Human Rights in the Military: The Role of Psychology FAILING ETHICS 101: PSYCHOLOGISTS, THE U.S. MILITARY ESTABLISHMENT, AND HUMAN RIGHTS J. Wesley Boyd, Alice LoCicero, Monica Malowney, Rajendra Aldis, and Robert P. Marlin
The American Psychological Association (APA) has long maintained a close, even symbiotic, relationship with the Department of Defense (DOD) and the Veterans Administration (VA). Herein we highlight these close ties and describe psychologists’ participation in interrogations by U.S. military and intelligence entities. We then review the APA’s statements about the permissibility of psychologist participation in the interrogation and torture of suspected terrorists. These issues are significant in and of themselves and because the VA and DOD have been described as “growth careers” for psychologists of the future (1). Additionally, the Health Care Personnel Delivery System allows the drafting of civilian clinical psychologists into military service even in the absence of a general draft. In light of psychologists’ extensive involvement in the interrogation process of suspected terrorists, and the possibility that psychologists without prior military experience may be drafted, we wondered how much psychologists have been taught about their ethical duties should they find themselves in military settings. The results of our pilot study of U.S. psychology graduate students, which assessed their knowledge of military ethics, raise concerns that psychologists receive inadequate formal training in these matters. This may leave psychologists vulnerable to misinformation about proper ethical conduct in their future work.
Psychology in the United States has a longstanding, close relationship with the military. Psychologists contributed significantly to the U.S. military effort in both World Wars, including evaluating new recruits, assisting in the treatment of International Journal of Health Services, Volume 44, Number 3, Pages 615–625, 2014 © 2014, Baywood Publishing Co., Inc. doi: http://dx.doi.org/10.2190/HS.44.3.j http://baywood.com
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soldiers with “shell shock,” and offering advice about the enemy in order to make interrogations more effective (2). After World War II, the relationship between psychology and the military took new and various forms. The Army and the Navy, for example, utilized psychological input and consultation in addressing various Cold War issues and tactics, including mind control and sensory deprivation. U.S. Department of Defense (DOD) funding went to leaders within the American Psychological Association (APA) and actually drove the research agenda of the APA in particular and the discipline in general (2). Psychology became so integral to the DOD that by 1952, 78 percent of all federal funding to psychology came through the DOD. By 1960, the DOD was spending almost its entire US$15 million social science research budget on psychology, equivalent to roughly US$120 million in today’s dollars (2). The APA has experienced dramatic growth over the last 70 years. Between 1945 and 1970, the APA’s membership grew from just over 4,000 to more than 30,000. Today the APA has approximately 134,000 members (3). Many credit the prominence that psychology achieved through its work in the military as pivotal to the growth of the APA: “The burgeoning of psychology from a small academic discipline to the largest of the social sciences with 70 percent practitioners would have been unimaginable without the resources, support, and respect of the DOD and CIA” (4). This close relationship continues to this day, and research in psychology in academic settings still depends largely on military funding. The behavioral science research budget of the DOD is approximately US$400 million annually, with the majority devoted to psychological research, dwarfing other funders of psychological research (4). At the outset of the U.S. War on Terror in general and Operation Iraqi Freedom in particular, the U.S. government condoned interrogation tactics that were historically considered to constitute torture. It has been reported that psychologists conceived of the entire interrogation system employed by U.S. interrogators and, in some instances, informed interrogators about prisoners’ phobias and other psychological vulnerabilities that could be exploited during interrogation (5–8). For instance, an Army psychologist reportedly wrote to interrogators at Guantanamo about an inmate, “He appears to be rather frightened, and it looks as if he could break easily if he were isolated from his support network and made to rely solely on the interrogator.…Make him as uncomfortable as possible. Work him as hard as possible” (9). GENEVA CONVENTIONS AND OTHER INTERNATIONAL STANDARDS The Geneva Conventions are clear that prisoners of war are only obligated to divulge their name, service type, rank, and nothing more. The dictates to their
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captors are clear: “No physical or mental torture, nor any other form of coercion, may be inflicted on prisoners of war to secure from them information of any kind whatever. Prisoners of war who refuse to answer may not be threatened, insulted, or exposed to unpleasant or disadvantageous treatment of any kind” (10). Although the Geneva Conventions ban threatening, coercing, humiliating, degrading, injuring, or murdering prisoners of war for any reason, psychologists who have participated in interrogations of prisoners might not have been aware that they were engaged in conduct that violates international agreements. During President George W. Bush’s two terms in office, the U.S. government argued that prisoners arrested in the war on terror were “detainees” or “enemy combatants” rather than “prisoners of war” so the Geneva Conventions did not apply to their treatment, a position with which many ethical and legal analysts disagreed (11, 12). Psychologists without prior knowledge of international codes such as the Geneva Conventions and the Nuremberg Conventions, unprepared to disobey orders that violated these agreements, were likely to be unquestioning and compliant when told to assist the interrogators. Given that violating the Geneva Conventions can carry with it a death sentence, the stakes are high (13). AMERICAN PSYCHOLOGICAL ASSOCIATION STANCE ON PSYCHOLOGIST PARTICIPATION IN INTERROGATION In concert with the Bush administration’s efforts to bypass the mandates of the Geneva Conventions, the APA adopted a position that supported military psychologists who might decide to violate the organization’s own code of ethics if ordered to take an unethical action. The APA Ethics Code Principle 1.02 in effect from 2002 and 2010 and the 2005 Report of the Presidential Task Force on Psychological Ethics and National Security (PENS) allow for psychologists to participate in interrogations, including those that meet the definition of torture under international standards: “Psychologists may serve in various national securityrelated roles, such as a consultant to an interrogation, in a manner that is consistent with the Ethics Code, and when doing so psychologists are mindful of factors unique to these roles and contexts that require special ethical consideration” (14). It states further, “Psychologists do not engage in behaviors that violate the laws of the United States, although psychologists may refuse for ethical reasons to follow laws or orders that are unjust or that violate basic principles of human rights.” If there is a conflict between ethics and the law, the PENS report allows for psychologists to violate prevailing ethical norms and “adhere to the requirements of the law” (14). In so doing, the PENS report attempts to justify and codify what is generally called “the Nuremberg defense,” the stance taken by the Nazi doctors at Nuremberg who declared that they were merely following orders, a position repeatedly rejected by international courts and ethicists (15).
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The PENS report angered a number of psychologists, who assert that psychologists should never participate in interrogations and torture, a stance that the American Medical Association and the American Psychiatric Association have adopted for physicians and psychiatrists. As a result, in 2008 the APA adopted a referendum (approved by 59% of the 14,949 voting members) that concluded “psychologists may not work in settings where persons are held outside of, or in violation of, either International Law (e.g., the UN Convention Against Torture and the Geneva Conventions) or the U.S. Constitution (where appropriate), unless they are working directly for the persons being detained or for an independent third party working to protect human rights” (17). This policy effectively prohibits psychologists from working with the U.S. government in settings such as Guantanamo Bay. Despite the adoption of this 2008 referendum, to date the APA has not refuted, rescinded, or otherwise withdrawn support for the PENS report. Thus, the APA currently holds conflicting positions on the ethics of psychologist participation in interrogations and torture. This issue remains vitally important because the historical ties between psychology and the military remain strong. For example, 7 percent of APA members are employed directly by, or are working directly with, the DOD, and 5 percent of licensed psychologists in the United States are employed by the Veterans Administration (VA) (18, 19). The VA is also the largest provider of internships in clinical psychology in the United States, with 106 locations offering approximately 480 internship positions, 16 percent of the 3,071 internships available nationwide in 2011–2012 (20, 21). In addition, the APA has cited the DOD and the VA as “growth areas” where more psychologists will be needed, especially given the large number of active service personnel who suffer psychological injury and will require further care in the VA system long after they leave active service (1). HEALTH CARE PERSONNEL DELIVERY SYSTEM The APA position on psychologists’ role in interrogation is important not only because of the large number of psychologists currently working with and in the military, but also because of the existence of the Health Care Personnel Delivery System (HCPDS) (22). The HCPDS is a plan for drafting health care personnel into military service in a time of crisis. It was authorized by Congress in 1987 and remains in place. Congress and the president can activate this process and begin drafting civilian health care personnel, including psychologists, in a matter of weeks. The HCPDS allows for few exemptions and assumes a priori that professionals practicing in the civilian sector are physically fit for military service. Thus, were the government to implement it, the HCPDS would rapidly place numerous private psychologists into military service. Based on previous studies of medical students, we hypothesized that most psychology students would not know about the existence of the HCPDS, and
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would be largely unfamiliar with the mandates of international ethical standards and agreed-upon conventions (23). Inadequate knowledge and instruction on ethical issues are of particular concern given the APA’s lack of clear ethical guidance for military psychologists. SURVEY OF GRADUATE STUDENTS To explore psychology students’ knowledge of military psychologists’ ethical responsibilities, we developed an Internet survey and, with Cambridge Health Alliance Institutional Review Board approval, distributed it to graduate students in clinical psychology programs in several U.S. states. Utilizing contacts at graduate schools, we distributed the survey to students in 20 psychology graduate programs and received a total of 185 responses. Since we are unable to ascertain how many students received the e-mail invitation to complete the survey, we cannot calculate an exact response rate; however, we believe about 20–40 percent of those who received the survey completed it. Thus, we report our findings as preliminary and suggest that they warrant more rigorous study. Of our respondents, 81 percent were female, 82 percent were members of the APA, and 6 percent had present, past, or future obligations for military service (see Table 1). The vast majority of respondents, 73.6 percent, had received less than one hour of training in military ethics while in graduate school; 23 percent had received between one and five hours of such training; and only 3.4 percent had received more than five hours. Many of the psychology graduate students in our survey did not know about some of the major connections between the profession of psychology and the U.S. government (see Table 2). For example, although 57.5 percent were aware that the VA is the single largest provider of internships for psychologists, only 13.7 percent were aware that 7 percent of APA members work with or for the DOD. Only 5.1 percent were aware of the HCPDS. If drafted into military service, 14.4 percent of our respondents said they would volunteer for service. Most would not volunteer: 43.1 percent would await draft notification, 27.0 percent would use all legal means to avoid service, 11.5 percent would consider emigration, and 4.0 percent would refuse military induction as an act of civil disobedience. While almost three quarters of respondents said that they were either “very familiar” or “somewhat familiar” with the Geneva Conventions, only 36.7 percent correctly answered that the Geneva Conventions apply regardless of whether or not one’s country has formally declared war. When asked which wounded individuals should be treated first, 57.2 percent of our sample answered correctly that physicians should “treat the sickest first, regardless of nationality.” Just over one quarter (26.5%) incorrectly answered that they should “treat their own soldiers according to level of severity and then attend to the wounded enemy.”
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Characteristics Gender Male Female Present, past, or future obligation for military service Member of the APA Hours of training in military ethics in graduate school Less than 1 1–5 Greater than 5 Candidate supported in the last U.S. president election McCain Obama Other candidate Did not vote
Percent
18.9% 81.1% 6.0% 82.1% 73.6% 23.0% 3.4% 7.4% 75.4% 1.7% 9.7%
We asked about acceptable interrogation practices according to the Geneva Conventions if a prisoner is refusing to answer questions about a recent skirmish in which U.S. soldiers died. Almost half (49.7%) of respondents did not know that the Geneva Conventions stipulate that it is never acceptable to deprive prisoners of war of food or water, expose them to physical stresses such as heat, cold, and uncomfortable positions, or threaten them with physical violence even if these threats are not carried out. We asked under what circumstances an officer is ethically required to disobey a direct order from a superior and offered the following options: “(a) when ordered to threaten a prisoner with injection of a psychoactive drug that will not actually be administered; (b) when ordered to inject a harmless bolus of saline into a prisoner who fears he is receiving a lethal injection; (c) when ordered to inject a lethal drug into a prisoner; (d) all of the above; (e) none of the above.” Only 52.1 percent correctly answered “all of the above.” Many respondents were not fully informed about the APA’s stance on psychologists’ participation in interrogation as outlined in the 2005 PENS report (whose implications only 24.8% correctly understood), as outlined by the 2008 referendum (55.2% answered correctly) or as outlined in a 2009 APA official statement (66.5% answered correctly).
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Table 2. Psychology graduate students’ knowledge regarding the Geneva Conventions and the military draft and their likely responses to a medical draft Measurement item
Percent
Aware that the Veterans’ Administration is the single biggest sponsor of internships for psychologists?
57.5%
Aware that 7 percent of APA members work with or for the U.S. Department of Defense?
13.7%
Aware of the Health Care Personnel Delivery System?
5.1%
Aware that psychologists up to age 44 are draft-eligible?
5.1%
Aware that psychologists in the civilian sector would be presumed fit for military service without exemption?
4.4%
Likely response to a medical draft: Volunteer for service Await draft notification Use all legal means to avoid service Consider emigration Refuse military induction as an act of civil disobedience
14.4% 43.1% 27.0% 11.5% 4.0%
Self-reported famliarity with the Geneva Conventions? Very familiar Somewhat familiar Not at all familiar
4.6% 70.1% 24.7%
Correctly identified physicians’ obligations under Geneva Conventions: Situations in which Geneva Conventions apply Priorities for treatment of wounded individuals Acceptable interrogation practices Situations in which orders must be disobeyed
36.7% 57.2% 49.7% 52.1%
Correctly identified APA’s stance on psychologists’ participation in interrogation: As outlined in the 2005 PENS report As outlined by a 2008 referendum As outlined in 2009 official statement
24.8% 55.2% 66.5%
The PENS Task Force included members with strong ties to the military: six out of nine were either active or former U.S. military or intelligence personnel and the report was adopted by the APA under unusually hasty, secretive procedures (16).
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Our results suggest that graduate students in psychology receive little instruction in military medical ethics and, consequently, know little about the ethical requirements for professional behavior of psychologists who serve in the U.S. military. Given that students from 20 institutions consistently reported little or no teaching about these matters, we suggest that programs review the content of their ethics courses and significantly bolster teaching about ethics in general and international standards and guidelines in particular. Further scientific study is warranted to fully assess the teaching and knowledge about these issues among graduate students in psychology. Several limitations in our survey should be noted. The representativeness of our sample in unknown. In some instances, we could not calculate response rates from particular schools. In those cases where we could, our response rates ranged from 20–40 percent. We cannot tell how many students never received the e-mail containing the survey link, nor, among those who did receive it, how many never opened the e-mail. Therefore, our observed response rate likely underestimates the true response rate, perhaps dramatically. It is notable that the responses to each survey item varied little between schools. Wider participation in future incarnations of our survey should provide us with more reliable data and should be encouraged by graduate programs in clinical psychology. Why is there so little teaching about these matters? It may be that these issues are not on the minds of most psychologists in their daily work. However, there is a more worrisome possibility. Given the extent of military funding of psychological research—and, more generally, the extent to which the military and professional psychology are intertwined—such education might be actively discouraged by some psychologists who fear that wider education about human rights might lead to more vocal protest of the APA’s failure to repeal the PENS report and condemnation of psychologists’ participation in interrogations. More instruction in these matters might also make psychology doctoral students less likely to join the APA because of its lack of a clear ethical stance on the permissibility of psychologist participation in interrogations. The issue of psychologists participating in military interrogation sessions in contravention of international norms and standards is a specific instance of a broader ethical concern, namely that of dual loyalties. Conflicts of interest can arise when a health professional is expected to adhere to good ethical practice, but is also expected to follow the orders of an institution with goals and responsibilities beyond health care. Such is potentially the case for military physicians, nurses, and medics, as well as psychologists. Psychologists and other health professionals who are not properly educated about their duties in military settings might fail to navigate their dual loyalties in as ethical a manner as possible (24).
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Since a large number of psychologists will be military-involved at some point in their careers, the issue of dual loyalties should be part of the curriculum in every psychology training program. Such curricula should address the obligations imposed by the Geneva Conventions and other international codes, as well as the likelihood of psychologists being drafted under the HCPDS. In order for this change to take place, the profession as a whole, and the APA in particular, will have to confront the issue of psychologist participation in military interrogations. In light of the clear international guidelines about torture, and the fact that the Nuremberg defense has been consistently rejected by legal and ethical panels since it was first offered, psychologists should stand on the right side of history, annul the PENS report, and issue a clarion call for ethical and humane behavior by all psychologists. We believe that educating psychologists about these matters ought to begin in graduate school. Waiting to educate psychologists about these matters until after they have begun military service is too late. ADDENDUM In August, 2013, the APA Council of Representatives adopted a resolution that rescinds the PENS report and maintains that “psychologists may not work in settings where persons are held outside of, or in violation of, either International Law or the U.S. Constitution” unless they are working on behalf of those being detained (25). Although this measure represents a significant advance for the APA, we maintain our call for significantly increased education about human rights during psychology training to ensure that psychologists are never again susceptible to succumbing to public opinion or political pressure and adopting positions that flout international law, much less basic human decency. Acknowledgments — Each of the authors listed on the manuscript except one (RA) participated in the original conceptualization of the project and in formulating the online survey. All of the authors had full access to all of the survey results and participated in analyzing those results, composing and editing drafts of the manuscript, and approving the final draft. We had no outside funding for this project and we have no conflicts of interest to declare. We would like to thank Kaja R. Johnson, MA, Richelle S. Allen, MA, and Twyla Wolfe, MA, for their assistance in distributing our survey. REFERENCES 1. DeAngelis, T. Psychology’s growth careers: Psychologists’ expertise in human behavior is increasingly welcomed in many nontraditional career settings. Monitor Psychol. 39:64, 2008.
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2. Jonas, M. A Short History of the Relationship Between the American Psychological Association and the U.S. Military. Updated 2010. http://www.law.berkeley.edu/files/ HistoryofAPAandMilitarypaper(final)11June10.pdf (accessed August 26, 2013). 3. About the APA. http://www.apa.org/about/index.aspx (accessed August 14, 2013). 4. Summers, F. Making sense of the APA: The history of the relationship between psychology and the military. Psychoanal. Dialogues 18(3):614, 2008. 5. Lewis, N. Interrogators cite doctors’ aid at Guantanamo. The New York Times, June 24, 2005, p. A1. 6. Lifton, R. J. Doctors and torture. N. Engl. J. Med. 351(5):415–416, 2004. 7. Bloche, M. G., and Marks, J. H. When doctors go to war. N. Engl. J. Med. 352(1):3–6, 2005. 8. Wilks, M. A stain on medical ethics. Lancet 366(9484):429–431, 2005. 9. Wills, S. The role of health professionals in detainee interrogation. The Atlantic, 2012. 10. Convention (III) relative to the treatment of prisoners of war. Updated 1949. http:// www.icrc.org/ihl/INTRO/375 (accessed August 26, 2013). 11. The president and the courts. The New York Times, March 20, 2006, p. A22. 12. Gill, K. Issue Summary: Geneva Conventions. http://uspolitics.about.com/od/anti terrorism/i/geneva_conv_2.htm (accessed August 13, 2013). 13. United States Code, Title 18 – Crimes and Criminal Procedure, Chapter 188 Section 2441. http://www.law.cornell.edu/uscode/text/18/2441 (accessed August 26, 2013). 14. American Psychological Association. Report of the American Psychological Association Presidential Task Force on Psychological Ethics and National Security. Updated 2005. http://www.apa.org/news/press/releases/2005/07/pens.aspx (accessed August 26, 2013). 15. Pope, K. Psychologists and detainee interrogations: Key decisions, opportunities lost, and lessons learned. Ann. Rev. Clin. Psychol. 7:459, 2011. 16. The Constitution Project. The Role of Medical Professionals in Detention and Interrogation Operations. http://detaineetaskforce.org/report/download/ (accessed July 22, 2013). 17. 2008 APA Petition Resolution Ballot. http://www.apa.org/news/press/statements/ work-settings.aspx (accessed August 14, 2013). 18. Law, B. M. Service, in plain clothes. gradPSYCH Magazine 9:22, 2011. 19. Big growth in the number of VA psychologists. Monitor on Psychol. 41:11, 2010. 20. Veterans Administration. Psychology training. Updated 2012. http://www.psychology training.va.gov/ (accessed August 1, 2013). 21. Association of Psychology Postdoctoral and Internship Centers. Directory online: Internships. http://www.appic.org/directory/search_dol_internships.asp (accessed August 14, 2013). 22. Selective Service System. Medical Draft in Standby Mode. Updated 2008. http:// www.sss.gov/FSmedical.htm (accessed August 14, 2013). 23. Boyd, J. W., et al. U.S. medical students’ knowledge about the military draft, the Geneva conventions, and military medical ethics. Int. J. Health Serv. 37(4):643–650, 2007. 24. Ethics Study Guide: Health Professional Ethics and Dual Loyalty Conflicts. http:// doctorsofthedarkside.com/ethicsstudyguide (accessed August 14, 2013).
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25. American Psychological Association. Policy Related to Psychologists’ Work in National Security Settings and Reaffirmation of the APA Position Against Torture and Other Cruel, Inhuman, or Degrading Treatment or Punishment. http://apa.org/ about/policy/national-security.aspx?item=1 (accessed December 10, 2013).
Direct reprint requests to: J. Wesley Boyd, MD, PhD 26 Central Street Somerville, MA 02143 [email protected]
The American Psychological Association (APA) has long maintained a close, even symbiotic, relationship with the Department of Defense (DOD) and the Veterans Administration (VA). Herein we highlight these close ties and describe psychologists’ participation in interrogations by U.S. military and intelligence entities. We then review the APA’s statements about the permissibility of psychologist participation in the interrogation and torture of suspected terrorists. These issues are significant in and of themselves and because the VA and DOD have been described as “growth careers” for psychologists of the future (1). Additionally, the Health Care Personnel Delivery System allows the drafting of civilian clinical psychologists into military service even in the absence of a general draft. In light of psychologists’ extensive involvement in the interrogation process of suspected terrorists, and the possibility that psychologists without prior military experience may be drafted, we wondered how much psychologists have been taught about their ethical duties should they find themselves in military settings. The results of our pilot study of U.S. psychology graduate students, which assessed their knowledge of military ethics, raise concerns that psychologists receive inadequate formal training in these matters. This may leave psychologists vulnerable to misinformation about proper ethical conduct in their future work.
Psychology in the United States has a longstanding, close relationship with the military. Psychologists contributed significantly to the U.S. military effort in both World Wars, including evaluating new recruits, assisting in the treatment of International Journal of Health Services, Volume 44, Number 3, Pages 615–625, 2014 © 2014, Baywood Publishing Co., Inc. doi: http://dx.doi.org/10.2190/HS.44.3.j http://baywood.com
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/ Boyd et al.
soldiers with “shell shock,” and offering advice about the enemy in order to make interrogations more effective (2). After World War II, the relationship between psychology and the military took new and various forms. The Army and the Navy, for example, utilized psychological input and consultation in addressing various Cold War issues and tactics, including mind control and sensory deprivation. U.S. Department of Defense (DOD) funding went to leaders within the American Psychological Association (APA) and actually drove the research agenda of the APA in particular and the discipline in general (2). Psychology became so integral to the DOD that by 1952, 78 percent of all federal funding to psychology came through the DOD. By 1960, the DOD was spending almost its entire US$15 million social science research budget on psychology, equivalent to roughly US$120 million in today’s dollars (2). The APA has experienced dramatic growth over the last 70 years. Between 1945 and 1970, the APA’s membership grew from just over 4,000 to more than 30,000. Today the APA has approximately 134,000 members (3). Many credit the prominence that psychology achieved through its work in the military as pivotal to the growth of the APA: “The burgeoning of psychology from a small academic discipline to the largest of the social sciences with 70 percent practitioners would have been unimaginable without the resources, support, and respect of the DOD and CIA” (4). This close relationship continues to this day, and research in psychology in academic settings still depends largely on military funding. The behavioral science research budget of the DOD is approximately US$400 million annually, with the majority devoted to psychological research, dwarfing other funders of psychological research (4). At the outset of the U.S. War on Terror in general and Operation Iraqi Freedom in particular, the U.S. government condoned interrogation tactics that were historically considered to constitute torture. It has been reported that psychologists conceived of the entire interrogation system employed by U.S. interrogators and, in some instances, informed interrogators about prisoners’ phobias and other psychological vulnerabilities that could be exploited during interrogation (5–8). For instance, an Army psychologist reportedly wrote to interrogators at Guantanamo about an inmate, “He appears to be rather frightened, and it looks as if he could break easily if he were isolated from his support network and made to rely solely on the interrogator.…Make him as uncomfortable as possible. Work him as hard as possible” (9). GENEVA CONVENTIONS AND OTHER INTERNATIONAL STANDARDS The Geneva Conventions are clear that prisoners of war are only obligated to divulge their name, service type, rank, and nothing more. The dictates to their
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captors are clear: “No physical or mental torture, nor any other form of coercion, may be inflicted on prisoners of war to secure from them information of any kind whatever. Prisoners of war who refuse to answer may not be threatened, insulted, or exposed to unpleasant or disadvantageous treatment of any kind” (10). Although the Geneva Conventions ban threatening, coercing, humiliating, degrading, injuring, or murdering prisoners of war for any reason, psychologists who have participated in interrogations of prisoners might not have been aware that they were engaged in conduct that violates international agreements. During President George W. Bush’s two terms in office, the U.S. government argued that prisoners arrested in the war on terror were “detainees” or “enemy combatants” rather than “prisoners of war” so the Geneva Conventions did not apply to their treatment, a position with which many ethical and legal analysts disagreed (11, 12). Psychologists without prior knowledge of international codes such as the Geneva Conventions and the Nuremberg Conventions, unprepared to disobey orders that violated these agreements, were likely to be unquestioning and compliant when told to assist the interrogators. Given that violating the Geneva Conventions can carry with it a death sentence, the stakes are high (13). AMERICAN PSYCHOLOGICAL ASSOCIATION STANCE ON PSYCHOLOGIST PARTICIPATION IN INTERROGATION In concert with the Bush administration’s efforts to bypass the mandates of the Geneva Conventions, the APA adopted a position that supported military psychologists who might decide to violate the organization’s own code of ethics if ordered to take an unethical action. The APA Ethics Code Principle 1.02 in effect from 2002 and 2010 and the 2005 Report of the Presidential Task Force on Psychological Ethics and National Security (PENS) allow for psychologists to participate in interrogations, including those that meet the definition of torture under international standards: “Psychologists may serve in various national securityrelated roles, such as a consultant to an interrogation, in a manner that is consistent with the Ethics Code, and when doing so psychologists are mindful of factors unique to these roles and contexts that require special ethical consideration” (14). It states further, “Psychologists do not engage in behaviors that violate the laws of the United States, although psychologists may refuse for ethical reasons to follow laws or orders that are unjust or that violate basic principles of human rights.” If there is a conflict between ethics and the law, the PENS report allows for psychologists to violate prevailing ethical norms and “adhere to the requirements of the law” (14). In so doing, the PENS report attempts to justify and codify what is generally called “the Nuremberg defense,” the stance taken by the Nazi doctors at Nuremberg who declared that they were merely following orders, a position repeatedly rejected by international courts and ethicists (15).
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The PENS report angered a number of psychologists, who assert that psychologists should never participate in interrogations and torture, a stance that the American Medical Association and the American Psychiatric Association have adopted for physicians and psychiatrists. As a result, in 2008 the APA adopted a referendum (approved by 59% of the 14,949 voting members) that concluded “psychologists may not work in settings where persons are held outside of, or in violation of, either International Law (e.g., the UN Convention Against Torture and the Geneva Conventions) or the U.S. Constitution (where appropriate), unless they are working directly for the persons being detained or for an independent third party working to protect human rights” (17). This policy effectively prohibits psychologists from working with the U.S. government in settings such as Guantanamo Bay. Despite the adoption of this 2008 referendum, to date the APA has not refuted, rescinded, or otherwise withdrawn support for the PENS report. Thus, the APA currently holds conflicting positions on the ethics of psychologist participation in interrogations and torture. This issue remains vitally important because the historical ties between psychology and the military remain strong. For example, 7 percent of APA members are employed directly by, or are working directly with, the DOD, and 5 percent of licensed psychologists in the United States are employed by the Veterans Administration (VA) (18, 19). The VA is also the largest provider of internships in clinical psychology in the United States, with 106 locations offering approximately 480 internship positions, 16 percent of the 3,071 internships available nationwide in 2011–2012 (20, 21). In addition, the APA has cited the DOD and the VA as “growth areas” where more psychologists will be needed, especially given the large number of active service personnel who suffer psychological injury and will require further care in the VA system long after they leave active service (1). HEALTH CARE PERSONNEL DELIVERY SYSTEM The APA position on psychologists’ role in interrogation is important not only because of the large number of psychologists currently working with and in the military, but also because of the existence of the Health Care Personnel Delivery System (HCPDS) (22). The HCPDS is a plan for drafting health care personnel into military service in a time of crisis. It was authorized by Congress in 1987 and remains in place. Congress and the president can activate this process and begin drafting civilian health care personnel, including psychologists, in a matter of weeks. The HCPDS allows for few exemptions and assumes a priori that professionals practicing in the civilian sector are physically fit for military service. Thus, were the government to implement it, the HCPDS would rapidly place numerous private psychologists into military service. Based on previous studies of medical students, we hypothesized that most psychology students would not know about the existence of the HCPDS, and
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would be largely unfamiliar with the mandates of international ethical standards and agreed-upon conventions (23). Inadequate knowledge and instruction on ethical issues are of particular concern given the APA’s lack of clear ethical guidance for military psychologists. SURVEY OF GRADUATE STUDENTS To explore psychology students’ knowledge of military psychologists’ ethical responsibilities, we developed an Internet survey and, with Cambridge Health Alliance Institutional Review Board approval, distributed it to graduate students in clinical psychology programs in several U.S. states. Utilizing contacts at graduate schools, we distributed the survey to students in 20 psychology graduate programs and received a total of 185 responses. Since we are unable to ascertain how many students received the e-mail invitation to complete the survey, we cannot calculate an exact response rate; however, we believe about 20–40 percent of those who received the survey completed it. Thus, we report our findings as preliminary and suggest that they warrant more rigorous study. Of our respondents, 81 percent were female, 82 percent were members of the APA, and 6 percent had present, past, or future obligations for military service (see Table 1). The vast majority of respondents, 73.6 percent, had received less than one hour of training in military ethics while in graduate school; 23 percent had received between one and five hours of such training; and only 3.4 percent had received more than five hours. Many of the psychology graduate students in our survey did not know about some of the major connections between the profession of psychology and the U.S. government (see Table 2). For example, although 57.5 percent were aware that the VA is the single largest provider of internships for psychologists, only 13.7 percent were aware that 7 percent of APA members work with or for the DOD. Only 5.1 percent were aware of the HCPDS. If drafted into military service, 14.4 percent of our respondents said they would volunteer for service. Most would not volunteer: 43.1 percent would await draft notification, 27.0 percent would use all legal means to avoid service, 11.5 percent would consider emigration, and 4.0 percent would refuse military induction as an act of civil disobedience. While almost three quarters of respondents said that they were either “very familiar” or “somewhat familiar” with the Geneva Conventions, only 36.7 percent correctly answered that the Geneva Conventions apply regardless of whether or not one’s country has formally declared war. When asked which wounded individuals should be treated first, 57.2 percent of our sample answered correctly that physicians should “treat the sickest first, regardless of nationality.” Just over one quarter (26.5%) incorrectly answered that they should “treat their own soldiers according to level of severity and then attend to the wounded enemy.”
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Characteristics Gender Male Female Present, past, or future obligation for military service Member of the APA Hours of training in military ethics in graduate school Less than 1 1–5 Greater than 5 Candidate supported in the last U.S. president election McCain Obama Other candidate Did not vote
Percent
18.9% 81.1% 6.0% 82.1% 73.6% 23.0% 3.4% 7.4% 75.4% 1.7% 9.7%
We asked about acceptable interrogation practices according to the Geneva Conventions if a prisoner is refusing to answer questions about a recent skirmish in which U.S. soldiers died. Almost half (49.7%) of respondents did not know that the Geneva Conventions stipulate that it is never acceptable to deprive prisoners of war of food or water, expose them to physical stresses such as heat, cold, and uncomfortable positions, or threaten them with physical violence even if these threats are not carried out. We asked under what circumstances an officer is ethically required to disobey a direct order from a superior and offered the following options: “(a) when ordered to threaten a prisoner with injection of a psychoactive drug that will not actually be administered; (b) when ordered to inject a harmless bolus of saline into a prisoner who fears he is receiving a lethal injection; (c) when ordered to inject a lethal drug into a prisoner; (d) all of the above; (e) none of the above.” Only 52.1 percent correctly answered “all of the above.” Many respondents were not fully informed about the APA’s stance on psychologists’ participation in interrogation as outlined in the 2005 PENS report (whose implications only 24.8% correctly understood), as outlined by the 2008 referendum (55.2% answered correctly) or as outlined in a 2009 APA official statement (66.5% answered correctly).
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Table 2. Psychology graduate students’ knowledge regarding the Geneva Conventions and the military draft and their likely responses to a medical draft Measurement item
Percent
Aware that the Veterans’ Administration is the single biggest sponsor of internships for psychologists?
57.5%
Aware that 7 percent of APA members work with or for the U.S. Department of Defense?
13.7%
Aware of the Health Care Personnel Delivery System?
5.1%
Aware that psychologists up to age 44 are draft-eligible?
5.1%
Aware that psychologists in the civilian sector would be presumed fit for military service without exemption?
4.4%
Likely response to a medical draft: Volunteer for service Await draft notification Use all legal means to avoid service Consider emigration Refuse military induction as an act of civil disobedience
14.4% 43.1% 27.0% 11.5% 4.0%
Self-reported famliarity with the Geneva Conventions? Very familiar Somewhat familiar Not at all familiar
4.6% 70.1% 24.7%
Correctly identified physicians’ obligations under Geneva Conventions: Situations in which Geneva Conventions apply Priorities for treatment of wounded individuals Acceptable interrogation practices Situations in which orders must be disobeyed
36.7% 57.2% 49.7% 52.1%
Correctly identified APA’s stance on psychologists’ participation in interrogation: As outlined in the 2005 PENS report As outlined by a 2008 referendum As outlined in 2009 official statement
24.8% 55.2% 66.5%
The PENS Task Force included members with strong ties to the military: six out of nine were either active or former U.S. military or intelligence personnel and the report was adopted by the APA under unusually hasty, secretive procedures (16).
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/ Boyd et al. DISCUSSION
Our results suggest that graduate students in psychology receive little instruction in military medical ethics and, consequently, know little about the ethical requirements for professional behavior of psychologists who serve in the U.S. military. Given that students from 20 institutions consistently reported little or no teaching about these matters, we suggest that programs review the content of their ethics courses and significantly bolster teaching about ethics in general and international standards and guidelines in particular. Further scientific study is warranted to fully assess the teaching and knowledge about these issues among graduate students in psychology. Several limitations in our survey should be noted. The representativeness of our sample in unknown. In some instances, we could not calculate response rates from particular schools. In those cases where we could, our response rates ranged from 20–40 percent. We cannot tell how many students never received the e-mail containing the survey link, nor, among those who did receive it, how many never opened the e-mail. Therefore, our observed response rate likely underestimates the true response rate, perhaps dramatically. It is notable that the responses to each survey item varied little between schools. Wider participation in future incarnations of our survey should provide us with more reliable data and should be encouraged by graduate programs in clinical psychology. Why is there so little teaching about these matters? It may be that these issues are not on the minds of most psychologists in their daily work. However, there is a more worrisome possibility. Given the extent of military funding of psychological research—and, more generally, the extent to which the military and professional psychology are intertwined—such education might be actively discouraged by some psychologists who fear that wider education about human rights might lead to more vocal protest of the APA’s failure to repeal the PENS report and condemnation of psychologists’ participation in interrogations. More instruction in these matters might also make psychology doctoral students less likely to join the APA because of its lack of a clear ethical stance on the permissibility of psychologist participation in interrogations. The issue of psychologists participating in military interrogation sessions in contravention of international norms and standards is a specific instance of a broader ethical concern, namely that of dual loyalties. Conflicts of interest can arise when a health professional is expected to adhere to good ethical practice, but is also expected to follow the orders of an institution with goals and responsibilities beyond health care. Such is potentially the case for military physicians, nurses, and medics, as well as psychologists. Psychologists and other health professionals who are not properly educated about their duties in military settings might fail to navigate their dual loyalties in as ethical a manner as possible (24).
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Since a large number of psychologists will be military-involved at some point in their careers, the issue of dual loyalties should be part of the curriculum in every psychology training program. Such curricula should address the obligations imposed by the Geneva Conventions and other international codes, as well as the likelihood of psychologists being drafted under the HCPDS. In order for this change to take place, the profession as a whole, and the APA in particular, will have to confront the issue of psychologist participation in military interrogations. In light of the clear international guidelines about torture, and the fact that the Nuremberg defense has been consistently rejected by legal and ethical panels since it was first offered, psychologists should stand on the right side of history, annul the PENS report, and issue a clarion call for ethical and humane behavior by all psychologists. We believe that educating psychologists about these matters ought to begin in graduate school. Waiting to educate psychologists about these matters until after they have begun military service is too late. ADDENDUM In August, 2013, the APA Council of Representatives adopted a resolution that rescinds the PENS report and maintains that “psychologists may not work in settings where persons are held outside of, or in violation of, either International Law or the U.S. Constitution” unless they are working on behalf of those being detained (25). Although this measure represents a significant advance for the APA, we maintain our call for significantly increased education about human rights during psychology training to ensure that psychologists are never again susceptible to succumbing to public opinion or political pressure and adopting positions that flout international law, much less basic human decency. Acknowledgments — Each of the authors listed on the manuscript except one (RA) participated in the original conceptualization of the project and in formulating the online survey. All of the authors had full access to all of the survey results and participated in analyzing those results, composing and editing drafts of the manuscript, and approving the final draft. We had no outside funding for this project and we have no conflicts of interest to declare. We would like to thank Kaja R. Johnson, MA, Richelle S. Allen, MA, and Twyla Wolfe, MA, for their assistance in distributing our survey. REFERENCES 1. DeAngelis, T. Psychology’s growth careers: Psychologists’ expertise in human behavior is increasingly welcomed in many nontraditional career settings. Monitor Psychol. 39:64, 2008.
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2. Jonas, M. A Short History of the Relationship Between the American Psychological Association and the U.S. Military. Updated 2010. http://www.law.berkeley.edu/files/ HistoryofAPAandMilitarypaper(final)11June10.pdf (accessed August 26, 2013). 3. About the APA. http://www.apa.org/about/index.aspx (accessed August 14, 2013). 4. Summers, F. Making sense of the APA: The history of the relationship between psychology and the military. Psychoanal. Dialogues 18(3):614, 2008. 5. Lewis, N. Interrogators cite doctors’ aid at Guantanamo. The New York Times, June 24, 2005, p. A1. 6. Lifton, R. J. Doctors and torture. N. Engl. J. Med. 351(5):415–416, 2004. 7. Bloche, M. G., and Marks, J. H. When doctors go to war. N. Engl. J. Med. 352(1):3–6, 2005. 8. Wilks, M. A stain on medical ethics. Lancet 366(9484):429–431, 2005. 9. Wills, S. The role of health professionals in detainee interrogation. The Atlantic, 2012. 10. Convention (III) relative to the treatment of prisoners of war. Updated 1949. http:// www.icrc.org/ihl/INTRO/375 (accessed August 26, 2013). 11. The president and the courts. The New York Times, March 20, 2006, p. A22. 12. Gill, K. Issue Summary: Geneva Conventions. http://uspolitics.about.com/od/anti terrorism/i/geneva_conv_2.htm (accessed August 13, 2013). 13. United States Code, Title 18 – Crimes and Criminal Procedure, Chapter 188 Section 2441. http://www.law.cornell.edu/uscode/text/18/2441 (accessed August 26, 2013). 14. American Psychological Association. Report of the American Psychological Association Presidential Task Force on Psychological Ethics and National Security. Updated 2005. http://www.apa.org/news/press/releases/2005/07/pens.aspx (accessed August 26, 2013). 15. Pope, K. Psychologists and detainee interrogations: Key decisions, opportunities lost, and lessons learned. Ann. Rev. Clin. Psychol. 7:459, 2011. 16. The Constitution Project. The Role of Medical Professionals in Detention and Interrogation Operations. http://detaineetaskforce.org/report/download/ (accessed July 22, 2013). 17. 2008 APA Petition Resolution Ballot. http://www.apa.org/news/press/statements/ work-settings.aspx (accessed August 14, 2013). 18. Law, B. M. Service, in plain clothes. gradPSYCH Magazine 9:22, 2011. 19. Big growth in the number of VA psychologists. Monitor on Psychol. 41:11, 2010. 20. Veterans Administration. Psychology training. Updated 2012. http://www.psychology training.va.gov/ (accessed August 1, 2013). 21. Association of Psychology Postdoctoral and Internship Centers. Directory online: Internships. http://www.appic.org/directory/search_dol_internships.asp (accessed August 14, 2013). 22. Selective Service System. Medical Draft in Standby Mode. Updated 2008. http:// www.sss.gov/FSmedical.htm (accessed August 14, 2013). 23. Boyd, J. W., et al. U.S. medical students’ knowledge about the military draft, the Geneva conventions, and military medical ethics. Int. J. Health Serv. 37(4):643–650, 2007. 24. Ethics Study Guide: Health Professional Ethics and Dual Loyalty Conflicts. http:// doctorsofthedarkside.com/ethicsstudyguide (accessed August 14, 2013).
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25. American Psychological Association. Policy Related to Psychologists’ Work in National Security Settings and Reaffirmation of the APA Position Against Torture and Other Cruel, Inhuman, or Degrading Treatment or Punishment. http://apa.org/ about/policy/national-security.aspx?item=1 (accessed December 10, 2013).
Direct reprint requests to: J. Wesley Boyd, MD, PhD 26 Central Street Somerville, MA 02143 [email protected]
