During the Middle Ages in Europe the practice of torture drew distinction from its association with confessed truth, repentance, and salvation, yet by 1874 Victor Hugo could write that “torture has ceased to exist.” However there has never been any doubt that torture would outlive its obituarists. In 2015 Amnesty International noted that 157 states had ratified the UN Convention of Torture, yet 141 states had used torture in the previous 5 years – this included Western supposedly liberal democracies. Torture is a form of terrorism.
What of doctors and torture? The World Medical Association (WMA), created after World War II following the outrageous ethical abuses of Japanese and German physicians, carries the membership of over 100 national medical associations – from many of the nations implicated by Amnesty. The WMA’s Declaration of Tokyo is the seminal anti-torture manifesto for doctors, forbidding not just direct involvement (“in the room”) but also mandating doctors to speak out, protest and protect the torture victim whenever encountered. There are also UN Special Rapporteurs on Torture supposedly tasked with paying particular attention to medical complicity.
What is the response of a national medical association when there is credible evidence incriminating their own doctors. And do international conventions and declarations forbidding medical complicity with torture, and the organizations set up to regulate these, carry out their mandate effectively and evenhandedly? In a recent paper in the Journal of Medical Ethics I set out two parallel stories: one concerns how far evidence counts in cases which incriminate a Western state with powerful friends; the other describes the experience of trying over years to engage the relevant parties – the national medical association in question, the WMA, UN Rapporteurs, etc. – to get them to do what they were set up to do.1 I give a blow-by-blow account of convening and running a principled evidence-based appeal launched in 2009, and dedicate the paper to the 725 physicians from 43 countries who gave their names to this endeavour and still do. Our conclusions have been sobering.
Torture in Israel
Israel is a signatory to the U.N. Convention against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment (UNCAT) but evidence of the routine use of torture on Palestinian detainees has long been accumulating in the public domain. In May 1998, a Human Rights Watch report to UNCAT recorded that Israel “continues to use torture and cruel, inhuman or degrading treatment during the interrogation of Palestinian detainees.” The magnitude of Israel’s violations of UNCAT is well known to the Committee, having been extensively documented by UN bodies and international, Israeli and Palestinian human rights organizations. In 2007 B’Tselem, the Israeli Information Center for Human Rights in the Occupied Territories, studied the testimony of 73 Palestinian prisoners gathered since 2005 and concluded that Shin Bet, the Israeli intelligence agency, had inflicted physical and mental abuse amounting to torture on almost all of them. Amnesty briefed UNCAT in September 2008 regarding Israel’s failure to implement the Convention in the Occupied Territories and intensification of measures amounting to torture. In its 2008 Annual Report, the United Against Torture (UAT) Coalition of 14 Palestinian and Israeli human rights organizations, concluded that “the use of torture and ill-treatment by Israeli authorities against Palestinians is both widespread and systematic. The UAT Coalition has observed and recorded evidence of acts, omissions and complicity by agents of the State at all levels, including the army, intelligence service, police, judiciary and other branches of government”. In November 2008 the Public Committee Against Torture in Israel (PCATI) filed a contempt of court motion to the High Court of Justice against the government of Israel and the General Security Service for their responsibility for a policy that granted a priori permits to use torture in interrogations. No Israeli official had ever been charged or sentenced for torture-related crimes.
Medical complicity with torture and the Israeli Medical Association (IMA)
In 1993 Amnesty International concluded that Israeli doctors working with the security services, “form part of a system in which detainees are tortured, ill-treated and humiliated in ways that place prison medical practice in conflict with medical ethics”. Amnesty pointed to the implication of statements by Israeli officials (intended to allay concerns about ill-treatment) that detainees were “under constant medical supervision”.
Also in 1993 Amnesty documented the telling example of the Nader Qumsieh case. Five days after his arrest, Qumsieh was brought to a medical center in Be’er Sheva, where a urologist diagnosed a torn scrotum and bleeding. Qumsieh testified that he had been beaten during interrogation and kicked in the testicles. The urologist later received a call from the Israeli military, and as a result wrote a second report which he antedated by two days, without further examination of the patient. In it he recorded that “according to the patient, he fell downstairs two days before he came to the emergency room.” This time his medical findings were recorded as: “superficial haematoma in the scrotal area, which corresponds to local bruises sustained between 2 and 5 days prior to the examination.” The urologist’s original report disappeared from Qumsieh’s medical file.
IMA President Yoram Blachar defended Israeli practices in a Lancet letter in 1997. He wrote that “the guidelines on interrogation recommend only that ‘moderate physical pressure’ be sanctioned. Even this is restricted to cases defined in terms of a ‘ticking bomb’”. Yet in 1994 UNCAT had reiterated that “moderate physical pressure” was indeed torture, and also outlawed the ‘ticking bomb’ justification. Here a president of a national medical association was defending torture in the pages of a famous medical journal. In November 1999 the then Head of Ethics of the IMA Eran Dolev was interviewed by a delegation from the London-based Medical Foundation for the Care of Victims of Torture (where I was then the principal psychiatrist). During the interview he stated that “a couple of broken fingers” during the interrogation of Palestinians was a price worth paying for information. When I quoted this in the Journal of Royal Society of Medicine (JRSM) in 2001, IMA President Blachar castigated this in JRSM as “lies and vilification” and threatened to sue me. The four delegation members responded in JRSM by affirming that this was exactly what Professor Dolev had said.
In 2007 PCATI published “Ticking Bombs”, the detailed testimony of nine Palestinian men tortured between 2004 and 2006, painting a graphic picture of how Israeli doctors formed an integral part of the running of interrogation units whose output included torture. They alleged that doctors, several of whom were named, saw the prisoners at various points before, between or after experiences of torture (which in one case led to spinal damage and disability), did not take a proper history, made no protest on these men’s behalf as the Declaration of Tokyo demands, and typically prescribed simple analgesia before returning them to their interrogators. Several cases had allegedly been known to the Chief Medical Officers of the Israeli Prison Service and Police Service.
Following repeated requests by PCATI, the IMA eventually agreed to investigate “Ticking Bombs”. Professor Avinoam Reches, Chairman of the IMA Ethics Board, sent a 14 line letter dated 9 March 2009 back to PCATI to report the outcome. The investigation had amounted to phone calls to a few of the named doctors, all of whom denied involvement, and no examination of the relevant medical files. Reches concluded that there was no evidence, “other than the word of the prisoners”. What kind of investigation discounts victim testimonies at the outset? When six UK doctors wrote about “Ticking Bombs” in the Lancet in 2007, the IMA threatened to sue.
The British Medical Association (BMA) is a WMA member and I drew the issue to the attention of the BMA as early as 1997. I was asking them to take the matter up at the WMA, as they were entitled to do. I sent the same material to the then WMA Secretary General Delon Human in 2001, who defended the IMA largely on the grounds that they had ratified the Declaration of Tokyo. In 2005 Edwin Borman, Chair of the BMA International Committee, wrote to me to say they “sought to engage constructively with our Israeli colleagues” and would not be “partisan”.
In now preparing a formal international appeal to the WMA, we were aware that campaigning about human rights issues in Israel-Palestine is qualitatively different from human rights work elsewhere. Publications deemed critical of Israel often evoke vitriolic and ad hominem attacks upon writer and medical journal – though little engagement with the cited evidence base. There are calls for journal editors to be disciplined or dismissed. In response to a BMJ paper of mine in 2004, Yoram Blachar, IMA President as well as then WMA Chair of Council (the political head of the WMA), posted a bmj.com Rapid Response stating that “the lies and hatred he spews are reminiscent of some of the worst forms of anti-semitism ever espoused.” Yet the paper was based on work by a UN Rapporteur, the International Court of Justice, Amnesty International, Johns Hopkins and Al Quds Universities, Physicians for Human Rights Israel (PHRI), and the Palestinian Environmental NGOs Network. The same paper produced nearly 1,000 hostile emails sent directly to the editor Kamran Abbasi, mostly crude, abusive and with recurrent reference to antisemitism, some threatening violence against the editor or his family and myself. In 2007 the Royal Society of Medicine were pressured by pro-Israel doctors into withdrawing an invitation to me to speak at a conference on religion, spirituality and mental health.
In May 2009 725 doctors, including 115 professors, from 43 countries (235 from UK) made a joint appeal to WMA Chair of Council Edward Hill from USA. I was convenor and Professor Alan Meyers of Boston University and Jewish Voice for Peace USA, was lead signatory. We attached a detailed dossier of evidence as above and requested that it be distributed to all Council members (these are geographically scattered around the world and only convene yearly). The WMA is mandated to ensure that its member associations do not breach WMA codes like the Declaration of Tokyo. We asked the Council to investigate the IMA’s ethical track record in the light of the evidence, and thus to review the probity of their recent appointment of IMA President Yoram Blachar as WMA President. We had public support from Professors Noam Chomsky and Norman Finkelstein in the USA, and from Dr Wendy Orr in South Africa. Orr had been working as a medical officer for the District Surgeon in Port Elizabeth in the 1980s and blew the whistle on torture and the complicity of state doctors in cases she saw- her ethical duty under the Declaration of Tokyo.
Our appeal was covered by the BMJ and various newspapers. The Jewish Chronicle quoted Blachar as saying the appeal was a “joke” and “you will see that many of the names are Arab”. The IMA launched a campaign to gather 10,000 signatures to counter these “slanderous charges”. In an unprecedented move in July the IMA formally announced severance of any further contact with PHRI because PHRI founder, Israeli psychiatrist Ruchama Marton, was one of the 725 signatories, and because PHRI publications were giving comfort to Israel’s enemies. In a letter explaining this to PHRI, Blachar described the IMA as a “defensive barrier” against “international anti-Israeli bodies”.
In August 2009 a libel action was initiated against me personally in London by Dr. Blachar and the IMA through Mark Stephens of Finer, Stephens, Innocent, libel lawyers. The current president of the world’s official medical ethical watchdog was suing someone for pointing to an incriminating evidence base and asking the watchdog to act as mandated. They alleged that I was conducting “a malicious campaign of vilification” that was “promiscuous with falsehoods”, and that I had deceived the other 724 signatories. They demanded immediate public retraction in the Lancet, BMJ and Guardian, and substantial damages. I resisted the case and a large number of signatories emailed Mark Stephens direct to assert that they were not deceived. Echoing our appeal, Dr Ishai Menuchin, Executive Director of PCATI was reported in the Jewish Chronicle as re-affirming the complicity of Israeli doctors in a “black hole” in which torture was going unchecked. The libel action was not pursued.
But from the WMA Council Chair Hill we heard nothing, not even acknowledgement of receipt of the material, even after reminders to him and to Dr Otmar Kloiber, permanent WMA Secretary General. Months later lead signatory Alan Meyers managed to get Dr Hill on the phone at his clinic. Hill told him firmly that the WMA would not be responding and not to send further material. We found out later that our request for the appeal to be circulated from WMA headquarters in France to Council members was not honored. When the WMA Presidency passed to Dr Dana Hanson of Canada later in the year we re-sent the appeal and evidence base, but with the same result. Calls in the BMJ from the executive directors of PHRI and PCATI for the WMA to act were similarly fruitless.
Appeals to UN Special Rapporteurs on Torture on the basis of new evidence
Finding the WMA resistant we turned in 2010 to the UN Special Rapporteur on Torture, who then was Manfred Nowak from Austria. In March 2009 UN Human Rights Council Resolution A/HRC/10/L.32 had tasked the Rapporteur to give particular attention to the problem of medical complicity. We got no acknowledgement from him but repeated the appeal when he was succeeded by Juan Mendez of Argentina (the first Rapporteur to have himself been a torture victim). His reports noted that the government of Israel routinely did not respond to representations by the Rapporteur.
A paper copy of a yet more detailed report, “Doctoring the Evidence, Abandoning the Victim”, recently published, was given directly to Juan Mendez in London in 2011. Based on testimonies and evidence from the files of over 100 torture victims assisted by PHRI/PCATI since 2007, the report demonstrated an institutionalized pattern of active or passive involvement by doctors in torture in Israel. Not one doctor had spoken out and sought to protect the victim. Case studies included doctors’ names. The executive summary concluded that “medical professionals abandon their duty by failing to document and report torture; by passing on medical information to interrogators; returning interrogees to the custody of their interrogators when in danger of being exposed to further torture or ill-treatment; and in extreme cases, by taking an active part in the interrogation. Because of their unique social status, the presence of medical professionals in facilities where torture or ill-treatment are carried out indicates the boundaries between the permissible and the impermissible: it grants Israeli Security Agency (ISA) interrogators a stamp of approval. It furthermore precludes the victim from presenting evidence which can aid in pursuing justice through legal or administrative proceedings. Over 700 complaints alleging torture/ill-treatment by ISA interrogators have been filed since 2001 and not one criminal investigation has been initiated. Medical staff in prisons, detention centers and hospitals which treat prisoners are part of the broader administrative systems, primarily the medical apparatus of the Prison Service, the IMA and the Ministry of Health. There are serious doubts that the IMA is willing to enforce these rules: persistently repeated requests by PCATI/PHRI calling the IMA’s attention to cases arousing suspicion of doctors’ involvement in torture and cruel or degrading treatment, have not been dealt with substantively.” PCATI/PHRI noted that IMA ethical codes contained clauses placing the needs of the security apparatus above medical ethics. This is inconsistent with UNCAT and the Declaration of Tokyo, which brook no exceptions. PHRI said that if doctors were taken out of the system in Israel, the practice of torture could not be maintained.
In 2014, the BMJ published a progress report on our campaign five years on and asked Rapporteur Mendez to comment. He wrote that the IMA’s silence on torture might well be a breach of medical ethics but that the IMA and WMA were outside his mandate. It was not clear why he had not taken up directly the evidence in “Doctoring the Evidence, Abandoning the Victim”.
Following further representations from us, Hamish Meldrum, BMA Council Chair, wrote to signatory Ghada Karmi in March 2010 to say that the BMA had formally written to the WMA regarding the IMA. Nothing came of this.
A fresh appeal to the WMA
In 2015 another incriminating study was published by B’Tselem and by HaMoked, Centre for the Defence of the Individual. It was based on affidavits from 116 Palestinians held and interrogated at the Shikma facility from August 2013 to March 2014. Five were children. Nearly every detainee was exposed to a range of measures described: single or concerted beatings, sometimes with rifle butts and often while detainee was handcuffed and blindfolded; repeated interrogations of up to 35 hours at a time and for up to 40 days whilst tied tightly in an unnatural position on a special chair; sleep deprivation; solitary confinement; extremes of temperature; threats to the family of the detainee; prolonged periods tied spreadeagled to the 4 corners of a bed in solitary confinement; poor or absent medical care. 4 of the children were subjected to physical violence.
In January 2016, 71 UK doctors made a fresh appeal to the new WMA President, the prominent UK medical academic Sir Michael Marmot, attaching the new evidence from B’Tselem and PCATI as above, and a paper on the sexual torture of Palestinian detainees. I was convenor and Dr Chris Burns-Cox lead signatory. Within days we were astonished to see published on the website of the Simon Wiesenthal Centre a letter from WMA President Marmot on WMA notepaper, dated 25 January, written to Dr Shimon Samuels, Director for International Relations at the Centre. The Wiesenthal Centre is self-described as a Jewish, pro-Israel organization and was an entirely uninvolved party. WMA President Marmot had instantly exonerated the IMA and afforded them a widely publicized propaganda coup. He wrote that “investigations have revealed no wrong doing” by the IMA. This is contradicted by the whole evidence base cited above. After we published an account as a bmj.com Rapid Response, the BMJ asked Marmot three times for a response but he declined. The matter was referred to the General Medical Council (GMC) but I was told that they were unable to appraise the duties of a WMA President.
Our last appeal to the WMA, submitting the new evidence, was in 2017 when the President was now Dr Desai Dhinjlal of India. The result was as before.
The recent case of Sameer Arbeed
Amnesty reported that in September 2019 a healthy 44-year-old Palestinian man Sameer Arbeed was arrested in the course of a murder investigation. Severe torture led to his admission to intensive care at Hadassah hospital, reportedly on a ventilator with broken ribs and kidney failure. The authorities were quoted as stating that once he improved he could be taken back for further interrogation. By knowing exactly how Arbeed had sustained his injuries, by treating him but not protesting about the torture, by tolerating his return to a situation in which he could be further tortured, all the hospital doctors who dealt with him were in clear breach of the WMA Declaration of Tokyo. The IMA has remained silent.
A principled, evidence-based appeal by 725 doctors from 43 countries regarding medical complicity with torture in Israel has lasted 12 years to date, spanning four WMA Presidencies and two UN Special Rapporteurs on Torture. It has been a litmus test of whether there is rigorous and even-handed regulation of doctors worldwide regarding complicity with torture. We have found that there is not, and that regulation is largely window dressing. The bodies whose mandate it is to address the issue have not acted. If such weight of incriminating evidence, using the case of Israel as example, does not make a difference at the WMA or elsewhere, no evidence ever would. UN Rapporteurs seem largely impotent. The WMA acts in partisan violation of its mandate when it acts at all, and does not appear accountable. We endorse public calls for its reform. The WMA has spoken out about states like Iran or Bahrein but would not act against Israel or, it seems, other powerful Western states. Political power trumps ethics. The WMA provides a fig leaf in that membership per se is held up as evidence of ethical probity. What happens when the national medical association is itself the principally accused party?
Israel is of course not a unique case, albeit it is the most comprehensively documented, as here. The complicity of doctors with torture worldwide is described by Steven Miles in “The Torture Doctors” (2020) as “pandemic” and that “a complete lack of accountability is the norm”. In the USA the American Psychological Association (APA) refused to act on cast-iron evidence of active complicity with torture by one of its members after 9/11 In 2014 the European Centre for Constitutional and Human Rights and Public Interest lawyers detailed 58 separate allegations regarding UK doctors acting in violation of the Declaration of Tokyo in Iraq in 2003-8. Only one case, the torture-murder of hotel receptionist Baha Mousa, led to sanctions against a doctor for failing to record the 93 injuries on his body. In one of the unexamined cases, from Al Shaibah Detention Center, the victim said he told the doctor about the beatings he had suffered at the hands of British soldier but that the doctor made no comment. “He told me he thought I had a stomach ulcer. He said this without examining me. I told him that I never had anything wrong with my stomach before, until the soldier had smashed me in it with the hammer. My t-shirt and shorts were covered in blood from the beatings to my face and in particular my nose. The doctor could clearly see this and didn’t ask me about it. I told him about the injury I had received to my nose and I thought it was broken because it was so swollen but he didn’t do or say anything”.
There is no glib answer to why doctors are prepared to collude with torture and my paper had insufficient space to address it. However I would point to a famous lecture by the sociologist Max Weber on “Politics as a Vocation”. Weber distinguished between an “ethic of responsibility” and an “ethic of conviction”. By “ethic of responsibility”, Weber meant conformity to professional standards and frameworks of accountability. In the medical profession this means a commitment to factual evidence and to standards in clinical practice determined by peer opinion, patients, general public and employers. By “ethic of conviction” Weber was identifying actions that were inspired by personally valued ideals, political or other philosophies, and identities. In my decades of anti-torture work I have witnessed how regularly, in doctors, an ethic of convention trumped an ethic of responsibility, even when it came to torture or other human rights abuses. The case of Israel bears this out clearly in my paper, with the Israeli Medical Association seeing itself as functioning in patriotic defense of state policies.
A version of this article appeared in the Journal of Medical Ethics in the UK (a publication of the BMJ) in July. Sources are available on request from the author.