Ethics, Interrogation, and the American Psychiatric Association

Recently, it has been alleged that the American Psychological Association colluded with the George W. Bush administration to allow psychologist participation in enhanced interrogations of detainees in the war on terror. James Risen writing in The New York Times (1) asserted that a recent review of emails suggests that the American Psychological Association policy that supported this interrogation was adopted with the direct involvement of psychologists who worked in the U.S. national security apparatus and structured to overcome objections from the Office of Legal Counsel in the Department of Justice over the continuation of the enhanced interrogation program. The American Psychological Association Board of Directors in late 2014 announced an independent legal review of these allegations to be overseen by a special committee of their board (2).

These reports led us to review the history of the adoption in 2006 of the formal position of the American Psychiatric Association that states categorically that psychiatrists should not participate in such enhanced interrogations (3). Sharfstein served as President of the American Psychiatric Association in 2005–2006 when the position statement was written and adopted; Summergrad served as President in 2014–15 when these new allegations regarding the American Psychological Association arose, and worked to make the American Psychiatric Association’s long-standing opposition to psychiatrist involvement in interrogations clear to the general public (4).

Looking back on the 2005–2006 period, the question of whether physicians, especially psychiatrists, were participating in the interrogation of detainees had become a particular focus of concern at the Guantanamo Naval Base in Cuba in 2005. Concerns about national security and possibility that enhanced interrogation might foil further terrorist attacks seemed to take priority over other concerns.

Upon reading 2006 reports in The New Yorker magazine and the New England Journal of Medicine alleging psychiatrist participation in so-called “behavioral science consultation teams”, Sharfstein wrote to Assistant Secretary for Defense for Health Affairs William Winkenwerder, MD, stating that such participation “could be construed as facilitating treatment of prisoners in a manner inappropriate to psychiatry and possibly in violation of medical ethics” (5). The American Psychiatric Association formally requested a visit to the Guantanamo Base. This request led to an October 19, 2005 visit that included Department of Defense personnel; Steven Sharfstein, MD, in his role as President of the American Psychiatric Association; the President of the American Psychological Association; the Surgeon General of the United States; and the Surgeons General of the Army, Navy, and Air Force. The day-long visit included discussions with the base commander as well as a walkthrough of the prison complex, observation of the detainee hospital, and a tour of the nearly $3 million psychiatric wing. Upon their return at 8 p.m. to Andrews Air Force Base, participants engaged in a spirited three-hour discussion. Sharfstein distributed a position paper developed by the American Psychiatric Association Council of Psychiatry and Law that raised concerns regarding psychiatric participation in the interrogation of detainees. This statement had been developed after a two-day meeting of the American Psychiatric Association’s Council of Psychiatry and Law, Ethics Committee, the Committee on Judicial Action, the Committee on Misuse and Abuse of Psychiatry, and representatives of military psychiatry. It was clear at this postvisit dinner that the American Psychiatric Association position contrasted sharply with the position of the American Psychological Association. In 2005 the American Psychological Association had taken the position that “Psychologists may serve in various national security roles, such as consultants to an interrogation, in a manner that is consistent with their ethics code…” (6). The military health leaders at the meeting asked why psychiatrists might object to participation in these interrogations but not psychologists. Emphasizing our Hippocratic oath, our profound ethical obligations to patients, and our abiding concern that such consultation could involve psychiatrists in facilitating deception and cruel and degrading treatment, we argued that it was wrong to permit skills that offer healing to ever be used for gaining intelligence. The difference between psychiatry and psychology was clear in the deep rooting of the psychiatric canon in medical ethics.

Sharfstein then took the statement crafted by the Council of Psychiatry and Law to the American Psychiatric Association Board of Trustees for final debate and action. There was again spirited and open discussion that included both our national security role as psychiatrists and the ethics of psychiatric care. The position statement was passed by the American Psychiatric Association Assembly in May 2006, adopted later that afternoon by the American Psychiatric Association Board of Trustees, and immediately made public. It states: “The American Psychiatric Association reiterates its position that psychiatrists should not participate in, or otherwise assist or facilitate, the commission of torture of any person.” It continues: “No psychiatrist should participate directly in the interrogation of persons held in custody by military or civilian investigative or law enforcement authorities, whether in the United States or elsewhere.” Shortly thereafter at the June meeting of the American Medical Association, a similar position statement was passed by its House of Delegates. That summer, the Royal College of Psychiatrists adopted a similar position at their annual meeting.

Implications / Lessons Learned

What are lessons we can draw from the 2006 decision of the American Psychiatric Association board to adopt a formal position of nonparticipation in interrogation of detainees?

First, the American Psychiatric Association must take positions when fundamental issues of science, ethics, or practice are either called into question or need articulation as a matter of public policy. While it requires careful judgment as to which issues rise to that level, if psychiatrists are pressured to behave in a way which violates well-defined professional standards or ethics, our obligation is to speak out as a profession. Second, American Psychiatric Association actions on difficult issues for our profession require principled leadership from the highest governance level of the organization as Sharfstein demonstrated, with open discussion and decisions that included the Councils, Assembly, and ultimately the Board of Trustees. The Board reaffirmed the 2006 statement in 2014. While the process took the time and effort of the many psychiatrists who serve on the American Psychiatric Association’s committees, it led to a considered result that has stood the test of time.