Bioethics Discussion Blog: Teaching Medical Students What is Torture and When to Disobey Orders

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Saturday, February 09, 2008

Teaching Medical Students What is Torture and When to Disobey Orders

It would seem that based on the formal survey of medical students published the International Journal of Health Services, Volume 37, Number 4, Pages 643–650, 2007, currently medical students are unaware that later as physicians they can be drafted into the Armed Services of the United States if the need arises, many are unaware of the Geneva Convention requirements regarding care of the wounded or about torture and many are divided on what orders represent torture and what orders in the military they ethically would be obliged not to follow.

Amongst other elements of the survey, the students were asked under what circumstances an officer is ethically required to disobey a direct order from a superior:

1) When ordered to threaten a prisoner with injection of a psychoactive drug which will not actually be administered.
2) When ordered to inject a harmless bolus of saline into a prisoner who fears he is receiving a lethal injection.
3) When ordered to inject a lethal drug into a prisoner.

According to the article “over 27 percent of respondents thought that the only scenario in which they were ethically required to disobey was when asked to inject a lethal drug into a prisoner; over 6 percent felt that none of these scenarios required them to disobey and 66.1 percent correctly answered 'all of the above.'"

“...only a small percentage of respondents had received any instruction in
military medical ethics. About 94 percent had received less than 1 hour of
instruction during medical school about the ethical obligations of physicians
serving in the military. Just over 4 percent had received between 1 and 5 hours
of instruction, and 1.5 percent reported receiving more than 5 hours of teaching about these matters."

If you were setting up the curriculum for a medical student’s education, would you include military ethics? What standards of a physician’s behavior which a physician should follow would you expect to be taught? Would you teach about a physician disobeying a military order and, if so, under what circumstances? ..Maurice.

2 Comments:

At Wednesday, March 26, 2008 3:45:00 AM, Blogger luisjusto said...

Dear Mo: I agree with you. Torture is an issue that should be taught in medical schools, as I suggested in this 2003 comment.
Best
Luis

BMJ 2003;326:1405 (21 June)
reviews
PERSONAL VIEW
Argentina: torture, silence, and medical teaching

More than 30 years ago I asked my surgical instructor about petechial lesions on the scrotums of some criminals interned in the surgical ward. The shocking answer was, "Oh, yes, the police make them all go through 'the machine' before taking them to the hospital." The machine, the "picana eléctrica," was a device for torturing prisoners with electric shocks, usually in the vagina, testicles, mouth, anus, or nipples. I was horrified by the fact itself but no less by the matter of fact tone in which the answer was given. As a medical student I was pretty powerless, but I went to the head of the surgical service and tried to lodge a formal complaint. I was rebuffed without any chance to make my argument heard.
Since 1983 we have been living under a "democratic" government, but torture is still rampant in
Argentina. Sergio Gustavo Durán was arrested by the police in 1992. He was 17 years old. The arrest
was routine—he wasn't involved in any criminal activity. The next day he was found dead. Puncture
wounds reported in the autopsy by the police doctor were explained as "scratching lesions." A subsequent non-official autopsy described intraalveolar haemorrhages typical of the "dry submarine," a torture in which a plastic bag is put over the head until the victim nearly suffocates.
The authors of this crime were not detained until four years later, when some of them, though
fugitives, were still getting their monthly pay from the police. The police doctor is being prosecuted,
but the verdict has not yet been issued. Every year several episodes of this kind are denounced by
human rights organisations, each time starting the usual chain of denial and cover up from official
institutions, often with the collusion of doctors.

We should make human rights central to our teaching
But what I wish to comment on is the continuing passivity of medical teaching organisations— difficult to understand in a democracy. Sergio Pesutic, a Chilean psychiatrist, has described the
phenomenon of torture and the role of Chilean health professionals, ranging from active complicity
to denial of its existence and sometimes to resistance. He concluded that several primary prevention measures should be taken to avoid torture, including the incorporation of human rights teaching into formal and non-formal medical curriculums, the application of codes of medical ethics, and research into the long term effects of torture. It's high time to heed Dr Pesutic's suggestions.
Although most Argentinian doctors react with horror to the idea of torture, the medical establishment
has not come to the same categorical rejection. Human rights is not yet a standard subject in medical schools, even in bioethics courses. The national academies remained silent on the issue after the end of the military dictatorship in 1983. In 2001 most of the members of the National Commission of Biomedical Ethics resigned in protest at the appointment of Alberto Rodríguez Varela, a former justice minister in the military dictatorship. Ironically but alarmingly, Dr Rodríguez Varela was proposed by the National Academy of Moral and Political Sciences.
Dr Pesutic described torture as the "criminal expression of a perversion of society's values." The criminal and unethical behaviour of doctors involved in or colluding in torture reflects a society's moral decline. The US bioethicist Edmund Pellegrino wrote: "Protection of the integrity of medical ethics is important for all of society. If medicine becomes, as Nazi medicine did, the handmaiden of economics, politics, or any force other than one that promotes the good of the patient, it loses its soul and becomes an instrument that justifies oppression and the violation of human rights." I agree with
other writers that the social and economic status of doctors places them closer to the well off and
influential than to the poorer sectors of society and that, historically, torture has targeted poor people and their advocates. Almost all current victims of police brutality and torture practices in Argentina
are poor and so are relatively defenceless. Argentinian doctors, although not usually rich, have high social prestige—perhaps this accounts for their silence.
Until a serious effort is made to reconstruct a values system that is based on people's intrinsic
dignity, torture will persist —as it did in my student years, long before the military took power. This reconstruction must involve access to education and health for all and the eradication of misery. As doctors we should make human rights central to our teaching, and students must learn that to be
complicit with torture is despicable.
However, military dictatorships are not responsible for all our evils. Shared social values in
Argentina have deteriorated so much that there is little chance of putting an end to these crimes
against humanity without a serious commitment to change by all social groups. Perhaps this is a warning to other countries in these uncertain days, when the deaths of human beings are termed
"collateral damage"—an expression of scorn for human dignity.
Luis Justo, Chair in Bioethics
Comahue National University, Argentina

 
At Wednesday, March 26, 2008 8:54:00 AM, Blogger A, a fourth-year medical student said...

The above commentary is striking and doctors should be aware of human rights in their practice. However, there is so little room for ethics currently I don't see how military ethics could possibly be discussed as well at any length. We MAY be drafted or join the military, at which point we should look up the ethical codes governing that situation.

Add it to medical school? Sure, there's nothing to cover so far in the curriculum.

 

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