Doctors and torture: the difficulty of being ethical in unethical places

By Jacqueline Hansen, Major Campaigns and Women’s Rights Campaigner, in conversation with Dr. Donald Payne, Health Network Coordinator

Toronto-based psychiatrist Dr. Donald Payne has treated survivors of torture for almost four decades, and has been Amnesty International Canada’s health network coordinator since 1982.  He helped to found the Canadian Centre for Victims of Torture (CCVT) and served as the Canadian representative, one of two North American representatives, on the International Rehabilitation Council for Torture Victims (IRCT).  Dr. Payne’s work has focused both on treating those who have experienced torture and on advocating for countries to stop torturing. We recently spoke with Dr. Payne about the role of medical professionals in both preventing and carrying out torture, and how this relates to the case of jailed Saudi blogger Raif Badawi, who has been sentenced to 10 years in prison, 1000 lashes (flogging is a form of torture), and a hefty fine, in addition to a decade-long post-prison sentence ban on working in the media or traveling outside Saudi Arabia.

Dr. Payne, can you tell us a bit about your experience working with survivors of torture?

For more than 35 years I have worked with individuals who have experienced torture. In that time, I have seen more than 1,500 people from over 90 countries.  Initially most refugees came from Chile, with later spread to other countries as Canada took in more refugees.   Over the years, Iran has produced a steady flow of torture survivors. Whenever there is an uprising that is repressed somewhere in the

 world, we usually see torture survivors from that country arriving in Canada.  I have not seen an individual who has been flogged.  Flogging is not one of the usual methods of torture in countries that produce refugees arriving in Canada. 

How do torture survivors find their way to you?

In most cases, the lawyers of refugee claimants seek the assistance of the Canadian Centre for Victims of Torture (CCVT) for medical or psychological assessments to support the refugee’s claim for refugee status. Other individuals are referred by refugee settlement workers, other agencies or by personal contact. They are usually referred on to me through CCVT.

We expect medical professionals to heal us. How have you seen medical professionals be complicit in torture?

There are health professionals who chose to be actively and purposefully involved in torture, such as the psychologists involved in the CIA torture at Guantanamo and doctors who actively work for repressive regimes. There are others who would prefer to act ethically but are caught up in the system, where they are employees of a state that tortures. They have a dual allegiance. They are responsible to their state employer, but they are also responsible for upholding their professional ethics, which dictate that they should not participate in any way in torture. In such circumstances, ethical standards indicate that the professional ethical standards supersede loyalty to the employer.

However, what works well in theory, can run into great difficulty in practice. As Jim Welsh, Amnesty International’s former Health and Human Rights Coordinator, recently said, “it is difficult to act ethically in unethical places.” In many countries there are few private doctors, and the only choice is to work for the state.  Standing up to a state that tortures can lead to immediate self-destruction, with the loss of one’s job, and possibly one’s career, if not worse.  As one such physician told me, “I have a responsibility to act ethically, but I also have a responsibility to support my family.” We cannot ethically ask doctors to stand up to torturers and risk losing their jobs and possibly more unless there is a network of support available to them to do this, such as through the active involvement of professional associations and others.

Are there medical professionals who take a stand against torture?

Usually we would not hear about an individual doctor who stood up to torturers. If a doctor in Saudi Arabia said he wouldn’t authorize flogging for Raif Badawi, would we hear about it? Such a doctor would presumably immediately lose his job and could be accused of supporting opponents of the government, with almost no way of letting the outside world know what had happened to him.  Amnesty International usually calls for independent medical examinations in order to ensure that the doctors performing the examinations do not have dual loyalty and are much freer to provide honest and reliable reports. It is hopeful that a group of independent doctors performing an assessment in a hospital would be able to be helpful to Raif Badawi in providing reliable independent assessments in a situation of group support.

The British Medical Association has taken the lead in dealing with physician’s involvement in torture following the torture of one of its members, Dr. Sheila Cassidy, in Chile in 1975 for treating an opponent of Pinochet. In 1992, it published Medicine Betrayed: The Participation of Doctors in Human Rights Abuses outlining various ways that physicians and several medical associations were involved in opposing governments’ human rights abuses. In January 2015, it held a conference along with Amnesty International and the British torture treatment centre, Freedom from Torture, dealing with this issue, which was highlighted again by the case of Raif Badawi.

Medical professionals need a strong active supportive network to be able to stand up and act ethically. The 1992 British Medical Association report strongly opposed physician involvement in torture but also recognized that “the individual physician surrounded by men with guns is in a very weak position to assert moral beliefs let alone putting them into practice” and did not recommend that they become “heroes.”

As a psychiatrist, what is your reaction to the flogging sentence of Raif Badawi?

No one should ever be subjected to flogging as it is a form of torture. Flogging causes serious physical damage to the skin, with high risk of infection, and may affect underlying muscles. The psychological impacts of flogging may cause the most stress in the long-term. Waiting every week in anticipation of the lashes causes extreme psychological distress as well as physiological changes, such as high blood pressure.  People subjected to torture can be strong and resilient at first, but the ongoing torture and related dehumanization can wear them down over time. Once the torture is over, torture survivors may continue to struggle with Post-Traumatic Stress Disorder with long-term symptoms including nightmares, anxiety, depression, and increased hyper arousal.

I hope that Raif Badawi is not in solidarity confinement. It’s very difficult when prisoners are left with only their own thoughts—that greatly encourages losing hope and becoming demoralized. When they are with other prisoners, the prisoners often comfort and support each other, in particular around the medical results of torture.

How can people get involved in the sort of work that you do?

LEARN: Stop Torture campaign;  “Doctors Against Torture, ”British Medical Association conference, January 2015

ACT: Sign e-action to free Raif Badawi

GET INVOLVED: Amnesty’s Health Network