I knew it was time to leave the military when physicians started being dragooned into 
supporting interrogations of prisoners.  The scandal at Abu Ghraib was all the more 
personal because physicians either looked the other way, or collaborated by faking 
death certificates of detainees tortured to death.  I never thought I would run 
smack into the brick wall of military incomprehension of the fact that military 
physicians are physicians first, and officers second...until the Pitifully Peculiar Case of the Poisoned Pizza.

Thurs, 18 Nov 04

During an 89th Air Wing war game exercise at Andrews AFB, MD, commanders placed simulated terrorists in an aircraft
on the flightline holding simulated hostages.  The base Command Post called the Medical 
Group (Malcolm Grow "Medical Center") for advice.  The acting SGH (Chief Physician of the
Hospital), a dermatologist M.D., called into the Operating Room for "any anesthesiologist".  
My junior colleague, a Captain right out of residency, took the call, then came nearly running to me in our
shared office (where 2 male LtCol anesthesiologists, one civilian contractor ex-LtCol, and our female
Captain were stuffed like sardines).

"Rob, this guy is asking me what anesthetic we could put on a pizza to subdue these
terrorists on an airplane during an exercise.  I don't know what to tell him."

"What?  Who is wanting to know?"

"The acting SGH," she said, waving a sticky note with his call-back number.

"Here, gimme that...I'll take care of this...and have a seat...I want witnesses."

One ringy dingy...Two ringie dingies...

"Col. R."

"Yes, hello, is this the acting SGH?"

"Yes, this is LtCol R."

"This is LtCol Jones, ranking anesthesiologist on duty, and acting Chief Anesthesiologist.  Can you explain to me again
what you are asking our department to help you with?"

"The command post wants to know what anesthetic agent you could put on a pizza the terrorists are demanding in order
to subdue them."

"O.K., LtCol R. here's our official response as a Department.  Two things: 

First, in the year 2004, there is no anesthetic agent that can act selectively to "subdue" a person without 
risking death to the patient, which is why we get paid reasonably big bucks to provide anesthesia care after 
twelve years of training.  We have no idea of the co-morbidities of our potential victims/patients.  
The U.S. military should have learned from the disastrous results of the Russian response to the 
Chechen rebel takeover of that opera house, where hundreds of hostages were killed by the
still-classified anesthetic cocktail they pumped into the air supply.  More people by far died of anesthetic overdose and/or
aspiration than died from any direct action of the terrorists.  Anesthesia is not inherently safe; and 
without monitoring of vital signs or knowledge of patient medical conditions, it is tantamount to poisoning.

Second, the Hippocratic oath expressly forbids physicians from advising people on how to poison others.  Even if there
were some perfect, tasteless, colorless, odorless drug which could be put on pizza to poison a person with relative
safety, I would not tell you about it.  The Line of the Air Force, especially after Abu Ghraib, should not even ask this of us medics.
Period.  It is inappropriate even to consider that physicians would be expected to be complicit in such an action.
If the special forces rescue team or whatever injure the simulated terrorists during the exercise, we will be
happy to use our deep knowledge of physiology and pharmacology to save the patients' lives...and that is all
that we, as health care professionals, can or should be expected to do in support of this exercise."

"Oh, O.K. then.  Thanks. Click."


What scared me the most was the response I got from a very junior anesthesiologist fresh out of civilian residency training.  
Later that day, when said junior anesthesiologist came in for call, I gave him the scenario:  You are only anesthesia provider in house.  
One night at 0300, you are paged by someone high up in the hospital hierarchy with the following scenario: 
Terrorists are on the flightline holding hostages; the command post wants to know what drugs can be placed 
on the pizzas the perps are demanding in order to incapacitate the bad guys.  

Here’s how his gung-ho, conservative religious, Red State thinking process went: 

"Well, you could try (drug 1), but that’s really bitter, and they’d taste it right away...
or you could try (drug 2), but it would take a whole lot, and it’s not predictable, 
because they might just become disinhibited, or you could try (drug 3), but..."

"Dude, you're thinking too hard.  Think first principles.  You are a doctor, right?"

"Yes...what does that have to do with it?"

"Think Hippocratic oath, _primum non nocere_, that sort of thing"

"Huh?"

"You...are...a...physician...so...you...cannot...use...your...knowledge...to...harm...anyone. 
Just like Luke Skywalker and Yoda: The dark side is easy, seductive...but it will corrupt you.  
Your answer to the commander should be that, as a Medical Officer, you cannot advise 
command on how to administer poisons to ANYONE, terrorist or not, even if a safe and effective 
drug existed for such a purpose, which it doesn't."

"But, if they are not legal combatants, then it's OK."

"Legal, shmegal, they are HUMAN combatants, and you are NOT to use your deep 
knowledge of human physiology and applied pharmacology to harm ANYONE.  
How do you know what co-morbidities the bad guys might have?  Do you know their 
weight for appropriate dosing?  Do you know their NPO status?  Any drug you give 
that could cause unconsciousness runs the serious risk of killing the patient 
dead from aspiration, apnea, cardiac toxicity, or all of the above."

"Yes, but, Rob, if they're terrorists, it's OK, because they're not lawful combatants…"

"Aaargh.  As the senior anesthesiologist today, and as a USU and ROTC grad, 
I am TELLING you what your answer should be."

After that, I was so concerned that our military physicians had been blinded by 
White House propaganda (the infamous Gonzales ruling on torturing detainees 
who had been labeled "unlawful enemy combatants" so that Geneva Conventions and 
other Laws of Armed Conflict [LOAC] did not apply), I took the matter directly to our 
Squadron commander.  She was and is a very nice and extremely talented retinal ophthalmologist M.D., 
whose outstanding clinical skills were sadly atrophying in her administrative role.  
I told her that I was not shocked that some non-physician on the flightline
was "spitballing" a possible solution to their hostage scenario by thinking 
about anesthetic/chemical restraints; I was appalled that the acting Chief 
Physician of the hospital did not politely tell the line officers where to 
stick their request, given that physicians can, in no way, shape or form,
use their medical knowledge potentially to harm or even kill people.

She listened to my concerns, promised to take the issue to the Hospital Executive Committee,
and sent out the following e-mail (put in chronological order, from the reverse chronological 
order of the e-mail thread).  Note the chilling, Machiavellian response
from our Medical Law Consultant hospital lawyer:

---------------------------------------------------------------
E-mail traffic: (Note: last names redacted --RCJ)
---------------------------------------------------------------

Here's the flow of communication. If you want further clarification please contact Maj K. directly.
 
Col H.


    -----Original Message-----
From: H. Dianne Y Col 89 MSGS/SGC (Surgical Operations Squadron Commander)
Sent: Thursday, November 18, 2004 2:14 PM
To: C. James P Col 89 MDG/CC (Hospital Vice Commander/Acting Hospital Commander); R. Brian LtCol 89 MDG/SGOMD (acting SGH)
Subject: Today's Exercise
			
			
Col C.,
	One of my staff brought up a concern about a component of today's exercise. 
I probably don't have the complete story, but from what I understand we were asked 
what medication could be placed in a pizza to sedate/subdue a hijacker. There were 
a few concerns, but the overriding concern was that such a use would be unethical 
and particularly a medic's role in providing such advice would also be unethical 
and probably a Geneva Convention or Laws of Armed Combat violation. Please mull 
over this issue. We need to advise the Wing exercise developers accordingly 
and we need to advise our providers accordingly.
			 
			Col H.

-----Original Message-----
From: R. Brian LtCol 89 MDG/SGOMD 
Sent: Friday, November 19, 2004 7:21 AM
To: K. Jason Maj 89 MDG/SGJ
Cc: C. James P Col 89 MDG/CC; H. Dianne Y Col 89 MSGS/SGC
Subject: FW: Today's Exercise
			
			
Jason
At excercise yesterday, MCC received request: "hijackers have requested pizza.  What could be added to incapacitate them."  
I was in MCC and our thoughts were to queiry (sic) BE (bio-environmental health), and anesthesia.  Anesthesia felt it was 
against the laws of armed conflict and Geneva convention to provide pharmaceutical guidance to attempt 
to harm or incapacitate a hijacker.  For future reference in potential scenarios, Col C. would like your take on this issue.  Thanks

BWR
Brian W. R., LtCol, USAF, MC 
Chief of Dermatology 
89th Medical Group/MDOS/SGOMD 
Malcolm Grow USAF Medical Center 
1050 West Perimeter Road 
Andrews AFB, MD  20762-6601 
(phone redacted)
(e-mail redacted)@andrews.af.mil 

-----Original Message-----
From: K. Jason Maj 89 MDG/SGJ 
Sent: Friday, November 19, 2004 8:35 AM
To: R. Brian LtCol 89 MDG/SGOMD
Cc: C. James P Col 89 MDG/CC; H. Dianne Y Col 89 MSGS/SGC
Subject: RE: Today's Exercise
		
		
I assume that the hijacker was not in a distinct uniform and carrying his arms openly, etc.  
If that is that case they are not a combatant under the Geneva (G)Conventions ( See generally G1- Art 13 (2), 
and Additional Protocol I, Arts 43 and 44), and therefore not entitled to the protections of the Conventions 
(though some benefits should be afforded once in custody).  That said medical personnel can assist, because 
if they don't fall into the rules, we don't have to follow all of them.  
Even if they are considered lawful combatants this does not mean the medical side of the house could not assist; 
this is in fact an area of debate internationally right now.  Certainly a person  who has medical training 
who is not claiming the status of a medical person covered under Art 24 of G1 could (such as a physician 
in the pilot/ Doc program - see G3, Art .32, and AFI 11-405). 
My bottom line analysis is the purpose of the medical involvement - save or take lives - 
that should tell you what to do.
		 
V/R
		 
Jason

-----Original Message-----
From: H. Dianne Y Col 89 MSGS/SGC 
Sent: Friday, November 19, 2004 8:53 AM
To: K. Jason Maj 89 MDG/SGJ; R. Brian LtCol 89 MDG/SGOMD
Cc: C. James P Col 89 MDG/CC
Subject: RE: Today's Exercise
	
	
Great discussion. Thanks for considering the issue. 
As Col C. put it: a bullet vs a pill. However, 
it sounds like our concerns are in line with international concerns. 
As our medical law consultant, Maj K., will you keep us informed 
about this and other debates about the medic's role in such conflicts? 
(Easy for me to ask...)
	 
	Col H.

-----Original Message-----
From: K. Jason Maj 89 MDG/SGJ 
Sent: Friday, November 19, 2004 9:28 AM
To: H. Dianne Y Col 89 MSGS/SGC; R. Brian LtCol 89 MDG/SGOMD 
Cc: C. James P Col 89 MDG/CC 
Subject: RE: Today's Exercise


As I hear it I will - most of what I know though comes from the International Committee 
on Military Medicine's LOAC Course which I have helped put together and teach 
every August for the last 4 years.  We get people in from all over and it generates some interesting debates.  
 
As a side note - the press has misstated a lot of the rules over the last year or so, 
as a result there is a lot of misinformed people out there.
 
V/R
 
Jason

-------------------------------------------------------------


To anyone who thinks that today's military physicians are being advised to honor the Geneva Convention, UN Resolutions
on military ethics, and the Laws of Armed Conflict I grew up on since 1981, think again.  In an empire, only the
will of the God-Emperor is paramount.  All other ethical or legal concerns MUST be subordinated to His will.  You are
an officer first, and a physician second, and don't you forget it, on pain of reprimand, court-martial, or worse, declaration
that YOU TOO are an Enemy of the State, subject to imprisonment indefinitely without trial, torture, and silent murder
on distant shores far from your beloved native land, the formerly free United States of America.

This consitutes reason #314 why I left the U.S. military as a senior LtCol 3/4th of the way to a cushy retirement,
resigned my Regular Air Force Commission, and did not join the reserves.  I will not EVER use my knowledge of medicine
to harm anyone...even if that person killed my entire family in front of my eyes.  I may be tempted to find other
ways, but NOT anesthesiologic ways.  Period.


-----------------------------------
References:
-----------------------------------

From: http://www.pbs.org/wgbh/nova/doctors/oath_classical.html


The Hippocratic Oath:

I will neither give a deadly drug to anybody who asked for it, nor will I make a suggestion to this effect... 

Whatever houses I may visit, I will come for the benefit of the sick, remaining free of all intentional injustice, of all mischief...


http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=184479
BMC Med Ethics. 2003; 4: 4. 
Published online 2003 August 1. doi: 10.1186/1472-6939-4-4.
Copyright © 2003 Singh; licensee BioMed Central Ltd. This is an Open Access article: 
verbatim copying and redistribution of this article are permitted in all media for 
any purpose, provided this notice is preserved along with the article's original URL.


American physicians and dual loyalty obligations in the "war on terror"
Jerome Amir Singh1,2 

1Howard College School of Law, King George V Ave, University of Natal, Durban, 4041, South Africa
2University of Toronto Joint Centre for Bioethics, 88 College St, Toronto, M5G 1L4, Canada


Background
Post-September 11, 2001, the U.S. government has labeled thousands of Afghan war detainees "unlawful combatants". 
This label effectively deprives these detainees of the protection they would receive as "prisoners of war" 
under international humanitarian law. Reports have emerged that indicate that thousands of detainees being 
held in secret military facilities outside the United States are being subjected to questionable "stress and duress" 
interrogation tactics by U.S. authorities. If true, American military physicians could be inadvertently becoming 
complicit in detainee abuse. Moreover, the American government's openly negative views towards such detainees 
could result in military physicians not wanting to provide reasonable care to detainees, despite it being 
their ethical duty to do so.

Discussion
This paper assesses the physician's obligations to treat war detainees in the light of relevant 
instruments of international humanitarian law and medical ethics. It briefly outlines how detainee 
abuse flourished in apartheid South Africa when state physicians became morally detached from the 
interests of their detainee patients. I caution U.S physicians not to let the same mindset befall 
them. I urge the U.S. medical community to advocate for detainee rights in the U.S, regardless of 
the political culture the detainee emerged from. I offer recommendations to U.S physicians facing 
dual loyalty conflicts of interest in the "war on terror".

Summary
If U.S. physicians are faced with a conflict of interest between following national policies or 
international principles of humanitarian law and medical ethics, they should opt to adhere to the 
latter when treating war detainees. It is important for the U.S. medical community to speak out 
against possible detainee abuse by the U.S. government.

.......
 
In their seminal work Principles of Biomedical Ethics Thomas Beauchamp and James
Childress argue that a set of principles should function as an analytical framework that expresses 
the general values underlying rules in the common morality. [16] They have suggested that (a) 
respect for autonomy, (b) nonmaleficence, (c) beneficence and (d) justice should serve as guiding 
principles for professional ethics. Since its evocation this framework has won critical appraisal 
and has been widely embraced by the biomedical community.

[16] Beauchamp T and Childress J: Principles of Biomedical Ethics. Fifth edition. New York: Oxford University Press: 2001.

.......
According to the Tokyo Declaration, a physician should not "countenance, condone or participate in the practice of 
torture or other forms of cruel, inhuman or degrading procedures, whatever the offence of which the victim of such 
procedures is suspected, accused or guilty, and whatever the victim's beliefs or motives, and in all situations, 
including armed conflict and civil strife". [49] It states that the physician "shall not provide any premises, 
instruments, substances or knowledge to facilitate the practice of torture or other forms of cruel, inhuman or 
degrading treatment or to diminish the ability of the victim to resist such treatment". [50] Military 
physicians who participate in interrogation sessions, either directly, or by resuscitating unconscious 
detainees for the purposes of further interrogation by the detaining power, could be determined as having 
diminished the ability of detainees to resist such treatment. The mere presence of any military physicians 
during any inhumane treatment of detainees is also a violation of the Tokyo Declaration. [51]



http://www.amnesty.org/resources/pdf/combating_torture/chapter8.pdf

The absence of a specific medical declaration against physician participation in torture was
remedied by the World Medical Association at its annual assembly in Tokyo, Japan, in 1975. The Declaration of Tokyo 
(Article 1) states:“The doctor shall not countenance, condone or participate in the practice of torture 
or other forms of cruel, inhuman or degrading procedures, whatever the offence of which the victim of such 
procedures is suspected, accused or guilty, and whatever the victim’s beliefs or motives, and in all situations, 
including armed conflict and civil strife.”37This code remains the strongest statement of the organized medical 
profession against participation in, or tolerance of, torture, although it has not resolved the problems 
confronted by those doctors who witness torture and are uncertain of how they can act to stop it.



http://www.un.org/documents/ga/res/37/a37r194.htm

                                                   Resolution 37/194
                                                   111th plenary meeting
                                                   18 December 1982
 
 
          37/194.  Principles of Medical Ethics



                                 Principle 2
 
               It is a gross contravention of medical ethics, as well as an
          offence under applicable international instruments, for health
          personnel, particularly physicians, to engage, actively or
          passively, in acts which constitute participation in, complicity in,
          incitement to or attempts to commit torture or other cruel, inhuman
          or degrading treatment or punishment.
 
                                 Principle 3
 
               It is a contravention of medical ethics for health personnel,
          particularly physicians, to be involved in any professional
          relationship with prisoners or detainees the purpose of which is not
          solely to evaluate, protect or improve their physical and mental
          health.



Dual Loyalty and Human Rights:
http://phrusa.org/healthrights/dual_loyalty.html
http://phrusa.org/healthrights/dl_4.html#e

1. The military health professional’s first and overruling identity and priority is that of a health professional. 

Commentary: Although this guideline appears self-evident, many military organizations teach physicians 
that they are officers or soldiers first and physicians second. As such, they are supposed to make their 
medical skills available exclusively for military purposes. In some countries, such as France, the military 
physician is trained in a separate miltary medical school, rather than trained as a military doctor after 
graduating from civilian medical school. Even where such training takes place, the primacy of the medical 
function should always be reinforced, even if there exist circumstances where the needs of the military 
prevail over the needs of the soldiers.