Medical Ethics Suborned by Tyranny and War

Tyranny and war have always brought out the noblest and the most reprehensible in human conduct. This is particularly true for physicians, whose ancient code of beneficence toward the sick is severely tested when medical knowledge is used for military and political purposes as well as for healing.¹ The survey of physician participation in human rights abuses in southern Iraq reported by Reis and colleagues² in this issue of THE JOURNAL is another painful reminder of how physicians may violate the most rudimentary ethical duties under the exigencies of war or despotic national rule. Its methodological shortcomings notwithstanding, the study reveals, once again, how often ruthlessly tyrannical regimes suborn the uses of medical knowledge for execrable ends.

Iraqi physicians who responded to this survey reported that physicians in southern Iraq were forced to commit a number of abuses, including amputation of ears as a form of punishment, falsification of medical-legal reports of torture and death certificates, release of medical records, and removal of patients' organs without consent, among others. The list of ethical malfeasances and the way they were justified by Iraqi physicians are frightening repetitions of the justifications used by Nazi physicians in their testimonies at the Nuremberg trials.³ Similar reasoning was used by the nurses who participated in the German eugenics program.⁴ The same reasoning is not unknown in democratic societies.

In some ways, the oppressive threats and resultant fears of tyrannical rule and war are like perverse retroviruses. They transform moral DNA so drastically that what in peace is unthinkable becomes permissible, and even mandatory, for some. Yet it is nearly impossible to plumb the depths of such moral quandaries. For example, where should the line be drawn on violations of medical ethics in the name of national security?

Reis and colleagues conclude their article with the hope that "legal, educational, and institutional reform" will prevent these violations in the future. Commendable as they certainly are, these reform efforts have had little effect in the past. What is needed is a more direct confrontation with the moral dilemma—are violations of the ethics of medicine ever justifiable? Is moral compromise sustainable without loss of professional integrity? Perhaps the report by Reis et al, and many others on medical complicity of various kinds,^{5 - 7} can be a stimulus to a more penetrating analysis than is now customary. After all, torture by physicians is not wrong just because it was the Baath Iraqis who used it.

While the survey by Reis et al establishes the fact of medical ethical violations in Iraq, its extent must be interpreted with caution. The survey was self-administered among a convenience sample of physicians in only 2 cities in southern Iraq, and the preponderance of respondents was Shi'a Muslim under a Baath regime. Only a small number of the physician respondents admitted to participation in torture themselves.

These shortcomings do not vitiate the value of the study, which documents a recurrent danger inherent whenever the moral center of medicine is subverted for political purpose. In many ways, medicine is a sensitive societal moral weather vane. When its beneficent focus is blurred, it is time for a society to examine its own claim to moral probity.

However, the conclusions of Reis et al about the role of ethics education warrant specific comment. The Iraqi physician respondents reported agreeing with Reis and colleagues that better education in ethics might have prevented the misconduct or can prevent physician involvement in future abuses. This tendency to see education as a panacea is a common misconception. Rarely do courses in ethics make one virtuous. Nor does extensive familiarity with the intricacies of moral discourse guarantee moral wisdom. Courses certainly are valuable in that they raise sensitivities to moral issues and generate critical self-evaluation. However, no amount of education in ethics can effectively counter the enormous pressures that governments, political ideologies, or peer pressures can exert on individual physicians and the profession as a whole.

The central problem in the case of Iraqi physicians who have engaged in torture and other abuses is the active and passive collusion of the profession with patriotic and defensive measures justified in the interest of the nation, one's career, or personal safety. The study by Reis et al shows again that national and international medical associations must examine more closely the implications of becoming instruments of anything other than the healing purposes for which the profession is ordained.

All of this becomes even more urgent as advances in biotechnology provide medicine and nations with unprecedented powerful tools for torture. These could be far more dangerous than the Iraqi regime's predilection for cutting off the ears of its government's enemies. This issue will be as critical for democratic as for despotic regimes, and it must become a global issue if the United Nations' Universal Declaration of Human Rights⁸ is to maintain significance. With such powerful tools in hand, will the medical profession remain a moral enterprise even in the face of threatening emergencies?

More than education is needed. Character formation is, in the end, the surest way to inculcate the virtues. This cannot occur unless the culture of the profession is itself ethically rigorous. Even the most virtuous physicians need a supportive culture to remain virtuous. Heroes can stand alone, but they are few and often castigated.

A companion study by Amowitz and colleagues,⁹ also in this issue, provides some insight into Iraqi culture, where human rights abuses are reported to have occurred in almost 50% of households since 1991. Most of this violence was attributed to the Baath regime. Given these findings, it may not be surprising that some Iraqi physicians were acclimated or relatively insensitive to the moral implications of violence, especially against purported enemies of the Baath regime.

Both of the articles on human rights abuses in Iraq published in this issue of THE JOURNAL alert the world to the continuing violation of the most fundamental human rights. Even though the United Nations declaration is now 50 years old, it risks becoming little more than a pious and self-righteous travesty if an orderly yet firm international means for enforcement is not found.¹⁰