Jonathan Bean, David Ng, & Hakan Demirtas,** PhD, and Patrick Guinan, MD***
This article was first published in TORTURE Journal, Volume 18, Number 2, 2008.
Torture, whether it be domestic or war related, is a public health issue of current concern. It is the position of the American Medical Association (AMA), The World Medical Association (WMA), the United Nations Declaration and the Geneva Convention, that torture is unethical, "morally wrong" and never to be condoned. The attitudes of medical students, our future physicians, will be critical in reducing the incidence of torture.
The purpose of this investigation was to assess medical student's attitudes regarding the permissibility and ethics of the use of torture.
A University of Illinois at Chicago College of Medicine's Institutional Review Board approved torture questionnaire was administered to 336 students of the University of Illinois College of Medicine.
35% of students agreed that torture could be “condoned” under some circumstances. Moreover, 24% of respondents disagreed that torture should "be prohibited" as a matter of state policy and a similar 24% disagreed that torture was "intrinsically wrong."
It is concluded that most students felt that torture was "not permissible" and "intrinsically wrong", a disturbing 27%-35% felt that it could be permitted or condoned at times. Moreover, 27% felt that torture was not unethical. Given the strong condemnation of torture by the AMA, the WMA and the Geneva Convention these medical student attitudes, albeit by a minority of students, are disturbing. It is suggested that medical school curriculum committees review this matter.
Keywords: ethics to torture, questionnaire technique, medical students, Hippocratic oath.
The American Medical Association (AMA) defines torture as "the deliberate, systematic, or wanton administration of cruel, inhumane, and degrading treatments or punishments during imprisonment or detainment."1 Torture has been condemned not only by the American Medical Association2 but also the World Medical Association and United Nations Universal Declaration of Human Rights,3 and Convention Against Torture4. Moreover, Article 3 of the Geneva Convention5 states that torture is "morally wrong". Indeed it categorically states that torture "should remain prohibited at any time and in any place whatsoever."
Given these strong condemnations of torture, it is surprising that physicians have been implicated in torture in a variety of settings, including Chile, the Soviet Union, and South Africa, but most recently and notoriously at Abu Ghraib.6-8 Relatively little is known about medical student's attitudes about torture. Given the presumed idealism of medical students one might assume that they would subscribe to the Hippocratic idea of "primum non nocere," or do no harm.
The purpose of this investigation was to assess the attitudes of medical students regarding torture. To focus the inquiry, two issues were addressed: 1) is it permissible to torture to obtain information, and 2) are there ethical imperatives that always forbid certain behavior, in this instance, torture?
Three hundred and thirty-six M-1 through M-4 medical students were asked to voluntarily complete a six item questionnaire that was University of Illinois-College of Medicine (UIC-COM) IRB (#2006-02681) approved (Table 1). There were no identifiers of participants on the questionnaires. The M-1 and M-2 (classroom years) student questionnaires were completed in the lecture rooms. The M-3 and M-4 (clinical years) student questionnaires were mailed to the students with a prepaid return envelope. The selection of the students was somewhat uneven because it was done at postgraduate levels and many of the clinical year students were on off-campus rotations. This should not constitute a bias because these students were randomly distributed. The 336 students represent approximately one-half (49%) of 690 students of the College of Medicine student population. While the options were "strongly agree", "agree", "undecided", "disagree", "strongly disagree", for the purposes of this analysis, "strongly agree" and "agree" were reported as "agree," and "disagree" and "strongly disagree" were reported as "disagree".
The six questions were in two categories:
Table 1. Torture questionnaire
Q1 and Q3 asked if the students thought torture "should be prohibited" and was "immoral." Questions 2, 4, 5, and 6 asked if torture was "permissible" or could be "condoned" under some circumstances.
Our research hypothesis was that more than 20% of medical students would either 1) disagree that torture was immoral and/or intrinsically wrong, or 2) agree that torture was permissible under some circumstances. An arbitrary 20% cut-off point was chosen because it was midway between an ideal 0% tolerance for torture and the 37% tolerance expressed in the ABC poll of the American public.9 Analysis performed was a one sample z test for proportion.
Table 2. Medical Student responses
# Agree (%)
|Q-1||216 (64%)||80 (24 %)||40 (12 %)||More than 20% disagree||3.02||0.001|
|Q-2||119 (35 %)||163 (49 %)||54 (16 %)||More than 20% agree||9.32||<0.001|
|Q-3||213 (63 %)||80 (24 %)||43 (13 %)||More than 20% disagree||3.03||0.001|
|Q-4||91 (27 %)||170 (51 %)||75 (22 %)||More than 20% agree||6.00||<0.001|
|Q-5||170 (50 %)||100 (30 %)||66 (20 %)||More than 20% agree||7.00||<0.001|
|Q-6||73 (22 %)||195 (58 %)||68 (20 %)||More than 20% agree||1.96||0.002|
Twenty-four percent of students disagreed that torture "should be prohibited" (Q1) and a similar 24% disagreed that torture was "intrinsically wrong" (Q3) (Table 2). The proportion of students who agreed that torture was sometimes permissible was 35%, 27%, 50%, and 22% for Q 2,4,5, and 6 respectively (Table 2). The results shown in Table 2 indicate that our research hypotheses are substantiated by the data (all p-values are less than 0.05).
Torture is a broad and complex subject. There is a vigorous debate, in and out of the government, as to what constitutes torture. This was highlighted in a recent (November 2007) senate confirmation of the United States Attorney General. For the purpose of this study the AMA's definition: "the deliberate, systematic, or wanton administration of cruel, inhumane, and degrading treatments during imprisonment or detainment" will be used.
As mentioned before we will focus on two issues. 1) Is there an ethical imperative that always forbids certain behavior: in this instance, torture? 2) Can torture ever be permitted to obtain information?
Relatively little is known about medical student's (or physician's, for that matter), attitudes regarding torture. Verma,10 using a questionnaire technique, evaluated the attitudes about torture of 98 Indian medical students. Fifty-seven percent of the students responding to a question about employing torture to obtain information or a confession thought that it was acceptable. In another questionnaire study, this time of Indian physicians, a similar 57% (of 843 respondents) felt that torture was justified to elicit information.11 A more recent e-mail survey of American medical students suggested that they were deficient in knowledge about the Geneva Convention as well as military medical ethics. They were not specifically asked about the ethics of torture.12
Given the clear-cut and repeated blanket condemnations of torture by not only the United Nations Declaration of Human Rights, but particularly international medical organizations such as the World Medical Association, the Geneva Convention and our own American Medical Association these, admittedly few, reports of doctors approving of torture, or in rare cases participating in it, are of concern.
Medical ethics and the Hippocratic admonition of "do no harm" are assumed to be ingrained in the medical profession and have contributed to the public perception of medicine as an honorable and moral profession. But if torture is "morally wrong" (as stated in the Geneva Convention), these literature reports are troubling.
The results of this study suggest that while most students disapprove of torture, many (35% in question #2 and 27% in question #4 and 22% in question #6) would still allow it under some circumstances. No question addressed actual physician participation in torture and such a question might have elicited a stronger negative response.
Of interest is the recent United States Army report “Attitudes Regarding the Treatment of Insurgents and Non-Combatants.”13 This survey of combat soldiers and marines in Iraq revealed that 41% of the soldiers and 44% of marines would torture to “save the life of a soldier/marine.” One might have expected combat soldiers to be more approving of torture to save the life of a comrade. It is disturbing that 27% of medical students would allow torture to obtain “life saving information” (question 4). The medical students are not that much less accepting of torture than soldiers.
Given the strong absolute prohibition of torture by virtually all medical organizations it is noteworthy that about one quarter of the students (24% in question #1) did not agree that torture should "be prohibited" or that torture is "immoral and intrinsically wrong"(24% in question #3). Putting it another way, more than one-fourth could approve of torture.
There are limitations to this study that must be noted. Some of the questions are less than focused by allowing two interpretations, making the participants answers to those questions somewhat ambiguous. Collapsing "strongly agree" and "agree," and "strongly disagree," and "disagree" into single choices of "agree" and "disagree" erases a range of opinions that could be informative. It was assumed that no systematic trends exist among students whose response was "undecided" as to approving or disapproving torture under some circumstances. In other words, little or no discernible bias was assumed to occur, and "undecided" responses were likely to follow the trends among participants who chose "agree" or "disagree," if they were forced to choose another option.
This study brings to the ethics community's attention an issue that tends to be ignored—that is intrinsically unethical actions. As mentioned in the introduction, the Geneva Convention states that torture is "morally wrong," and continues that it is "always intrinsically wrong." At a time when relativists question whether any human action can always be intrinsically unethical, the case of torture might be the issue that we all can agree is morally evil.
Given the findings of the Boyd Report12 it would appear that torture receives little attention (less than 1 hour for 94.2% of respondents) in the curriculum of many medical schools. Perhaps our medical educators might want to emphasize the relationship between the ethics of torture and medical practice.
In summary, this survey of 336 M-1 through M-4 medical students suggest that a majority of students agreed that torture was unacceptable. However, a troubling minority, perhaps as many as one third, were ambiguous or even approving of torture. If one believes that torture is intrinsically unethical, this acceptance rate is too high.
- American Medical Association. Code of medical ethics, 2.067. Chicago, IL: AMA Press, 2004.
- World Medical Association Declaration of Tokyo. www.wmc.net/e/policy/c18.html (May 2006).
- United Nations Universal Declaration of Human Rights, Article 5, 1948. www.un.org/Overview/ rights.html.
- United Nations Convention Against Torture, Article 2. www.hrweb.org/legal/cat.html.
- Geneva Convention, Part 1, Article 3. Adopted August 12th, 1949. www.unhctr.ch/html/menu3/ b/91.html.
- Lifton RJ. Doctors and torture. N Engl J Med 2004;351:415-6.
- Bloche M., Marks J. When doctors go to war. N Engl J Med 2005;352:3-6.
- Wilks M. A stain on medical ethics. Lancet 2005;366:429-31.
- Terror suspect treatment: most Americans oppose torture techniques. http://abcnews.go.com/ section/us/Polls/torture_poll_040527.html.
- Verma SK, Bisivas G. Knowledge and attitudes on torture by medical students in Delhi. Torture 2005;15:46-50.
- Sobti ]W, Chapparawal BS, Holst E. Study of knowledge, attitudes and practice concerning aspects of torture. J Ind Med Assoc 2000;989:336-9.
- Boyd JW, Himmelstein D, Lasser K, McCormick D, Bor DH, Cutrona S et al. U.S. medical students knowledge about the military draft, the Geneva Convention, and military medical ethics. Int J Health Serv 2007;37:643-50.
- Mental Health Advisory Team IV. Operation Iraqi Freedom 2000;98:336-9. Final Report 17. Office of the Surgeon Multinational Force-Iraq and the Office of the Surgeon General, United States Army Medical Command, 2006:34.