought to light even more damage caused by interrogation techniques that amounted to torture, namely the possibility that key statements made by the detainees will never be able to be used during their trials. The trial for the mastermind of 9/11 and his co-defendants has been delayed and may not begin until 20 years after the attacks. It is distressing that, in its war on terror, the U.S. government used techniques that might preclude the families of the victims and all Americans from witnessing justice. In the end, it appears that our own moral disengagement may prevent us from utilizing the key accountability mechanism of a system dedicated to the rule of law, the courts.

Listening to Dr. Mitchell's testimony affirmed my convictions that all physicians have a responsibility and duty to object in the face of morally reprehensible policies and practices. The health care professions rely on trust, and a central pillar of that trust is the premise that under no circumstances can practitioners abandon their roles to competing interests, including the security interests of the government in time of war.

• © 2020 American Academy of Psychiatry and the Law