The tortured patient: a medical dilemma

Philosophy

Torture is unethical and usually counterproductive. It is prohibited by international and national laws. Yet it persists: according to Amnesty International, torture is widespread in more than a third of countries. Physicians and other medical professionals are frequently asked to assist with torture.

          Medical complicity in torture, like other forms of involvement, is prohibited both by international law and by codes of professional ethics. However, when the victims of torture are also patients in need of treatment, doctors can find themselves torn. To accede to the requests of the torturers may entail assisting or condoning terrible acts. But to refuse care to someone in medical need may seem like abandoning a patient and thereby fail to exhibit the beneficence expected of physicians.

          In this paper, we argue that this dilemma is real and that sometimes the right thing for a doctor to do, overall, is to be complicit in torture. Though complicity in a wrongful act is itself prima facie wrongful, this judgment may be outweighed by other factors. We propose three criteria for analyzing how those factors apply to particular cases of medical complicity in torture.

HASTINGS CENTER REPORT May-June 2011 Torture is unethical and usually counter-productive.	It	is	prohibited	by	international	and	national laws.	Yet it	persists:	according to	Amnesty International, torture is	widespread in more	than	a	third	of	countries.1	Physicians	and	other medical	professionals are frequently asked to assist with	torture.	For	example,	a	recently	declassified	report	from	the	Central	Intelligence	Agency	on	interrogation	at	Guantanamo	Bay	states:	"OMS	[Office of	Medical	Services]	provided	comprehensive	medical	attention	to	detainees	.	.	.	where	Enhanced	Interrogation	Techniques	were	employed	with	high	value detainees."2 Such "high value detainees" were exposed to death	threats	with	handguns	and	power	drills,	waterboarded more than 180 consecutive times, and subjected	to	lifting	"off	the	floor	by	arms,	while	arms were	bound	behind	his	back	with	a	belt,"	a	medieval form	of	torture	known	as	strappado.3 The medical professionals described in this extract	might	not	have	actually	engaged	in	torture.	But by	providing	medical	attention	to	prisoners	subjected to practices that the Inspector General defined as	"un-authorized	and	inappropriate"4	and	that	most commentators consider torture,5 some were surely complicit	in	it. Medical	complicity	in	torture,	like	other	forms	of involvement,	is	prohibited	both	by	international	law and	by	codes	of	professional	ethics.	However,	when the victims of torture are also patients in need of treatment,	doctors	can	find	themselves	torn.	To	accede	to	the	requests	of	the	torturers	may	entail	assisting	or	condoning	terrible	acts. But	to	refuse	care	to someone	in	medical	need	may	seem	like	abandoning a	patient	and	thereby	fail	to	exhibit	the	beneficence expected	of	physicians. In	this	paper,	we	argue	that	this	dilemma	is	real and	that	sometimes	the	right	thing	for	a	doctor	to do, overall, is to be complicit in torture.	Though complicity in a wrongful act is itself prima facie wrongful, this judgment may be outweighed by The Tortured Patient A Medical Dilemma BY CHIARA LEPORA AND JOSEPH MILLuM Doctors sometimes find themselves presented with a grim choice: abandon a patient or be complicit in torture. Since complicity is a matter of degree and other moral factors may have great weight, sometimes being complicit is the right thing to do. Chiara	Lepora	and	Joseph	Millum,	"The	Tortured	Patient:	A	Medical	Dilemma,"	Hastings Center Report	41,	no.	3	(2011):	38-47. May-June 2011 HASTINGS CENTER REPORT 39 other factors. We propose three criteria for	analyzing	how	those	factors apply to particular cases of medical complicity in torture. First, doctors should assess the consequences of the different options open to them, including	not	only	consequences for themselves and for the patient, but also	the	possible	wider	social	effects, such	as encouraging	or	discouraging policies that	permit torture.	Second, doctors should attempt to discern and	follow	the	requests	of	the	patient regarding	his	or	her	care.	Finally,	doctors	should	weigh	the	degree	to	which the	act	would	be	complicit	in	torture. Where complicity is justified, it should also be minimized, and we provide	some	analysis	of	how	to	minimize	it.	As	with	other	difficult	ethical	dilemmas,	there	is	no	formula	for determining the right course of action;	careful	judgment	must	be	used to	weigh	these	moral	factors	in	different	situations.	Our	analysis	provides	a way	to	think	through	such	dilemmas and takes them seriously, in a way that	blanket	prohibitions	on	medical complicity	in	torture	fail	to	do. We	should	make	two	preliminary points about the scope of our argument.	First,	we	assume that the	acts of torture with which doctors are asked to be involved are unethical. Though there remains some debate over the permissibility of torture in narrowly	specified,	extreme	cases,	the vast	majority	of	real	acts	of	torture	do not	fit	these	specifications.6	For	those who do think that torture could be justified in some circumstances, we ask	that	they	restrict	themselves	here to	consideration	of	cases	they	believe to be unethical. Second, while we discuss	the	role	of	doctors,	our	arguments	apply	equally	to	other	medical professionals,	such	as	nurses	and	psychologists,	who	may	also	be	asked	to involve	themselves	in	torture. Physicians and Torture The United Nations Convention	against	Torture	and	Other	Cruel, Inhuman	or	Degrading	Treatment	or Punishment sets out a basic definition	of	torture: the term "torture" means any act by	which	severe	pain	or	suffering, whether	physical	or	mental,	is	intentionally inflicted on a person for such purposes as obtaining from	him	or	a	third	person	information	or	a	confession,	punishing him	for	an	act	he	or	a	third	person has committed or is suspected of having committed, or intimidating or coercing him or a third person,	or	for	any	reason	based	on discrimination	of	any	kind,	when such	pain or suffering is inflicted by	or	at	the	instigation	of	or	with the consent or acquiescence of a public	official	or	other	person	acting in	an	official	capacity. It	does not	include	pain	or	suffering	arising	only	from,	inherent	in	or	incidental	to	lawful	sanctions.7 Torture therefore encompasses cases ranging from	exposing	a	prisoner to electroshock to extract information, to	beating	or	slapping	to	"induce	surprise, shock, or humiliation,"8 and cutting	off	a	prisoner's	healthy	ear	or limb	as	punishment.9 Prohibitions	on	physicians	participating	in	torture	are	a	relatively	recent development.	From	the	Middle	Ages through	to	the	modern	era,	physician involvement	in	torture	was	a	professional requirement.	This	ended	only when	torture	itself	ceased	to	be	legally and socially acceptable.10 In the last century, international agreements prohibited	all	forms	of	torture.11	The prohibition on torture, including complicity in torture, was explicitly extended to medical professionals. For	example,	Article	3	of	UN	Resolution	37	states: 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.12 Medical participation in torture is similarly condemned by all professional codes of ethics, including the World Medical Association's Tokyo and	Malta	declarations,	the	American Medical	Association's	Resolution	10, the American College of Physicians' conclusions and recommendations, a	joint	position	statement	from	U.S. psychiatry and psychology associations, and the	World Psychiatry Association's	Madrid	Declaration.13 Legal, ethical, and medical condemnation	have	not	been	as	effective as	their	proponents	hoped:	torture	is widespread in more than a third of countries,14 and	medical implication is	described	in	at least	40	percent	of reported torture cases.15 Doctors are frequently required to be on hand for	acts	ranging	from	falsifying	death certificates to the	amputation	of	detainees'	limbs. Some	of	these	doctors	may	simply be	engaged	in	torture,	or	at	least	sympathetic	to	the	aims	and	methods	of the	torturing	regime.	But	others	who oppose torture find themselves in a If the state is going to amputate a limb as punishment, it is surely better for the victim that it be done in a surgical theater under anesthesia administered by a qualified surgeon than without anesthetic in the public square by an untrained official. 40 HASTINGS CENTER REPORT May-June 2011 difficult situation.	While the torturers may ask them to provide some form	of	medical	attention	for	purposes	unrelated to the	prisoner's	health, the prisoner may actually need that medical	attention	in	order	to	be	properly	treated.	In	some	circumstances,	a prisoner	may	be	better off cared for by a doctor, despite the complicity entailed. If the	state is	going	to	amputate	a	limb	as	punishment,	regardless	of	the	international	prohibitions, it is surely	better for the	victim	that the amputation be performed in a surgical theater, under anesthesia administered	by	a	qualified	surgeon, than	without	anesthetic	in	the	public square	by	an	untrained	official.	Thus, doctors	may	be	conflicted	about the right	course	of	action	to	take. This conflict also arises from the international instruments and codes of	medical	ethics.	While	they	extend a	blanket	prohibition	on	all	forms	of participation	in	torture,	they	also	exhort	physicians to treat the interests of	their	patients	as	a	guiding	concern. The	same	U.N.	resolution	that	condemns	medical	complicity	in	torture also states that "Medical and other health	personnel	have	a	duty	to	provide competent medical service in full	professional	and	moral independence, with compassion and respect for	human	dignity,	and	to	always	bear in	mind	human	life	and	to	act	in	the patient's	best	interest."16 The tension between these two directives has been neglected by the substantial literature addressing the ethics of torture and medical complicity. A literature search of philosophical,	medical, and legal journals over the last ten years yielded more than	four	hundred	papers	that	mentioned "physicians" and "ethics" along with "torture," "interrogation," or "forced treatment."17 But despite deep and divergent views, only a couple of publications present	the	issue	of	medical	participation in torture as any sort of dilemma;18 the majority propose or repropose exceptionless prohibitions on physician complicity in torture,19 discuss whether specific mentioned acts are indeed	tantamount	to	torture,20	argue about whether torture is justified in some	exceptional	cases	when	national security is threatened,21 or consider whether	medical	participation	is	necessary	and	even	morally	required	for some	cases	of	torture.22 Complicity and Wrongdoing Before	we	can	address the	specific	problem of medical complicity in torture, we need a clear analysis of	what it	means to	be complicit in wrongdoing.	The	most	basic case	of complicity in wrongdoing involves a principal actor who carries out a wrongful act and an accessory who does	not	actually	perform	the	wrongful act but is in some way involved in	it.23	Complicity	comes	in	degrees: someone can be more or less complicit	in	an	act.	The	degree	to	which someone	is	complicit	is	a	function	of two	factors:	assistance	and	shared	intention	(corresponding	to	the	Catholic concepts of material and formal complicity24). Assistance is a function	of	the	complicit	agent's	expected causal	contribution	to	the	act.	Shared intention is a function	of the	extent to	which	she	has the same	wrongful ends	as	the	principal. The idea of assistance should be relatively straightforward, even though exactly how to measure the extent	of someone's causal contribution is complex. The intuitive notion is that the more the complicit agent's acts are expected to help in achieving the wrongful ends, the more complicit she is. (Of course, as	with	other	cases	of	moral responsibility, it must be the case that she acts voluntarily and that she	knows, or should	know, that she is	assisting the	wrongful	act.)	Consider	an	arms dealer who sells weapons to terrorists:	the	more	weapons	he	sells	them, the	greater	his	complicity	in	the	acts they	perform	with	the	weapons.	Or, to take a medical example, contrast two psychologists who examine a prisoner	and	record their	assessment in his medical records, knowing that the records will be read by the torturers. One psychologist reports the	patient's extreme fear	of spiders; the other reports only that the patient suffers from anxiety disorder. Although	both	reports	are	technically correct, the first, by giving the torturers specific information, thereby helps	them	more	with	their	interrogation.	With	the	information	she	gives them,	the	torturers	are	able	to	exploit the	prisoner's	fears:	confining	him	in a	cramped	box	and	inserting	insects. Such	an	experience	was	designed	by interrogators	at	Guantanamo	Bay.25 Complicity	is	not	just	a	matter	of voluntarily	and	knowingly	providing assistance	to	the	principal's	wrongdoing; the intentions with which the accessory	acts	are	important,	too.	To amend	a	famous	example	of	Bernard Williams,	there	is	something	morally better about the actions of George, who	takes	a	job	at	a	chemical	weapons	factory	as	a	last	resort	to	pay	his bills,	than	Henry,	who	takes	the	same job	because	he	wants	to	advance	the effectiveness of chemical warfare.26 Focusing on whether intentions are shared	allows	us	to	distinguish	a	case of two people who are engaged in the same activity (even if their actions take place at different times) from	a case in	which the accessory's acts simply enable or make it easier for the principal to engage in the activity. This explains the different intuitions about the chemical	weapons employees. It can also explain why	simply	being	associated	with	an activity,	without	causally	assisting it, may entail complicity. Suppose	Victor joins a neo-Nazi party (again, voluntarily	and	knowingly).	He	may then be judged complicit in the racially motivated violence it incites even	if	he	does	nothing	to	facilitate	it himself.	A	natural	explanation	of	why we	regard	him	as	complicit	is	that	his membership signifies that he shares the party's goals. Similarly, a doctor who	agrees	to	attend	a	waterboarding torture	session	is	complicit	in	torture regardless	of	whether	she	actually	intervenes	at	any	point in	the	process, since her presence can be plausibly May-June 2011 HASTINGS CENTER REPORT 41 interpreted as implicit endorsement of	the	procedure. What	does	it	mean	to	share	intentions?	To share someone's intentions is	to	act	for	the	same	reasons	as	that person.	Thus,	if	we	are	dance	partners and you step left in order to waltz and I step right in order to waltz, then	we share the joint intention to waltz.	Likewise, if	one	person	plants the bomb in the basement and his partner	lights	the	fuse,	they	share	an intention	to	blow	up	the	building.27 Complex	acts like torture involve a	number	of	distinct	intentions.	The torturer must intend each of the component acts that constitute an instance	of torture-for example, to secure the prisoner's restraints, attach	the	wires,	check	the	circuit,	turn the	switch,	and	so	on.	Moreover,	the same act may be performed with multiple intentions, under different intentional	descriptions;	for	example, the torturer may turn the switch in order to make the current flow, but also in order to cause the prisoner pain	and in	order to	make	him	give up information. This entails that, depending on the number of component intentions that	are shared, it is	possible to	share the intentions	of another	to	a	greater	or lesser	degree. Thus, as with providing assistance, complicity through shared intention comes	in	degrees,	depending	on	how many of the intentions to commit wrongful acts are shared. This will prove important when we consider the	different	motivations that	might lead a physician to be complicit in torture. To summarize, there are two dimensions to complicity, assistance and	shared	intention,	both	of	which are	a	matter	of	degree.	Most	cases	of complicity involve someone being complicit to some degree on both dimensions, though it is possible to	be complicit only	by assisting	or, through	acts	with	symbolic	meaning, only	by sharing intentions.	Roughly speaking, the further along each dimension one lies, the greater one's total	complicity.	How	bad	it	is	to	be complicit	in	a	wrongful	act	is	then	a function	of both the extent of one's complicity	in	that	act	and	of	how	bad the act is (since the wrong of complicity is	derived from the	wrong	of the	act	with	which	one	is	complicit). Is Complicity in Wrongdoing Always Wrong? When someone is complicit in	wrongdoing, she does not herself	commit	the	wrong.	Thus,	the wrongfulness	of	the	primary	act	does not	entail	that	the	complicit	act	is	itself	wrong,	all	things	considered.	The act	may	have	other	features	that	speak in	favor	of	it;	for	example,	it	might	be expected	to	produce	a	greater	balance of benefits over harms than other acts.	Alternatively,	it	may	be	the	best option among the choices available to someone, all of which are problematic. Moreover, as we just saw, complicity comes in degrees. Someone's actions could be only slightly complicit in wrongdoing (and so, depending on the principal's act, only	slightly	prima	facie	wrong).	It	is therefore	possible that	other	morally relevant features of a complicit act could outweigh the wrong of complicity	and	make	that	act	permissible or	obligatory,	all	things	considered. This theoretical point can be illustrated	with	a	well-known	example. Oskar Schindler was a member of German Military Intelligence and a businessman who took advantage of the German invasion in 1939 to acquire a bankrupt Polish factory. Schindler created strong and longlasting friendships with members of the	Wehrmacht	and	the	SS,	and	became their trusted source of cognac and	cigars.	Until	his	encounter	with Itzhak Stern, a Jewish accountant, Schindler exhibited interest only in business. As a respected and wellconnected	member	of	Nazi	high society,	Schindler	was	able to	hire	and keep	Jewish	workers in	his factories, eventually saving more than 1,200 from deportation and death.28 His workers	were	glad	of	his	position	and requested	that	he	maintain	it. There is no doubt about Schindler's early complicity in the Nazi regime and the ongoing war, which	he	fueled	with	the	products	of his factories.	But,	on the	commonly held	assumption	that	the	good	he	did by	saving	Jews	outweighed	the	negative consequences of his compliance with	the	Nazi	regime,	there	is	also	little	doubt	that	Schindler	did	the	right thing. Given the circumstances, he would	have	been	mistaken to refuse complicity	and	thus	be	unable	to	help his	employees. Cases like Schindler's show that complicity	in	even	the	most	heinous of	acts	may	not	be	wrong,	all	things considered.	The prima facie wrongness	of	complicity	in	wrongdoing	can be	outweighed	by	other	moral	reasons in	favor	of	the	act.	But	this	can	apply to	medical	complicity	in	torture,	just as	it	did	to	Schindler's	complicity	in the	Nazi	war	machine.	In	certain	circumstances,	patient-centered	considerations	will	be	important	enough	to outweigh	complicity	in	torture. The following sections elucidate the two moral considerations that we regard as most important in the context of medical complicity:	consequences	and	patient	preferences. We then consider how these If the torturing authorities demand that a prisoner be treated and the prisoner also asks for treatment, then the doctor, in treating, will inevitably be complicit in the torture. But if she treats because of the prisoner's request and not the torturer's, the degree to which she is complicit will be low. 42 HASTINGS CENTER REPORT May-June 2011 considerations	relate	to	a	doctor's	potential	complicity	in	torture. Consequences The consequences of our actions	clearly affect their moral evaluation. In Schindler's case, the good of	helping	1,200	people survive	was sufficient to outweigh the wrong of being	complicit	with	the	Nazis.	Likewise, there will be a point at which the	beneficial	consequences	of	an	act that is	complicit in torture	will	outweigh the prima facie wrong of the complicity. However, exactly how and	how	much	consequences	matter in moral decision-making is controversial.	It	is	notoriously	hard	to	weigh the importance	of	different states	of affairs against each other, let alone against	very	different	values, such	as avoiding complicity. Here we have space only to indicate the types of consequences	that	ought	to	be	taken into	account. Three broad classes of relevant consequences may be distinguished: personal	consequences,	consequences for the prisoner, and social consequences. Personal consequences are those that affect the doctor herself (or other people who are significant in	her life).	Some	should	clearly	not be	given	moral	weight.	For	example, if a doctor stands to profit or to be promoted	as	a	result	of	her	complicity with	a	torturing	institution,	this	is	no justification	for	complicity	at	all.	On the	other	hand,	credible	vital	threats to	the	doctor	or	her	family	might	excuse her complicity. The Iraqi doctor who was executed for refusing to participate in torture might have done	a	noble	thing,29	but	many	people would judge his action beyond the call of duty-where someone is threatened	with	death,	his	complicity in	acts	he	cannot	prevent	is	excusable. Such	reasoning	should	not	be	taken	too	far, though.	The	fact that	we excuse	people	who	assist	in	wrongdoing	when they are	under great	pressure	should	not	be	taken	to	excuse	all actions taken under any pressure at all.	Doctors should accept	moderate risks in the service of right action. Quite apart from the general duty that	people	have	to	accept	moderate risks to preserve the rights of others, physicians are usually thought to have special duties to take risks for	the	sake	of	their	patients-for	example,	by	risking	exposure	to	nosocomial	infections.30 Whether a	doctor should	be taking personal risks by refusing to cooperate	also	depends	on	the	consequences	of	her	cooperation	or	refusal for	other	parties.	Consider	those	occasions	when	the	complicit	acts that doctors	are	asked	to	perform	are	also in the medical interests of the prisoner being tortured. For example, the	surgeon	who	is	asked	to	perform an	amputation	as	part	of	a	court-ordered	punishment	may	rightly	judge that	the	prisoner	will	be	better	off	if she complies than if she refuses and leaves the punishment in the hands of	someone	with	no	medical	training. Benefits	to	the	prisoner	should	count in	favor	of	doing	as	the	authorities	request.	However,	what	counts	as	being in	the	prisoner's	interests	is	a	complicated	question:	medical	benefit	does not exhaust what constitutes wellbeing,	and	frequently,	what	someone subjectively	values	makes	a	difference to	what	is	good	for	him. A doctor's complicity in torture may	also	affect	the	interests	of	people outside	the	doctor-prisoner	dyad,	and doctors	should	also	take	into	account these broader social consequences. This	point is	not	about the	possible social	benefits	of	torture-we	assume that	torture	is	wrong	and	also	that	it is not socially beneficial.31 Instead, the	issue	is	about	the	possible	political	consequences if	doctors	refuse	to be	complicit.	For	example,	one	might argue	that	an	effective	physician	boycott of all forms of association with torture might limit a government's ability	to	torture.32	If	a	doctor's	refusal to	comply	can	have	a	foreseeable	impact	on	whether	torture	occurs,	then she ought to take this consequence into account. In many cases, however, the social	benefits	of	noncooperation	are	likely	to	be	speculative	at best:	a	doctor	will	often	lack	any	real evidence	concerning	the	beneficial	or harmful long-term effects of her actions. In such cases, she should not neglect	someone's	immediate	medical needs. Prisoner Preferences In	considering	the	consequences	of	complicity,	the	interests	of	the	victims are of great importance. However, as in standard cases	of	medical care,	a	physician's judgment	of	what is in	a	patient's interests	may	not	be sufficient for her to decide whether and	how	to	treat	him.	Instead,	where a patient is competent to make decisions about medical care, his own treatment	preferences	should	normally	be	respected.33	This	is	for	three	reasons:	first,	because	people	are	usually knowledgeable	about	what	is	in	their own interests; second, because what people value	partly	determines	what is	in	their	interests;	and	third,	because respect for autonomy extends to respecting a patient's decisions about what	is	or	is	not	done	to	his	body. Consider the following case. A doctor	is	called	to	provide	treatment to a prisoner who has been severely beaten	during	interrogation.	The	prisoner's	current	prognosis	is	quite	poor but could be significantly improved with immediate, expert treatment. However,	if	the	prisoner's	health	improves sufficiently, then the doctor expects	that	he	will	be	tortured	again. Should	she	treat	him	or	leave	him?	It seems to us that this question cannot	be	answered	without	finding	out what	the	prisoner	wants.	Only	he	can decide	whether	it	is	preferable	to	survive	and	be	tortured,	or	to	avoid	further torture	but increase	his	chances of dying. Further, by soliciting and following	his	decision,	the	doctor	allows	the	prisoner	some	degree	of	control over	what	happens to	him, and thereby	respects	his	autonomy. Doctors	might	wonder	how	standards of care and informed consent can	possibly	be	respected	in	a	setting such	as	a	prison,	where	obvious	violations of rights are	being	perpetrated May-June 2011 HASTINGS CENTER REPORT 43 and where open complaints about torture	may	be	punished.	Several	eyewitness	accounts	of	doctors	involved in	torture	report	the	presence	of	security	guards at	medical examinations. Nonetheless, in most cases, doctors remain able to talk to their patientprisoners, and they are able to ask whether	they	wish	to	receive	medical care.34	For	instance,	in	the	case	quoted at	the	beginning	of	the	article,	a	doctor	is	reported	to	have	examined	the prisoner	more	than	twenty-five	times and conversed with him on more than	half	of	those	occasions.35	Admittedly, eliciting treatment preferences from prisoners in places where they are tortured is unlikely to reach the same	standards	for	informed	consent that	we	aim	for	in	more	typical	clinical care. But it is still far better for doctors	to	seek	their	patients'	views	to the	best	of	their	ability	than	to	ignore them	entirely. What should a doctor do if the prisoner is unconscious? In such a case,	she	should	follow	the	same	principles	laid	out	in	guidelines	for	emergency rooms and for the treatment of hunger strikers: in the absence of an expressed preference from the patient, the doctor should promote what	is	in	the	presumed	best	medical interests	of	the	patient.36	However,	if and	when	the	patient	is	conscious	and competent,	his	preferences	trump	the principle of medical beneficence. Once	he	has	been	revived,	these	preferences	should	be	elicited. Someone might object that patients	who	are also	prisoners	do	not have medical rights as extensive as those	of	other	patients, and so their preferences should	not	always	be respected	even	when they can	be elicited.	For	example,	prisoners	may	not refuse	treatment	for	a	medical	condition such as active tuberculosis-a condition that poses a risk to other inmates	or	to	the	security	of	the	institution.	But	such	limits	on	the	right	to refuse	treatment	are	no	different	than limits	that	also	apply	to	nonprisoners living	in	confined	settings.37	Both	the Geneva	Convention	on	the	rights	of war	prisoners	and	the	preponderance of U.S. case law reaffirm that competent prisoners should be afforded the	same	rights	to	refuse	treatment	as patients outside a prison.38 Furthermore,	doctors	and	other	medical	personnel	have	a	duty	to	provide	care	to prisoners	at	the	same	standards	as	for nonprisoner	patients.39 Finally, one might object that talk	of	autonomy	is	misplaced	in	the context of torture. If the patient is not only a prisoner, but a prisoner who has been or will be tortured, then	one	might argue that she faces too	much coercion to be capable of autonomous action. However, this objection conflates autonomy with liberty.	Someone	is	autonomous-in the sense that his choices should be respected-when	he	is	capable	of	reasoning	about	what	to	do	in	the	light of	his	values	and	making	decisions	on that	basis.	This	is	a	capacity	that	does not	rely	on	having	the	ability	to	carry out his decisions-that is, on having sufficient liberty. So long as the prisoner	is	capable	of	making	an	autonomous	choice	about	his	care,	that choice should be respected; the fact that	his liberty	is	very	constrained	is no reason to	deny	him this	piece	of control	over	his	life. Patient-Centered Reasons and Complicity in Torture In	working	out	the	ethics	of	a	par-ticular complicit act, it is important	to	note	the	relationship	between respecting the prisoner's welfare or preferences and a doctor's degree of complicity in torture. To return to the	previous	example,	if	the	prisoner asks	for	treatment,	the	same	action	is simultaneously	the	one	requested	by the torturing authorities and by the prisoner.	If	the	doctor	wishes	to	carry out	the	prisoner's	will	(which	is	what is involved in respecting someone's autonomy), then she must do what the	torturers	request.	Inevitably,	then, she	will be complicit in the torture. However,	if	that	the	doctor	treats	the prisoner	just	because	it	is	the	prisoner's	request,	then	the	degree	to	which she	is	complicit	will	actually	be	quite low.	This is	because	her intention is not	to	have	the	prisoner	tortured,	but to	follow	his	health	care	wishes.	(This assumes	that	if	the	prisoner	asked	for treatment	that	differed	from	what	the authorities had requested, then the doctor would follow that course instead,	and	if	the	authorities	requested treatment contrary to the patient's wishes, then the doctor would refuse.)	Thus, in these cases, the doctor may provide some assistance to the torturers, but, not sharing their wrongful	intentions,	she	is	minimally complicit. This case can be helpfully contrasted with an alternative motivation.	Consider	a	second	doctor,	who does	as	the	torturers	request	and	treats the	prisoner	because	that	is	what	she is	paid	to	do.	Imagine	this	doctor	defending	her	actions	by	pointing	to	her benign intentions: "I	was just	doing my job-I didn't want the prisoner to	be	tortured!"	Such	a	defense	would seem fake, and our earlier analysis of complicity can explain why.	This doctor	may	indeed	have	the	ultimate goal of being paid. But a necessary proximate	intention	for	reaching	this goal	is	that	she	carries	out	the	orders of	her	superiors,	and	this	requires	that she intentionally facilitate torture. Thus, she intends a wrongful act: helping	people	carry	out	torture.	Our first	doctor,	on	the	other	hand,	need Codes of professional ethics give physicians duties to act in their patients' interests, to respect their patients' autonomy, and to refrain from any association with torture. But sometimes fulfilling all of these duties at once is not possible. 44 HASTINGS CENTER REPORT May-June 2011 not	intend	anything	of	the	sort.	She does what the torturers request, but not because they request it, and so need	not	share	any	of	their	wrongful intentions. Her contribution is only instrumental. These are fine distinctions, but important: with them we can separate	hypocritical	doctors	who	are	really part of the torturing institution from doctors who are struggling to serve their patients under difficult circumstances. Potential Objections Someone	might	accept	the	analysis	given so far, agree that ordinary people	faced	with	difficult	dilemmas like the	ones	we	describe sometimes ought to be complicit in wrongdoing,	but	deny	that	the	analysis	applies to physician complicity in torture. Physicians have general ethical duties	like	everyone	else,	but	they	have additional special	duties in	virtue	of being physicians. (Similarly, nurses, psychologists,	and	so	forth	each	have their own role-based duties.) Some commentators	believe	that these	duties imply	that they	should	never	be complicit in torture.40 For example, some argue that the physician's role as healer entails that she has a special	duty	to	refrain	from	actions	that cause harm, and this includes any form	of	support	for	torture.41 We believe that such objections miss the force of the problem with which we began. The dilemmas we describe	arise	because	different	principles, all of which are internal to the role	of the	physician, come into conflict.	Codes	of	professional	ethics give	physicians	duties	to	act	in	the	interests	of	their	patients	(even	at	some risk	to	themselves),	to	respect	patient autonomy, and to refrain from any form	of	association	with	torture.	But sometimes	it	is	not	possible	to	fulfill all	of	these	duties	at	once.	Reference to the role morality of physicians therefore does not resolve these dilemmas;	rather,	it	shows	why	they	are so	difficult. A	related	possible	objection	is	that complicity in torture could require doctors	to	sacrifice	their	personal	integrity.	Here	the	objection	is	not	that complicity in torture is inconsistent with	the	values	that	make	up	the	role morality of a physician, but that it may	be inconsistent	with the	deeply held values of individual physicians. Arguments	like	this	have	been	developed	to	defend	limited	forms	of	conscientious	objection for	physicians,42 and to argue against moral theories that require individuals to sacrifice their	personal	projects	whenever	doing so could attain a greater good.43 In	both	cases,	the	form	of	argument is	the	same:	to	ask	someone	to	act	in a way that is inconsistent with her deeply	held	values	threatens	her	identity	as	a	moral	agent.	Hence,	people have	a	prerogative	not	to	act	in	such ways.	Might	a	physician	legitimately refuse to be complicit in torture on the grounds of personal integrity in cases	like	the	ones	we	describe?	Maybe,	but such	a refusal is	neither	easily defended nor morally decisive if defended. Note	first	that	an	appeal	to	personal integrity	must cite	more than the doctor's	moral	opposition	to	torture. The arguments of this paper start from	the	premise	that	the	torture	we are considering is immoral, and we assume	that	the	physicians	we	address agree	with	this	judgment.	We	have	argued	that	even if this	is	true,	there	are cases in which a physician ought to act	in	a	way	that	is	complicit	in	acts of	torture.	Someone	who	rejects	this conclusion	on the	grounds	of integrity	must	therefore	argue	that	there	is something	particular	about	her	values that makes acts complicit in torture worse	for	her	than	for	other	similarly situated	people.	Further,	she	must	argue	that	complicity	in	torture	would violate	her	integrity	more	than	would abandoning a	patient in	need.	After all,	another	doctor	may	be	equally	appalled	by	torture	yet	believe	that	she ought	to	act	in	a	way	that	minimizes the damage torture causes, whether that	makes	her	complicit	or	not.44 Second,	even	in	a	case	in	which	we can	make	sense	of	someone	appealing to	her integrity in	spite	of	our	arguments, it	does	not follow	that	she is ethically permitted to refuse to be complicit. Even those philosophers who	defend	the	importance	of	integrity	acknowledge	that	there	can	come a	point	when	other	factors	outweigh the importance of maintaining integrity and that an agent therefore ought	to	act	contrary	to	her	personal values.45 Hence, integrity becomes just another of the considerations that	must	be factored into the	complex	moral	calculus	and	weighed	with the	disvalue	of	complicity,	the	consequences	of	different	courses	of	action, and	the	patient's	preferences. Moral integrity is an important concern,	and	one	that	should	not	be dismissed	out	of	hand.	But	the	appeal to integrity in the face of another's wrongdoing	is	neither	always	applicable	nor	decisive	where	it	is	applicable. Dealing with Medical Complicity in Torture Other	things	being	equal,	it	is	bet-ter	for	a	physician	not	to	be	complicit	in	torture.	But	other	things	are rarely	equal,	and	as	we	have	argued,	a physician	ought	sometimes	to	accept complicity	in	torture	for	other	moral reasons.	Even	in	such	cases,	however, she	should	do	what	she	can	to	minimize her complicity in wrongdoing. This	can	be	achieved	by	assessing	and minimizing	the	two	component	parts of complicity: shared intentions	and assistance. The	first important	way to	minimize complicity is to ensure that wrongful intentions are not shared with the wrongdoers. In the case of medical complicity in torture, this may be achieved primarily through the doctor taking as her intentions just those reasons that justify her complicit	actions.	If,	for	example,	the reason that she should provide immediate supportive care is that this is in the	medical interests	of an	unconscious	patient,	then	she	should	be resuscitating	him	only	because it	is	in May-June 2011 HASTINGS CENTER REPORT 45 his	interests.	Or,	if	the	reason	that	she should treat a condition that would otherwise preclude the patient from interrogation on medical grounds is that this is exactly what the patient requested, then she should be treating him because it is what he requested.	The	physician	and	torturers	may	then	share	some	of	the	same subsidiary	goals,	such	as	keeping	the patient/prisoner alive, but will have quite	different	ultimate	goals,	whose moral evaluations are diametrically opposed. The second feature of complicity concerns the assistance provided by the physician to the torturer. Consider the example of a doctor who is asked to provide a certificate of fitness for a prisoner.	The doctor is aware	that	her	certificate	will	be	used to	tailor	the	torture	to	the	prisoner's health	condition,	so	that	it	will	be	as "effective"	and	"safe"	as	possible.	She also	knows	that	refusing	to	write	the certificate would put the patient at undue	risk	because	(let's	say)	of	a	preexisting	heart	problem.	In	the	course of the doctor's routine examination in the prisoner's cell, with a guard waiting	outside,	she	asks	the	prisoner whether	he	wants	to	receive	medical care. When the prisoner expresses a strong preference to be kept alive despite	the	torture,	the	physician	accepts her complicity and writes the certificate	mentioning	the	heart	condition.	In	this	case,	however,	in	order to	minimize	complicity,	the	physician should not write a standard certificate,	which	would	cover	all	aspects	of the	patient's	health	and	might	therefore	unnecessarily	expose	weaknesses to the torturers. Instead, she should focus	her	report	on	the	risks	of	death the	patient	would	be	exposed	to,	and avoid	any	additional	information	that might abet the torture, such as the patient's	fear	of	death. A	physician	can	further	reduce	her complicity if, while complicit, she carries	out	acts	that	mitigate,	prevent, or help redress acts of torture. For example,	one	way	to	compensate	for complicity is to secretly collect data that can be used for reporting the occurrence	of	torture	and	to	provide them to investigative	bodies as soon as possible. Where physicians have been	coerced	into	assisting	with	torture,	they	have	often	been	among	the first sources of essential information for international tribunals pursuing justice.46 Medical associations also have a role to	play in	dealing	with	medical complicity. Medical participation in torture is blankly condemned by all associations,	all	professional	codes	of ethics, and	a	majority	of legal codes worldwide. Should these codes be changed, given the arguments in this paper, to reflect the complexities faced by physicians working in extreme conditions? Alternatively, should these codes be strongly enforced	in	every	case,	despite	the	ethical	reasons	some	doctors	may	have	to be complicit in torture? We believe that	both	of these	options	would	be mistaken. First, we do not think that these arguments provide sufficient reason to alter the clear, simple rules currently	promulgated	in	the	codes.	The value	of	these	rules	is	threefold.	First, they constitute a powerful condemnation	of	torture.	Second,	they	have an aspirational character: they look forward	to	a	world	in	which	there	is never a reason for a	medical professional to be associated with torture. And	third,	they	provide	a	defense	for doctors	who	should	not	be involved in	torture,	and	should	be	able	to	cite binding	rules that forbid	them	from being	involved.47 However, the enforcement	of the codes is a different matter. History suggests that proper enforcement of the	prohibition	on	medical	participation	in	torture	is	very	unlikely.	From the Nuremberg trial to the present, only	thirty-five	physicians	are	known to have been held accountable for involvement in torture-a trivial number	compared	to	the	number	of physicians	reported	as	being	involved, and even more trivial compared to the number of physicians who have been involved in torture but have not been reported at all.48 But even if	enforcement	were	possible,	and	so physicians who were involved with torture could expect to be excluded from the medical community, this would not fully solve the problem. Excluding from the medical community any physician who assisted with	torture,	no	matter	what	the	justification, would penalize physicians who	have	to	work	in	countries	where torture is widespread and would be unfair	to	doctors	willing	to	compromise	themselves	for	the	sake	of	their patients. These considerations suggest that a more nuanced, case-bycase	approach	to	enforcement	would be	much	preferable	and	have	a	greater prospect	of	being	effective. One	possible	option	would	be to create	an international self-reporting system-a sort of "ethical ombudsman" whom physicians could confidentially approach to report cases of coercion or special circumstances that prompted medical complicity in	torture.	Such	a	system	could	provide	the	necessary	support	for	physicians	who face complex choices and strengthen	their	witnessing	capacities for international tribunals. It would Excluding from the medical community any physician who assists with torture penalizes those who must work in countries where torture is widespread and is unfair to doctors willing to compromise themselves for their patients. A more nuanced, case-by-case approach would be much preferable. 46 HASTINGS CENTER REPORT May-June 2011 also constitute a body that could help differentiate cases that require and	deserve	support	from	the	plainly criminal cases of willing or careless participation	in	torture. This	is	just	one	suggestion;	the	key point	is	that	whatever	system	is	used, it	should	be	designed	to	take	into	account	the	ethical	complexities	of	the situations in	which	doctors can	find themselves when they work in contexts	where	torture	takes	place.	While it	may	be	unflagging	in	its	denunciation	of	torture,	it	should	provide	support to	doctors	who	want to	do the right	thing	in	difficult	circumstances. Physicians who assist in torture without regard for its victims may rightly be condemned. However, doctors sometimes find themselves presented with the grim choice of either abandoning a patient or being complicit in torture. Such doctors face	a	genuine	ethical	dilemma. Here, we have outlined the factors that should	be considered	when	deciding	how	to	respond	to	these	dilemmas: the expected consequences of the	doctor's	actions,	the	wishes	of	the patient,	and	the	extent	of	the	doctor's complicity with wrongdoing. Since complicity is	a	matter	of	degree	and other moral factors may have great weight, sometimes the right action involves medical complicity in torture. Consequently, the problem of medical involvement in torture will not	be	resolved	by	blanket	denunciations	of complicity. Instead, associations	of	medical	professionals	should take into account the circumstances we	have	described	and	provide	more supportive	and	efficacious	systems	of reporting for medical professionals who	face	such	dilemmas. Acknowledgments We gratefully acknowledge helpful comments from Marion Danis, Michael Garnett, Christine Grady, Alan Wertheimer, and an anonymous reviewer for the Hastings Center Report. The	opinions	expressed	are	the	view	of the	authors.	They	do	not	represent	any position	or	policy	of	the	U.S.	National Institutes	of	Health,	the	Public	Health Service, or the Department of Health and	Human	Services. References 1.	Amnesty	International,	"Doctors	and Torture," Amnesty International annual report (New	York: Amnesty International, 2002). 2.	Pentagon's	Joint	Task	Force	at	Gitmo, "Interrogation Log Detainee 063 in SECRET	ORCON-Classified	Army	Documents," 2002–2003, Guantanamo: U.S. Army,	p.	83. 3.	"On	another	occasion	***	said	he	had to intercede after **** expressed concern that	Al	Nasihiri's	arms	might	be	dislocated from his shoulders. *** explained that, at the time, the interrogators were attempting to	put	Al	Nasihiri in a standing stress position. Al Nasihiri was reportedly lifted off the floor by his arms while his arms were	bound	behind	his back	with a	belt." C.I.A.	Inspector	General,	"Special	Review; Counterterrorism	Detention	and	Interrogation Activities (September 2001–October 2003),"	Central	Intelligence	Agency,	document	number	2003-7123-IG,	p.	44. 4.	Ibid.,	77. 5. L.S. Rubenstein and S.N. Xenakis, "Roles of CIA Physicians in Enhanced Interrogation and Torture of Detainee," Journal of the American Medical Association 304	(2010):	569-70;	O.V.	Rasmussen	et	al., "The	Ethical and	Legal	Responsibilities	of the	Medical	Profession	in	Relation	to	Torture	and the Implications	of	Any	Form	of Participation	by	Doctors	in	Torture,"	Medicine and War 8,	no.	1	(1992):	44-47. 6. D. Luban, "Unthinking the	Ticking Bomb," in Global Basic Rights, ed. C.R. Beitz and R.E. Goodin (New York: Oxford University Press, 2009), 181-206; on extreme cases: M. Gross, "Doctors in the Decent	Society:	Torture,	Ill-Treatment	and Civic Duty," Bioethics, 18, no. 2 (2004): 181-203. 7. United Nations, Convention against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment (Geneva, Switzerland:	United	Nations,	1984). 8.	J.S.	Bybee,	"Interrogation	of	al	Qaeda Operative-Memorandum	for	John	Rizzo, Acting	General	Counsel	of	the	Central	Intelligence	Agency,"	U.S.	Department	of	Justice,	2002,	p.	18. 9. D. Allbrook, "Medical Participation in Flogging and Punitive Amputation in Pakistan," Medical Journal of Australia 1, no. 10 (1982): 411. Although interrogation and punishment have quite different functions,	both	can	involve	torture.	In	both cases, what is wrong about the act is the same-it	is	the	unjustified	infliction	of	severe	pain	or	suffering.	Moreover,	in	practice it	is	normally	difficult	to	separate	the	infliction	of	punishment,	intimidation,	coercion, and	the	extraction	of	information	from	one another: the same act may serve all these functions. 10. G. Maio, "History of Medical Involvement in Torture-Then and Now," Lancet 357	(2001):	1609-1611. 11. Geneva Conventions, Convention (IV)	Relative to the	Protection	of	Civilian Persons	in	Time	of	War,	1949. 12.	United	Nations,	Principles of Medical Ethics (1982): Resolution 37/194 (Geneva, Switzerland:	United	Nations,	1982). 13. World Medical Association, "Declaration of	Tokyo: Guidelines for Medical Doctors,"	World Medical Journal 22,	no.	6 (1975):	87-90;	World	Medical	Association, World Medical Association Declaration on Hunger Strikers, November 1991 (revised in 1992 and 2006), http://www.wma.net/ en/30publications/10policies/h31/index. html;	American	Medical	Association,	"Opposing Cooperation of Physicians and Health Professionals in Torture," Resolution	10	(amendment,	A-05),	June	18,	2005; American	College	of	Physicians,	"The	Role of	the	Physician	and	the	Medical	Profession in the Prevention of International	Torture and	in	the	Treatment	of	Its	Survivors," Annals of Internal Medicine	122,	no.	8	(1995): 607-613; American Psychiatrists Association and American Psychologists Association,	"Against	Torture: Joint	Resolution	of the American Psychiatric Association and the American Psychological Association," 1985 Position Statement, http://www.apa. org/news/press/statements/joint-resolution-against-torture.pdf; World Psychiatrists	Association,	"Madrid	Declaration	on Ethical	Standards for	Psychiatric	Practice," August 25, 1996 (revised in 1999, 2002, and 2005), http://www.wpanet.org/detail. php?section_id=5&content_id=48. 14. Amnesty International, "Report 2009: The State of the World's Human Rights,"	Amnesty International annual report,	2009. 15.	O.V.	Rasmussen,	"The	Involvement of	Medical	Doctors in	Torture:	The	Stateof-the-Art," Journal of Medical Ethics 17, no.	4	(1991):	26-28. 16.	United	Nations,	Convention	against Torture	and	Other	Cruel,	Inhuman	or	Degrading	Treatment	or	Punishment. 17. C. Lepora, "Meta-Analysis of the Literature	on	Medical	Participation	in	Torture,"	personal	communication	to	Michael Gross,	2009. 18.	R.M.	Hare,	"The	Ethics	of	Medical Involvement in Torture: Commentary," Journal of Medical Ethics 19,	no.	3	(1993): 138-41; M.L. Gross, Bioethics and Armed Conflict: Moral Dilemmas of Medicine and War (Cambridge,	Mass.:	MIT	Press,	2006), 211-44. 19. S.H. Miles, Medical Ethics and the Interrogation of Guantanamo (New York: Routledge,	2007),	5-11. May-June 2011 HASTINGS CENTER REPORT 47 20. M. Nowak, "What Practices Constitute Torture? US and UN Standards," Human Rights Quarterly 28,	no.	4 (2006): 809-841. 21. Gross, "Doctors in the Decent Society." 22.	F.	Allhoff,	"Physician	Involvement	in Hostile Interrogations," Cambridge Quarterly of Healthcare Ethics 15,	no.	4 (2006): 392-402. 23.	Our	use	of	"accessory" is related	to, but should not be conflated with, legal concepts	with the same	name.	For	a	comprehensive analysis of the legal notion of complicity,	see	L.	May,	"Complicity	and	the Rwandan	Genocide,"	Res Publica 16,	no.	2 (2010):	135-52. 24.	M.T.	Brown,	"Moral	Complicity in Induced Pluripotent Stem Cell Research," Kennedy Institute of Ethics Journal 19,	no.	1 (2009):	1-22. 25.	"You	would like to	place	Zubaydah in	a	cramped	confinement	box	with	an	insect.	You	have	informed	us	that	he	appears to have fear of insects. In particular, you would	like	to	tell	Zubaydah	that	you	intend to	place	a	stinging	insect	into	the	box	with him.	You	would,	however,	place	a	harmless insect	in	the	box";	Bybee,	"Interrogation	of al	Qaeda	Operative,"	18. 26. J.J.C. Smart, and	B.A.O.	Williams, Utilitarianism: For and Against (Cambridge, U.K.: Cambridge University Press, 1973), 87-100. 27.	C.	Kutz,	Complicity: Ethics and Law for a Collective Age (Cambridge, U.K.: Cambridge	University	Press,	2000),	74-81. 28.	T.	Keneally,	Schindler's Ark (London, U.K.:	Hodder	and	Stoughton,	1982). 29. C.A.A. Reis et al., "Physician Participation in Human Rights Abuses in Southern Iraq," Journal of the American Medical Association 291 (2004): 1480-86; T.A. Brennan and R. Kirschner, "Medical Ethics	and	Human	Rights	Violations:	The Iraqi	Occupation	of	Kuwait	and	Its	Aftermath,"	Annals of Internal Medicine 117,	no. 1	(1992):	78-82. 30. For instance, Norman Daniels argues	that,	in	the	years	when	HIV	was	still	a deadly	condition,	doctors	and	dentists	had a	duty to treat	HIV-positive	patients.	The "moderate risk" of contracting the disease they	undertook	was	not	different	from	similar risks they agreed to expose themselves to	when	they	become	doctors;	N.	Daniels, "Duty to	Treat	or	Right to	Refuse?"	Hastings Center Report 21,	no.	2	(1991):	36-46. 31.	S.H.	Miles,	"Torture:	The	Bioethics Perspective," in From Birth to Death and Bench to Clinic: The Hastings Center Bioethics Briefing Book for Journalists, Policymakers, and Campaigns,	ed.	M.	Crowley	(Garrison, N.Y.:	The	Hastings	Center,	2008). 32. G. Seelmann, "The Position of the Chilean Medical Association with Respect to Torture as an Instrument of Political Repression," Journal of Medical Ethics 17, suppl.	(1991):	33-34. 33. W.J. Kalk and Y. Veriava, "Hospital Management of Voluntary Total Fasting	among	Political	Prisoners,"	Lancet 337 (1991): 660-62;	T.L. Beauchamp and J.F. Childress, Principles of Biomedical Ethics, 6th ed. (New	York:	Oxford	University Press,	2009),	99-149. 34. As reported in personal correspondence	and	in	the	literature.	See	J.	PagaduanLopez,	"Medical	Professionals	and	Human Rights	in	the	Philippines,"	Journal of Medical Ethics 17,	suppl.	(1991):	42-50;	Brennan and	Kirschner,	Medical	Ethics	and	Human Rights Violations"; V. Iacopino, "Turkish Physicians	Coerced to	Conceal Systematic Torture,"	Lancet 348	(1996):	1500. 35. Pentagon's Joint	Task Force at Gitmo, "Interrogation Log Detainee 063 in SECRET ORCON – Classified Army Documents," Guantanamo: U.S. Army, 2002–2003,	p.	83. 36.	World	Medical	Association,	"World Medical Association Declaration on Hunger	Strikers";	B.	Arda,	"How	Should	Physicians	Approach	a	Hunger	Strike?"	Bulletin of Medical Ethics	181	(2002):	13-18. 37. F.R. Parker and C.J. Paine, "Informed	Consent	and	the	Refusal	of	Medical	Treatment	in	the	Correctional	Setting," Journal of Law, Medicine and Ethics 27,	no. 3	(1999):	240-51. 38. "Every human being of adult years and sound mind has a right to determine what shall be done with his own body; and	a surgeon	who	performs	an	operation without his patient's consent commits an assault,	for	which	he	is liable	in	damages"; Court of Appeals of New York, Mary E. Schloendorff, Appellant, v. The Society of the New York Hospital,	Respondent	1914;	Geneva	Conventions,	Convention (IV) Relative to the Protection of Civilian Persons in Time of War;	D.	Bertrand	and	T.	Harding,	"European	Guidelines	on	Prison	Health,"	Lancet 342	(1993):	253-54. 39.	"Principle	1:	Health	personnel,	particularly	physicians,	charged	with	the	medical care of prisoners and detainees have a duty to provide them with protection of their	physical	and	mental	health	and	treatment of disease of the same quality and standard	as	is	afforded	to	those	who	are	not imprisoned or detained"; United Nations, Principles of Medical Ethics (1982): Resolution 37/194.	See	also	C.	Lepora,	M.	Danis, and A. Wertheimer, "No Exceptionalism Needed	to	Treat	Terrorists,"	American Journal of Bioethics 9,	no.	10	(2009):	53-54. 40. S.H. Miles, "Doctors' Complicity with	Torture-Time	for	Sanctions,"	British Medical Journal 337	(2008):	a1088. 41. Rasmussen et al., "The Ethical and Legal Responsibilities of the Medical Profession	in	Relation	to	Torture	and	the	Implications	of	Any	Form	of	Participation	by Doctors	in	Torture." 42.	D.	Brock,	"Conscientious	Refusal	by Physicians	and	Pharmacists:	Who	Is	Obligated	to	Do	What,	and	Why?"	Theoretical Medicine and Bioethics 29, no. 3. (2008): 187-200;	M.	Wicclair,	"Conscientious	Objection in Medicine," Bioethics 14, no. 3 (2000):	205-227. 43.	Smart	and	Williams,	Utilitarianism. 44.	Compare	Thomas	Nagel,	who	writes: "First, it is	a	confusion	to	suggest	that	the need to	preserve	one's	moral purity	might be the source of an obligation. For if by committing murder one sacrifices one's moral	purity	or integrity, that	can	only	be because there is already something wrong with murder. The general reason against committing murder cannot therefore be merely that it	makes	one	an immoral	person. Secondly, the notion that one might sacrifice	one's	moral	integrity	justifiably,	in the	service	of	a	sufficiently	worthy	end,	is	an incoherent	notion.	For	if	one	were	justified in	making	such	a	sacrifice	(or	even	morally required	to	make	it),	then	one	would	not	be sacrificing	one's	moral	integrity	by	adopting that	course:	one	would	be	preserving	it";	T. Nagel,	"War	and	Massacre,"	Philosophy and Public Affairs 1, no. 2 (1972): 123-44, at 132-33. 45.	Smart and	Williams,	Utilitarianism, 117;	Wicclair,	"Conscientious	Objection	in Medicine,"	218. 46. Brennan and Kirschner, "Medical Ethics	and	Human	Rights	Violations:	The Iraqi Occupation of Kuwait and its Aftermath"; Seelmann, "The Position of the Chilean Medical Association with Respect to Torture as an Instrument of Political Repression." We should point out that it is	not	a	physician's	primary	duty	to	collect evidence	against torture,	and	no	physician would	be	"excused"	for	participation	in	torture	on	the	grounds	that	she	did	it	only	to collect	evidence.	Reporting	could	be	a	compensatory	practice	only	for	physicians	who have been coerced into assisting torture, or who were justifiably complicit on the grounds	we	have	suggested. 47.	P.B.	Polatin,	J.	Modvig,	and	T.	Rytter, "Helping	to	Stop	Doctors	Becoming	Complicit in Torture," British Medical Journal 340	(2010):	c973. 48.	S.	Miles	and	A.	Freedman,	"Medical Ethics and	Torture: Revising the Declaration	of	Tokyo,"	Lancet 373	(2009):	344-48.