The US government released a series of documents about the CIA torture program on June 14 and 15, in response to Freedom of Information Act lawsuits by the ACLU and Vice News. The documents contain important revelations about one of the most crucial, but least understood, parts of the CIA’s rendition, detention, and interrogation program: the role of the CIA’s Office of Medical Services (OMS). They also include detainees’ firsthand descriptions of the involvement of health professionals in their torture, and shed light on the Defense Department’s failure to provide adequate medical or mental health care to survivors of the CIA’s “black site program.” When taken together with what was already known about OMS’s actions from the executive summary of the Senate Intelligence Committee’s torture report, we now have clear evidence of serious breaches of medical ethics by OMS physician(s).

OMS’s Role in “Enhanced Interrogations”

Unlike contract psychologists James Mitchell and Bruce Jessen, OMS personnel did not design the torture program, nor did they personally waterboard detainees. But OMS personnel — including psychologists, physician’s assistants, and physicians — were nonetheless involved in the program from Abu Zubaydah’s “enhanced interrogation” sessions in 2002 onwards.

In January 2003, CIA Director George Tenet issued guidance formally requiring medical personnel to be present whenever “enhanced interrogation” techniques were used. Beginning in March 2003, the head of the Office of Medical Services distributed several sets of written guidelines to OMS personnel who were stationed at black sites. The Justice Department’s Office of Legal Counsel relied heavily on these documents, and further assurances about careful medical monitoring of interrogation, in re-authorizing the torture program in 2005 and 2007 (see here, here, and here).

OMS’s monitoring of torture sessions was a clear violation of medical ethics. The World Medical Association’s Declaration of Tokyo, adopted in 1975, states (among other things) that doctors:

  • “[S]hall not countenance, condone or participate in the practice of torture or other forms of cruel, inhuman or degrading procedures. whatever the offense of which the victim of such procedures is suspected, accused or guilty ….”
  • “[S]hall 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.”
  • “[S]hall not be present during any procedure during torture or other forms of cruel, inhuman or degrading treatment is used or threatened.”

The torture report’s executive summary provided evidence that OMS personnel not only monitored torture sessions, but carried out “rectal rehydration” and “rectal feeding” of prisoners, which independent medical experts have described as “sexual assault masquerading as medical treatment.” The newly released documents demonstrate that the leadership of the Office of Medical Services condoned these practices, though there was a minimal attempt to discourage the worst abuses.

New Details on OMS’s Monitoring of Abusive Interrogations

The recent CIA FOIA releases include two versions of the guidelines that the head of OMS distributed to personnel assigned to black sites. One is marked “Draft” and dated September 4, 2003 (starting on p. 150); the other is dated December 2004. While the documents were included in previous FOIA releases, they now have many fewer redactions, and the new details are chilling.

Both sets of OMS guidelines state that medical treatment for a detainee “should not undermine the anxiety and dislocation that the various interrogation techniques are designed to foster.” The guidelines instruct clinicians on how many hours or days detainees can withstand being shackled in stress positions — including prisoners with broken or missing limbs — and how to treat sores or swelling caused by shackling to allow interrogation to continue. If swelling reaches the knees or detainees’ skin becomes infected, OMS encourages medical officers to shackle the detainee in a different position and begin antibiotics, so that “sleep deprivation can be continued.”

The guidelines state that a series “of relatively rapid waterboard applications is medically acceptable in all healthy subjects” absent signs of breathing problems, and “[s]everal such sessions per 24 hours have been employed without apparent medical complication.” They do warn that after three to five days, “cumulative effects become a potential concern” and “continued intense waterboard applications may not be medically appropriate.”

OMS suggests sleep deprivation and stress positions as “a medically less risky option” than waterboarding, which can be used in combination with “moderate use of the waterboard” in order to extend the time waterboarding can be safely used. The guidelines describe sleep deprivation as “among the most effective techniques” and “the only technique with a demonstrably cumulative effect—the longer the deprivation (to a point) the more effective the impact.” It states that “perceptual distortion effects are not uncommon after 96 hours,” but distinguishes these from “frank psychosis,” which is “very rare.”

The documents warn that confining detainees in coffin-sized or smaller boxes has “not proved particularly effective, as they may become a safehaven offering a respite for interrogation,” but states that the larger boxes can be used for up to 18 hours a day, and the smaller box for up to two hours. They also provide guidance on how long “water dousing” and nudity can be used at various temperatures without risk of hypothermia. A chart in the 2004 guidelines summarizes the medical limits on techniques such as diapering (“evidence of loss of skin integrity”), hooding (none, other than “careful handling when moving subject”), “walling” (“[c]orrect technique; no preexisting injury likely to be aggravated”); and isolation (none).

Direct Abuse by OMS Personnel

The torture report’s executive summary documented at least five detainees being subjected to “rectal rehydration” or “rectal feeding” without any medical basis: Khalid Sheikh Mohammed (March 2003), Abd al Rahim al-Nashiri (May 2004), Majid Khan (September 2004), and Marwan Jabbour and Abu Zubaydah (on unspecified dates). Three others were threatened with the procedure: Ramzi Bin al-Shibh, Khallad bin Attash, and Adnan al-Libi. At least two detainees had rectal exams conducted with “excessive force” in Afghanistan in 2003, including Mustafa al-Hawsawi, who was later diagnosed with an anal fissure and rectal prolapse.

According to the Senate report, Khalid Sheikh Mohammed’s “rectal rehydration” occurred at detention site COBALT in early March 2003, shortly after his capture. The Chief of Interrogations ordered the procedure be performed “without a determination of medical need,” and later described it as demonstrating “total control over the detainee.” An OMS official described the procedure “as helping to ‘clear a person’s head’ and effective in getting KSM to talk.”

The September 4, 2003 OMS guidelines do not list “rectal rehydration” as an interrogation technique, but they do state that:

Brief periods during which food is withheld (24-48 hours) as an adjunct to interrogation are acceptable. Individuals refusing adequate liquids during this stage should have fluids administered at the earliest signs of dehydration. For reasons of staff safety, the rectal tube is an acceptable method of delivery.

No explanation is given for how, precisely, rectal hydration ensures “staff safety.”

The same guidelines discuss hunger strikes only briefly. The document states that federal prisoners whose weight drops far enough “have force feedings through a naso-gastric tube,” but “to date this has not been an issue” in the CIA program.

In 2004, however, several detainees took part in hunger strikes, and the CIA responded with a particularly brutal and ineffective form of force feeding. According to the Senate report, officers “rectally fed” al-Nashiri with Ensure in response to a “short-lived hunger strike” in May 2004. Khan began a long series of hunger strikes and suicide attempts in 2004. In September 2004, Khan was initially given IV fluids and fed with a nasogastric tube, and CIA records show that he cooperated with this treatment. After three weeks, though, he was subjected to involuntary rectal hydration and rectal force-feeding with Ensure and pureed food.

Khan described this treatment in a recently released transcript from his Combatant Status Review Tribunal (CSRT) in Guantánamo. During the hearing, which occurred on April 15, 2007, Khan stated that in 2004,

I decided to go on hunger strike for five weeks. During the whole time of hunger strike, the same doctor who torture me [redacted] used all kind of method to torture me in name of health reason, or to make me eat my own or break my hunger strike. … He would put tubes in my rectum and put lot of food in it, so I would use toilet bucket right away.

Khan said this occurred during the last 10 days of September 2004. At around the same time, he said, the doctor

took my Quran and he handcuffed my one hand with ring which was built into the wall, so I could not stand straight. I could not roll over while lying down. I was like this for two straight weeks until I broke my strike.

Although Khan and other detainees describe the OMS personnel who took part in their sexual abuse as “doctors,” it is not clear if they were actually physicians, as opposed to physician’s assistants, nurses, or other medical personnel. But even when they were not present at black sites, medical doctors were clearly involved in supervising physician’s assistants and drafting and reviewing the OMS guidelines.

The December 2004 OMS guidelines, in addition to repeating the previous statement that detainees undergoing interrogation can be rehydrated rectally “[f]or reasons of staff safety,” contain an extensive discussion of hunger strikes, force feeding, and hydration. Incredibly, the document states that rehydration can be carried out either intravenously or with a rectal tube, but “because it is less invasive as a medical procedure, the rectal tube is considered by OMS the first line intervention.”

These guidelines do at least discourage rectal feeding (as opposed to hydration), though not particularly emphatically. The guidelines state, “[n]ote that the rectal tube is not an efficient way to deliver nutrients other than fluids, salts and glucose, and thus is not recommended for feeding.” Despite this admonition, Khan alleged during his CSRT that a CIA “doctor” again subjected him to violent rectal feeding on December 31, 2004.

The CIA’s 2013 response to the Senate study, like the OMS guidelines, does not attempt to defend rectal feeding, but it does defend rectal hydration as a “well-acknowledged medical technique to address pressing health issues” (p. 54). As was documented (e.g., here and here) after the Senate report’s release, this is false. Rectal hydration was once a genuine medical technique, used on soldiers during World War I, but according to emergency physicians, “[f]or all practical purposes it’s never used” in the United States because of the widespread availability of sterile IV therapy. Doctors described its use by OMS as “barbaric” and a form of “torture” and “sexual abuse”. OMS’s claim that rectal hydration is a “first line treatment” that is “less invasive” than IVs, which are routinely given to thousands of hospital inpatients every day, is absurd — and a sign that OMS leadership condoned medical officers’ abuse of prisoners.

Remember, unlike Mitchell and Jessen, the CIA physicians and medical officers who participated in torture have not faced civil suits, attempts at professional sanctions, or even public disapproval. Their identities remain secret, as do most of the details of OMS’s participation in the torture program, even with the recent FOIA disclosures. Of the recently released documents, the one that likely provides the most information about OMS’s complicity, an 89-page “Summary and Reflections of Chief of Medical Services on OMS Participation in the RDI Program,” was entirely redacted except for one paragraph. Physicians for Human Rights denounced this concealment, but most of the medical community was silent.

Lack of Torture Treatment or Rehabilitation at Guantánamo

Contrary to the CIA’s representations to the Justice Department, doctors’ and psychologists’ involvement in the torture program did not, in fact, protect detainees from severe pain or prolonged mental harm. For many, the harm continues today, and it has been compounded by inadequate medical treatment at Guantánamo. According to both detainees’ lawyers and independent doctors who have examined Guantánamo prisoners, medical personnel at the detention facility appear to consistently not ask former CIA detainees about their torture at black sites, even where such information is medically relevant. As described by Dr. Sondra Crosby in a court declaration filed in the case of al-Nashiri:

medical professionals, including mental health care providers, have apparently been directly or indirectly instructed not to inquire into the causes of Mr. Al-Nashiri’s mental distress, and as a consequence, he remains misdiagnosed and untreated. Any discussion of his experience of torture, which is the primary cause of his most chronic physical and mental ailments, appears to be off limits.

In al-Nashiri’s case, shortly before a hearing on the adequacy of his care, his mental health provider changed his diagnosis from PTSD to “Narcissistic Personality Disorder,” which Dr. Crosby described as both “professionally irresponsible and … representative of the quality of mental health care that Mr. Al Nashiri receives.” Another former CIA detainee, Ramzi Bin al-Shibh, recently testified that soon after he arrived in Guantánamo, a psychiatrist who had never taken a history of his treatment at the black sites responded to his complaints about “noises and vibrations” in his cell with a series of involuntary injections of a powerful antipsychotic. Al-Shibh said the medication “ma[d]e me completely dead in my bed. I cannot do anything for months.”

Detainees have also received inadequate treatment for the harmful physical effects of CIA torture, at least in part because of the failure to inquire into what happened in the black sites. These include serious rectal injuries resulting from sexual assault, traumatic brain injury, seizures, severe gastrointestinal problems, and chronic pain.

One of the FOIA documents recently released by the CIA may provide some insight into why the Guantánamo clinicians’ failed to ask more questions about the black sites. The document is a Memorandum of Agreement signed by Secretary of Defense Donald Rumsfeld and CIA Director Michael Hayden on August 31 and September 1, 2006 — less than a week before 14 high value CIA detainees were transferred to Guantánamo. One section discusses jurisdiction over investigations into detainees’ allegations of mistreatment. It states that “[i]nvestigation of, or inquiries into, allegations of detainee mistreatment that pertain to activities occurring after the arrival of a detainee at GTMO shall be the responsibility of DoD.” But the rest of that section, which would logically discuss how to handle detainees’ allegations of mistreatment they suffered in CIA custody, is entirely redacted on grounds that is properly classified.

The Defense Department’s Public Affairs office declined to comment about whether the Memorandum of Agreement remained in effect. Even if it has been formally superseded or withdrawn, an agreement by DOD not to investigate or inquire into detainees’ torture by the CIA could have an ongoing chilling effect on Guantánamo medical personnel.

Lawyers for military commission defendants said they had not received an unredacted copy of the document, and were unaware of its existence before the FOIA release. Hopefully either detainees’ counsel or the ACLU attorneys who brought the FOIA suit will succeed in challenging the redactions. But the CIA’s and Defense Department’s ongoing medical ethics problems are unlikely to be solved without sustained attention and pressure from the US medical community.